Feasibility study of integrated ePROs in routine care during radiation therapy for head and neck cancer

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Background: Use of electronic Patient Reported Outcomes (ePRO) tools in the routine care of cancer patients remains challenging despite data showing that they can improve resource utilization and patient outcomes. Patients with head and neck cancer during intensive therapy with radiation therapy (RT) may particularly benefit from interventions focused on early symptom management. Methods: 34 patients with head and neck cancer were enrolled in an implementation study and received ePROs integrated within the electronic medical record (EMR) weekly during radiation therapy (RT) within a large integrated health care delivery system. ePROs consisted of the FACT G7 and FACT-HN. After completion of each survey on the patient portal, a radiation oncology RN documented any abnormal findings and subsequent interventions using a standardized format within the EMR. If patients did not have access to the patient portal or had language barriers, they could complete ePROs with a translator by phone or video. Results: Between January and December of 2021, 34 patients with head and neck cancer receiving curative RT were enrolled. The median age 65 years (range 46-84). 74% of patients were male. 59% were white, 26% Asian/PI, 5% Black, and 5% Hispanic. The most common primary cancer sites were: oropharynx (32%), nasopharynx (24%), larynx (18%), oral cavity (9%). 65% of patients received concurrent chemotherapy with RT and 35% received RT alone. 97.4% of patients had access to the online portal. The total number of surveys completed was 194 with a median of 7 per patient (range 1-8). There was a total of 887 abnormal findings reported and 887 documented and corresponding interventions resulting in a 100% intervention rate. Over the course of RT the mean number of abnormal findings increased from 2.26 at baseline (n = 34) to 6.27 at week 7 (n = 24), P < 0.0001. Hospitalizations and Emergency Department (ED) visit data were collected during the study and up to 30 days from last day of RT. There was a total of 2 hospitalizations and 8 ED visits. Conclusions: ePROs integrated within the patient portal and EMR are feasible during RT for patients with head and neck cancer within a large integrated health care system. The use of ePROs integrated within the patient portal and EMR can lead to a high rate of intervention. The increasing number of abnormal findings on ePRO during intensive treatment for head and neck cancer is consistent with known patterns of toxicity and confirm the value of studying methods for improving quality of life in this patient population.[Table: see text]

Long-term treatment of chronic venous insufficiency of the leg with micronized purified flavonoid fraction in the primary care setting of India

Objective: This study investigates whether micronized purified flavonoid fraction (MPFF) is effective and acceptable without compression or surgical intervention for the management of chronic venous insufficiency of the leg (CVIL) in the primary care setting of a tropical country such as India.

Methods: A prospective observational study on patients with early CVIL drawn from the clinical practice of randomly selected physicians distributed across India. Patients received MPFF 1000 mg/day for six months without compression stockings or surgery. The primary outcome was a change in their CEAP (clinical, aetiological, anatomical, pathophysiological) classification of CVIL severity. Secondary outcomes were changes in leg oedema, symptom intensity and quality of life.

Results: Of the 308 patients recruited by 72 physicians, 166 (53.9%, 95% confidence interval (CI) 48.3-59.5) had regression in the CEAP severity stage. Mean leg circumference in those with oedema decreased by 2 cm (95% CI 1.7-2.3, P <0.05). Patient-assessed mean percentage decrease in symptom intensity was 32.3 for cramps (28.9-35.7, P <0.01); 32.4 for heaviness (29.8-35.7, P <0.01); 28.2 for pain (25.6-30.8, P <0.01); and 21.5 for swelling (18.7-24.3, P <0.01). Quality of life improved by 21.7% (16.9-26.5, P <0.01) in the physical domains, 25.9% (20.8-31.0, P <0.01) in the social domains, and 19.2% (14.7-23.7, P <0.01) in the psychological domains.

Conclusions: When used alone, MPFF was effective and acceptable for the management of CVIL in primary care. This may be useful in tropical climates where compliance with compression stockings is poor and access to surgery limited.

Test day variability in yield and composition of Surti and Mehsani buffaloes milk at day 15 and 60 postpartum

Aim:

To estimate individual test day variability in yield and composition of Surti and Mehsani buffaloes milk at day 15 and 60 postpartum (pp).

Materials and Methods:

A total of 13 normally calved Surti and Mehsani buffaloes each maintained at Livestock Research Stations of Navsari and Sardarkrushinagar Dantiwada Agricultural Universities, respectively, were selected for the study. Milk sample was collected from each selected buffalo at day 15 and 60 pp to study milk yield and composition variability between these two breeds. Buffaloes were categorized for the ease of data analysis and comparisons into four groups, viz., S15 (Surti buffaloes 15^th day pp), S60 (Surti buffaloes 60^th day pp), M15 (Mehsani buffaloes 15^th day pp), and M60 (Mehsani buffaloes 60^th day pp).

Results:

There were 37.20% and 25.03% significant (p≤0.05) increase in mean test day milk yield (TDMY) of S60 and M60 as compared to S15 and M15 groups, respectively. The mean TDMY of Mehsani buffalo was 99.19% and 81.53% significantly (p≤0.05) higher than Surti buffaloes at day 15 and 60 pp, respectively. The mean fat and protein corrected test day milk yield (FPCTDMY) of all the groups was found to be significantly different (p≤0.05) from each other. There was significant (p≤0.05) increase of 1.94 and 3.45 kg in mean FPCTDMY with the progression of lactation between day 15 and 60 pp in Surti and Mehsani buffaloes, respectively. Similarly, the mean FPCTDMY of Mehsani buffaloes were approximately double with 103.27% and 96.36% higher yield as compared to Surti buffaloes at day 15 and 60 pp, respectively. Among milk composition, significant differences were observed for solid not fat (SNF) and protein%, whereas fat and lactose% were steady among four groups. The only significant (p≤0.05) difference was observed for SNF in M60 group, which was 8.29%, 6.85%, and 10.70% higher as compared to S15, S60, and M15 groups, respectively. The mean protein% in milk of Mehsani buffaloes was 21.01% and 33.05% significantly (p≤0.05) higher than Surti buffaloes milk at day 15 and 60 pp, respectively. However, there was a significant difference in protein% observed with the advancement of lactation in Mehsani buffaloes, but it was not so in the case of Surti buffaloes.

Conclusion:

Major consistent finding of the present study reveals that milk yield and protein% of Mehsani buffalo was significantly higher than Surti buffalo at day 15 and 60 pp.

Comparative efficacy of anthelmintics and their effects on hemato-biochemical changes in fasciolosis of goats of South Gujarat

Aim:

Fasciolosis is a parasitic disease caused by Fasciola spp. of the family Fasciolidae (trematodes) characterized by bottle jaw, anemia, progressive debility, and potbelly condition. There are many aspects of fasciolosis remaining unknown thus hemato-biochemical alterations in closantel, triclabendazole + ivermectin, and oxyclozanide + levamisole treated goats were studied.

Materials and Methods:

A total of 40 naturally fasciolosis infected goats having egg per gram more than 100 were randomly divided into four groups. Goats of Group I-III were treated with three different anthelmintics, whereas, goats of Group-IV were kept as control or untreated. Whole blood, serum, and fecal samples were collected on 0, 7^th, and 30^th day of treatment.

Results:

During the study, values of hemoglobin, total erythrocyte count, pack cell volume, and total protein were significantly elevated to their normal levels in anthelmintics treated groups. Whereas, values of total leukocyte count, aspartate transaminase (AST), lactate dehydrogenase (LDH), and gamma-glutamyl transferase (GGT) were significantly reduced to their normal level in anthelmintics treated groups. The efficacy of closantel (T1), triclabendazole + ivermectin (T2), and oxyclozanide + levamisole (T3) was 99.63%, 100%, and 94.74% and 100%, 100%, and 97.38% on 7^th and 30^th day of treatment, respectively.

Conclusions:

Fasciolosis in goats can be diagnosed on the basis of fecal sample examination, but alterations in important biomarkers such as AST, GGT, and LDH are also helpful for early diagnosis. The use of newer anthelmintic either alone or in combination showed a higher therapeutic response in fasciolosis of goats.

Effect of sugar beet tubers as a partial replacer to green fodder on production performance and economics of lactating Surti buffaloes in lean period

Aim:

The objective of this study was to evaluate the effects of sugar beet tubers as a replacer to green fodder on production performance and economics of lactating Surti buffaloes.

Materials and Methods:

This trial was conducted at the Livestock Research Station, Navsari Agricultural University, Navsari. Twenty lactating Surti buffaloes in a changeover experimental design were selected to assess the effects of replacing green fodder with sugar beet (Beta vulgaris L.) tubers on production performance, economics of feeding sugar beet and blood biochemical profile. Half (50%) of the hybrid Napier was replaced with sliced sugar beet tubers in the ration of experimental animals.

Results:

Partial replacement of hybrid Napier with that of sugar beet tubers numerically improved dry matter intake, milk yield, 4% fat corrected milk and milk composition parameters such as fat, solid non-fat, protein and lactose, but not significantly. The blood parameters were in normal range and non-significant except that of glucose and triglycerides, which were increased in the sugar beet group. Replacing sugar beet tubers also proved to be cost-effective with improved net profit around Rs. 6.63/day.

Conclusion:

It can be concluded that 50% hybrid Napier fodder can be replaced with sugar beet tubers without any adverse effect on animal production performance, milk composition blood biochemical profile and economics of feeding.

Why don't elderly hospital inpatients eat adequately?

BACKGROUND

Malnutrition is common among older hospital patients and contributes to poor clinical outcomes. Poor intake among this group of patients could be due to a variety of factors.

OBJECTIVE

To better understand the causes and consequences of inadequate food intake among hospitalised elderly patients, specifically: to determine (i) the prevalence of factors contributory to inadequate food intake, (ii) the relationship of these factors to nutritional status and course of hospital stay.

DESIGN

A longitudinal observational study of a convenience sample.

SETTING

Inpatients of an inner city elderly care unit in the UK.

METHODS

One hundred patients (mean 81.7 years (sd 7.2);27 male,73 female) were observed twice weekly, from admission to discharge/maximum of 4 weeks. Anthropometric assessments of nutritional status were made on admission and discharge. At each visit, adequacy of intake in the preceding 24-hour period, and reasons for inadequate intake, were determined using nurse observations, food-charts, case-notes, and interviews of patients/carers. With all available information, adequacy was estimated whether the subject had consumed at least three-quarters of their standard diet along with any prescribed food supplements. Inadequate nutritional intake was defined as completing less than this amount.

RESULTS

On admission, 21 patients were malnourished [below the 10th percentile for demiquet (weight/demispan2) for males or mindex (weight/demispan) for females. Three patients became malnourished during their stay. At 285/425 assessments (67%), patients were judged to be eating inadequately. Acute illness, anorexia, catering limitations and oral problems were the most prevalent reasons for inadequate intake during the earlier part of patients' hospital stay. Confusion, low mood and dysphagia remained prevalent throughout. Compared to well-nourished patients (n=67), malnourished patients (n=24) had higher prevalence of oral problems (22%v6%;p<0.001), mood/anxiety disturbances (33% v 19%;p=0.02), anorexia (38% v 23%;p=0.02) and catering limitations (34% v 12%;p<0.001), but lower prevalence of dysphagia (4% v 13%,p=0.015). Of 51 patients in hospital for less than 10 days, 36 were eating inadequately.

CONCLUSION

Reasons for inadequate intake vary according to stage of hospital stay and nutritional status. Inadequate intake in the early stage after admission is mainly due to self-limiting temporary factors associated with acute illness.

Clinical determinants of long-term quality of life after stroke

OBJECTIVES

To determine factors that independently predict health-related quality of life (HRQOL) 1 and 3 years after stroke.

METHODS

Subjects numbering 397, from a population-based register of first-ever strokes were assessed for HRQOL using the Short Form 36 (SF36) 1 year after stroke. Physical (PHSS) and mental health (MHSS) summary scores were derived from the eight domains of HRQOL in the SF36. Multivariate stepwise regression analyses were conducted to determine independent predictors of these scores; beta coefficients with 95% CI were obtained.beta coefficient is the difference between average value of the variable (e.g. male) and average value under consideration (e.g. female). Demographic and stroke risk factors, neurological impairments and cognitive impairment (MMSE <24) were included in the models. Similar analyses were undertaken on 150 subjects 3 years post-stroke.

RESULTS

A year after stroke, independent predictors of the worst PHSS were of females (beta coefficient -3.3: 95% CI -5.7 to -0.8), manual workers (-3.2: -5.9 to -0.4), diabetes (-4.2: -7.7 to -0.8), right hemispheric lesions (-4.9: -8.7 to -1.2), urinary incontinence (-7.8: -11.6 to -4.1) and cognitive impairment (-2.7: -5.5 to -0.1); the worst MHSS were associated with being Asian (-11.8: -20.6 to -3.0), ischaemic heart disease (-2.7: -5.4 to -0.03), cognitive impairment (-3.04: -5.8 to -0.3). Subjects aged 65-75 years (5.4: 2.5 to -8.4) had better MHSS than those <65 years. Three years post-stroke, independent predictors of worse PHSS were hypertension (-8.7: -13.5 to -3.9), urinary incontinence (-8.1: -15 to -1.1) and cognitive impairment (-8.3: -13.2 to -3.5).

CONCLUSIONS

Determinants of HRQOL vary both over time after stroke and whether physical or psychosocial aspects of HRQOL are being considered. This study provides valuable information on factors predicting long-term HRQOL, which can be taken into consideration in audits of clinical practice or in future interventional studies aiming to improve HRQOL after stroke.

Relationships between long-term stroke disability, handicap and health-related quality of life

OBJECTIVES

To estimate levels of disability, handicap and health-related quality of life (HRQOL) up to 3 years after stroke and examine the relationships between these domains.

DESIGN

A longitudinal, observational study

SETTING

Population-based register of first-ever strokes

METHODS

Subjects, registered between 1 January 1995 and 31 December 1997, were assessed at 1 year (n = 490) and 3 years (n = 342) post-stroke for disability [Barthel index (BI)], handicap [Frenchay activity index (FAI)] and HRQOL (SF-36). BI was categorised as severe, moderate, mild and independent (0-9, 10-14, 15-19 and 20); FAI was categorised as inactive, moderately active and very active (0-15, 16-30 and 31-45). SF-36 domains include: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). Physical (PHSS) and Mental Health (MHSS) Summary Scores were computed.

RESULTS

at 1 and 3 years, 26.1 and 26.3%, respectively, were disabled (BI < 15); 55 and 51%, respectively, were handicapped (FAI = 0-15); and survivors had low mean PHSS (37.1 and 37.9), but satisfactory mean MHSS (46.6 and 47.7). There was a graded positive relationship between all SF-36 domains and the categories of BI and FAI. Spearman rank correlations were significant between BI and all SF-36 domains at both time points: strong (r > 0.70) with PF, moderate (r = 0.31-0.70) with RP, SF and PHSS, but weak (r < 0.30) with other domains. Correlations between FAI and SF-36 domains were strong with PF, weak with BP, RE and MHSS, and moderate with other domains.

CONCLUSIONS

Disability and handicap remain highly prevalent up to 3 years after stroke. Patients' perception of physical health is persistently low, but mental health perception is satisfactory up to 3 years. Due to variable correlations between different HRQOL domains with disability and handicap, it is suggested that disability, handicap and HRQOL should all be assessed to acquire a broader measure of stroke outcome.

Microarray analysis of gene regulation by oxygen, nitrate, nitrite, FNR, NarL and NarP during anaerobic growth of Escherichia coli: new insights into microbial physiology

RNA was isolated from cultures of Escherichia coli strain MG1655 and derivatives defective in fnr, narXL, or narXL with narP, during aerobic growth, or anaerobic growth in the presence or absence of nitrate or nitrite, in non-repressing media in which both strain MG1655 and an fnr deletion mutant grew at similar rates. Glycerol was used as the non-repressing carbon source and both trimethylamine-N-oxide and fumarate were added as terminal electron acceptors. Microarray data supplemented with bioinformatic data revealed that the FNR (fumarate and nitrate reductase regulator) regulon includes at least 104, and possibly as many as 115, operons, 68 of which are activated and 36 are repressed during anaerobic growth. A total of 51 operons were directly or indirectly activated by NarL in response to nitrate; a further 41 operons were repressed. Four subgroups of genes implicated in management of reactive nitrogen compounds, NO and products of NO metabolism, were identified; they included proteins of previously unknown function. Global repression by the nitrate- and nitrite-responsive two-component system, NarQ-NarP, was shown for the first time. In contrast with the frdABCD, aspA and ansB operons that are repressed only by NarL, the dcuB-fumB operon was among 37 operons that are repressed by NarP.

Endometriomas: diagnostic performance of US

PURPOSE

To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses.

MATERIALS AND METHODS

Two sonologists independently reviewed the sonograms of 252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated.

RESULTS

There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%).

CONCLUSION

An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.

Cystic teratomas of the ovary: diagnostic value of sonography

OBJECTIVE

This study was undertaken to determine if the diagnosis of cystic teratomas of the ovary can be made by experienced sonologists using only specific associated sonographic features.

MATERIALS AND METHODS

Two sonologists independently reviewed the sonograms of 252 adnexal masses. For each mass, each sonologist recorded sonographic features using a standardized checklist, which included four descriptions associated with cystic teratomas. From a list of diagnostic possibilities, each reviewer chose one specific conclusion, with emphasis on achieving the highest combination of sensitivity and positive predictive value for any particular diagnosis. The sensitivity, positive predictive value, and positive likelihood ratio for the diagnosis of cystic teratoma were evaluated for each sonographic finding and for each sonologist's interpretation.

RESULTS

Of the 252 masses, 74 cystic teratomas were found, 55 of which showed two or more associated sonographic features. Each reviewer had a 98% positive predictive value with 85% sensitivity for the diagnosis and identification of cystic teratomas (positive likelihood ratio = 152). The positive predictive value was 100% when an adnexal mass had two or more sonographic features associated with dermoid masses. The positive predictive value for individual sonographic features associated with dermoid masses was 80% for a shadowing echodensity, 75% for regionally bright echoes, 50% for hyperechoic lines and dots, and 20% for a fluid-fluid level.

CONCLUSION

An adnexal mass showing two or more of the sonographic features associated with cystic teratomas can be confidently diagnosed as a cystic teratoma.

Development and evaluation of the Osteoporosis Self-Efficacy Scale

The Osteoporosis Self-Efficacy Scale was developed as a measure of self-efficacy, or confidence, for behaviors related to physical activity and calcium intake. An item pool of 21 statements, responded to on a visual analog self-report format, was reviewed by a panel of expert judges. The revised item stems were tested with a sample of 201 women, ages 35 to 95. Concurrent data on sport, leisure, and exercise activity and calcium in diet and dietary supplements were collected from the respondents. Factor analysis of responses to the self-efficacy items revealed a logical, theoretically meaningful two-factor structure, one for physical activity and one for calcium intake. Internal consistency estimates for each of the two factors were in the .90s. Convergent and discriminant validity analyses as well as hierarchical regression analyses to explain self-reports of physical activity and calcium intake were supportive. The final version of the brief, psychometrically sound scale contains items reflecting initiation, maintenance, and persistence at osteoporosis preventive behaviors; thus, the Osteoporosis Self-Efficacy Scale is a potentially beneficial research instrument.

Recombinant human monoclonal antibody IgG1b12 neutralizes diverse human immunodeficiency virus type 1 primary isolates

The CD4-binding domain of human immunodeficiency virus type 1 (HIV-1) gp120 elicits antibodies that are present in infected human sera. Monoclonal antibodies that recognize the HIV-1 gp120 CD4-binding domain have been isolated. Some of these antibodies can neutralize laboratory-adapted strains of HIV-1 and probably mediate neutralization by interfering with virus binding to its cellular CD4 receptor. However, most anti-CD4 binding domain antibodies do not neutralize primary HIV-1 isolates. We used primary HIV-1 isolates in an infectivity reduction assay to test the uniquely derived anti-CD4 binding domain recombinant human monoclonal antibody, IgG1b12. All of the tested HIV-1 isolates were neutralized by this antibody. Additional studies indicated that neutralization of a primary isolate with MAb IgG1b12 did not require continuous exposure of human peripheral blood mononuclear cell cultures to the antibody. Finally, a complete IgG1 molecule of an in vitro-selected b12 FAb mutant with a > 400-fold increase in affinity was assembled, expressed in mammalian cells, and evaluated in the infectivity reduction assay in comparative studies with the parent IgG1b12 antibody. The mutant did not retain the level of primary isolate neutralization potency that was a property of the parent molecule. Thus, we confirm that recombinant IgG1b12 has a unique specificity, and that it can neutralize all primary isolates tested in human PBMC cultures in vitro.

Evaluation of a sonographic PACS in clinical practice: analysis of technical and analytical time savings

The aim of this study was to generate quantitative data regarding technical and analytical time savings obtained by use of an ultrasonographic PACS. Data/time cards were recorded for each patient encountered in an outpatient diagnostic ultrasound facility for a 4 week period immediately before and a 1 year period after installation of a PACS environment. Use of a sonographic PACS resulted in a per case time savings of 293 s in the technical component and 51 to 63 s in the analytical component of an average ultrasonographic examination. We conclude that use of a PACS workstation has the potential to increase productivity for both the sonographer and the radiologist.

Transjugular intrahepatic portosystemic shunts: accuracy of Doppler US in determination of patency and detection of stenoses

PURPOSE

To evaluate the accuracy of Doppler ultrasonography (US) in determination of patency and detection of stenosis in transjugular intrahepatic portosystemic shunts (TIPS).

MATERIALS AND METHODS

Retrospective review was performed of 251 Doppler sonograms obtained in 79 patients who underwent TIPS placement. Sonograms were evaluated for (a) the presence of a spectral waveform or color flow signal within the shunt, (b) the maximum peak flow velocity (Vmax) measured at the midportion of the TIPS, and (c) the direction of intraparenchymal portal venous flow. Independent review was performed of 116 transjugular portal venograms obtained after TIPS placement.

RESULTS

Doppler US showed TIPS occlusion in 25 of 26 (96%) cases and confirmed patency in 192 of 193 (99%) cases. Low Vmax within the TIPS (< 50 cm/sec) correlated to a diameter stenosis of 50% or greater at angiography in 25 of 32 (78%) stenotic cases and was not present in 71 of 72 (99%) cases in which no hemodynamically significant stenosis was seen. An interval change in direction of intraparenchymal portal venous flow from hepatofugal to hepatopetal was seen in association with TIPS stenoses in all stenotic cases and was not found in 24 of 26 (92%) cases in which stenosis was not seen.

CONCLUSION

Doppler US allows accurate determination of TIPS patency. A Vmax of 50 cm/sec or less within the shunt and interval change from hepatofugal to hepatopetal intraparenchymal portal venous flow are reliable indicators of stenosis.

Microabscesses of the liver and spleen in AIDS: detection with 5-MHz sonography

PURPOSE

To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency syndrome (AIDS).

MATERIALS AND METHODS

Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination.

RESULTS

The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans.

CONCLUSION

In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.

Homozygous achondroplasia: US distinction between homozygous, heterozygous, and unaffected fetuses in the second trimester

PURPOSE

To determine if and at what gestational age prenatal ultrasonography (US) enables distinction between homozygous, heterozygous, and unaffected fetuses when both parents have heterozygous achondroplasia.

MATERIALS AND METHODS

Serial US scans of 15 fetuses at 25% risk of homozygous achondroplasia were reviewed retrospectively. Femoral growth curves were established and compared with published standards to determine the gestational age, calculated according to biparietal diameter (BPD), at which femoral length crossed below the 3rd percentile. The presence and severity of achondroplasia were determined clinically after birth.

RESULTS

Femoral length crossed the 3rd percentile at 14.0-16.5 weeks BPD age (mean, 15.6 weeks) in the four homozygous fetuses and at 18.2-26.2 weeks BPD age (mean, 21.5 weeks) in the eight heterozygous fetuses. In the three unaffected fetuses, femoral length did not cross percentiles as gestational age increased.

CONCLUSION

Establishment of a femoral growth curve in the second trimester with serial US scans enables prenatal distinction between homozygous, heterozygous, and unaffected fetuses when both parents have heterozygous achondroplasia.

Lateral ventricular effacement as an isolated sonographic finding in premature infants: prevalence and significance

OBJECTIVE

The sonographic finding of effaced lateral ventricles in premature infants, defined as the absence of visible CSF within the lateral ventricles on both coronal and sagittal sonograms, may be cause to suspect diffuse cerebral edema, especially as published reference standards do not address this phenomenon. This investigation was undertaken to determine the prevalence and significance of effaced lateral ventricles without associated parenchymal abnormality (isolated lateral ventricular effacement, or ILVE) in premature infants.

MATERIALS AND METHODS

Sonographic records of 398 consecutive newborns examined from January 1 to December 31, 1993, were reviewed retrospectively to identify those premature infants (< 36 weeks of gestational age) whose initial sonograms showed no evidence of intracranial hemorrhage, ventriculomegaly, structural abnormality, or abnormal parenchymal echogenicity. We identified 142 neonates who met these criteria. Patients were separated into two groups on the basis of whether they had at least one sonographic study in which CSF was not visible within both lateral ventricles on coronal and sagittal images. Medical records were reviewed to assess neurologic outcome.

RESULTS

Forty patients (28%) had at least one sonogram demonstrating ILVE, with neurologic follow-up in 33 (representing group A). One hundred two patients (72%) never demonstrated ILVE, with neurologic follow-up established in 86 (representing group B). A comparison of the two groups showed no significant difference in the development of ischemic injury (one patient in each group). ILVE was first detected on the initial sonogram obtained (mean, 4 days) in 30 of the 33 neonates in group A. ILVE was demonstrated beyond the seventh day of life in 30%. Of the 89 patients whose initial sonograms showed CSF in the lateral ventricles (86 in group B and three in group A), three (3%) subsequently had sonograms that showed ILVE; all three were normal at follow-up.

CONCLUSION

ILVE in premature infants is common and not associated with neurologic deficits indicative of hypoxic-ischemic encephalopathy. By itself, ILVE is not a significant finding.

Fetal cerebral ventricular atrium: difference in size according to sex

PURPOSE

To determine whether the diameter of the fetal lateral ventricular atrium is larger in male than in female fetuses.

MATERIALS AND METHODS

The atrial diameter in 219 fetuses retrospectively identified from a consecutive group of healthy newborns was measured without knowledge of the subject's sex.

RESULTS

Atrial size demonstrated a near-normal distribution, with mean size for all subjects 6.1 mm +/- 1.3 (standard deviation). When separated by sex, the mean atrial diameter of 122 female fetuses was 5.8 mm +/- 1.3, and the mean atrial diameter of 97 male fetuses was 6.4 mm +/- 1.3. The difference in mean size is statistically significant (P < .005).

CONCLUSION

Male fetuses have a slightly larger atrial size than female fetuses. This discovery has implications for defining the upper limit of normal for fetal ventricular atrial size.

Isolated mild fetal cerebral ventriculomegaly: clinical course and outcome

PURPOSE

To assess the outcome of fetuses with isolated mild ventriculomegaly (IMVM).

MATERIALS AND METHODS

The clinical course of 44 fetuses with IMVM was investigated. Cognitive and motor development was classified as normal or delayed.

RESULTS

Clinical data were available for 37 subjects. Three (8%) neonates died. Of the 34 living children, follow-up was limited (< 9 months) in six and the clinical course beyond the 1st year of life was established in 28. Twenty-two (79%) of the 28 children are developing normally, whereas six (21%) are developmentally delayed. More than 90% of fetuses with ventricular atrial diameter of 10-11 mm are normal. Seventy-five percent of fetuses with IMVM were male. With exclusion of the six children with limited follow-up, 78% of boys older than 1 year are developmentally normal compared with only 50% of girls.

CONCLUSION

The majority of living children with prenatally detected IMVM are developmentally normal, especially those with borderline ventriculomegaly. Gender differences in prevalence and outcome deserve further investigation.

Anatomic and sonographic features of the fetal skull

This article reviews developmental skull anatomy, especially as it relates to the formation of cranial sutures and fontanelles, and demonstrates the appearance of these structures on prenatal sonograms, illustrating the framework these structures provide to enable one to accurately identify components of the fetal skull. Examples are provided to illustrate the utility of this knowledge. An understanding of fetal skull development and appearance enables the sonographer to better characterize fetal cranial abnormalities. More importantly, recognition of the location of cranial sutures and fontanelles and their ability to serve as acoustic windows assists the sonographer in evaluation of the fetal brain.

Sonographically detected testicular microlithiasis and testicular carcinoma

Testicular microlithiasis is an uncommon abnormality that produces the characteristic sonographic appearance of diffuse, punctate, hyperechoic foci throughout the testicular parenchyma. We have detected this distinctive sonographic pattern in 4 patients during a seven-year period. Three of the patients had proven concurrent testicular carcinoma. We describe our experience and review previous reports of testicular microlithiasis. We conclude that testicular microlithiasis may be associated with testicular neoplasia, and advocate particularly careful evaluation and follow-up of the testes when this abnormality is detected.

Motion of the patella during walking: a video digital-fluoroscopic study in healthy volunteers

OBJECTIVE

The alignment of the quadriceps muscle and patella suggests that the patella should deviate laterally out of the patellar groove as the quadriceps muscle contracts during walking. The surgical treatment of patellar subluxation has been based on this presumption. The purpose of this study was to determine the movements of the patella in relation to the other bones of the knee joint during normal walking. This is the first study we know of that uses radiographs to show these movements.

SUBJECTS AND METHODS

Eight healthy adult volunteers with no previous complaints referable to the knee walked on a slowly moving treadmill while their patellae were imaged fluoroscopically in the anteroposterior plane with a Toshiba C-arm. Images were retrieved, transferred to radiographic film, and randomized to prevent the observers from knowing the order of images. The position of the patella was measured and plotted in relation to fixed points of the knee.

RESULTS

In each of the subjects at every gait cycle, the patella was observed to move vertically first, followed by a sudden shift to the medial side before returning to its original position.

CONCLUSION

Contrary to conventional understanding, our results show that the patella deviates medially rather than laterally during walking. This occurs because of differential contraction of the components of the quadriceps muscle during walking. The management of painful and subluxated patellae must be reevaluated in light of this finding.

The direct effect of graft compliance mismatch per se on development of host arterial intimal hyperplasia at the anastomotic interface

To study the direct and sole effect of compliance mismatch on anastomotic intimal hyperplasia of the host arterial wall and to minimize possible confounding factors, dogs with a low thrombotic potential were selected as experimental subjects. Externally supported 6 cm x 5 mm Dacron grafts with a compliance value of approximately 1/300 of the host artery were implanted into the carotid arteries with end-to-end anastomoses on one side and end-to-side anastomoses on the other. The control graft was an autogenous carotid artery segment 4 cm in length transplanted into the femoral artery. Eight cases (24 grafts) were studied for 1 year and three (nine grafts) for 6 months. All were patent throughout the study period except for two noncompliant grafts with end-to-end anastomoses; thrombosis was the documented cause of occlusion. For the patent grafts, follow-up arteriograms showed no progressive narrowing of noncompliant anastomoses. Whether compliant or noncompliant, light microscopy studies showed slight intimal thickening within 1 to 2 mm of the anastomotic line, possibly the result of the normal healing response to stitch and surgical trauma. Quantitatively, 22 measurements representing longitudinal and circumferential thickness of the neointima were taken at each of the 40 patent noncompliant and 22 patent compliant control anastomoses. There was no statistically significant difference in anastomotic neointimal thickness in compliant and noncompliant grafts or for the different implantation periods. These data suggest that graft/host artery compliance mismatch does not cause arterial intimal hyperplasia at the anastomotic interface.

Implant site: a determinant of completeness of arterial prosthesis healing in the dog and possibly in humans

This paper compares the healing of supported knitted Dacron prostheses implanted in the descending thoracic aorta and in the subcutaneous carotid-femoral positions in each of 10 dogs. The descending thoracic aorta prostheses were 6 cm long and the carotid-femoral prostheses averaged 76 cm in length. The healing of four porous clinical axillofemoral grafts is compared to that of the experimental carotid-femoral grafts. There was little similarity between the healing observed in the descending thoracic aortic and subcutaneous positions; the descending thoracic aorta grafts healed rapidly and completely by eight weeks, with thrombus-free flow surfaces covered with confluent endothelial cells. However, the inner wall of the carotid-femoral grafts remained largely unhealed at one year, with endothelialization largely confined to a limited pannus ingrowth across the anastomoses. This indicates that the implant site in the dog is a primary determinant of the rapidity and completeness of healing. The clinical axillofemoral grafts explanted after 20 months to six and one-half years exhibited healing characteristics that were similar to those seen in the carotid-femoral position in the dog. These findings suggest that valid comparisons of interspecies healing require data obtained from similar implant locations. They present a challenge to the previously held concepts of major interspecies differences in speed and extent of tissue ingrowth based on data obtained from noncomparable implant sites.

Spatial regulation of homeobox gene fusions in the embryonic central nervous system of transgenic mice

The spatially restricted expression of mammalian homeobox genes in teh embryonic central nervous system (CNS) provides an opportunity to study the basis of spatial gene regulation in mammalian development. Here, we define a regulatory region of the murine Hox 1.3 gene that mediates such a region-specific expression pattern. The Hox 1.3 gene contains two exons, encodes a putative protein of 270 amino acids, and is expressed preferentially in the spinal cord at midgestation. We have analyzed transgenic mice containing various Hox 1.3 DNA fragments fused to reporter sequences, such as a human growth hormone gene fragment or the E. coli lacZ structural gene. As shown by RNAase protection assays or by in situ analyses of beta-galactosidase activity, several hybrid genes are expressed in the embryonic central nervous system in a spatially restricted manner, along both the rostrocaudal and dorsoventral axes. A 912 nucleotide sequence located immediately upstream of the Hox 1.3 coding sequence is sufficient to direct expression to the dorsolateral cells of the brachial spinal cord.

Cocaine abuse, attention deficit disorder, and bipolar disorder

Cocaine is a potent dopamine agonist that frequently stimulates the central nervous system and is often manifested by increased psychomotor activity, impulsivity, euphoria, and rapid thoughts. Attention deficit disorder (ADD) and bipolar disorder also present with physical restlessness, racing thoughts, distractibility, and mood instability. Although these three disorders rarely appear in the same individual, they are important differential diagnoses when considering any one illness with the above symptom complexes. We report two cases of cocaine abuse with ADD residual type in patients who were previously diagnosed as having atypical bipolar disorder. The adverse effects were reversed by the dopamine agonist bromocriptine.

Multiple kinases and signal transduction. Phosphorylation of the T cell antigen receptor complex

Multiple kinases interact at the multicomponent murine T cell antigen receptor. Antigen induces serine phosphorylation of the 21-kDa gamma glycoprotein and tyrosine phosphorylation of p21, a distinct 21-kDa chain. We demonstrate that tyrosine phosphorylation is due to kinase activation, and that all phosphorylated p21 is associated with the antigen receptor. We also show that antigen leads to polyphosphoinositide metabolism and subsequent protein kinase C activation. The two phosphorylation events can be dissociated by protein kinase C depletion, which eliminates phorbol 12-myristate 13-acetate-induced serine but not tyrosine phosphorylation. Activation of a third kinase, cyclic AMP-dependent protein kinase, inhibits both serine and tyrosine events, yet this inhibition can be modulated by addition of the protein kinase C activator, phorbol 12-myristate 13-acetate. Receptor-mediated signal transduction may be understood as the interaction of multiple stimulatory and inhibitory kinase activities.

Phosphorylation of the T cell antigen receptor: multiple signal transduction pathways

In our previous description of the murine T cell antigen receptor complex (Samelson et al., 1985a), we demonstrated that the clonotypic alpha-beta heterodimer is associated with four additional polypeptides. These include the 26 kd delta chain, the 25 kd epsilon chain, a 21 kd glycoprotein probably homologous with the human T3 gamma chain, and a 16 kd homodimer, the zeta chain. These polypeptides are co-immunoprecipitated from T cell clones and normal peripheral T cells with monoclonal antibodies that bind the alpha-beta heterodimer or with antisera that bind the delta chain (Samelson et al., 1986b) or the zeta chain (Weissman et al., 1986). All of these murine polypeptides have counterparts on human T cells. These results indicated that the T cell antigen receptor is a seven-chain complex.

Antigen activation of murine T cells induces tyrosine phosphorylation of a polypeptide associated with the T cell antigen receptor

The antigen receptor complex on murine MHC class II-restricted T cells consists of disulfide-linked alpha and beta chains noncovalently associated with four additional polypeptides, two that are endoglycosaminidase F-sensitive, gp26 and gp21, and two that are endoglycosaminidase F-resistant, p25 and p16. We demonstrate here that treatment of murine T cell hybridomas with phorbol 12-myristate 13-acetate results in phosphorylation of p25 and gp21 on serine residues. However, activation of cells by antigen results in the phosphorylation of the gp21 chain and a heretofore unidentified 21 kd protein. This newly defined polypeptide, p21, is specifically immunoprecipitated with the antigen receptor complex, is endoglycosaminidase F-resistant, and is itself part of a disulfide-linked molecule. Unlike antigen-induced phosphorylation of gp21, which occurs on serine residues, phosphorylation of p21 occurs uniquely on tyrosine residues.

A mouse homeo box gene is expressed in spermatocytes and embryos

The MH-3 gene, which contains a homeo box that is expressed specifically in the adult testis, was identified and mapped to mouse chromosome 6. By means of in situ hybridization with adult testis sections and Northern blot hybridization with testis RNA from prepuberal mice and from Sl/Sld mutant mice, it was demonstrated that this gene is expressed in male germ cells during late meiosis. In the embryo, MH-3 transcripts were present at day 11.5 post coitum, a stage in mouse development when gonadal differentiation has not yet occurred. The MH-3 gene may have functions in spermatogenesis and embryogenesis.

Determination of apo and holo retinoic acid-binding protein levels in retinoid-responsive transformed cells by high-performance size-exclusion chromatography

A method to measure the endogenous levels of apo and holo cellular retinoic acid-binding proteins was developed using calf testis cytosol as the source of retinoic acid-binding protein. [3H]Retinoic acid-retinoic acid-binding protein complexes were assayed by high-performance size-exclusion chromatography. Preincubation of cytosol with 10 mM p-hydroxymercuribenzoate at 4 degrees C resulted in complete inhibition of retinoic acid binding to apo retinoic acid-binding protein. In addition, total dissociation of preformed holo retinoic acid-binding protein complexes was noted within 20 min after mercurial addition. Thus, p-hydroxymercuribenzoate converted the total pool of cellular retinoic acid-binding protein (apo plus holo) to mercurial-protein complexes unable to bind retinoic acid in vitro. Mercurial inhibition of retinoic acid-retinoic acid-binding protein complex formation was totally reversed upon the addition of 50 mM dithiothreitol. Total cytosolic retinoic acid-binding protein was determined from specific retinoic acid binding after treatment with p-hydroxymercuribenzoate and dithiothreitol. Apo cellular retinoic acid-binding protein concentration was measured by determining specific radioligand binding prior to p-hydroxymercuribenzoate treatment, and correcting for exchange of endogenously bound retinoid with exogenous tritiated retinoic acid. Holo cellular retinoic acid-binding protein concentration was derived from the difference between total and apo retinoic acid-binding protein concentrations. Using this method, we have demonstrated that retinoid-responsive EJ and T24 human bladder carcinoma cell lines and AT3A and AT3B rat pancreatic acinar carcinoma cell lines lack detectable levels of either apo or holo cellular retinoic acid-binding protein. These results established that retinoid inhibition of transformed bladder and acinar cell proliferation in culture was mediated by a cellular retinoic acid-binding protein-independent mechanism.

Insertion mutagenesis of embryonal carcinoma cells by retroviruses

Mutagenesis was studied in cultured F9 embryonal carcinoma cells infected with a variant of Moloney murine leukemia virus. Proviral insertion induced the inactivation of the hypoxanthine phosphoribosyltransferase locus, and the virus was used to isolate the mutated genes rapidly. Mutagenesis by these methods may be useful for the genetic dissection of the various mammalian cell phenotypes.

The Ganser syndrome: evidence suggesting its classification as a dissociative disorder

The past and present nosology of Ganser's syndrome is discussed. The anomaly is defined as the presence of approximate answers with hallucinations, clouded sensorium, somatic conversion, and amnesia. The characteristic symptom of the syndrome, paralogia, is appreciated as an associated feature of Factitious Disorder with Psychological Symptoms. It is suggested that Ganser syndrome may be linked inappropriately with the concept of factitious illness. Two new cases of the Ganser syndrome are presented, and an additional forty-one case reports are reviewed. A high correlation between the presence of paralogia and amnesia is revealed, which suggests that paralogia and related psychological symptoms are better classified as associated features of Atypical Dissociative Disorder.