A phase I trial of LXS196, a protein kinase C (PKC) inhibitor, for metastatic uveal melanoma

BACKGROUND

Up to 50% of patients with uveal melanoma develop metastases (MUM) with a poor prognosis and median overall survival of approximately 1 year.

METHODS

This phase I study evaluated the safety, tolerability, pharmacokinetics, pharmacodynamics and efficacy of the oral protein kinase C inhibitor LXS196 in 68 patients with MUM (NCT02601378). Patients received LXS196 doses ranging from 100-1000 mg once daily (QD; n = 38) and 200-400 mg twice daily (BID; n = 30).

RESULTS

First cycle dose-limiting toxicities (DLTs) were observed in 7/38 (18.4%) QD and 2/17 (11.8%) BID patients. Hypotension was the most common DLT, occurring at doses ≥500 mg/day, and manageable with LXS196 interruption and dose reduction. Median duration of exposure to LXS196 was 3.71 months (range: 1.81-15.28) for QD and 4.6 months (range: 0.33-58.32) for BID dosing. Clinical activity was observed in 6/66 (9.1%) evaluable patients achieving response (CR/PR), with a median duration of response of 10.15 months (range: 2.99-41.95); 45/66 had stable disease (SD) per RECIST v1.1. At 300 mg BID, the recommended dose for expansion, 2/18 (11.1%) evaluable patients achieved PR and 12/18 (66.7%) had SD.

CONCLUSION

These results suggest manageable toxicity and encouraging clinical activity of single-agent LXS196 in patients with MUM.

Leveraging metabolic modeling to identify functional metabolic alterations associated with COVID-19 disease severity

OBJECTIVE

Since the COVID-19 pandemic began in early 2020, SARS-CoV2 has claimed more than six million lives world-wide, with over 510 million cases to date. To reduce healthcare burden, we must investigate how to prevent non-acute disease from progressing to severe infection requiring hospitalization.

METHODS

To achieve this goal, we investigated metabolic signatures of both non-acute (out-patient) and severe (requiring hospitalization) COVID-19 samples by profiling the associated plasma metabolomes of 84 COVID-19 positive University of Virginia hospital patients. We utilized supervised and unsupervised machine learning and metabolic modeling approaches to identify key metabolic drivers that are predictive of COVID-19 disease severity. Using metabolic pathway enrichment analysis, we explored potential metabolic mechanisms that link these markers to disease progression.

RESULTS

Enriched metabolites associated with tryptophan in non-acute COVID-19 samples suggest mitigated innate immune system inflammatory response and immunopathology related lung damage prevention. Increased prevalence of histidine- and ketone-related metabolism in severe COVID-19 samples offers potential mechanistic insight to musculoskeletal degeneration-induced muscular weakness and host metabolism that has been hijacked by SARS-CoV2 infection to increase viral replication and invasion.

CONCLUSIONS

Our findings highlight the metabolic transition from an innate immune response coupled with inflammatory pathway inhibition in non-acute infection to rampant inflammation and associated metabolic systemic dysfunction in severe COVID-19.

Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes

BACKGROUND

Little is known about clinical characteristics, hospital course, and longitudinal outcomes of patients with cardiogenic shock (CS) related to heart failure (HF-CS) compared to acute myocardial infarction (AMI; CS related to AMI [AMI-CS]).

METHODS

We examined in-hospital and 1-year outcomes of 520 (219 AMI-CS, 301 HF-CS) consecutive patients with CS (January 3, 2017-December 31, 2019) in a single-center registry.

RESULTS

Mean age was 61.5±13.5 years, 71% were male, 22% were Black patients, and 63% had chronic kidney disease. The HF-CS cohort was younger (58.5 versus 65.6 years, P<0.001), had fewer cardiac arrests (15.9% versus 35.2%, P<0.001), less vasopressor utilization (61.8% versus 82.2%, P<0.001), higher pulmonary artery pulsatility index (2.14 versus 1.51, P<0.01), lower cardiac power output (0.64 versus 0.77 W, P<0.01) and higher pulmonary capillary wedge pressure (25.4 versus 22.2 mm Hg, P<0.001) than patients with AMI-CS. Patients with HF-CS received less temporary mechanical circulatory support (34.9% versus 76.3% P<0.001) and experienced lower rates of major bleeding (17.3% versus 26.0%, P=0.02) and in-hospital mortality (23.9% versus 39.3%, P<0.001). Postdischarge, 133 AMI-CS and 229 patients with HF-CS experienced similar rates of 30-day readmission (19.5% versus 24.5%, P=0.30) and major adverse cardiac and cerebrovascular events (23.3% versus 28.8%, P=0.45). Patients with HF-CS had lower 1-year mortality (n=123, 42.6%) compared to the patients with AMI-CS (n=110, 52.9%, P=0.03). Cumulative 1-year mortality was also lower in patients with HF-CS (log-rank test, P=0.04).

CONCLUSIONS

Patients with HF-CS were younger, and despite lower cardiac power output and higher pulmonary capillary wedge pressure, less likely to receive vasopressors or temporary mechanical circulatory support. Although patients with HF-CS had lower in-hospital and 1-year mortality, both cohorts experienced similarly high rates of postdischarge major adverse cardiovascular and cerebrovascular events and 30-day readmission, highlighting that both cohorts warrant careful long-term follow-up.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03378739.

P785 Left ventricular geometry and myocardial contractility modulate impact of statins on prognosis in patients with acute heart failure

Funding Acknowledgements

N/A

Background/Introduction: The benefit of statins in patients with heart failure (HF) remains controversial and the mechanism of action is largely speculative. We investigated whether survival benefit with statins differs according to left ventricular (LV) geometry and myocardial contractility in acute HF patients.

Methods

We enrolled 1792 acute HF patients receiving statins and 2296 patients not receiving statins admitted from 2009 to 2016. The LV and right ventricular (RV) global longitudinal strain (GLS) was assessed as a measure of myocardial contractility. Patients were classified into 2 groups based on ischemic etiology of HF and further divided into 4 subgroups according to the median values of LV-GLS or RV-GLS. The primary outcome was 5-year all-cause mortality. The study protocol was approved by the ethics committee at each institute and complied with the Declaration of Helsinki. The need for written informed consent was waived.

Results

During the 5-year follow-up, 1740 (40.4%) patients died and they had more unfavorable baseline characteristics. Statin therapy was significantly associated with improved survival in overall patients and in both groups with and without ischemic etiology (all p &lt;0.001). Patients with concentric remodeling/hypertrophy and eccentric hypertrophy demonstrated survival benefit with statin therapy (P = 0.033, 0.004, and 0.008, respectively), while those with normal geometry did not (p = 0.123). In the non-ischemic HF group, survival benefit with statin therapy was confined to patients with low LV-GLS (p = 0.045) or those with low RV-GLS p = 0.003). On the contrary, in ischemic HF group, survival benefit with statin therapy was observed in all patients regardless of the values of LV-GLS or RV-GLS. Significant interactions were present between statin use and diabetes mellitus and IHD (p for interaction = 0.027 and 0.003, respectively) regarding mortality.

Conclusions

LV geometry and myocardial contractility may modulate the effects of statins in patients with acute HF. These echocardiographic measures can provide prognostic information to guide tailored statin treatment in this population. Our findings may also help to develop more well-designed prospective studies, in terms of a more homogenous study population, to confirm survival benefit with statin therapy.

Abstract P785 Figure. Multivariate Cox survival curves

Second messengers and divergent HD-GYP phosphodiesterases regulate 3',3'-cGAMP signaling

3',3'-cyclic GMP-AMP (cGAMP) is the third cyclic dinucleotide (CDN) to be discovered in bacteria. No activators of cGAMP signaling have yet been identified, and the signaling pathways for cGAMP have been inferred to display a narrow distribution based upon the characterized synthases, DncV and Hypr GGDEFs. Here, we report that the ubiquitous second messenger cyclic AMP (cAMP) is an activator of the Hypr GGDEF enzyme GacB from Myxococcus xanthus. Furthermore, we show that GacB is inhibited directly by cyclic di-GMP, which provides evidence for cross-regulation between different CDN pathways. Finally, we reveal that the HD-GYP enzyme PmxA is a cGAMP-specific phosphodiesterase (GAP) that promotes resistance to osmotic stress in M. xanthus. A signature amino acid change in PmxA was found to reprogram substrate specificity and was applied to predict the presence of non-canonical HD-GYP phosphodiesterases in many bacterial species, including phyla previously not known to utilize cGAMP signaling.

A Novel Collateral Imaging Method Derived from Time-Resolved Dynamic Contrast-Enhanced MR Angiography in Acute Ischemic Stroke: A Pilot Study

BACKGROUND AND PURPOSE

Assessment of the collateral status has been emphasized for appropriate treatment decisions in patients with acute ischemic stroke. The purpose of this study was to introduce a multiphase MRA collateral imaging method (collateral map) derived from time-resolved dynamic contrast-enhanced MRA and to verify the value of the multiphase MRA collateral map in acute ischemic stroke by comparing it with the multiphase collateral imaging method (MRP collateral map) derived from dynamic susceptibility contrast-enhanced MR perfusion.

MATERIALS AND METHODS

From a prospectively maintained registry of acute ischemic stroke, MR imaging data of patients with acute ischemic stroke caused by steno-occlusive lesions of the unilateral ICA and/or the M1 segment of the MCA were analyzed. We generated collateral maps using dynamic signals from dynamic contrast-enhanced MRA and DSC-MRP using a Matlab-based in-house program and graded the collateral scores of the multiphase MRA collateral map and the MRP collateral map independently. Interobserver reliabilities and intermethod agreement between both collateral maps for collateral grading were tested.

RESULTS

Seventy-one paired multiphase MRA and MRP collateral maps from 67 patients were analyzed. The interobserver reliabilities for collateral grading using multiphase MRA or MRP collateral maps were excellent (weighted κ = 0.964 and 0.956, respectively). The agreement between both collateral maps was also excellent (weighted κ = 0.884; 95% confidence interval, 0.819-0.949).

CONCLUSIONS

We demonstrated that the dynamic signals of dynamic contrast-enhanced MRA could be used to generate multiphase collateral images and showed the possibility of the multiphase MRA collateral map as a useful collateral imaging method in acute ischemic stroke.

Structure and mechanism of a Hypr GGDEF enzyme that activates cGAMP signaling to control extracellular metal respiration

A newfound signaling pathway employs a GGDEF enzyme with unique activity compared to the majority of homologs associated with bacterial cyclic di-GMP signaling. This system provides a rare opportunity to study how signaling proteins natively gain distinct function. Using genetic knockouts, riboswitch reporters, and RNA-Seq, we show that GacA, the Hypr GGDEF in Geobacter sulfurreducens, specifically regulates cyclic GMP-AMP (3′,3′-cGAMP) levels in vivo to stimulate gene expression associated with metal reduction separate from electricity production. To reconcile these in vivo findings with prior in vitro results that showed GacA was promiscuous, we developed a full kinetic model combining experimental data and mathematical modeling to reveal mechanisms that contribute to in vivo specificity. A 1.4 Å-resolution crystal structure of the Geobacter Hypr GGDEF domain was determined to understand the molecular basis for those mechanisms, including key cross-dimer interactions. Together these results demonstrate that specific signaling can result from a promiscuous enzyme.

Microscopic organisms known as bacteria are found in virtually every environment on the planet. One reason bacteria are so successful is that they are able to form communities known as biofilms on surfaces in animals and other living things, as well as on rocks and other features in the environment. These biofilms protect the bacteria from fluctuations in the environment and toxins.

For over 30 years, a class of enzymes called the GGDEF enzymes were thought to make a single signal known as cyclic di-GMP that regulates the formation of biofilms. However, in 2016, a team of researchers reported that some GGDEF enzymes, including one from a bacterium called Geobacter sulfurreducens, were also able to produce two other signals known as cGAMP and cyclic di-AMP. The experiments involved making the enzymes and testing their activity outside the cell. Therefore, it remained unclear whether these enzymes (dubbed ‘Hypr’ GGDEF enzymes) actually produce all three signals inside cells and play a role in forming bacterial biofilms.

G. sulfurreducens is unusual because it is able to grow on metallic minerals or electrodes to generate electrical energy. As part of a community of microorganisms, they help break down pollutants in contaminated areas and can generate electricity from wastewater. Now, Hallberg, Chan et al. – including many of the researchers involved in the 2016 work – combined several experimental and mathematical approaches to study the Hypr GGDEF enzymes in G. sulfurreducens.

The experiments show that the Hypr GGDEF enzymes produced cGAMP, but not the other two signals, inside the cells. This cGAMP regulated the ability of G. sulfurreducens to grow by extracting electrical energy from the metallic minerals, which appears to be a new, biofilm-less lifestyle. Further experiments revealed how Hypr GGDEF enzymes have evolved to preferentially make cGAMP over the other two signals.

Together, these findings demonstrate that enzymes with the ability to make several different signals, are capable of generating specific responses in bacterial cells. By understanding how bacteria make decisions, it may be possible to change their behaviors. The findings of Hallberg, Chan et al. help to identify the signaling pathways involved in this decision-making and provide new tools to study them in the future.

Anemia in Older Adults

Anemia is associated with increased morbidity and mortality in older adults. Diagnostic cutoff values for defining anemia vary with age, sex, and possibly race. Anemia is often asymptomatic and discovered incidentally on laboratory testing. Patients may present with symptoms related to associated conditions, such as blood loss, or related to decreased oxygen-carrying capacity, such as weakness, fatigue, and shortness of breath. Causes of anemia in older adults include nutritional deficiency, chronic kidney disease, chronic inflammation, and occult blood loss from gastrointestinal malignancy, although in many patients the etiology is unknown. The evaluation includes a detailed history and physical examination, assessment of risk factors for underlying conditions, and assessment of mean corpuscular volume. A serum ferritin level should be obtained for patients with normocytic or microcytic anemia. A low serum ferritin level in a patient with normocytic or microcytic anemia is associated with iron deficiency anemia. In older patients with suspected iron deficiency anemia, endoscopy is warranted to evaluate for gastrointestinal malignancy. Patients with an elevated serum ferritin level or macrocytic anemia should be evaluated for underlying conditions, including vitamin B12 or folate deficiency, myelodysplastic syndrome, and malignancy. Treatment is directed at the underlying cause. Symptomatic patients with serum hemoglobin levels of 8 g per dL or less may require blood transfusion. Patients with suspected iron deficiency anemia should be given a trial of oral iron replacement. Lower-dose formulations may be as effective and have a lower risk of adverse effects. Normalization of hemoglobin typically occurs by eight weeks after treatment in most patients. Parenteral iron infusion is reserved for patients who have not responded to or cannot tolerate oral iron therapy.

Association of clinicopathological features of melanoma with total naevus count and a history of dysplastic naevi: a cross-sectional retrospective study within an academic centre

BACKGROUND

High naevus count (HNC) (≥ 50 naevi) and presence of dysplastic naevi (DN) are risk factors for malignant melanoma (MM); however, MMs also occur in patients with low naevus count (LNC) (< 50 naevi) and in patients without DN. Little is known about differences between MMs in these groups.

AIM

To characterize the clinicopathological differences between MMs in patients with HNC and those in patients with LNC, with or without biopsy-proven DN.

METHODS

This was a cross-sectional retrospective chart review of 281 patients with MM seen between April 2013 and March 2014 at an academic pigmented lesion clinic (Boston, MA, USA).

RESULTS

Patients with LNC MMs were diagnosed at an older age (51 vs. 41 years, P < 0.001, OR = 0.95, 95% CI 0.93-0.97), with more aggressive MM features, including greater Breslow thickness (1.1 vs. 0.8 mm, P = 0.01), more mitoses (2 vs. 1 mitoses/mm² , P < 0.001), lower rate of superficial spreading subtype (58 vs. 78%, P < 0.01, OR = 2.57, 95% CI 1.31-5.03) and higher MM stage (P < 0.001), compared to patients with HNC. Patients with DN had similar trends as those in patients with HNC described above, and in addition, were more likely to have a truncal MM (55 vs. 39%, P < 0.01, OR = 1.97, 95% CI 1.22-3.18) with less ulceration (13 vs. 29%, P < 0.01, OR = 0.36, 95% CI 0.19-0.71). Patients without DN were more likely to have a history of a non-MM skin cancer (32 vs. 19%, P = 0.01, OR = 0.49, 95% CI 0.28-0.85) and an amelanotic MM (33 vs 21%, P = 0.03, OR = 0.55, 95% CI 0.31-0.96).

CONCLUSIONS

Patients with LNC may develop MMs with more aggressive features at an older age than patients with HNC. A history of biopsy-proven DN reveals distinct MM differences compared to patients without DN.

Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab

Background

Anti-PD-1 antibodies (anti-PD-1) have clinical activity in a number of malignancies. All clinical trials have excluded patients with significant preexisting autoimmune disorders (ADs) and only one has included patients with immune-related adverse events (irAEs) with ipilimumab. We sought to explore the safety and efficacy of anti-PD-1 in such patients.

Patients and methods

Patients with advanced melanoma and preexisting ADs and/or major immune-related adverse events (irAEs) with ipilimumab (requiring systemic immunosuppression) that were treated with anti-PD-1 between 1 July 2012 and 30 September 2015 were retrospectively identified.

Results

One hundred and nineteen patients from 13 academic tertiary referral centers were treated with anti-PD-1. In patients with preexisting AD (N = 52), the response rate was 33%. 20 (38%) patients had a flare of AD requiring immunosuppression, including 7/13 with rheumatoid arthritis, 3/3 with polymyalgia rheumatica, 2/2 with Sjogren's syndrome, 2/2 with immune thrombocytopaenic purpura and 3/8 with psoriasis. No patients with gastrointestinal (N = 6) or neurological disorders (N = 5) flared. Only 2 (4%) patients discontinued treatment due to flare, but 15 (29%) developed other irAEs and 4 (8%) discontinued treatment. In patients with prior ipilimumab irAEs requiring immunosuppression (N = 67) the response rate was 40%. Two (3%) patients had a recurrence of the same ipilimumab irAEs, but 23 (34%) developed new irAEs (14, 21% grade 3-4) and 8 (12%) discontinued treatment. There were no treatment-related deaths.

Conclusions

In melanoma patients with preexisting ADs or major irAEs with ipilimumab, anti-PD-1 induced relatively frequent immune toxicities, but these were often mild, easily managed and did not necessitate discontinuation of therapy, and a significant proportion of patients achieved clinical responses. The results support that anti-PD-1 can be administered safely and can achieve clinical benefit in patients with preexisting ADs or prior major irAEs with ipilimumab.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome

AIM

Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms.

METHOD

A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed.

RESULTS

Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001).

CONCLUSION

Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Prospective analysis of the sealing ability of the ENSEAL® G2 Articulating Tissue Sealer and transector on human mesenteric vessels in colorectal surgery

BACKGROUND

The sealing and transection of mesenteric vessels is a crucial step in minimally invasive colorectal surgery. We examined the sealing quality of the ENSEAL^® G2 Articulating Tissue Sealer in three different articulations in mesenteric vessels.

METHODS

This was a prospective experimental study within a tertiary healthcare center, and 30 patients were recruited. Burst pressures for each specimen were measured as the primary outcome. Ten specimens at each of the three articulations were also histologically assessed for the quality of seal.

RESULTS

We evaluated 54 sets of specimens from 30 patients for bursting pressure, all of which were harvested and sealed in the operating room. No statistical difference was seen in burst pressures from seals recorded at no angulation, half-maximal angulation, or maximal angulation (1604, 1507, 1478 mmHg; p = 0.07). Histological analysis showed no statistical differences in the average vessel diameter (p = 0.57), lateral extent of thermal injury (p = 0.48), degree of vascular sclerosis, or the integrity of seal at the three articulations. No cases of intraoperative or postoperative bleeding were observed in any of the patients. Five (16.7%) of the ENSEAL^® devices developed breaks in the black, heat-shrink, polyethylene covering as a result of repeated articulation and disarticulation. Electrical arcing did not appear to have occurred as a result of the break, although this was not formally examined.

CONCLUSIONS

The maximum sustainable pressure in mesenteric vessels sealed with a bipolar electrothermal device is supraphysiological, and consequently, the device can be safely used at various articulations to seal vessels during colorectal surgery.

Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.

Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection?

AIM

The aim of the study was to evaluate the value of routine intra-operative flexible sigmoidoscopy (IOFS) for left-sided anastomotic integrity and to determine the safest step after a positive leak test.

METHOD

All consecutive patients undergoing left-sided colorectal resections for benign and malignant disease between August 2005 and April 2011 were included. Data regarding procedure, type of anastomosis and outcomes of IOFS were collected. A positive intra-operative leak test resulted in redoing the anastomosis and repeating the leak test.

RESULTS

A total of 415 consecutive patients underwent hand-assisted laparoscopic colorectal resection with a colorectal/ileoanal anastomosis. All patients underwent IOFS. Seventeen patients had abnormality on IOFS. Fifteen patients had a positive air leak test. One patient had anastomotic bleeding. There was one stapler misfiring. Fourteen anastomoses were redone without diversion. One patient required diversion to protect the ileoanal anastomosis and another had already been diverted. Minor bleeding from the staple line in one patient resolved without intervention; however, he had a postoperative anastomotic leak needing surgical intervention. None of the patients who had a takedown and refashioning of the anastomosis following a positive leak on IOFS had postoperative anastomotic leakage or bleeding. Our overall anastomotic leak rate was 2.1%.

CONCLUSIONS

Intra-operative flexible sigmoidoscopy for restorative colorectal resection is safe and reliable and should be performed routinely to assess anastomotic integrity and bleeding. Refashioning the anastomosis after formal takedown would obviate the risk of leakage and is our recommended method of managing intra-operative leaks.

Comparison of RECIST 1.0 and RECIST 1.1 on computed tomography in patients with metastatic colorectal cancer

OBJECTIVE

We conducted this study to compare tumor measurement by computed tomography (CT) and tumor response assessment between Response Evaluation Criteria In Solid Tumors (RECIST) 1.0 and RECIST 1.1 in patients with metastatic colorectal cancer (CRC).

METHODS

We reviewed the medical records of patients with metastatic CRC who received first-line chemotherapy between January 2004 and December 2012 and compared CT tumor measurement using two RECIST versions.

RESULTS

A total of 58 patients who had target lesions according to RECIST 1.0 were included in the study. The number of target lesions recorded by RECIST 1.1 was significantly lower than that by RECIST 1.0, with a decrease experienced in 48 patients (82.7%). Six patients had no target lesions because of the new criteria of RECIST 1.1 for lymph node size. Out of 95 lymph nodes from 58 patients, only 40% were defined as target lesions according to RECIST 1.1. The overall response rate of first-line chemotherapy according to RECIST 1.0 and 1.1 was 41.5 and 40.4%, respectively. The best tumor responses showed almost perfect agreement between RECIST 1.1 and RECIST 1.0 (ĸ = 0.913). Three patients showed disagreement of the best responses between the two RECIST versions.

CONCLUSION

RECIST 1.1 showed a highly concordant response assessment with RECIST 1.0 in metastatic CRC and its clinical impact on therapeutic decisions was minimal.

A curious case of unilateral spider nevi, cirrhosis and stroke: unilateral nevoid telangiectasia syndrome

A 55-year-old Caucasian man presented with unilateral right facial spider nevi. Relevant medical history included a right-sided cerebrovascular accident (CVA) in 1997 and decompensated alcoholic liver disease, diagnosed in 2007. The literature describes approximately 100 cases of unilateral spider nevi associated with different aetiologies, grouped under 'unilateral nevoid telangiectasia syndrome' (UNTS). This is a rare presentation of a commonly observed sign in clinical practice. This case offers an opportunity to explore the origins of spider nevi and highlights the benefit of sharing knowledge in order to help elucidate the potential mechanisms underlying common signs.

Is hybrid robotic laparoscopic assistance the ideal approach for restorative rectal cancer dissection?

AIM

While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors' preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra-operative and short-term outcomes.

METHOD

Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intra-operative and short-term outcomes were evaluated.

RESULTS

The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and nine had a coloanal pull-through procedure (mean age 60.1 years; mean body mass index 28.0 kg/m(2) ; mean operative time 327 min; conversion rate 3.9%). Three patients (3.9%) had positive resection margins (one circumferential, two distal). Five patients had an anastomotic leak (6.4%). No robot-specific complications were observed.

CONCLUSION

The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection.

Estimation of the nares-to-epiglottis distance and the nares-to-vocal cords distance in young children

BACKGROUND

Estimation of the nares-to-epiglottis and nares-to-vocal cords distances would facilitate the selection of properly sized nasopharyngeal airways and appropriate positioning of a fibreoptic bronchoscope in young children. The purposes of this study were to measure the nares-to-epiglottis and nares-to-vocal cords distances and to create an algorithm to predict these distances based on anatomical landmarks and paediatric characteristic data.

METHODS

Two hundred and eleven children, aged 1-10 yr, undergoing elective surgery were investigated. After induction of general anaesthesia, the distances from the nares to the epiglottis/vocal cords were measured using a nasogastric tube. After intubation, the distances from the lateral border of the nose to the ipsilateral mandible angle (nares-to-mandible distance) and the tragus of the ear (nares-to-tragus distance) were measured using a tape measure.

RESULTS

The nares-to-epiglottis and nares-to-vocal cords distances were significantly correlated with the age, weight, height, and external measurements (P<0.001). By stepwise multiple linear regression analysis, formulas were obtained for the nares-to-epiglottis distance (cm)=2.606+0.058×height (cm)+0.231×the nares-to-mandible distance (cm)-0.304 (gender) (r(2)=0.754) and for the nares-to-vocal cords distance (cm)=4.947+0.06×height (cm)+0.228×nares-to-mandible distance (cm)-0.283 (gender) (r(2)=0.803).

CONCLUSIONS

The nares-to-epiglottis and nares-to-vocal cords distances can be predicted using the height and the nares-to-mandible distance in young children.

CLINICAL TRIAL REGISTRATION NUMBER

Clinical Research Information Service KCT0000150.

Mucosal protective effect of PGI2 on canine small bowel auto-transplantation

PURPOSE

We designed this experimental study to assess the mucosal protective effects of continuous prostaglandin I2 (PGI2) infusion after canine small bowel autotransplantation.

MATERIALS AND METHODS

Six Mongrel dogs were randomly divided two groups: PGI2 (n = 3) and control (n = 3). The small bowel from jejunum to ileum was obtained, including the mesenteric vascular pedicle. After cold flushing ex vivo, the harvested segment was preserved in an icebox for 3 hours. Thereafter we reimplanted the harvested intestinal segment. While completing the anastomosis, PGI2 (50 μg) was slowly infused through the mesenteric artery in the PGI2 group versus the same volume of saline in the control group. At 1, 3 and 6 days after autotransplantation, we obtained blood samples, and at 6 days, small bowel segments. Endotoxin and interleukin 6 (IL-6) levels were measured and all histologic specimens stained with hematoxylin-eosin H-E were reviewed by a pathologist to grade mucosal damage as: mild (1 point), moderate (2 points), or severe (3 points) change.

RESULTS

Mean basal serum endotoxin levels were similar in both groups the PGI2 groups versus control group were 0.216 ± 0.018 versus 0.223 ± 0.040 EU/mL, respectively. However, on day 3 after the operation, the PGI2 group showed much decreased levels of serum endotoxin compared to control levels: 0.349 ± 0.196 versus 0.842 ± 0.446 EU/mL. The mean concentration of serum IL-6 on day 1 after operation among the PGI2 versus control group were 32.13 ± 7.13 pg/mL versus 36.96 ± 3.65 pg/mL. The histologic scores at 6 days after the operation were PGI2 group versus control group: 1.33 versus 1.66 (P = NS).

CONCLUSION

Continuous infusions of PGI2 through the mesenteric artery after the canine small bowel autotransplantation may protect the small bowel mucosal barrier.

Genome-wide significance and replication of the chromosome 12p11.22 locus near the PTHLH gene for peripartum cardiomyopathy

BACKGROUND

Peripartum (PP) cardiomyopathy (CM) is a rare condition of unknown etiology that occurs in late pregnancy or early postpartum. Initial evidence suggests that genetic factors may influence PPCM. This study evaluated and replicated genome-wide association of single nucleotide polymorphisms with PPCM.

METHODS AND RESULTS

Genome-wide single nucleotide polymorphisms in women with verified PPCM diagnosis (n=41) were compared separately with local control subjects (n=49 postmenopausal age-discordant women with parity ≥1 and no heart failure) and iControls (n=654 women ages 30 to 84 years with unknown phenotypes). A replication study of independent population samples used new cases (PPCM2, n=30) compared with new age-discordant control subjects (local2, n=124) and with younger control subjects (n=89) and obstetric control subjects (n=90). A third case set of pregnancy-associated CM cases not meeting strict PPCM definitions (n=29) was also studied. In the genome-wide association study, 1 single nucleotide polymorphism (rs258415) met genome-wide significance for PPCM versus local control subjects (P=2.06×10(-8); odds ratio [OR], 5.96). This was verified versus iControls (P=7.92×10(-19); OR, 8.52). In the replication study for PPCM2 cases, rs258415 (ORs are per C allele) replicated at P=0.009 versus local2 control subjects (OR, 2.26). This replication was verified for PPCM2 versus younger control subjects (P=0.029; OR, 2.15) and versus obstetric control subjects (P=0.013; OR, 2.44). In pregnancy-associated cardiomyopathy cases, rs258415 had a similar effect versus local2 control subjects (P=0.06; OR, 1.79), younger control subjects (P=0.14; OR, 1.65), and obstetric control subjects (P=0.038; OR, 1.99).

CONCLUSIONS

Genome-wide association with PPCM was discovered and replicated for rs258415 at chromosome 12p11.22 near PTHLH. This study indicates a role of genetic factors in PPCM and provides a new locus for further pathophysiological and clinical investigation.

Common Variants in 6 Lipid-Related Genes Discovered by High-Resolution DNA Melting Analysis and Their Association with Plasma Lipids

BACKGROUND: Total cholesterol was among the earliest identified risk factors for coronary heart disease (CHD). We sought to identify genetic variants in six genes associated with lipid metabolism and estimate their respective contribution to risk for CHD. METHODS: For 6 lipid-associated genes (LCAT, CETP, LIPC, LPL, SCARB1, and ApoF) we scanned exons, 5' and 3' untranslated regions, and donor and acceptor splice sites for variants using Hi-Res Melting® curve analysis (HRMCA) with confirmation by cycle sequencing. Healthy subjects were used for SNP discovery (n=64), haplotype determination/tagging SNP discovery (n=339), and lipid association testing (n=786). RESULTS: In 17,840 bases of interrogated sequence, 90 variant SNPs were identified; 19 (21.1%) previously unreported. Thirty-four variants (37.8%) were exonic(16 non-synonymous), 28 (31.1%) in intron-exon boundaries, and 28 (31.1%) in the 5' and 3' untranslated regions. Compared to cycle sequencing, HRMCA had sensitivity of 99.4% and specificity of 97.7%. Tagging SNPs (n=38) explained >90% of the variation in the 6 genes and identified linkage disequilibrium (LD) groups. Significant beneficial lipid profiles were observed for CETP LD group 2, LIPC LD groups 1 and 7, and SCARB1 LD groups 1, 3 and 4. Risk profiles worsened for CETP LD group 3, LPL LD group 4. CONCLUSIONS: These findings demonstrate the feasibility, sensitivity, and specificity of HRMCA for SNP discovery. Variants identified in these genes may be used to predict lipid-associated risk and reclassification of clinical CHD risk.

Joint effects of common genetic variants from multiple genes and pathways on the risk of premature coronary artery disease

OBJECTIVE

The aim of this study is to discover common variants in 6 lipid metabolic genes and construct and validate a genetic risk score (GRS) based on the joint effects of genetic variants in multiple genes from lipid and other pathobiologic pathways.

BACKGROUND

Explaining the genetic basis of coronary artery disease (CAD) is incomplete. Discovery and aggregation of genetic variants from multiple pathways may advance this objective.

METHODS

Premature CAD cases (n = 1,947) and CAD-free controls (n = 1,036) were selected from our angiographic registry. In a discovery phase, single nucleotide polymorphisms (SNPs) at 56 loci from internal discovery and external reports were tested for associations with biomarkers and CAD: 28 promising SNPs were then tested jointly for CAD associations, and a GRS consisting of SNPs contributing independently was constructed and validated in a replication set of familial cases and population-based controls (n = 1,320).

RESULTS

Five variants contributed jointly to CAD prediction in a multigenic GRS model: odds ratio 1.24 (95% CI 1.16-1.33) per risk allele, P = 8.2 x 10(-11), adjusted OR 2.03 (1.53-2.70), fourth versus first quartile. 5-SNP genetic risk score had minor impact on area under the receiver operating characteristic curve (P > .05) but resulted in substantial net reclassification improvement: 0.16 overall, 0.28 in intermediate-risk patients (both P < .0001). GRS(5) predicted familial CAD with similar magnitude in the validation set.

CONCLUSIONS

The Intermountain Healthcare's Coronary Genetics study demonstrates the ability of a multigenic, multipathway GRS to improve discrimination of angiographic CAD. Genetic risk scores promise to increase understanding of the genetic basis of CAD and improve identification of individuals at increased CAD risk.

Neuroimaging and cerebral palsy in children

Cerebral palsy (CP) is a description of a spectrum of central nervous system (CNS) impairments that affect mobility, communication, intellectual ability, and neurobehavior as a result of developmental brain dysfunction. CP is the most common contributor to motor disability in children with prevalence of about 2-3/1000 live births globally. Presently, no curative therapies or successful methods of prevention on a population level are available for children with one of the cerebral palsy syndromes. Despite these challenges, orthopedic, rehabilitation, neuropharmacological, and other management interventions can help maintain mobility, prevent deformity, and promote quality of life for children with CP. Typically, the diagnosis of CP is based on clinical observations and parent concerns regarding delays in attaining motor milestones (e.g., rolling, sitting, crawling, walking), not on laboratory testing or neuroimaging. However, since 2004 the American Academy of Neurology (AAN) has recommended that neuroimaging of the CNS be part of diagnostic process for cerebral palsy. Although the guideline was initially met with controversy and criticism, neuroimaging has allowed a broader appreciation of timing of lesions, extent of white matter involvement, and the complexity of the motor spectrum of disability. In this article we shall describe the major types of neuroimaging techniques and review their roles in identification and evaluation of children with one of the cerebral palsy syndromes. The authors will focus on the emerging knowledge of how brain structure can inform us about children's functioning, especially among children with prematurity, recognizing that we are only beginning to understand brain plasticity and developmental resiliency.

Combination treatment with leflunomide and methotrexate for patients with active rheumatoid arthritis

OBJECTIVE

To determine the efficacy and safety of the combination of leflunomide and methotrexate for the treatment of patients with active rheumatoid arthritis (RA) in an open, non-comparative, multicentre trial.

METHODS

Seventy-four patients with active RA were enrolled to receive concomitantly leflunomide (no loading dose, 10 mg/day) and methotrexate (starting at 7.5 mg/week and titrating up to 15 mg/week) for 20 weeks. The primary end-point was a 20% improvement in the American College of Rheumatology (ACR) criteria at 20 weeks. Safety measures included evaluation of adverse events at each visit and laboratory data, including haematology and liver function tests. Intention-to-treat analyses were conducted.

RESULTS

Sixty-five patients completed 20 weeks of treatment, and 71.6% were responders based on the ACR20 criteria. After 20 weeks, the mean changes were -16.3 for tender joint count, -12.0 for swollen joint count, -44.0 for physician global assessment, -34.3 for patient global assessment, -22.7 for erythrocyte sedimentation rate, and -0.65 for the Health Assessment Questionnaire score. Adverse events occurred in 40.5% of the patients, and were considered serious in four patients who discontinued therapy. Abnormal liver function was noted for 16 patients (21.6%). Two of these patients were withdrawn from the study; after discontinuing the medication, their liver function recovered fully.

CONCLUSION

THE combination of leflunomide and methotrexate was effective and well tolerated in the treatment of active RA patients. This combination may be a useful option as an initial treatment for active RA before starting biological agents.

Efficacy of Helicobacter pylori eradication therapy in chronic liver disease

BACKGROUND/AIMS

Peptic ulcers occur more commonly in patients with liver cirrhosis (LC). Helicobacter pylori is recognized as the most important etiology in the pathogenesis of peptic ulcers. We investigated the efficacy of proton pump inhibitor (PPI)-based triple therapy in patients with chronic liver disease and peptic ulcer.

PATIENTS AND METHODS

One hundred sixty-three patients with LC or chronic hepatitis (CH) with a peptic ulcer and proven H. pylori infection were included. The combination of PPI, amoxicillin (1.0 g), and clarithromycin (500 mg), each given twice daily, was administered for 1 or 2 weeks. The eradication of H. pylori was determined by the rapid urease test, histology, or the 13C-urea breath test at least 4 weeks after completing the treatment.

RESULTS

The eradication rate of H. pylori was similar between the LC and CH groups; 82.6% and 88.1%, respectively. In addition, there were no significant differences in eradication rates between the patients with Child-Pugh class A and Child-Pugh class B/C disease. The side effects in each group were generally mild. Only the serum ALT levels showed a significant correlation with the success of H. pylori eradication in both the LC and CH groups.

CONCLUSION

The PPI-based triple therapy achieves high eradication rates for H. pylori infection, in patients with chronic liver disease, without significant side effects.

Genetic variation at the 9p21 locus predicts angiographic coronary artery disease prevalence but not extent and has clinical utility

BACKGROUND

Variants at the 9p21 locus have been associated with coronary heart disease, but their precise disease phenotype and utility for clinical risk assessment are uncertain.

METHODS

Consenting patients with early-onset angiographic coronary artery disease (CAD) (n = 1,011) were compared with matched subjects (n = 545) free of angiographic disease and with a random population sample (n = 565). Cases and controls were genotyped for 4 variants, and ORs for angio-CAD were determined. Findings were validated in a separate set of cases and controls (n = 1,452).

RESULTS

Alleles were highly correlated (r(2) > or = 0.9), and all predicted angio-CAD compared with both control groups. Genotype at rs2383206 (minor allele frequency 45.9%), the most predictive (P < .0001), was associated with an adjusted odds ratio for angio-CAD of 1.39 (95% CI, 1.05-1.85) for heterozygote and 1.73 (1.26-2.37) for homozygote risk-allele carriers and explained 21% of population attributable risk and was independent of traditional risk factors and myocardial infarction. For the comparison of combined cases versus combined control samples (N = 3,573), CAD was predicted by high-risk allele homozygosity at P = 9 x 10(-8). Despite this, extent of disease was not increased. Applied to patients with intermediate Framingham risk scores, 9p21 genotyping modified risk classification in 24%.

CONCLUSIONS

Variants at the 9p21 locus robustly predict angiographic CAD prevalence, independent of standard risk factors, but not CAD extent or myocardial infarction; provide pathophysiological insights; and may be clinically useful in refining coronary heart disease risk classification.

Change of melanocortin receptor expression in rat kidney ischemia-reperfusion injury

OBJECTIVES

alpha-Melanocyte stimulating hormone (alpha-MSH) may ameliorate renal ischemia-reperfusion (I/R) injury. Recent data suggest that melanocortin receptors may be related to the anti-inflammatory and immunomodulating action for alpha-MSH. We designed this experiment to determine the renal distribution of alpha-MSH receptors; melanocortin-1 receptor (MC-1R) and melanocortin-3 receptor (MC-3R).

METHODS

Sprague-Dawley male rats (n = 24) were randomly divided into 2 groups: the sham (n = 2) and the operation groups with warm ischemia (n = 12). Animals in the operation group were subjected to 40 minutes of warm renal ischemia. Western blotting analyses and immunohistochemistry were employed to determine expression of MC-1R and MC-3R.

RESULTS

Expression of MC-1R and MC-3R was decreased on 1 day after reperfusion. Immunohistochemical study confirmed the findings of Western blot analysis.

CONCLUSIONS

The present study demonstrated novel renal expression of MC-1R and MC-3R, especially in the outer medulla, representative of the renal I/R injury. Our current study suggested that the mechanisms of action of alpha-MSH may significantly attenuate the renal I/R injury by specific kidney-targeted effects via MC-Receptors as well as by systemic cytokine effects.

Biosorption of a reactive dye (Rhodamine-B) from an aqueous solution using dried biomass of activated sludge

Low cost, locally available biomaterial was tested for its ability to remove reactive dyes from aqueous solution. Granules prepared from dried activated sludge (DAS) were utilized as a sorbent for the uptake of Rhodamine-B (Rh-B) dye. The effects of various experimental parameters (dye concentration, sludge concentrations, swelling, pretreatment and other factors) were investigated and optimal experimental conditions were ascertained. Nearly 15min was required for the equilibrium adsorption, and Rh-B dyes could be removed effectively. Dye removal performance of Rh-B and DAS increased with increasing concentrations. The acid pretreated biomass exhibited a slightly better biosorption capacity than alkali pretreated or non-pretreated biomass. The optimum swelling time for dye adsorption of the DAS within the swelling time range studied was 12h. Both the Freundlich and Langmuir isotherm models could describe the adsorption equilibrium of the reactive dye onto the activated sludge with the Langmuir isotherm showing the better agreement of the two. Second-order kinetic models confirmed the agreement.

Analysis of nitrifying bacterial communities in aerobic biofilm reactors with different DO conditions using molecular techniques

In order to assess the relationship between the dissolved oxygen (DO) concentration and the characteristics of nitrifying bacterial communities in an aerobic biofilm reactor, molecular techniques including denaturing gradient gel electrophoresis (DGGE)/cloning based on PCR targeting 16S rRNA and the amoA gene and fluorescence in situ hybridisation (FISH) were conducted. The D-1, D-2, D-3 and D-4 reactors with different DO concentrations (1, 3, 5 and 7 mg/L, respectively) were set up in the thermostat and acclimated. The optimal DO concentration with stable nitrification efficiency was above 5.0 mg/L. As was shown by the results of DGGE and cloning, the community of ammonia-oxidising bacteria (AOB) and the ratio of Nitrosomonas sp. changed only slightly despite their differing nitrification efficiencies. The results of FISH indicated that higher DO concentrations resulted in an increase in AOB and nitrite-oxidising bacteria (NOB), and a reduction in heterotrophic microorganisms. The INT-dehydrogenase activity (DHA) test demonstrated that the activity of AOB decreased with reductions in the DO concentration. This means that the DO concentration does not influence the community of AOB, but rather the activity of AOB. In the relationship between the attached biomass and the nitrification efficiency, only the active biomass affected the nitrification efficiencies.

Serum galectin-3 and galectin-3 binding protein levels in Behçet's disease and their association with disease activity

OBJECTIVE

To determine the serum levels of galectin-3 (Gal-3) and galectin-3 binding protein (G3BP) and to evaluate the associations between clinical features and these levels in patients with Behçet's disease (BD).

METHODS

Fifty patients with BD (mean age 40.6 +/- SEM 1.4 years; 21 males, 29 females; 26 active and 24 inactive patients), 20 patients with rheumatoid arthritis (RA), and 20 patients with systemic lupus erythematosus (SLE) were enrolled. Clinical features of BD patients including BD activity and severity over the previous 4 weeks were reviewed and serum levels of Gal-3 and G3BP were determined using enzyme-linked immunosorbent assays (ELISA).

RESULTS

Serum Gal-3 levels were significantly higher in total BD patients than in healthy controls (mean +/- SEM, 10.68 +/- 0.93 versus 7.59 +/- 0.48 ng/mL; p = 0.0042 by Student's t-test), and active BD patients had significantly higher levels of serum Gal-3 than inactive patients and controls (13.08 +/- 1.53 in active BD, 8.08 +/- 0.71 ng/mL in inactive BD; p = 0.000039 by one way ANOVA). Although mean G3BP serum levels were not different in total BD patients and controls, active BD patients (6806.63 +/- 468.58 ng/mL) had higher G3BP levels than controls (5421.05 +/- 286.02 ng/mL; p = 0.031 by one way ANOVA). Additionally, serum Gal-3 significantly increased in patients with RA (p = 0.019 by t-test) and SLE (p = 0.00069) and G3BP increased in patients with SLE (p = 0.000012), compared to those in healthy controls. When we analyzed for associations with clinical features over the previous 4 weeks, Gal-3 was associated with orogenital ulcers (p = 0.036 by t-test) and time elapsed from symptom onset (p = 0.032, Pearson's coefficient = 0.314). Serum concentrations of Gal-3 (p = 0.013) and G3BP (p = 0.032) were positively correlated with the BD severity score for the previous 4 weeks. Gal-3 levels were significantly correlated with TNF-alpha (p = 0.048, Pearson's coefficient = 0.281) and G3BP levels were correlated with levels of C-reactive protein (p = 0.021, Pearson's coefficient = 0.329) in total BD patients. In multivariate analysis of all cytokines levels, only Gal-3 was significantly related to BD activity or severity for the previous 4 weeks.

CONCLUSION

These results suggest that serum levels of Gal-3 and G3BP are increased in active BD patients and Gal-3 can be a new biomarker indicating disease activity in BD although their increments are not disease-specific.

False susceptibility to cefotetan reported by MicroScan for DHA-type AmpC beta-lactamase-producing Klebsiella pneumoniae

This study evaluated the accuracy of cefotetan susceptibility determination using the MicroScan WalkAway system for AmpC-producing Klebsiella pneumoniae. In total, 57 K. pneumoniae isolates that showed a D-shape flattening in a double-disk synergy test were studied. Cefotetan MICs were determined by the agar dilution method. The bla(DHA) gene was detected in all 57 isolates, one of which co-harboured bla(CMY-1). According to the MicroScan system, 28 isolates were susceptible, 18 were intermediately-resistant, and 11 were resistant to cefotetan. Compared with the agar dilution method, very major, minor and major error rates were 28.1% (16/57), 47.4% (27/57) and 1.8% (1/57), respectively.

Association of nodular regenerative hyperplasia of the liver with porto-pulmonary hypertension in a patient with systemic lupus erythematosus

A 37-year old woman with systemic lupus erythematosus (SLE) complicated by pulmonary hypertension (PHT) was admitted to evaluate abnormal liver function. Radiological imaging study, including ultrasonography, computed tomography and magnetic resonance imaging and upper gastrointestinal endoscopy, revealed multiple hepatic nodules, hepatosplenomegaly and esophageal varices. Percutaneous needle liver biopsy showed non-cirrhotic hepatic nodules with hyperplastic hepatocytes surrounded by atrophic hepatocytes, confirming the diagnosis of nodular regenerative hyperplasia (NRH) associated with non-cirrhotic portal hypertension (PT). NRH of the liver is known to be a very rare hepatic manifestation in rheumatic diseases. This case shows the association of NRH with porto-pulmonary hypertension in SLE.

NOS3 Gene Polymorphisms and Exercise Hemodynamics in Postmenopausal Women

We tested whether the G894T and T-786C NOS3 polymorphisms were associated with exercise cardiovascular (CV) hemodynamics in sedentary, physically active, and endurance-trained postmenopausal women. CV hemodynamic parameters including heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressures and cardiac output (Q), as determined by acetylene rebreathing, stroke volume (SV), arteriovenous oxygen difference (a-vO2 diff), and total peripheral resistance (TPR) were measured during submaximal (40, 60, 80 %) and maximal (approximately 100 % VO2max) exercise. NOS3 G894T genotype was not significantly associated, either independently or interactively with habitual physical activity (PA) level, with SBP, Q, TPR, or a-vO2 diff during submaximal or maximal exercise. However, NOS3 894T non-carriers had a higher submaximal exercise HR than NOS3 894T allele carriers (120 +/- 2 vs. 112 +/- 2 beats/min, p = 0.007). NOS3 894T allele carriers had a higher SV than 894T non-carriers (78 +/- 2 vs. 72 +/- 2 ml/beat, p = 0.03) during submaximal exercise. NOS3 894T non-carriers also had a higher maximal exercise HR averaged across habitual PA groups than T allele carrier women (165 +/- 2 vs. 158 +/- 2 beats/min, p = 0.04). NOS3 894T allele carriers also tended to have a higher SV during maximal exercise than 894T non-carriers (70 +/- 2 vs. 64 +/- 2 ml/beat, p = 0.08). NOS3 T-786C genotype was not significantly associated, either independently or interactively, with any of the CV hemodynamic measures during submaximal or maximal exercise. These results suggest an association of NOS3 G894T genotype with submaximal and maximal exercise CV hemodynamic responses, especially HR, in postmenopausal women.

Assessing quality of life in Australian patients with Graves' ophthalmopathy

AIMS

To determine quality of life and adequacy of education and counselling in Australian patients with Graves' ophthalmopathy during the course of their illness.

METHODS

A cross sectional study was conducted at the orbital and endocrinology clinics of Royal Brisbane Hospital on 162 consecutive patients with Graves' ophthalmopathy who were managed between the 1992 and 2000. The Graves' ophthalmopathy quality of life (GO-QOL) survey modified for Australian conditions was distributed to study participants. Of the 19 questions asked, nine questions related to visual functioning, eight questions were about the psychosocial consequences of changed appearance, and two questions referred to education and counselling. Additionally, clinical data on the severity of illness were collected retrospectively from the medical notes of these patients.

RESULTS

Completed questionnaires were received from 128 patients. The majority of patients reported limitations in daily activities such as hobbies, driving, watching television and reading, as well as impaired self confidence. The mean GO-QOL scores in this study were (100 representing maximum QOL): visual functioning 59.0 (SD 28.0), psychosocial consequences of changed appearance 54.5 (28.4), and education and counselling 59.1 (38.8). Only about a quarter of patients indicated that education and counselling were adequate and helpful.

CONCLUSION

Graves' ophthalmopathy profoundly affects QOL and adequate education and counselling are essential for helping patients to cope with their illness. The GO-QOL survey is a simple, practical tool that can be used easily in a clinic to determine the QOL issues in subjects with Graves' ophthalmopathy.

Retinoic acid-mediated induction of neurons and glial cells from human umbilical cord-derived hematopoietic stem cells

Recent studies reporting trans-differentiation of mononucleated cells derived from human umbilical cord blood into neuronal cells aroused interest among investigators for their clinical implication and significance in regenerative medicine. In the present study, purified populations of hematopoietic stem cells were isolated via magnetic bead sorting and fluorescence-activated cell sorter (FACS) using a specific CD133 antibody, a cell type-specific marker for hematopoietic stem cells, and grown in culture in the presence of retinoic acid (RA). CD133+ hematopoietic stem cells expressed neuronal and glial phenotypes after RA treatment. RT-PCR analysis indicated that the RA treated CD133+ cells expressed mRNA transcripts for ATP-binding cassettes transporter ABCG2 (a universal stem cell marker), nestin (a specific cell type marker for neural stem cells), Musashi1 (a specific marker for neural stem cells) and RA receptors (RAR) including RAR-alpha, RAR-beta, and retinoid X receptor (RXR)-gamma. RA-treated CD133+ cells expressed mRNA transcripts for neuron-specific markers neurofilament proteins (NF-L, -M, -H) and synaptophysin as determined by RT-PCR, structural proteins characteristic of neurons including tubulin beta III and neuron specific enolase (NSE) by Western blot, and neuron-specific markers NeuN and microtubule-associated protein-2 (MAP2) by immunocytochemistry. RA-treated CD133+ cells also expressed the astrocyte-specific marker glial fibrillary acidic protein (GFAP), as demonstrated by RT-PCR, Western blot, and immunocytochemistry. In addition, RA-treated CD133+ cells expressed cell type-specific markers for oligodendrocytes including myelin basic protein (MBP) as shown by RT-PCR, proteolipid protein (PLP) by Western blot analysis, and cyclic nucleotide phosphodiesterase (CNPase) by immunostaining. Upregulated expression of several basic helix-loop-helix (bHLH) transcription factors important for early neurogenesis, including Otx2, Pax6, Wnt1, Olig2, Hash1 and NeuroD1, was also demonstrated in CD133+ cells after RA treatment. These results indicate that human cord blood-derived CD133+ hematopoietic stem cells could trans-differentiate into neural cell types of neuron-like cells, astrocytes, and oligodendrocytes by RA treatment.

Wave-front phase measurements of high-order harmonic beams by use of point-diffraction interferometry

We report the wave-front phase measurement of high-order harmonics employing point-diffraction interferometry. The high-order harmonics generated in a gas-filled hollow tube showed excellent spatial coherence over nearly the whole cross section of the harmonic beams. Using this coherent harmonic source in the extreme-ultraviolet-soft-x-ray region, we have demonstrated the operation of a point-diffraction interferometer and measured the wave-front phase of high-order harmonics.

Emission of a hot electron jet from intense femtosecond-laser-cluster interactions

A directional hot electron jet with energy higher than 100 keV was generated along the laser propagation direction from Ar clusters irradiated with a laser pulse of duration 28 fs and intensity 1 x 10(17) W/cm(2). The hot electron jet was detected only with linearly polarized laser pulses, not with circularly polarized pulses. Channel betatron resonance is believed to be the main accelerating mechanism for this directional hot electron jet.

Autologous cardiomyocyte transplantation in an ovine myocardial infarction model

BACKGROUND

To evaluate the possibility of autologous cardiomyocyte transplantation, we transplanted cultured autologous cells into an infarct region developed by coronary artery ligation in an ovine model.

MATERIALS AND METHODS

A chronic heart failure model with a considerable portion of myocardial infarction was created in sheep using sequential ligation of the homonymous artery and its diagonal branch. Autologous cardiomyocytes were cultured and isolated from the right ventricular infundibulum. After a predetermined interval (one animal for two months and the other for three months), the two animals were reanesthetized and a suspension of cultured autologous vetricular cells in 0.3 ml of culture medium (1.2 x 10(7) cells) was injected into the center of three out of the four sites in the infarcted area using a tuberculin syringe. The same amount of culture medium was injected with an identical procedure into the center of the remaining site, as control. The animals were kept alive for a further month, and then sacrificed for postmortem heart examinations. Light microscopic analysis and immunohistochemical study for myoglobin were done.

RESULTS AND CONCLUSIONS

On postmortem gross examination, well-demarcated thin-walled anteroseptal infarcts with chamber enlargement were clearly seen in specimens from the two animals. Microscopic analysis showed homogenous fibrosis throughout the infarcted areas. In both animals, one of the three sites of cardiomycyte injection showed an islet of cardiomyocytes in the mid-myocardium, while none were observed in the control site of either animal. A layer of cardiomyocytes was observed in subendocardial regions, as it was in the control areas. In conclusion, cardiomyocyte transplantation into the infarct regions developed by coronary artery ligation in an ovine model was achieved with only limited success. An understanding of why only 33% of cardiomyocyte-injection sites demonstrated viable cardiomyocytes, in the form of tiny cell islets, remains to be elucidated.