Pathway Mutations are Associated with Clinical Outcomes in Localized Pancreatic Cancer Treated with Neoadjuvant Chemoradiation Followed by Surgery

PURPOSE/OBJECTIVE(S)

The purpose of this study was to determine if mutations in biological pathways are associated with clinical outcomes in patients with localized pancreatic cancer who undergo neoadjuvant chemoradiation followed by surgical resection.

MATERIALS/METHODS

Patients treated with neoadjuvant chemoradiation followed by oncologic resection from 2015-2019 who also underwent next generation sequencing (NGS) of the primary tumor were included in this retrospective analysis. NGS was done using either Foundation One (n = 20), in-house Solid Tumor Panel (n = 121), or Tempus XT (n = 1). Genes were included in pathway analysis if at least one patient harbored a mutation in the gene. Pathways were defined from the Molecular Signatures Database Hallmark, KEGG, and Reactome gene sets. A pathway was deemed mutated if at least one gene within the pathway was mutated. Univariable Cox regression was performed to determine the association between pathway mutation status and overall survival (OS) as well as progression-free survival (PFS).

RESULTS

In total, 142 patients met criteria for study inclusion. For pathway analysis, 329 genes met inclusion criteria. Patients were typically treated with neoadjuvant chemotherapy (either 5-fluorouracil-based or gemcitabine-based) followed by radiation. Patients received SBRT (n = 104, most commonly 33 Gy in 5 fractions) or conventionally fractionated radiation (n = 38, most commonly 50.4 Gy in 28 fractions). For clinical variables, worse OS was significantly associated with T stage (p = 0.036), N stage (p = 0.044), and lymphovascular invasion (LVI, p = 0.011); worse PFS was significantly associated with T stage (p = 0.0008), N stage (p = 0.022), LVI (p = 0.026), and conventional RT (p = 0.007). Mutations in major pathways were associated with worse OS, notably hedgehog signaling (p = 0.001), chromatin modifying enzymes (p = 0.002), WNT/beta-catenin signaling (p = 0.005), mismatch repair (0.006), E2F targets (p = 0.008), FLT signaling (p = 0.012), VEGF signaling (0.025), innate immune system (p = 0.026), and NOTCH signaling (p = 0.029). Pathway mutations associated with worse PFS included mismatch repair (p = 0.007) and hedgehog signaling (p = 0.013).

CONCLUSION

For pancreatic cancer patients that undergo neoadjuvant chemoradiation followed by oncologic resection of the primary tumor, mutations in key biological pathways are associated with OS and PFS. Characterizing the importance of common pathway mutations may become increasingly valuable to help categorize less commonly mutated genes assayed by NGS.

Improving Cancer Care by Incorporating the Patient's Voice in Symptom Management (IMPROVE): A Multicenter-Prospective Pilot Study

PURPOSE/OBJECTIVE(S)

IMPROVE is a prospective multicenter pilot study. It evaluates whether routine physician review of patient-reported outcomes measures (PROMs) during radiotherapy alters physicians' perception of cancer patients' treatment-related toxicity and influences symptom management.

MATERIALS/METHODS

We are enrolling patients with thoracic or gastrointestinal cancers amenable to conventional-fractionated radiotherapy. Patients may receive concurrent chemotherapy. Patients report (1) symptoms, using PRO-CTCAE measures, (2) the most burdensome symptom, and (3) how symptoms interfere with daily activities. Patients complete the measures before seeing their physician during each on-treatment visit. During weekly visits and before reviewing the patient's PROMs, physicians rate the symptom burden for each patient from 0 to 10, using available clinical data. These data include vital signs, lab work, physical exams, nursing assessments, and physicians' clinical judgment. After reviewing the patients' PROMs, physicians re-rate each patient's symptom burden and report any changes in recommended interventions. Changes could include (1) additional counseling, (2) new medications or interventions, (3) referrals to other services, or (4) further testing or evaluation. After each patient's course of radiotherapy, providers complete a Clinician Feedback Form about the impact of PROM review on symptom perception and management during treatment. This study commenced November 11, 2020 at a multi-site tertiary academic cancer center (using electronic or paper questionnaires) and July 21, 2021 at a multi-site community cancer center (using paper forms).

RESULTS

To be determined.

CONCLUSION

To be determined.

Characterization of DNA Damage Response-Associated Somatic Mutations in Borderline Resectable and Locally Advanced Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

The role of radiation for pancreatic cancer remains controversial, with recent studies showing conflicting results, highlighting the need to develop biomarkers of radiation response. Despite its potential utility in predicting radiosensitivity, the landscape of somatic mutations in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), as related to DNA damage response (DDR), has not been well characterized. This study aimed to characterize the frequency of such mutations in a cohort of patients with BRPC/LAPC treated with neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

Mutational data was collected from patients with BRPC/LAPC treated at a single institution with neoadjuvant chemotherapy and SBRT, followed by surgical resection from 2016-2021. Chemotherapy consisted of modified FOLFIRINOX or gemcitabine/nab-paclitaxel, and patients were treated with SBRT in 33 Gy in 5 fractions. Genomic data was obtained from either endoscopic biopsy or surgical specimens, and next-generation sequencing was performed either in-house with a Solid Tumor Panel or with FoundationOne CDx. Specific emphasis was placed on the characterization of double-strand DNA break (DSB) repair genes, as this is the type of tumor cell damage traditionally induced by radiation therapy. Genes associated with the two main pathways of DSB repair, non-homologous end joining (NHEJ) and homologous repair (HR), were analyzed. Specific HR pathway mutations assessed were BLM, BRCA1/2, MRE11, NBN, PALB2, RAD50, RAD51B-D, and RAD54L, while PRKDC mutations were assessed for the NHEJ pathway. Mutations in ATM, an important initiator of DDR pathways, were also analyzed. Additionally, the frequency of mutations in TP53, CDKN2A and SMAD4 in patients with concomitant KRAS mutations was assessed.

RESULTS

Eighty-five patients were included in the study. Five (5.9%) patients had mutations in the NHEJ pathway of the PRKDC gene. Twenty (23.5%) patients had mutations in the HR pathway, including BRCA2 (10/85; 11.8%), PALB2 (5/85; 5.9%), BRCA1 (3/85; 3.5%), and RAD50 (1/85; 1.2%). Six (7.1%) patients had mutations in ATM. No patients were found to have mutations in BLM, RAD51B-D, RAD54L, or NBN. Amongst patients with KRAS mutations (72/85), concomitant mutations were observed in TP53 (47/85; 55.3%), CDKN2A (16/85; 18.8%), and SMAD4 (9/85; 10.6%).

CONCLUSION

Herein, we characterized the frequency of somatic mutations associated with DSB repair genes in patients with BRPC/LAPC. Data analysis on outcomes related to radiation response in patients with mutations in DDR pathways is ongoing, but will likely also benefit from multi-institutional efforts to increase the power to answer this question.

Utilization of the Triangle Volume in Patients with Localized PDAC Undergoing Pre-Operative SBRT: Report of Early Outcomes

PURPOSE/OBJECTIVE(S)

In patients with borderline resectable or locally advanced pancreatic adenocarcinoma (BRPC/LAPC), advances in neoadjuvant therapy have led to an increased proportion of patients undergoing margin negative resection. Nevertheless, locoregional recurrence rates remain high. We have previously reported that the location of locoregional recurrences in this setting map to the "Triangle Volume (TV)," the anatomical space between the celiac artery, superior mesenteric artery, common hepatic artery, and portal vein, which is enriched in extrapancreatic perineural tracts at risk for microscopic residual disease after resection. At the beginning of 2021, we systematically changed our target volume to include the TV, in addition to gross disease and involved vasculature. Herein, we report early locoregional failure outcomes after resection in the setting of BRPC or LAPC treated with pre-operative stereotactic body radiation therapy (SBRT) to the TV, as compared to historical rates.

MATERIALS/METHODS

Patients who received a diagnosis of BRPC or LAPC and who were treated at our institution with neoadjuvant chemotherapy (CTX) and SBRT between 2016 and 2022 were retrospectively reviewed. Between 2016 and 2020, the SBRT clinical tumor volume (CTV) included gross disease and full circumference of involved vasculature at the level of involvement. From 2021 onward, the CTV also included the TV. Survival was estimated using the Kaplan-Meier method. Statistical analyses were performed using scientific 2-D graphing and statistics software.

RESULTS

From January 2016 to December 2022, 204 patients with localized PDAC underwent neoadjuvant CTX followed by SBRT. After completion of SBRT, all patients proceeded with surgical exploration. Of these patients, 111 (54%) had LAPC and 92 (45%) had BRPC disease. All patients were treated with induction CTX, mostly commonly with FOLFIRINOX (N = 166, 81%). Following CTX, the most frequently used SBRT regimen was 33 Gy in 5 fractions (N = 191, 94%). 155 (67%) patients were treated between 2016 and 2020 to the traditional CTV, while 49 (24%) patients were treated after 2020 to a CTV that included the TV. The 2-year local progression free survival rate of patients treated with SBRT using the TV was 77.6% as compared to 47.5% in patients treated with the traditional CTV. Over a median follow up of 15.7 months (range: 1 to 78.2 months), 47% (N = 73 out of 155) of patients who underwent SBRT with the traditional CTV developed locoregional recurrence, but only 12% (N = 6 out of 49) treated with SBRT to the TV have thus far developed locoregional recurrence (p<0.0001).

CONCLUSION

In patients with localized PDAC who undergo pre-operative SBRT for BRPC/LAPC, targeting the TV may help reduce locoregional recurrence. More data and longer follow-up are needed to verify these findings and inform whether the TV may serve as a new standard for target volume delineation in this setting.

Prospective and Comprehensive Characterization of an Inpatient Radiation Oncology Consult Service: Examining Interdisciplinary Coordination of Palliative Radiation Access and Receipt

PURPOSE/OBJECTIVE(S)

Studies have increasingly demonstrated the benefit of dedicated palliative radiation therapy (PRT) models on care quality, coordination and cost-effectiveness. However, these studies are primarily retrospective and volume-based, limiting broad application of findings. Through prospective, comprehensive characterization of inpatient consults, we investigated trends in interdisciplinary coordination and PRT delivery.

MATERIALS/METHODS

Inpatient consult pages at a single institution from 11/1/21-5/31/22 were prospectively tracked and characterized. Consult type, temporality and decision-making, and patient demographics, disease and treatment details, and mortality outcomes were recorded. Chi-square and logistic and linear regressions evaluated associations between consult and patient-specific features.

RESULTS

Of 460 pages received, 131 (28.5%) were requests for further communication following initial consultation. For the 329 original consults, 20.1% related to care coordination for established on-treatment or recently treated patients who were hospitalized. RT was recommended for 57% of patients-81.3% with palliative intent. With a mean 1.85 vs. 0.8 consults per day for weekday vs. weekend, 52.6% and 34.0% of pages occurred from 7am-noon or noon-5pm respectively, with 13.4% received overnight. This distribution did not significantly differ between weekday vs. weekend. Consult type (RT consideration vs. care coordination) was not associated with day or time period. Concern regarding benefit and/or safety of radiation was the main reason for treatment deferral (31.3%). Neurologic compromise (38.7%), pain (33.8%) and obstruction (ex. airway, luminal; 11.6%) were the most frequent non-post-operative palliative indications. Median time from admission to consult was 2 days (range 0-70), with a median of 1 day for neurologic compromise, 2 days for pain and 4 days for obstruction. For PRT scenarios, patients treated or untreated with RT had no significant difference in 30 days (25.2% vs. 28.2%, respectively) or 60 days (39.6% vs. 46.3%, respectively) mortality. 53.5% of patients had either a palliative medicine consultation while an inpatient or one scheduled at the time of discharge.

CONCLUSION

Prospective characterization at a tertiary-care institution reveals high-volume care coordination- and communication-related consults with temporal distribution similar to consults for RT consideration for new patients. Association of timing with palliative indication and the observed rate of palliative medicine involvement highlight opportunities for interdisciplinary education regarding early multidisciplinary engagement to ensure provision of comprehensive palliative oncologic care.

Local Time-to-Event Endpoint Under-Reporting and Variability in Pancreatic Cancer Trials Involving Radiotherapy

PURPOSE/OBJECTIVE(S)

The role of radiotherapy (RT) for pancreatic adenocarcinoma (PDAC) remains controversial, with recent studies showing conflicting results. Importantly, endpoints used to evaluate efficacy in recent RT trials for PDAC have been highly variable. As variability in time-to-event (TTE) endpoint definitions is demonstrated to influence outcomes in other cancers, it is critical that radiation oncologists develop consensus around optimal endpoint definitions to use in future PDAC trial design. Thus, we conducted a systematic review of PDAC trials involving RT to characterize the frequency and variability in local TTE endpoint reporting.

MATERIALS/METHODS

An electronic database search was conducted of PubMed, EMBASE, and Cochrane Library to identify phase 2 and 3 clinical trials published from 2010-2022 of localized PDAC involving RT that reported any TTE endpoint (e.g., local control). After excluding duplicates, two independent reviewers screened full-text manuscripts for inclusion. Trial characteristics and local TTE endpoints/definitions were tabulated.

RESULTS

Three hundred twenty references were screened and 79 trials were included, of which 73 (92%) were phase 2 and 26 (33%) were randomized. Twenty (25%) trials reported a local TTE endpoint; these were local control (LC; N = 6), local progression-free survival (LPFS; N = 4), freedom from local progression (N = 6), locoregional progression-free interval (N = 1), cumulative incidence of local recurrence (N = 1), time to failure of sustained LC (N = 1), and local disease-free survival (N = 1). LC (N = 6) had 5 unique definitions and was undefined once; 1 definition included death as an event. LPFS (N = 4) had 3 definitions; 2 did not consider death an event. Among trials with local TTE endpoints, 9 trials specified the definition of a local recurrence/progression. Four trials defined local recurrence based on RT volumes; one counted clinical evidence of recurrence (e.g., tumor bleed); and one counted a rise in tumor markers without evidence of distant metastases. The index time ("time-zero") was defined for local TTE endpoints in 10 trials, including start of RT (N = 4) or chemo (N = 1), end of RT (N = 1), diagnosis (N = 1), enrollment (N = 1), and time of surgery (N = 1).

CONCLUSION

Few pancreatic cancer trials involving RT report local TTE endpoints, with significant heterogeneity in endpoints used and their definitions. Development of consensus endpoint definitions will be critical for future PDAC trial design.

Visceral Artery Pseudoaneurysm Rates after Pancreatoduodenectomy in Patients Who Received Pre-Operative Radiation for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

The role of pre-operative radiation therapy (RT) for localized pancreatic ductal adenocarcinoma (PDAC) with peri-pancreatic vascular involvement remains controversial, with two recent randomized controlled trials, namely PREOPANC-1 and Alliance A021501, showing conflicting results. Opponents of pre-operative radiation point towards the unclear oncologic benefit and potential added toxicity. While hemorrhage from a pseudoaneurysm (PsA) rupture is a known rare but potentially fatal complication after pancreaticoduodenectomy (PD), with published incidence rates of around 2 to 5%, it has been increasingly common in the pancreatic cancer surgical community for pre-operative RT to be cited as a risk factor for PsA development, despite the absence of data supporting this notion. Certainly, accurate characterization of relevant RT-related toxicities is critical to prevent inaccurate decision-making regarding foregoing its use. As such, we aim to report on the incidence of PsA in a cohort of patients with PDAC who underwent pre-operative RT prior to PD at a high-volume center.

MATERIALS/METHODS

Consecutive patients treated with pre-operative RT via stereotactic body radiation therapy (SBRT) or intensity modulated radiation therapy (IMRT) prior to PD for borderline resectable or locally advanced PDAC were retrospectively reviewed. Incidence of radiographic or clinically apparent PsA was reported. We also characterized the timing of PsA identification in relation to surgery and RT, the artery in which the PsA developed, and the clinical outcomes of patients after PsA identification.

RESULTS

One hundred seventy-five patients met eligibility criteria for our analysis. Most of our cohort (163 patients, 93%) received SBRT to a median dose of 6.6 Gy x 5 (median BED10 54.78 Gy, range: 48 Gy - 61.92 Gy), and only 12 patients (7%) received IMRT in various fractionation and dose patterns (median BED10 62.94 Gy, range 59.47 Gy - 97.5 Gy). The median time between surgery and last contrast-enhanced abdominal imaging was 17 months (range: 0.23 - 68 months). There were fourteen visceral arteries among thirteen patients (7%) that were found to have a PsA on routine follow-up imaging or after a post-PD hemorrhage. The median time between completion of radiation and surgery to PsA were 19.5 weeks (range: 8.6 to 98.1 weeks) and 13 weeks (range: 1.6 to 87.9 weeks), respectively. The two most commonly involved arteries were the gastroduodenal and superior mesenteric arteries. Rate of PsA development was similar among patients treated with SBRT (7%) and IMRT (8%). In terms of Clavien-Dindo classification of complications, there were six patients with grade 3a complications, five patients with grade 4b complications, and two patients with grade 5 complications.

CONCLUSION

Compared to historical data, pre-operative RT does not appear to significantly increase the risk of PsA development after PD. More data on the impact of pre-operative radiation dose-fraction regimen and longer follow-up are needed.

Impact of Local Therapy on Outcomes in Patients with Recurrent Hepatocellular Carcinoma after Liver Transplantation

PURPOSE/OBJECTIVE(S)

Patients with hepatocellular carcinoma (HCC) who recur after liver transplantation have limited systemic therapy options in part due to ineligibility for immune checkpoint inhibition. Thus, assessing the benefit of local, metastasis-directed therapy (MDT) is imperative. We aimed to evaluate the impact of MDT on outcomes in patients with post-transplant HCC recurrence.

MATERIALS/METHODS

Patients at a single center with recurrent HCC after liver transplant were identified. Recurrence/progression were assessed via RECIST criteria. At initial recurrence, patients with < = 3 metastases (mets) were considered oligorecurrent (oligoM1); those with >3 mets were polyrecurrent. Progression was defined as growth of existing mets or appearance of new mets. Poly-progression-free survival (polyPFS) was the time from oligorecurrence to polyprogression (>3 progressive mets) or death. Survival was estimated with the Kaplan-Meier method. Univariable Cox regression was used to identify covariates associated with outcomes; those with p<.05 were included in multivariable regression.

RESULTS

From 2005-2022, 43 patients with HCC who underwent liver transplantation experienced recurrence; 27 (63%) had oligoM1 disease at the time of recurrence. The most common sites of recurrence were liver (N = 14), abdominal nodes (N = 14), and lungs (N = 11). Low AFP (<400 ng/mL) and oligoM1 disease were associated with a favorable OS (P<.05) and these associations remained significant in multivariable analysis. Among patients with oligoM1 recurrence, 15/27 received MDT to all sites of disease (MDT-All). MDT consisted of stereotactic ablative radiotherapy (N = 6), intensity-modulated radiotherapy (N = 2), TACE (N = 1), microwave ablation (N = 3), cryoablation (N = 2), and surgery (N = 2). Among oligoM1 patients, more patients with MDT-All had liver involvement than those who did not have MDT-All (33% vs 0%, P = .047), but there was no difference in performance status, AFP, or systemic therapy receipt. Among oligoM1 patients, MDT-All was associated with improved polyPFS (median 11.7 vs 4.8 mos; P = .025), and OS (38.4 vs 16.1 mos; P = .021) compared to those who did not receive MDT-All. Two patients who received MDT-All remained alive at >4 years of follow-up from recurrence, while 1 patient remained alive at >14 years of follow-up.

CONCLUSION

Local therapy in patients with post-transplantation oligorecurrence (<3 mets) of HCC may delay disease progression and improve survival.

Evaluation of Impulse Attenuation by Football Helmets in the Frequency Domain

Design of helmets used in contact sports has been driven by the necessity of preventing severe head injuries. Manufacturing standards and pass or fail grading systems ensure protective headgear built to withstand large impacts, but design standards do no account for impacts resulting in subconcussive episodes and the effects of cumulative impacts on its user. Thus, it is important to explore new design parameters, such as the frequency-domain measures of transmissibility and mechanical impedance that are based on energy absorption from a range of impact loads. Within the experimentally determined frequency range of interest (FROI), transmissibilities above unity were found in the 0-40 Hz range with the magnitude characteristics varying considerably with impact location. A similar variability with location was observed for the mechanical impedance, which ranged from 9 N/m to 50 N/m. Additional research is required to further understand how changes in the components or materials of the components will affect the performance of helmets, and how they may be used to reduce both transmissibility and dynamic impedance.

Data Acquisition Protocol for Determining Embedded Sensitivity Functions

The effectiveness of many structural health monitoring techniques depends on the placement of sensors and the location of input forces. Algorithms for determining optimal sensor and forcing locations typically require data, either simulated or measured, from the damaged structure. Embedded sensitivity functions provide an approach for determining the best available sensor location to detect damage with only data from the healthy structure. In this video and manuscript, the data acquisition procedure and best practices for determining the embedded sensitivity functions of a structure is presented. The frequency response functions used in the calculation of the embedded sensitivity functions are acquired using modal impact testing. Data is acquired and representative results are shown for a residential scale wind turbine blade. Strategies for evaluating the quality of the data being acquired are provided during the demonstration of the data acquisition process.

Prevalence of diabetic retinopathy following a community screening for diabetes

Diabetic retinopathy is a public health challenge in developing countries including Nepal and is not like other preventable or treatable causes of blindness. The aim of study was to estimate the prevalence of diabetic retinopathy following a community screening for diabetes. A community-based, cross sectional study was designed to screen for diabetes in people age > or =40 years in a semi-urban community of Kathmandu, Nepal. In those individuals with detected diabetes, a comprehensive eye examination was performed by an ophthalmologist and diabetic retinopathy was graded using a standard protocol. 1475 persons were screened for diabetes with a mean age of 54.7 +/- 12 years with sex ratio of 0.69 male per female. Thirty-four subjects were found to have impaired fasting glucose and sixty subjects had diabetes. The prevalence of diabetes mellitus was 4.1% (60) but 6.4% (94) had an abnormal blood sugar level. Fifty-seven diabetic patients visited at-Tilganga Eye Centre for ocular examination. Among examined patients, the prevalence of diabetic retinopathy was 19.3% (11). Only one person had clinically significant macular edema requiring laser therapy. The prevalence of hypertension and cataracts were the same among patients with and without diabetic retinopathy. The prevalence of diabetic retinopathy was low but one of sixteen newly diagnosed diabetics did have evidence of diabetic retinopathy. Eighty-four percent of known diabetics had never had their eyes examined for ocular complications. Community awareness and physician coordination should be emphasized to increase the eye examination rate.

Inhibition of drug-sensitive and drug-resistant strains of Mycobacterium tuberculosis by diospyrin, isolated from Euclea natalensis

The binaphthoquinoid, diospyrin, was isolated from Euclea natalensis A.DC., and evaluated for its activity against drug-sensitive and drug-resistant strains of Mycobacterium tuberculosis. The minimal inhibitory concentration (MIC) of diospyrin was found to be 100 microg/ml for all the M. tuberculosis strains.

In vitro antiplasmodial activity and cytotoxicity of ethnobotanically selected South African plants

The resistance of Plasmodium spp. to currently used drugs has become a serious problem and efforts are being directed in obtaining new drugs with different structural features. One option favoured is the search for new plant derived antimalarial drugs. Bark and leaves of 20 extracts from 14 South African plant species were tested for in vitro antiplasmodial activity by means of the flow cytometric test. The most active extract of each species giving more than 70% inhibition at 50 microg/ml was selected for determination of IC(50) values. Two extracts had IC(50) values below 2 microg/ml, another seven had IC(50) values between 2 and 5 microg/ml while one had an IC(50) of 10.1 microg/ml. Chloroquine had an IC(50) of 0.043 microg/ml. Cytotoxicities of the five most active extracts at 50 microg/ml were determined with the monkey kidney cell toxicity test and the ID(50) values ranged between 35 and 100 microg/ml.

Combining phase and energy detection with mathematical morphology in dual time-frequency representation leads to improved SSP noise robustness

In this paper a fusion algorithm for the detection of specular echoes blurred by coloured Gaussian noise is proposed. The phase and energy criteria, characteristic of these echoes, are handled separately. First, the detection capabilities of split spectrum (phase) and short time Fourier transform spectrogram (energy) are compared theoretically and experimentally. Second, the new algorithm based on mathematical morphology operators using both time-frequency representations is proposed. In the last part our method is shown to be more robust than absolute minimisation split spectrum processing.

Transformation of naturally-occurring 1,9-trans-9,5-cis sweroside to all trans sweroside during acetylation of sweroside aglycone

From the rootstock of Scabiosa columbria L. loganin and sweroside were isolated. Sweroside showed moderate antibacterial activity. Pure sweroside was converted to the sweroside aglycone 1-acetoxy derivative (DABCO/Ac2O) after hydrolysis of the glucose unit. X-ray crystallography of the monoacetate showed unambiguously that it had been transformed to a new seco-iridoid having the novel trans diaxial configuration for the protons on C-1, C-9 and C-5. The mechanism for the rearrangement is discussed.

1999 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of incontinence and bladder cancer, and impact of managed care

PURPOSE

The Health Policy Survey and Research Committee of the American Urological Association and the Gallup Organization have performed a yearly survey of American urologists since 1992 to assess practice patterns. The results of the 1999 survey are presented.

MATERIALS AND METHODS

A random sample of 503 urologists was interviewed in February and March 1999. Major content areas were physician practice patterns, the impact of managed care, and the treatment of pediatric patients, prostate cancer and benign prostatic hyperplasia, female incontinence and bladder cancer.

RESULTS

The average urologist is 46.8 years old, certified by the American Board of Urology, sees 78 patients and performs 3.1 major surgical procedures weekly, refers moderate and complex pediatric procedures to specialists, and receives 40.6% of practice income from managed care.

CONCLUSIONS

In an era when large group practices seem to be the norm remarkably 32% of urologists remain in solo practice. There has been a shift in where urologists spend their time, that is more in the office and less in the operating room. Minor and major open surgical procedures increased from 12.4 weekly to 16.4 and 2.9 to 3.1 in 1995 and 1999, respectively. Most urologists are comfortable treating straightforward pediatric problems such as cryptorchidism but refer more complex problems to pediatric urologists. Managed care represents an ever increasing proportion of urologist practice income, while office expenses continue to increase.

Antibacterial activity of water and acetone extracts of the roots of Euclea natalensis

Water and acetone extracts of the roots of Euclea natalensis A.DC. were investigated for their in vitro antibacterial properties. The Gram-positive bacteria tested appeared to be more susceptible to the extracts than the Gram-negative bacteria. The water and acetone extracts inhibited the growth of Bacillus cereus, Bacillus pumilus, Bacillus subtilis, Micrococcus kristinae and Staphylococcus aureus at concentrations ranging between 0.1 and 6.0 mg/ml. The water extract did not exert any inhibitory action on Gram-negative bacteria while the acetone extract showed inhibitory activity at a concentration of 5.0 mg/ml against all the Gram-negative bacteria investigated. The antibacterial activity of acetone extract was also investigated by a direct bioassay on TLC plates against S. aureus.

Antibacterial activity of linoleic and oleic acids isolated from Helichrysum pedunculatum: a plant used during circumcision rites

The antibacterial activity-guided fractionation of the dichloromethane extract of leaves of Helichrysum pedunculatum resulted in the isolation of linoleic and oleic acids. Linoleic acid inhibited the growth of all the Gram-positive bacterial species tested with the minimum inhibitory concentration (MIC) varying between 0.01 and 1.0 mg/ml. Oleic acid was active against three of the five Gram-positive bacteria at a MIC of 1.0 mg/ml. Both compounds were inactive against the Gram-negative species tested. A synergistic effect between the two fatty acids was observed against Staphylococcus aureus and Micrococcus kristinae.

Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels

OBJECTIVE

Because of around-the-clock activities, environmental noise and light are among the many causes of sleep disturbance in an intensive care unit (ICU). The implementation of guidelines may potentially change behavior rules and improve sleep quality.

DESIGN

A prospective interventional study, observing the effects of simple nighttime guidelines on light and noise levels in an ICU.

SETTING

A modern surgical ICU, subdivided into six identical three-bed rooms.

PATIENTS

Critically ill adult patients.

INTERVENTION

Between two observation periods, five guidelines were implemented to decrease both light and noise during the night shift in the patient's room.

MEASUREMENT

Light levels and noise levels were obtained using a luxmeter and a sound level meter [A-weighted decibels (dB) scale] and were monitored continuously from 11 pm to 5 am both before (period P1) and after (period P2) the implementation of guidelines.

MAIN RESULTS

Similar patient's gravity and nursing workload scores were observed between P1 and P2. A low mean (<5 Lux) and maximal light level were measured during both P1 and P2. The implementation of guidelines lowered mean light disturbance intensity with a greater variability of light during P2. All noise levels were high and corresponded more to a quiet office for noise level equivalents and to a busy restaurant for peak noise levels during both P1 and P2. Guidelines decreased the noise level equivalent (P1, 51.3 dB; P2, 48.3 dB), peak noise level (P1, 74.9 dB; P2, 70.8 dB), and the number of acoustic identified alarms (P1, 22.1 dB; P2, 15.8 dB) during P2.

CONCLUSION

The night light levels were low during both periods, and lowering the light levels induced a greater variation of light, which may impair sleep quality. All measured noise levels were high during both periods, which could contribute to sleep disturbance, and the implementation of guidelines significantly lowers some important noise levels. The background noise level was unchanged.

Incidence and clinical significance of echogenic vasculature in the basal ganglia of newborns

Cranial sonography has become the main modality of the investigation and diagnosis of a wide variety of neonatal intracranial abnormalities. Occasionally, cranial sonograms reveal basal ganglia and thalami bright echoes. It is believed that these lesions are indicative of vasculitis due to intrauterine infections, in particular with cytomegalovirus (CMV). We hypothesized that the incidence of proven neonatal intrauterine TORCH infection is low and that screening of all asymptomatic infants with bright lenticulostriate echodensities would not be cost-effective. We reviewed brain sonograms of 3700 infants, performed over a period of 3 1/2 years. Echogenic basal ganglia vasculature were observed in 75 patients (2%). Chart review performed for clinical presentation and TORCH studies showed that only one infant had confirmed intrauterine congenital infection, which was by CMV. This infant had no signs or symptoms of CMV. In addition, there were 4 patients with chromosomal anomalies among the 75 patients (5%), of these one had trisomy 13 and another-trisomy 21. Our results indicate that echogenic basal ganglia blood vessels are not an exceptional finding on cranial sonograms, and are seldom associated with intrauterine infection. We conclude that it is not cost-effective to screen infants with echogenic basal ganglia blood vessels for intrauterine infection, unless clinical suspicion exists.

An acylated phloroglucinol with antimicrobial properties from Helichrysum caespititium

A new acylated form of a phloroglucinol with significant antimicrobial properties was isolated by bioactivity guided fractionation from Helichrysum caespititium (Asteraceae). The structure elucidation, and conformation of the new phloroglucinol, 2-methyl-4-[2',4',6'-trihydroxy-3'-(2-methylpropanoyl) phenyl]but-2-enyl acetate, was established by high field NMR spectroscopic and MS data. The compound inhibited growth of Bacillus cereus, B. pumilus, B. subtilis and Micrococcus kristinae at the very low concentration of 0.5 microg/ml and Staphylococcus aureus at 5.0 microg/ml. Six fungi tested were similarly inhibited at low MICs, Aspergillus flavus and A. niger (1.0 microg/ml), Cladosporium chladosporioides (5 microg/ml), C. cucumerinum and C. sphaerospermum (0.5 microg/ml) and Phylophthora capsici at 1.0 microg/ml.

1998 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of ureteral stones and impact of managed care

PURPOSE

The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the seventh consecutive Gallup Survey performed for the Association.

MATERIALS AND METHODS

A random sample of 537 American urologists who completed urological residency and practiced at least 20 hours weekly in 1997 were interviewed by telephone in March 1998. Major topic areas included general demographics, practice patterns, treatment of ureteral stones and experience with managed care.

RESULTS

Demographic trends indicated a significant decrease in average urologist age from 49.4 years in 1992 to 46.8 in 1998. Of the urologists 99% reported that they treat ureteral stones. Managed care had an increasingly larger role in most practices, particularly in the western United States, where 73% of urologists reported that they contract with a Medicare health maintenance organization.

CONCLUSIONS

The average age of practicing urologists significantly decreased, which may be due to an increasing number of urologists retiring at an earlier age, although this finding is not clear. Nearly all urologists treated ureteral stones with considerable consistency. Finally, managed care appeared to have a major impact on most urologists throughout the United States.

Characteristics of three homologous 202 genes (Ifi202a, Ifi202b, and Ifi202c) from the murine interferon-activatable gene 200 cluster

The Ifi202 gene is part of the interferon-activatable murine gene 200 cluster on chromosome 1. Ifi202 encodes the p202 protein whose overexpression is growth inhibitory and which can bind and inhibit the activity of numerous transcription factors including c-Jun, c-Fos, NF-kappaB, E2F-1, E2F-4, MyoD, and myogenin. We report here the exon-intron structure of Ifi202 and the discovery of Ifi202b and Ifi202c, close homologs of Ifi202 (whose designation we now change to Ifi202a). Ifi202a, b, and c were colocalized to chromosome 1 bands H4-H5 by fluorescence in situ hybridization. Ifi202b encodes p202b, which is interferon-inducible and differs from p202a in only 7 of 445 amino acids. 202b mRNA is constitutively expressed in tissues in which 202a mRNA is expressed. Ifi202c is apparently an unexpressed pseudogene. In murine embryonic fibroblasts (MEFs) from 129 mice, the level of 202b mRNA is approximately half that of 202a mRNA. We knocked out the Ifi202a gene from 129 mice. The expression of 202b mRNA, but not 202a mRNA, persisted in the knockout mice and their MEFs at the same level as in wildtype mice. However, in MEFs from the knockout mice, the constitutive and interferon-induced levels of p202b were approximately as high as the constitutive and the interferon-induced levels of p202a plus p202b, respectively, in MEFs from wildtype mice. These findings suggest dosage compensation at the posttranscriptional level. This might account for the apparent lack of phenotype of the knockout mice.

In vitro inhibition of drug-resistant and drug-sensitive strains of Mycobacterium tuberculosis by ethnobotanically selected South African plants

Twenty South African medicinal plants used to treat pulmonary diseases were screened for activity against drug-resistant and drug-sensitive strains of Mycobacterium tuberculosis. A preliminary screening of acetone and water plant extracts against a drug-sensitive strain of Mycobacterium tuberculosis, H37Rv, was done by the agar plate method. Fourteen of the 20 acetone extracts showed inhibitory activity at a concentration of 0.5 mg/ml against this strain. Acetone as well as water extracts of Cryptocarya latifolia, Euclea natalensis, Helichrysum melanacme, Nidorella anomala and Thymus vulgaris inhibited the growth of M. tuberculosis. Given the activity of 14 acetone extracts at 0.5 mg/ml against the drug-sensitive strain by the agar plate method, a further study was done employing a rapid radiometric method to confirm the inhibitory activity. These active acetone extracts were screened against the H37Rv strain as well as a strain resistant to the drugs isoniazid and rifampin. The minimal inhibitory concentration of Croton pseudopulchellus, Ekebergia capensis, Euclea natalensis, Nidorella anomala and Polygala myrtifolia was 0.1 mg/ml against the H37Rv strain by the radiometric method. Extracts of Chenopodium ambrosioides, Ekebergia capensis, Euclea natalensis, Helichrysum melanacme, Nidorella anomala and Polygala myrtifolia were active against the resistant strain at 0.1 mg/ml. Eight plants showed activity against both strains at a concentration of 1.0 mg/ml.

Two approaches to multiple specular echo detection using split spectrum processing: moving bandwidth minimization and mathematical morphology

A split spectrum processing technique using a novel moving bandwidth minimization (MBM) method was developed to detect multiple specular targets having different spectral characteristics. Mathematical morphology (MM) algorithms were also implemented in order to compare the results. An experimental approach to optimal parameter determination is described. These non-linear filtering methods are applied to medical in vivo imaging to illustrate specular detection and signal to noise ratio (SNR) enhancement.

1997 American Urological Association Gallup survey: Changes in diagnosis and management of prostate cancer and benign prostatic hyperplasia, and other practice trends from 1994 to 1997

PURPOSE

The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the 1997 survey, the sixth consecutive Gallup survey performed for the Association.

MATERIALS AND METHODS

A random sample of 502 American urologists who had completed urological residency and practiced at least 20 hours weekly in 1996 was interviewed by telephone in February and March 1997.

RESULTS

Emerging trends showed significant changes since 1994 in how urologists diagnosed and treated prostate cancer. The survey revealed a significant change in the tests routinely ordered to stage newly diagnosed prostate cancer and for diagnostic evaluation of patients with benign prostatic hyperplasia.

CONCLUSIONS

Urologists are becoming more cost conscious and effective in ordering pretreatment testing. Urologists are becoming more oriented toward medical treatment for the management of benign prostatic hyperplasia, and less laser surgery is being performed.

Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trail

OBJECTIVE

To compare the efficacy of conservative medical care with chiropractic care in the treatment of carpal tunnel syndrome.

DESIGN

Two-group, randomized, single-blind trial with 9 wk of treatment and a 1-month follow-up interview.

SETTING

Wolfe-Harris Center for Clinical Studies at Northwestern College of Chiropractic in Bloomington, Minnesota.

PATIENTS

Ninety-one of 96 eligible subjects who reported symptoms that were confirmed by clinical exam and nerve conduction studies.

INTERVENTIONS

Interventions included ibuprofen (800 mg 3 times a day for 1 wk, 800 mg twice a day for 1 wk and 800 mg as needed to a maximum daily dose of 2400 mg for 7 wk) and nocturnal wrist supports for medical treatment. Chiropractic treatment included manipulation of the soft tissues and bony joints of the upper extremities and spine (three treatments/week for 2 wk, two treatments/week for 3 wk and one treatment/week for 4 wk), ultrasound over the carpal tunnel and nocturnal wrist supports.

MAIN OUTCOME MEASURES

Outcome measures were pre- and postassessments of self-reported physical and mental distress, nerve conduction studies and vibrometry.

RESULTS

There was significant improvement in perceived comfort and function, nerve conduction and finger sensation overall, but no significant differences between groups in the efficacy of either treatment.

CONCLUSIONS

Carpal tunnel syndrome associated with median nerve demyelination but not axonal degeneration may be treated with commonly used components of conservative medical or chiropractic care.

Neuroimaging of children with partial seizures

The predictive value of abnormal neurological findings on neuroimaging (NI) of children with partial seizures (PS) was studied. The sample comprised 143 children and adolescents with PS from 1979 to 1996. Fifty patients had the following abnormal NI findings: diffuse atrophy and porencephalic cyst (5.6% each), hemiatrophy, tumors, neurocutaneous syndrome brain lesions, and dysgenesis (4.2% each), and arachnoid cyst and hydrocephalus (2.1% each). There were significantly more NI abnormalities among those with simple PS than among the other groups of complex PS or PS with secondary generalization. All cases of porencephalic cyst (n = 8), and hemiatrophy (n = 6) were in the hemiparetic group, all cases of tumor (n = 6) were in the normal group, while most cases of diffuse atrophy were in the mentally retarded group. Patients with abnormal NIs had a significantly earlier age of seizure onset than the others. The chance of finding a treatable abnormality in neuroimaging was 5% for tumors and 2% for arachnoid cysts in the group of patients with PS and normal neurological findings. Neither an abnormality detected in a neurological examination nor the type of seizure are predictive parameters for suggesting the presence of a resectable brain tumor. All patients with newly diagnosed PS should undergo an MRI.

Subspecialization, recruitment and retirement trends of American urologists

PURPOSE

Trends of urology workforce, subspecialization, recruitment practices, retirement planning, practice characteristics and managed care impacts in the United States were assessed.

MATERIALS AND METHODS

In February 1996 the executive interviewing branch of The Gallup Organization selected randomly and interviewed by telephone 507 practicing urologists in the United States who had provided urological patient care for more than 20 hours per week, practiced in 1995 and completed a urological residency program.

RESULTS

Several important issues emerged. Urologists think we may be training too many urologists, subspecialty board certification would be a divisive issue to urology as a whole and 90% of urologists have an active retirement plan, although 23% are not funding the plan fully.

CONCLUSIONS

The American Urological Association Gallup Poll, as refined by the Health Policy Survey and Research Committee, continues to be a unique and valuable tool in assessing practice patterns, gathering demographic data and measuring opinions of the American urologist. This information will help us chart our way to the twenty-first century.

The antimicrobial activity of 3,5,7-trihydroxyflavone isolated from the shoots of Helichrysum aureonitens

Extracts from Helichrysum aureonitens are used topically by the indigenous people of South Africa against infections. The antimicrobial activity-guided fractionation by bioautography of the acetone extract from the aerial parts of H. aureonitens led to the isolation of 3,5,7-trihydroxyflavone (galangin). Evaluation of the antibacterial activity of the compound against ten randomly selected bacteria indicated significant activity against all the Gram-positive bacteria tested with the minimum inhibitory concentration (MIC) ranging from 0.1 to 0.5 mg/ml. The compound was not active on Gram-negative bacteria except for Enterobacter cloacae which was significantly inhibited at an MIC of 0.1 mg/ml. Galangin indicated considerable activity against the fungi tested with the exception of Cladosporium herbarum. Penicillium digitatum and P. italicum appeared to be particularly susceptible at a concentration of 0.01 mg/ml.

Antiviral activity of galangin isolated from the aerial parts of Helichrysum aureonitens

The in vitro antiviral activity of galangin (3,5,7-trihydroxyflavone), the major antimicrobial compound isolated from the shoots of Helichrysum aureonitens, was investigated against herpes simplex virus type 1 (HSV-1), coxsackie B virus type 1 (Cox B1), adenovirus type 31 (Ad31) and reovirus. At concentrations ranging from 12-47 micrograms/ml galangin showed significant antiviral activity against HSV-1 and CoxB1, limited activity against reovirus, and no antiviral activity against Ad31.

Hippocampal acetylcholine increases during eyeblink conditioning in the rabbit

The classically conditioned rabbit nictitating membrane reflex (NMR) is modulated by the septohippocampal cholinergic system. Disruption of this system retards NMR acquisition. Aluminium (Al) is a neurotoxin that interferes with hippocampal acetylcholine (ACh) synthesis and release. Using microdialysis, this study tested the hypothesis that NMR acquisition in the rabbit is associated with hippocampal ACh release. This was conducted by measuring ACh release in control and A1-intoxicated rabbits during NMR training. NMR training consisted of four sessions of 100 conditioning trials/session in a delay paradigm. The percentage of conditioned responses (CRs) increased with each conditioning session for both groups, although percent CRs was significantly greater in the control group. Acetylcholine release in the ventral hippocampus increased significantly over baseline in the control group during the second and third conditioning sessions. In the Al-intoxicated group, ACh release did not increase significantly during any conditioning session. A separate group of rabbits was pseudoconditioned, receiving the same conditioning stimuli, although explicitly unpaired. This group did not acquire the CR. Acetylcholine release did not significantly increase during any conditioning session, suggesting that the increase in ACh release observed in the control group was not merely a product of conditioning stimuli presentation. The lack of increased ACh release in the Al-intoxicated rabbits was associated with a CR acquisition deficit. The results of this study are consistent with a role of hippocampal cholinergic function in NMR acquisition in the rabbit.

Antibacterial activity of Helichrysum pedunculatum used in circumcision rites

Antibacterial assays of Helichrysum pedunculatum showed that dichloromethane extracts are active against all the gram positive bacteria tested, as well as two gram negative bacteria, Enterobacter cloacae and Serratia marcescens. A water extract was effective against Staphylococcus aureus and Micrococcus kristinae, while a methanol extract showed no activity against any of the tested organisms. The antibacterial activity of dichloromethane extract was also investigated by direct bioassay on TLC plates against S. aureus.

Inhibition of herpes simplex virus type 1 by aqueous extracts from shoots of Helichrysum aureonitens (Asteraceae)

Helichrysum aureonitens, a southern African medicinal plant reported to have antibacterial properties, was evaluated for antiviral activity against herpes simplex virus type 1 (HSV-1) in vitro. The crude aqueous extract from shoots of H. aureonitens at a concentration of 1.35 mg/ml (w/v) showed significant antiviral activity on HSV-1 in human lung fibroblasts as demonstrated by the absence of a cytopathic effect.

Paraneoplastic encephalomyelitis in a child with neuroblastoma

We present the case of a 12-year-old boy who developed progressive limbic dysfunction associated with a posterior cord syndrome in conjunction with complex partial seizures and intrathecal synthesis of IgG. Although the cerebral CT scan appeared normal, MR imaging showed signal abnormalities in both temporal lobes. As these clinical features reminded us of the well-known paraneoplastic encephalomyelitis (PNEM) in adults, we looked for a tumour and found a pelvic neuroblastoma. The diagnosis of PNEM was supported by the discovery of the antibody anti-HU in the serum of our patient.

Chiropractic care, including craniosacral therapy, during pregnancy: a static-group comparison of obstetric interventions during labor and delivery

OBJECTIVE

To determine whether the addition of chiropractic care including craniosacral therapy to a regimen of standard obstetric pregnancy results in fewer obstetric interventions during labor and delivery.

DESIGN

Retrospective, case-matched, static-group comparison.

SETTING

The study group was obtained from a college faculty-based clinic and received chiropractic care in addition to their routine obstetrical care. The setting for the comparison group was unkown, but the care rendered was presumed to be primary medical obstetric care only.

PATIENTS

A consecutive sample of 63 pregnant women who sought chiropractic care within the period under study. The reason for seeking care was not necessarily related to the pregnancy. The sample was primarily between 18 and 35 yr, non-Hispanic caucasian and primiparous. After selection and matching criteria, 35 patients remained in the study group.

INTERVENTION

Chiropractic care and craniosacral therapy delivered during pregnancy vs. unknown care within the same county.

MAIN OUTCOME MEASURES

Obstetric interventions during labor and delivery as reported by the birth attendant on the certificate of live birth.

RESULTS

No statistical differences were detected in the rates of obstetric interventions used during labor or delivery between the two samples. Approximate large-sample 95% confidence intervals are provided.

CONCLUSION

Because of the limitations in the design of the project, this study provides no evidence that the addition of chiropractic care and craniosacral therapy during pregnancy results in any observable benefit or detriment with regard to obstetric interventions used during labor and delivery and that chiropractic care for pregnancy-related neuromusculoskeletal disorders should not complicate labor or delivery.

Delayed elevation of platelet activating factor in ischemic hippocampus

We used in vivo microdialysis to define the chronological relationship between release of thromboxane and platelet activating factor (PAF) into the extracellular space of ischemic hippocampus. The thromboxane level peaked after 20 min of postischemic reperfusion, followed by a delayed PAF response 120 min later. We conclude that cerebral ischemia causes delayed elevation of PAF in the extracellular space, long after the immediate synthesis and release of thromboxane metabolites.

Antibacterial activity of Helichrysum aureonitens (Asteraceae)

The antibacterial activity of extracts from Helichrysum aureonitens was investigated. The dichloromethane extract was active against all five gram positive bacteria tested and the methanol extract was active only against Bacillus cereus, B. pumilus and Micrococcus kristinae, while the water extract had no activity against any of the organisms. None of the extracts inhibited the growth of the five gram negative bacteria tested.

Studies of aluminum neurobehavioral toxicity in the intact mammal

1. Aluminum (Al) has been implicated in neurotoxic syndromes in several conditions, including Alzheimer's disease (AD). The developmental stage of the mammalian brain most susceptible to Al was determined in rabbits systematically exposed to Al during the prenatal, postnatal, or second month or for 1 month as adults or as aged subjects. Eyeblink reflex classical conditioning showed an Al-induced learning deficit only in the adult and aged rabbits. 2. 4-Aminopyridine, which was reported to improve learning in AD subjects, attenuated the Al-induced learning deficit. 3. Conditioned eyeblink acquisition is slower in AD subjects than controls, supporting the Al-loaded rabbit as a model of some AD effects. 4. To determine if the Al-loaded rabbit modeled the AD cholinergic deficit, acetylcholine (Ach) overflow was measured in rabbit hippocampus using microdialysis. Aluminum pretreatment reduced basal and potassium-stimulated Ach overflow compared to controls. 5. Acetylcholine overflow increased as control rabbits acquired the conditioned eyeblink reflex, then subsequently decreased, although conditioned eyeblink performance continued. In contrast, Al-loaded rabbits showed a delay in conditioned eyeblink acquisition and greatly attenuated Ach overflow. The Al-induced attenuation of Ach overflow may contribute to the Al-induced learning deficit. 6. Brain Al entry was studied using microdialysis of blood, brain, and lateral ventricle. Aluminum rapidly entered the brain and lateral ventricle. Frontal cortical Al was greater than lateral ventricular Al, suggesting that Al primarily enters the brain through the cerebral microvasculature. 7. The brain/blood Al ratio was always significantly less than 1. This ratio was influenced by the Al form administered, brain site and animal species. Thus, there appears to be an active process moving Al out of brain extracellular fluid (ECF). 8. Brain and blood dialysate Ach concentrations were not different after cyanide addition to the dialysate, supporting the conclusion that an active process moves Al out of brain ECF.

The validity of thoracolumbar paraspinal scanning EMG as a diagnostic test: an examination of the current literature

OBJECTIVE

The purpose of this literature review was to assess the current validity of thoracolumbar paraspinal scanning EMG as practiced by the chiropractic profession within the context of adequate and acceptable epidemiological standards for validating a new diagnostic test.

DATA SOURCES, STUDY SELECTION AND DATA EXTRACTION

Sources for the primary literature citations were obtained from several indexing services (MEDLINE--April 1993 to 1989; Index to Chiropractic Literature--1991 to 1980, Chiropractic Research Archives Collection--Vol. I-IV and Chiropractic Literature Analysis and Retrieval System) and hand searched under the subject heading of electromyography. For MEDLINE this was combined with electromyography as a title/abstract word and limited to "human." Primary literature citations were included in this review if the author, institution or journal was associated with the chiropractic profession and the paper dealt with thoracolumbar scanning EMG. Thirty-seven primary publications were identified and were systematically evaluated for contribution to any of the twelve key criteria used to validate a new diagnostic test. Secondary or tertiary citations from all sources were included if referenced in the primary literature as previous investigations supporting one of the key criteria. Additional secondary sources were included providing that the author was aware of them and the subject matter was germane to the EMG subtopic.

DATA SYNTHESIS

Based upon this review, none of the 12 key criteria used to validate a new diagnostic test have been adequately satisfied.

CONCLUSIONS

It is concluded that thoracolumbar paraspinal scanning EMG is premature for clinical application as a paraclinical diagnostic test. Recommendations for evaluation directions in the immediate future are provided.

[Endobronchial mass caused by tuberculosis]

A 2-year-old girl who presented with cough, had been started on prednisone and bronchodilators 10 days prior to admission because of presumed hyperactive, small airway obstruction. Fluoroscopy revealed hyperinflation of the right lung and mediastinal shift to the left on expiration. Bronchoscopy disclosed an endobronchial mass. At that time the tuberculin test was negative. Since such lesions are rare in young children, thoracotomy was performed. An enlarged mediastinal lymph node was removed and the histopathological findings were suggestive of tuberculosis. The tuberculin test 1 month following prednisone therapy was positive, suggesting that previously the skin reaction to tuberculin had been altered by the prednisone. Tuberculosis should be considered in the differential diagnosis of an endobronchial mass even in an otherwise apparently healthy child.

Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality: Part II

OBJECTIVE

The objectives of this study were to assess the interexaminer agreement of palpation for soft tissue and osseous pain along with visual observations in the lumbar spine. Second, the interexaminer agreement of dermothermograph and surface electromyographic (EMG) scans of the lumbar spine were assessed. Third, to perform these evaluations on symptomatic low back patients. Finally, the most reliable measurements were combined in a multidimensional index of segmental lumbar abnormality, which was assessed for interexaminer agreement.

DESIGN

This is an interexaminer reliability study of commonly used palpatory and instrumentation procedures used to assess lumbar segmental abnormality.

SETTING

This study was conducted at Pain Assessment and Rehabilitation Center (PARC) and the Center for Clinical Studies (CCS) at Northwestern College of Chiropractic.

PATIENTS

The patients involved in this study were symptomatic at the time of examination. The patients were recruited from the CCS clinic and PARC.

RESULTS

Palpation for osseous pain produced kappa coefficients ranging from .48-.90. Palpation for soft tissue pain produced kappa coefficients that ranged from .40-.79 and the kappas for visual observation ranged from .34-.84. The dermothermograph and surface EMG scanner were also assessed with the kappa coefficient for their reliability in assessing lumbar segmental abnormality. The kappa coefficients ranged from -.13 to .59 for the surface EMG and 0- .63 for the dermothermograph measurements. Intraclass correlation coefficients for the surface EMG measurements ranged from .20-.55 and the dermothermograph measurements ranged from .01-.55. Palpation for pain (osseous and soft tissue) and visual observation were included in the multidimensional index of abnormality. The interexaminer agreement of detecting a manipulable lesion was evaluated by designating a lesion present with a positive two out of three tests. Kappa coefficients for the multidimensional index of lumbar abnormality ranged from a low of .05 to a high of .52.

CONCLUSIONS

Palpation for pain (osseous and soft tissue) and visual observation produced good to excellent interexaminer agreement and were included in the multidimensional index of abnormality. The interexaminer agreement of surface EMG scans and dermothermograph measurements were poor and considered to be clinically unacceptable, thus were not included in the multidimensional index. Palpation for pain is the only spinal assessment procedure to show consistent reliability in a number of studies.

Recruitment patterns in the cervical paraspinal muscles during cervical forward flexion: evidence of cervical flexion-relaxation

The phenomenon of lumbar paraspinal flexion-relaxation has been well established and its clinical significance to low back pain has been demonstrated. Conversely, cervical paraspinal flexion-relaxation has not been consistently observed. This may be attributable to the inappropriate use of trunk flexion motion used to observe the phenomenon in previous studies. This investigation reports on the observance of cervical flexion-relaxation when flexion is limited to the cervical spine. Results demonstrate the observance of cervical flexion-relaxation in ten of ten asymptomatic subjects when flexion is limited to the cervical region in the seated orthograde position.

Hollow bone in the bronchus or the danger of chicken soup

A 6-month-old infant arrived at the emergency room with severe respiratory distress after being spoon-fed chicken soup. Air entry was normal, chest X-rays were normal, and bronchoscopy revealed a hollow chicken bone lining the whole left main bronchus.

Experimental nephrotoxicity of the radiocontrast agents iohexol, ioxaglate, and iothalamate. An in vitro and in vivo study

The authors compared the renal toxicity of the low osmolality radiocontrast agents, iohexol and ioxaglate, and the ionic agent, iothalamate, at equivalent iodine dose, using experimental models in vitro and in vivo. In isolated perfused rat kidneys, all agents induced comparable biphasic hemodynamic changes, associated with similar declines in glomerular filtration rate (GFR) and tubular necrosis. In two different in vivo models (using multiple insults combined with the administration of radiocontrast), iothalamate appeared to induce more severe morphologic injury. Despite similar nephrotoxic potential in vitro, the newer radiocontrast agents, iohexol and ioxaglate, cause in vivo less renal injury than iothalamate in the experimental models.