A Working TTFields Therapy Framework for Patient-Specific Segmentation-Based Treatment Planning and Dosimetry

PURPOSE/OBJECTIVE(S)

Previously reported data support the notion that patient-specific treatment planning in patients with newly diagnosed glioblastoma (GBM) could positively impact patient outcomes like overall survival and progression free survival and predictably affect imaging progression patterns (Ballo et al 2019; Glas et al 2021). These findings provide the grounds for a TTFields dosimetry and patient-specific segmentation-based treatment planning (SBTP) paradigm. This paradigm allows optimized delivery of TTFields to target regions of interest (ROIs) and ability to adjust the treatment during therapy. In this study, we describe a working framework for TTFields SBTP.

MATERIALS/METHODS

The working framework consists of the following process: First, a patient's high-resolution imaging data (MRI with or without a CT) is imported from the institution's PACS. The image is segmented to identify tissue types using a combination of automatic and semi-automatic algorithms. During this stage, the user indicates the target ROI subject to optimization. Then, a computational model of the patient is created in which typical electrical properties are allocated to each tissue type based on empirical measurements and/or literature. At this point, the user can mark avoidance zones on the skin identifying areas where the transducer arrays (TAs) should not be placed. Next, dedicated algorithms identify optimal arrangements of TAs to produce several options of TA layouts. Further, quantitative and qualitative evaluation tools such as color maps, iso-surfaces, and dose volume histogram (DVH) curves, are applied to choose the layouts that achieve the optimal distribution of TTFields therapy for each patient. Finally, each patient receives two SBTP to allow switching between the layouts in order to mitigate the risk of skin irritation.

RESULTS

Over 60 image sets from GBM patients were used to test the SBTP system. Our experience demonstrates a viable working framework that has the potential to boost TTFields delivery to target ROIs.

CONCLUSION

This working framework offers qualitative and quantitative tools for SBTP and streamlines the process of personalized treatment, allowing physicians to optimize treatment with TTFields therapy. Additionally, this system provides tools for developing an adaptive patient-specific SBTP in response to any clinical need (e.g., disease progression).

The Effect of Body Mass Index on Tumor Treating Fields (TTFields) Intensity Distribution in the Lungs

PURPOSE/OBJECTIVE(S)

Tumor Treating Fields (TTFields) therapy is a locoregional, noninvasive antimitotic cancer treatment modality. TTFields are electric fields that disrupt processes critical for cancer cell viability and tumor progression. They are generated by a portable medical device and delivered noninvasively to the tumor via two pairs of orthogonally placed transducer arrays. TTFields therapy is currently FDA-approved for recurrent and newly diagnosed glioblastoma and pleural mesothelioma, with ongoing studies in other solid tumor types including non-small cell lung cancer (NSCLC). In the phase 3 LUNAR study (NCT02973789), TTFields therapy demonstrated an improvement in overall survival when added to NSCLC standard of care. TTFields effectiveness depends upon several factors, including field intensity; thus, it is relevant to assess the impact of body mass index (BMI) on the distribution of TTFields in the lungs. This study utilized simulation-based approaches to assess the impact of BMI on electric field intensity distribution in the lungs.

MATERIALS/METHODS

Three computerized female phantom models (with BMIs of 22, 26 and 30), were used to simulate electric field intensity. Two different arrays sizes (small [13 disks] and large [20 disks]) were applied to the thoracic region of the models. An electric field intensity distribution map for each model was generated, and electric field intensity values across the entirety of the lungs were analyzed.

RESULTS

Electric field intensities were above 1 V/cm (amplitude), which is typically considered a sufficient level of TTFields dose to achieve a therapeutic effect, in all lobes in the lungs for all BMI models when large arrays were used. Therapeutic intensities were achieved in all lobes with the small arrays in all but one model (BMI 30), where intensities fell slightly below 1 V/cm in the right middle lobe.

CONCLUSION

Results from this simulation-based study demonstrate that delivery of TTFields at therapeutic intensities is feasible even in patients with a high BMI, provided the appropriately sized array is used. These findings support ongoing clinical studies of TTFields therapy in lung cancer, including the recently completed LUNAR study in advanced NSCLC, and could facilitate optimization of therapeutic TTFields delivery to individual patients, based on their BMI.

Patient-Specific Segmentation-Based Treatment Planning vs. NovoTAL for TTFields Therapy in Glioblastoma

PURPOSE/OBJECTIVE(S)

Patients treated with Tumor Treating Fields (TTFields) therapy for glioblastoma (GBM) have array layouts planned by NovoTAL. NovoTAL requires morphometric inputs and maximizes field intensity at the tumor. Patient-specific segmentation-based treatment planning (SBTP) software uses segmentation-based plans to maximize power density at defined regions of interest (ROIs). This technical analysis compared expected local minimum power density (LMiPD; mW/cm3) and local minimum field intensity (LMiFI; V/cm) delivered to ROIs with array layouts planned with SBTP vs NovoTAL. We hypothesized that SBTP has the potential to increase LMiPD and LMiFI to ROIs vs NovoTal.

MATERIALS/METHODS

37 patients from 5 sites who received TTFields therapy for GBM using NovoTAL were included. Treatment plans using the prescribed/treated NovoTAL layouts were created with SBTP. De novo SBTP layouts were also created. Three ROIs representing the original treated GBM (CTV), high risk margin around the GBM (CTV-2), and recurrent GBM (CTV-R) were created. Plans were optimized to CTV. SBTP vs NovoTAL LMiPD and LMiFI volumetrics to ROIs were evaluated. LMiPD and LMiFI were normalized with the delivered current from the treated NovoTAL layout. Layout rankings based on LMiPD and LMiFI, average LMiPD and LMiFI, D95, D5, DVHs, and voxel-by-voxel LMiPD and LMiFI for SBTP derived from NovoTAL layouts were compared to de novo SBTP layouts (paired t-tests).

RESULTS

Average LMiPD (1.551 vs 1.194) and LMiFI (1.115 vs 0.978) to CTV were significantly higher with SBTP vs NovoTAL (P < 0.0001 for each). Average LMiPD (1.445 vs 1.164) and LMiFI (1.197 vs 1.077) to CTV-2 were also higher (P < 0.0001 for each). There was a positive trend to higher average LMiPD (1.203 vs 1.157; P = 0.212) and LMiFI (1.103 vs 1.090; P = 0.311) to CTV-R. Top ranked overall layouts by LMiPD to CTV were SBTP layouts (97%; n = 36). Percent ratio ([SBTP-NovoTAL]/NovoTAL*100) D95 for LMiPD was 34% (to CTV), 24% (to CTV-2), and 5% (to CTV-R) and for LMiFI was 16%, 12%, and 2% respectively. Percent ratio D5 for LMiPD was 31%, 24%, and 3% and for LMiFI was 14%, 9%, and 0%, respectively. For a given percent CTV volume, minimum LMiPD and LMiFI were higher with SBTP (95%, n = 35; DVH curves shifted to right). SBTP yielded higher LMiPD and LMiFI to the majority of voxels within the CTV (95%, n = 35). With SBTP, LMiPD to CTV was significantly higher than to CTV-R (P < 0.001).

CONCLUSION

Overall, these data demonstrate that SBTP compared to NovoTAL yielded higher expected average LMiPD and LMiFI, D95, D5, and percent voxel LMiPD and LMiFI to defined ROIs. Higher LMiPD and LMiFI delivered to CTV vs CTV-R with SBTP suggests a benefit to re-planning if the GBM recurs. Given previous reports showing that higher LMiPD and LMiFI are positively correlated with improved overall and progression free survival, patient-specific SBTP may lead to improved clinical outcomes for GBM patients vs NovoTAL.

The Anthroposophic Artistic Movement Assessment for Eurythmy Therapy (AART-ASSESS-EuMove). A validation study

OBJECTIVE

Eurythmy Therapy (ET) is a mindfulness oriented therapy developed in the context of anthroposophic medicine. Despite commonly used in practice, it remains unclear whether active participation (Inner Correspondence) during ET can be observed in eurythmy gestures (EGest). So far, no validated peer-report instrument to evaluate EGest exists.

METHOD

To validate an 83-item ET peer-report scale, a nested study on a sample of n = 82 breast cancer survivors with cancer-related fatigue was conducted. EGest were evaluated twice, at baseline and at 10-week follow-up, by peer-reports from two separate therapists. Interrater-reliability (IRR) was estimated by Cohen's weighted kappa (κw) across all items. Additionally, reliability-(RA) and principal component analyses (PCA) were conducted. Patients completed two self-report scales: Satisfaction with ET (SET) and Inner Correspondence with the Movement Therapy (ICPH).

RESULTS

IRR was greater than or equal (κw ≥ 0.25) for 41 items (49.3%) with a mean weighted kappa of κ̅w = 0.40 (SD = 0.17, range = 0.25-0.85). RA resulted in the exclusion of 25 items with insufficient item-total correlations < 0.40. A PCA with 16 items revealed 3 subscales: 1. Mindfulness in Movement (8 items), 2. Motor Skills (5 items), 3. Walking Pattern (3items) explaining 63.86% of total variance. Internal consistency (Cronbach's alpha) was high for the sum score with α = 0.89 and for the subscales with α = 0.88, 0.86 and 0.84 respectively. Significant small to moderate subscale correlations were found ranging from r = 0.29-0.63 (all p < 0.01). Mindfulness in Movement correlated with Inner Correspondence (r = 0.32) and with Satisfaction with ET (r = - 0.25, both p < 0.05).

CONCLUSIONS

The new AART-ASSESS-EuMove is the first consistent and reliable peer-report instrument to evaluate EGest. It shows associations between peer-reported Mindful Movement and patients' self-reported ICPH and SET.

[Teaching otorhinolaryngology in times of COVID-19: to what extent can digital formats replace face-to-face teaching?]

OBJECTIVE

Due to the coronavirus disease 19 (COVID-19) pandemic, postgraduate training in otorhinolaryngology in 2020 was transferred completely from face-to-face to digital teaching. This paper assesses whether this change was possible without a reduction in the quality of teaching and learning.

METHODS

Results of final written examinations were compared for the years 2016-2020, and the results of the teaching evaluation by the students for 2017-2020. The evaluation by students in 2020 included additional questions related to the switch from face-to-face to digital teaching. Additionally, the lecturers and teachers were asked for their assessments.

RESULTS

Results of the final written examination did not show any significant differences between 2016-2019 and 2020. Students were highly satisfied with the digital format, but values did not reach the level of former years with face-to-face-teaching. Especially the interaction with patients and the teaching of manual skills were rated lower in the digital format. Lecturers emphasized the additional workload for preparation of digital teaching.

CONCLUSION

The results of written examinations showed no difference between digital and face-to-face teaching. Online communication and interaction were reduced and regarded as cumbersome by students and faculty. Digital solutions providing more interaction and active participation are required. The digital format is more appropriate for teaching basic knowledge than for teaching practical skills.

Evaluation of commercial composts and potting mixes and their ability to support arbuscular mycorrhizal fungi with maize (Zea mays) as host plant

The use of composts and potting mixes in food production systems is a promising way to counteract the effects of soil degradation and allows crop growth in soilless culture systems. Arbuscular mycorrhizal fungi (AMF) are a well-studied group of beneficial plant symbionts that have been shown to provide important ecosystem services. This study analysed the properties of nine commercial Australian potting mixes and composts and investigated whether they support colonization of maize plants with AMF in a plant growth bioassay. Physicochemical analyses showed highly variable properties between the substrates, with some extreme values that limited plant growth. DNA-based analysis revealed the presence of various plant pathogens, which was linked to inhibited plant growth in one substrate. Some substrates did not meet national quality standards, due to the concentrations of plant nutrients, heavy metals, or substrate maturity. Plant growth was mostly limited due to nitrogen immobilization, which required weekly fertilizer applications. Solid state ¹³C nuclear magnetic resonance spectroscopy gave insight into the decomposition state of the substrates. Plant roots in most substrates were well colonized with AMF (>60% root length), regardless of most substrate properties. Root colonization was negatively affected in only one substrate, likely due to ammonium toxicity. Results of this study show that not all commercial substrates adhered to national quality standards. Potting mixes and composts can support high mycorrhizal root colonization when plant growth is otherwise not limited.

Switching from healthy to unhealthy oxidative stress - does the radical type can be used as an indicator?

Ultraviolet (UV) radiation leads to the formation of free radicals, which may cause immunological modulations, skin aging or skin cancer. Sunlight exposure in the UVA region according to CIE 85 promotes almost 46% of radical formation in skin. A critical radical concentration characterized by the inversion of the domination of primary ROS (reactive oxygen species) to an excess of secondary LOS (lipid oxygen species) is proven for the spectral regions UV and or VIS light and is intended to be a marker for an imbalance in the redox system, which can no longer compensate harmful effects. To investigate whether this transition point is also universally valid for one spectral region, the radical formation during and after targeted UVA in situ-irradiation at 365 ± 5 nm and three different irradiances (31, 94 and 244 mW/cm²) was investigated in ex vivo porcine skin using x-band electron paramagnetic resonance (EPR) spectroscopy. The quantification was performed with the spin probe 3-(carboxy)-2,2,5,5-tetramethylpyrrolidin-1-oxyl (PCA), the spin trap 5,5-Dimethyl-1-Pyrroline-N-Oxide (DMPO) was used to characterize the radical species. Furthermore, the viability of the skin cells after irradiation was controlled by an MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay, skin integrity was examined by histological analysis. A significant dose dependence in the radical formation is given at higher irradiance. The transition point was detected in the range of 0.5 MED after irradiation with the highest irradiance. From this point on the proportion of LOS increases with increasing dose and the proportion of ROS decreases. After switching off the UVA irradiation no further quantitative changes were detected, but rapid changes in the radical pattern were observed demonstrating the importance of in situ irradiation during the use of spin traps. Heat-pre-stressed skin showed more LOS than ROS already at the beginning of the irradiation, leading to the assumption that the transition point to the distress-level has already been reached. In summary, a postulated transition point could be verified for the UVA spectral region using only one spin trap combined with in-situ irradiation. A certain degree of stress is necessary to detect an inversion of the ratio of ROS to LOS. This reversal indicates an imbalance in the redox status. However, at low intensities no changes at all in radical pattern appeared over time (dose), probably it can be compensated by adaptation processes of the skin.

P2519Multiprofessional intervention for fostering self management capabilities for patients with chronic heart disease - development of a common curriculum (MIFeSCH)

Background

Chronic cardiovascular disease (CAD) still is the leading cause of death in industrialized countries in spite of substantial progress in diagnostics and therapy. Programs of lifestyle management are effective but insufficiently established in usual patient care. The authors provide multi professional educational courses to strengthen self management capabilities for cardiovascular patients in five different institutions in Europe since up to 20 years in modification of the program of Dr. Dean Ornish. Physicians, psychologists, dietitians and artistic and movement therapists work together in courses lasting from half a year to one year.

To implement their programs in daily care, an association of these five institutions will evaluate a common lifestyle management program in four phases: 1. development of a common curriculum, 2. pilot study, 3. interventional study, 4. implementation study.

Phase 1 is now completed. The evaluation will show, whether this lifestyle management program leads to improvement of health in patients and in the therapeutic team.

Purpose of phase 1: development of a common curriculum by the five active members of the association.

Methods

The five existing educational programs were assessed and differences between the programs themselves and other existing programs of patient education were defined. Distinctive and common features of the different institutions were recorded. Structured interviews with members of all institutions acquired content, methods and eductional goals of the interventions according to predefined criteria for patient education programs in the respective countries. The results were discussed, reflected and a common curriculum was consented.

Results

The consented multi professional curriculum, comprising the activities of five active heart education programs defines five different levels of competence which are key of their patient education goals: (1) reflective self-awareness (I-competence), (2) artistic competence, (3) competence of ensouled movement, (4) nutritional competence and (5) social competence.

The main difference between the already existing programs for patients with CAD and the newly developed curriculum is the emphasis on training the participants' self awareness and social competence, for example by biography work in an interdisciplinary approach.

Levels of competence

Conclusion

The process of generating a common curriculum of competence levels, educational goals and necessary methods comprising the work of five different but associated institutions was successful. A pilot study will now be performed to show the effects of this program on cardiovascular health and quality of live of study participants and the therapeutic team as well to show, whether this intervention reduces the risk of burn out for the therapists.

By this the authors hope to implement their education program according to the curriculum as an improvement of standard therapy for patients with cardiovascular disease.

Acknowledgement/Funding

Universität Witten-Herdecke

Using High-Throughput Phenotyping to Explore Growth Responses to Mycorrhizal Fungi and Zinc in Three Plant Species

There are many reported benefits to plants of arbuscular mycorrhizal fungi (AMF), including positive plant biomass responses; however, AMF can also induce biomass depressions in plants, and this response receives little attention in the literature. High-throughput phenotyping (HTP) technology permits repeated measures of an individual plant's aboveground biomass. We examined the effect on AMF inoculation on the shoot biomass of three contrasting plant species: a vegetable crop (tomato), a cereal crop (barley), and a pasture legume (Medicago). We also considered the interaction of mycorrhizal growth responses with plant-available soil zinc (Zn) and phosphorus (P) concentrations. The appearance of a depression in shoot biomass due to inoculation with AMF occurred at different times for each plant species; depressions appeared earliest in tomato, then Medicago, and then barley. The usually positive-responding Medicago plants were not responsive at the high level of soil available P used. Mycorrhizal growth responsiveness in all three species was also highly interactive with soil Zn supply; tomato growth responded negatively to AMF inoculation in all soil Zn treatments except the toxic soil Zn treatment, where it responded positively. Our results illustrate how context-dependent mycorrhizal growth responses are and the value of HTP approaches to exploring the complexity of mycorrhizal responses.

Tracking Dark Excitons with Exciton Polaritons in Semiconductor Microcavities

Dark excitons are of fundamental importance for a wide variety of processes in semiconductors but are difficult to investigate using optical techniques due to their weak interaction with light fields. We reveal and characterize dark excitons nonresonantly injected into a semiconductor microcavity structure containing InGaAs/GaAs quantum wells by a gated train of eight 100 fs pulses separated by 13 ns by monitoring their interactions with the bright lower polariton mode. We find a surprisingly long dark exciton lifetime of more than 20 ns, which is longer than the time delay between two consecutive pulses. This creates a memory effect that we clearly observe through the variation of the time-resolved transmission signal. We propose a rate equation model that provides a quantitative agreement with the experimental data.

Reliability and first validity of the inner correspondence questionnaire for painting therapy (ICPTh) in a sample of breast cancer patients

Objectives Art therapy (ArT) such as mindfulness-oriented painting therapy is increasingly used in psychosomatic, oncological integrative and rehabilitative medicine. Though it remains unknown how ArT works, we hypothesize that an engaged participation with painting ('Inner-Correspondence') contributes to improved symptom scores. In the context of a comprehensive cohort study for breast cancer survivors with cancer-related fatigue, we developed a patient-reported outcome measure to assess 'Inner Correspondence' with painting therapy and conducted a first validation study. Design A 24-item questionnaire on 'Inner Correspondence' (ICPTh) was administered after ten weeks of intervention and at six month followup together with concurrent scales (Inner Correspondence and Peaceful Harmony, Cancer Fatigue Scale, Hospital Anxiety and Depression Scale, Internal Coherence Scale). Statistical assessment included reliability- and factor analyses. Results A total of n = 68 BC (mean age, 58.2 years, SD = 8.7) participated in the preliminary validation study. Exploratory factor analysis revealed a robust 22-item scale with an unambiguous four-factor solution explaining 78% of total variance and the following subsales: 1) therapy congruence and relaxation (11 items), 2) inner development and mood (6 items), 3) artistic skill (3 items) and 4) task congruence (2 items). The 22-item ICPTh yielded high reliability (Cronbach's alpha = .966, item-total correlation = .497 - .883, test-retest reliability = .888). Conclusions We present a reliable instrument to measure 'Inner Correspondence' with painting therapy. Due to the small sample size and sample selection further validation studies are indicated.

Does the maternal vaginal microbiota play a role in seeding the microbiota of neonatal gut and nose?

The acquisition and early maturation of infant microbiota is not well understood despite its likely influence on later health. We investigated the contribution of the maternal microbiota to the microbiota of infant gut and nose in the context of mode of delivery and feeding. Using 16S rRNA sequencing and specific qPCR, we profiled microbiota of 42 mother-infant pairs from the GUSTO birth cohort, at body sites including maternal vagina, rectum and skin; and infant stool and nose. In our study, overlap between maternal vaginal microbiota and infant faecal microbiota was minimal, while the similarity between maternal rectal microbiota and infant microbiota was more pronounced. However, an infant's nasal and gut microbiota were no more similar to that of its own mother, than to that of unrelated mothers. These findings were independent of delivery mode. We conclude that the transfer of maternal vaginal microbes play a minor role in seeding infant stool microbiota. Transfer of maternal rectal microbiota could play a larger role in seeding infant stool microbiota, but approaches other than the generally used analyses of community similarity measures are likely to be needed to quantify bacterial transmission. We confirmed the clear difference between microbiota of infants born by Caesarean section compared to vaginally delivered infants and the impact of feeding mode on infant gut microbiota. Only vaginally delivered, fully breastfed infants had gut microbiota dominated by Bifidobacteria. Our data suggest that reduced transfer of maternal vaginal microbial is not the main mechanism underlying the differential infant microbiota composition associated with Caesarean delivery. The sources of a large proportion of infant microbiota could not be identified in maternal microbiota, and the sources of seeding of infant gut and nasal microbiota remain to be elucidated.

Automated high throughput analysis of antiretroviral drugs in dried blood spots

For therapeutic drug monitoring in remote settings, dried blood spots (DBS) are particularly advantageous, as blood sample collection and handling is uncomplicated. The aim of this study was to develop and validate an automated extraction method for the analysis of nevirapine, efavirenz and lopinavir in DBS samples. Automated extraction was performed with methanol : water (70 : 30 v/v), using a DBS-MS 500 autosampler coupled to a liquid chromatography tandem mass spectrometry system. The autosampler used digital images of each DBS to position the extraction head, sprayed 10 μl of internal standard onto each DBS and extracted a 4-mm disc (Ø) from the centre of each spot by unilateral flow using 25-μl extraction solvent. The analytes were baseline separated on a pentafluorophenyl column and analysed by using electrospray ionization with multiple reaction monitoring in positive polarity mode for nevirapine and lopinavir and in negative mode for efavirenz. The method was linear between 10 and 10 000 ng/ml for all analytes. Automated sample extraction resulted in consistent recoveries (nevirapine: 70 ± 6%, efavirenz: 63 ± 11% and lopinavir: 60 ± 10%) and matrix effects between different donors and concentration levels. Intra-day and inter-day accuracy and precision deviations were ≤15%. Manual and automated extractions of DBS samples collected within the framework of an adherence assessment study in rural Tanzania showed good agreements with deviations of less than 10%. Our study highlights that therapeutic drug monitoring samples obtained in the resource-constrained setting of rural Africa can be reliably determined by automated extraction of DBS. Overall, automatization improved method sensitivity and facilitates analysis of large sample numbers. Copyright © 2017 John Wiley & Sons, Ltd.

Luminal contents from the gut of colicky infants induce visceral hypersensitivity in mice

BACKGROUND

The pathophysiology of infantile colic is poorly understood, though various studies report gut microbiota dysbiosis in colicky infants. We aimed to test the hypothesis that colic-related dysbiosis is associated with visceral hypersensitivity triggered by an altered luminal milieu.

METHODS

Fecal samples from seven colicky and seven non-colicky infants were studied. Fecal supernatants (FS) were infused into the colons of C57/Bl6 mice (n=10/specimen). Visceral sensitivity was subsequently assessed in the animals by recording their abdominal muscle response to colorectal distension (CRD) by electromyography (EMG). Serine and cysteine protease activities were assessed in FS with specific substrates. Infant fecal microbiota composition was analyzed by DNA extraction and 16S rRNA gene pyrosequencing.

KEY RESULTS

FS from colicky infants triggered higher EMG activity than FS from non-colicky infants in response to both the largest CRD volumes and overall, as assessed by the area under the curve of the EMG across all CRD volumes. Infant crying time strongly correlated with mouse EMG activity. Microbiota richness and phylogenetic diversity were increased in the colicky group, without showing prominent microbial composition alterations. Only Bacteroides vulgatus and Bilophila wadsworthia were increased in the colicky group. Bacteroides vulgatus abundance positively correlated with visceral sensitivity. No differences were found in protease activities.

CONCLUSIONS & INFERENCES

Luminal contents from colicky infants trigger visceral hypersensitivity, which may explain the excessive crying behavior of these infants. Additional studies are required to determine the nature of the compounds involved, their mechanism of action, and the potential implications of intestinal microbiota in their generation.

Health care provider communication training in rural Tanzania empowers HIV-infected patients on antiretroviral therapy to discuss adherence problems

Objectives

Self‐reported adherence assessment in HIV‐infected patients on antiretroviral therapy (ART) is challenging and may overestimate adherence. The aim of this study was to improve the ability of health care providers to elicit patients’ reports of nonadherence using a “patient‐centred” approach in a rural sub‐Saharan African setting.

Methods

A prospective interventional cohort study of HIV‐infected patients on ART for ≥ 6 months attending an HIV clinic in rural Tanzania was carried out. The intervention consisted of a 2‐day workshop for health care providers on patient‐centred communication and the provision of an adherence assessment checklist for use in the consultations. Patients’ self‐reports of nonadherence (≥ 1 missed ART dose/4 weeks), subtherapeutic plasma ART concentrations (< 2.5th percentile of published population‐based pharmacokinetic models), and virological and immunological failure according to the World Health Organization definition were assessed before and after (1–3 and 6–9 months after) the intervention.

Results

Before the intervention, only 3.3% of 299 patients included in the study reported nonadherence. Subtherapeutic plasma ART drug concentrations and virological and immunological failure were recorded in 6.5%, 7.7% and 14.5% of the patients, respectively. Two months after the intervention, health care providers detected significantly more patients reporting nonadherence compared with baseline (10.7 vs. 3.3%, respectively; P < 0.001), decreasing to 5.7% after 6–9 months. A time trend towards higher drug concentrations was observed for efavirenz but not for other drugs. The virological failure rate remained unchanged whereas the immunological failure rate decreased from 14.4 to 8.7% at the last visit (P = 0.002).

Conclusions

Patient‐centred communication can successfully be implemented with a simple intervention in rural Africa. It increases the likelihood of HIV‐infected patients reporting problems with adherence to ART; however, sustainability remains a challenge.

Fetal gender and gestational age differentially affect PCSK9 levels in intrauterine growth restriction

BACKGROUND

Maternal and fetal Low Density Lipoprotein-Cholesterol (LDL-C) concentrations are compromised in intrauterine growth restriction (IUGR). Generally, LDL-C catabolism is under control of PCSK9 by binding to the LDL-receptor leading to its degradation. Hence, we hypothesized a role for PCSK9 in the modulation of lipid metabolism and placental transport in IUGR.

METHODS

172 women, 70 IUGR and 102 controls were included in the study. Maternal and fetal serum PCSK9 levels and lipid profiles including LDL-C were measured. Placental LDL-receptor and PCSK9 expressions were estimated by tissue microarray immunohistochemistry, and analyzed by two blinded observers using an immunoreactivity score. Non-parametric tests and multivariate regression analyses were used for statistical estimations.

RESULTS

PCSK9 levels in the maternal and fetal compartment independently predicted LDL-C levels (maternal compartment: adjusted R 2 = 0.2526; coefficient b i  = 0.0938, standard error s bi =0.0217, rpartial = 0.4420, t-value = 4.323, p < 0.0001; fetal compartment: adjusted R 2 = 0.2929; b i  = 0.1156, s bi =0.020, rpartial = 0.5494, t-value = 5.81, p < 0.0001). We did not find significant differences in maternal PCSK9 concentrations between IUGR and controls. However, we found lower fetal serum PCSK9 concentrations in IUGR than in controls (IUGR median 137.1 ng/mL (95% CI 94.8-160.0) vs. controls 176.8 (154.6-202.5), p = 0.0005). When subgrouping according to early onset, late onset IUGR, and fetal gender differences remained consistent only for male neonates born before 34 weeks of gestation. In the placenta we found no correlation between PCSK9 and LDL-receptor expression patterns. However, the LDL-receptor was significantly upregulated in IUGR when compared to controls (p = 0.0063).

CONCLUSIONS

Our results suggest that PCSK9 play a role in impaired fetal growth by controlling fetal LDL-C metabolism, which seems to be dependent on gestational age and fetal gender. This underlines the need to identify subgroups of IUGR that may benefit from individualized and gender-specific pharmacotherapy in future studies.

Report of Enodiotrema megachondrus (Looss, 1899) Looss, 1901 (Digenea: Plagiorchiidae) in a green turtle Chelonia mydas Linnaeus, 1758 (Testudines, Cheloniidae) from Brazil

This paper describes the occurrence of Enodiotrema megachondrus (Looss, 1899) Looss, 1901 in a juvenile green sea turtle (Chelonia mydas Linnaeus, 1758) found on the coast of Brazil. This parasite has been described in Caretta caretta from Egypt, France, the Mediterranean Sea, the Madeira Archipelago, the Adriatic Sea and the USA, in C. mydas from Egypt and the USA, in Eretmochelys imbricata from Cuba, in Lepidochelys olivacea from Mexico and Costa Rica and in Lepidochelys kempii from USA. This note represents the first report of E. megachondus in a green sea turtle in the South-West Atlantic Ocean.

High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia

BACKGROUND

Aspiration pneumonia (AP) is caused by dysfunctional swallowing resulting in aspiration of material colonized by respiratory pathogens. The aim of this study was to assess and compare the swallowing physiology, health status, oral health status, and oral/nasal microbiota in frail older patients (FOP) with oropharyngeal dysphagia (OD) and a control group.

METHODS

We studied 47 FOP (>70 year) with OD by videofluoroscopy (17 with acute pneumonia -APN-, 15 with prior pneumonia-PNP- and 15 without) and 14 older controls without OD (H). Oral/nasal colonization by five respiratory pathogens was evaluated by qPCR, whereas commensal microbiota composition was assessed by pyrosequencing.

KEY RESULTS

(i) Frail older patients with OD presented similar comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3-61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 ± 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented periodontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx (>10(8) CFU/mL) than in the nose (<10(6) CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%).

CONCLUSIONS & INFERENCES

Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP.

Long-term outcome after surgical treatment of cranial cruciate ligament rupture in small breed dogs. Comparison of tibial plateau leveling osteotomy and extra-articular stifle stabilization

OBJECTIVE

Cranial cruciate ligament rupture is the most frequently occurring disease of the canine stifle. After introduction of corrective osteotomies of the proximal tibia as surgical treatment option in medium, large and giant breeds, the tibial plateau leveling osteotomy (TPLO) evolved into one of the favorite procedures. In the past small breed dogs have usually been treated by extra-articular stabilization techniques. TPLO has recently become an accepted treatment method in these breeds as well as, and is nowadays used with increasing frequency. The purpose of this study was to evaluate long-term outcomes of TPLO compared to an extra-articular stabilization technique in small breed dogs.

MATERIAL AND METHODS

A total of 40 stifles of 30 small breed dogs weighing ≤ 15 kg were treated for cranial cruciate ligament rupture with either TPLO (n = 23) or a lateral capsular-fascial imbrication technique (CFI; n = 17). Dogs were clinically examined before and at least 6 months after surgery by treadmill analysis and radiography. Moreover a questionnaire was provided to the owners to assess postoperative function and overall satisfaction.

RESULTS

Twenty-one of 23 operated limbs (91.3%) treated with TPLO and five of 17 (29.4%) treated with the CFI showed absolute values comparable to healthy dogs when evaluated by peak vertical force, vertical impulse and its symmetry index during objective gait analysis. Both groups showed mild, but continuous progression of osteoarthritis. TPLO led to a significantly faster recovery and a higher degree of owner satisfaction.

CONCLUSION

Based on clinical examination and objective gait analysis TPLO yielded excellent long-term results and a high degree of owner satisfaction in small breed dogs ≤ 15 kg treated for cranial cruciate ligament rupture.

CLINICAL RELEVANCE

TPLO seems to be superior to CFI treatment of small breed dogs in this study, although CFI should be considered as treatment option under certain circumstances.

Microscopic findings associated with blood pressure indices in postmortem human aorta samples from young people (ages 15-34)

Standardized postmortem samples of thoracic and abdominal aortas from traumatic death victims (aged 15-34 inclusive) were selected according to renal indices of estimated blood pressure. Half of the males had renal small-artery evidence of elevated blood pressure, and half did not. The group consisted of an approximately equal number of black and white males. All of the individuals were nonsmokers and had similar age, cholesterol, and HDL distribution. Lipid deposition in the thoracic and abdominal aorta sections was determined quantitatively by means of computer micromorphometry in sections stained with Oil Red O. Results showed that there is a marked increase in extracellular lipid deposition in the intima for those arteries studied with elevated renal indices of hypertension. In addition, there is significantly more extracellular lipid in the abdominal aortas in black males than in white males. Also notable was the finding that the thoracic aorta samples exhibited significantly thicker intimas and larger intimal areas in the high blood pressure index groups than in the low blood pressure index groups. These results suggest that the development of atherosclerotic lesions may be due to an increased deposition of extracellular lipid in the matrix of the arterial intima.

Utilization of a high-throughput shoot imaging system to examine the dynamic phenotypic responses of a C4 cereal crop plant to nitrogen and water deficiency over time

The use of high-throughput phenotyping systems and non-destructive imaging is widely regarded as a key technology allowing scientists and breeders to develop crops with the ability to perform well under diverse environmental conditions. However, many of these phenotyping studies have been optimized using the model plant Arabidopsis thaliana. In this study, The Plant Accelerator(®) at The University of Adelaide, Australia, was used to investigate the growth and phenotypic response of the important cereal crop, Sorghum bicolor L. Moench and related hybrids to water-limited conditions and different levels of fertilizer. Imaging in different spectral ranges was used to monitor plant composition, chlorophyll, and moisture content. Phenotypic image analysis accurately measured plant biomass. The data set obtained enabled the responses of the different sorghum varieties to the experimental treatments to be differentiated and modelled. Plant architectural instead of architecture elements were determined using imaging and found to correlate with an improved tolerance to stress, for example diurnal leaf curling and leaf area index. Analysis of colour images revealed that leaf 'greenness' correlated with foliar nitrogen and chlorophyll, while near infrared reflectance (NIR) analysis was a good predictor of water content and leaf thickness, and correlated with plant moisture content. It is shown that imaging sorghum using a high-throughput system can accurately identify and differentiate between growth and specific phenotypic traits. R scripts for robust, parsimonious models are provided to allow other users of phenomic imaging systems to extract useful data readily, and thus relieve a bottleneck in phenotypic screening of multiple genotypes of key crop plants.

Patients who die during palliative radiotherapy. Status survey

BACKGROUND AND PURPOSE

Palliative radiotherapy (RT) is routinely used in end of life care of patients with advanced malignancies; however, unnecessarily burdensome treatment shortly before death should be avoided. There is little knowledge on incidence and causes of intercurrent deaths during palliative RT.

PATIENTS AND METHODS

In this study death events among inpatients receiving palliative RT between January 2009 and December 2011 at this department were retrospectively analyzed. Among epidemiological factors, treatment schedule and chronology, latency and duration of treatment in relation to the actual survival were identified.

RESULTS

In this study 52 patients died during or shortly after palliative RT. Symptomatic bone metastases and brain metastases represented the most common RT indications. The general health status was poor with a median Karnofsky performance score of 50 %, RT was realized with a median single dose of 2.5 Gy to a median total dose of 30.5 Gy and was stopped prematurely in 73 % of patients. On average 53 % of the remaining lifetime was occupied by latency to starting RT. Once RT was begun the treatment duration required a median 64 % of the still remaining lifetime.

CONCLUSION

The majority of patients who died had explicitly adverse pre-existing factors and rarely completed RT as scheduled. Latency to RT and RT duration occupied more than half of the remaining lifetime.

Interferon-α abrogates the suppressive effect of apoptotic cells on dendritic cells in an in vitro model of systemic lupus erythematosus pathogenesis

OBJECTIVE

An increased incidence of apoptotic cells and an increased activation of dendritic cells (DC) may be involved in the pathogenesis of systemic lupus erythematosus (SLE). We investigated the characteristics of apoptotic neutrophils and monocyte-derived DC of patients with SLE, their interaction, and the influence of autoantibodies and inflammatory cytokines on this interaction.

METHODS

Kinetics of neutrophil apoptosis and DC activation were studied by flow cytometry. To analyze the interaction of apoptotic cells with phagocytes, crossover coculture experiments were performed with DC from patients with SLE and apoptotic Jurkat T cells as well as with apoptotic neutrophils from patients with SLE and the monocytic cell line U937. SLE serum and cytokines were added to this coculture, and activation and suppression of DC were quantified by levels of inflammatory cytokine secretion.

RESULTS

Apoptotic neutrophils and DC from patients with SLE showed no inherent defects compared to healthy controls, and the suppressive nature of their interaction was not affected. Autoantibodies as well as the inflammatory cytokines interleukin 17 (IL-17) and IL-1β had no influence on the interaction in this setup. Interferon (IFN)-α, however, substantially reduced the suppressive effect of apoptotic cells on DC.

CONCLUSION

The data suggest that aberrant immune reactivity in SLE is not generally due to an intrinsic defect in apoptotic cells, their processing, or their interaction with DC, but likely arises from the milieu in which this interaction takes place. Our study highlights the importance of IFN-α during early stages of SLE and its potential as a therapeutic target.

Fast screening of Bifidobacterium longum sublethal stress conditions in a novel two-stage continuous culture strategy

A central issue in the application of probiotics as food additives is their fastidious production and their sensitivity to many environmental stresses. The importance of inducible cell-protective mechanisms triggered by application of sublethal stresses for survival under stress conditions has been demonstrated. Continuous cultures could be a suitable and more efficient method to test stress factors on one culture instead of several repeated batch cultures. In this study, the application of a two-stage continuous culture of Bifidobacterium longum NCC2705 was investigated. The first reactor was operated under fixed conditions at 37 °C and pH 6.0 and used to produce cells with controlled physiology, mimicking cells in the late exponential growth phase. Stress pretreatment combinations of pH (6.0, 5.0 and 4.0), temperature (37, 45 and 47 °C) and NaCl (0, 5 and 10%) were tested in the second reactor. Of all tested combinations, only those of pH 4.0 significantly decreased cell viability in the second reactor compared to control conditions (37 °C, pH 6.0, 0% NaCl) and, therefore, could not be considered as sublethal stresses. Pretreatments with 5 or 10% NaCl had a negative effect on cell viability after gastric lethal stress. A significant improvement in cell resistance to heat lethal stress (56 °C, 5 min) was observed for cells pretreated at 47 °C. In contrast, heat pretreatment negatively affected cell viability after freeze drying and osmotic lethal stresses. The two-stage continuous culture allowed for efficient screening of several stress pretreatments during the same experiment with up to four different conditions tested per day. Optimal sublethal stress conditions can also be applied for producing cells with traditional batch cultures.