Hospital and community care costs for people newly diagnosed of living with HIV in London, UK

This study of people newly diagnosed of living with HIV (ND-PLHIV) calculated the use, cost and outcome of HIV services at a London HIV centre. ND-PLHIV were followed July 2017-October 2018. Hospital data included inpatient days (IP), outpatient (OP), dayward (DW) visits, tests and procedures, and anti-retroviral drugs (ARVs). Community services were recorded in daily diaries. Mean per patient-year (MPPY) use was multiplied by unit costs. 13.6 MPPY (95%CI 12.4-14.9) OP visits, 0.4 MPPY (95%CI 0.1-0.7) IP days, 0.09 MPPY (95%CI 0.01-0.2) DW visits and 4.6 MPPY community services (95%CI 3.4-5.8). Total annual costs per patient-year (CPPY) was £11,483 (95%CI £10,369-12,597): ARVs comprised 63% and community services 2%. White participants used fewer hospital and more community services compared with minority ethnic community (MEC) participants. Costs for White ND-PLHIV was £10,778 CPPY (95%CI £9629-11,928); £13,214 (95%CI £10,656-15,772) for MEC ND-PLHIV (p < 0.06). Annual costs were inversely related to CD4 count at entry (r = -5.58, p = 0.02); mean CD4 count was 476 cells/mm³ (95%CI 422-531) versus 373 cells/mm³ (95%CI 320-425) for White and MEC participants respectively (p = 0.03). Annual costs for ND-PLHIV with CD4 ≤ 350 cells/mm³ was £2478 PPY higher compared with CD4 count >350 cells/mm³ (p = 0.04).

Chronic inflammation in psoriasis promotes visceral adipose tissue association with lipid-rich necrotic core through atherogenic myeloid score

Background/Introduction

Psoriasis is a chronic inflammatory condition associated with adipose dysfunction and high-risk coronary artery disease features, including non-calcified coronary burden (NCB) and lipid-rich necrotic core (LRNC). Visceral adipose tissue (VAT) is a metabolically-active depot that secretes inflammatory and proatherogenic factors, and is associated with increased NCB. Additionally, an atherogenic myeloid score (AMS) comprised of classical monocytes, low-density granulocytes, and platelets was shown to associate with psoriasis severity and NCB.

Purpose

To investigate the relationship between VAT and high-risk plaque features and test whether this relationship was potentially mediated by myeloid cells.

Methods

A cohort of 131 psoriasis patients were included in this study. Atherogenic myeloid score components were calculated using complete blood count data (platelets) and by flow cytometry (monocytes, LDGs). Coronary NCB and LRNC were quantified using QAngio and vascuCAP respectively. VAT was defined as intra-abdominal fat and was quantified using an automated contouring software with abdominal CT scans. Statistical analyses were performed using STATA 12.

Results

The cohort was middle-aged 50 (42–61) (median (IQR)), and predominantly male (61%). High VAT vs low VAT groups differed significantly in their NCB ((0.910±0.279) vs (1.431±0.517)); p&lt;0.001), (mean ± SD). After adjustment for cardiovascular risk factors, VAT associated with the atherogenic myeloid score (β=0.221, p=0.044), with LRNC (β=0.128, p=0.047), and atherogenic myeloid score associated with LRNC (β=0.161, p=0.003). The relationship of VAT to LRNC was partially mediated by atherogenic myeloid score (25.14%, p=0.029) (Figure 1).

Conclusions

VAT associated with LRNC, and this relationship was partially mediated by the atherogenic myeloid score. These findings suggest that bioactive VAT may impart risk on coronary artery disease in part through myeloid cells.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute Intramural Research Program in Bethesda, Maryland Figure 1. Log-transformed atherogenic myeloid score partially mediates the relationship between VAT and log-transformed LRNC. Adjusted by Framingham Risk Score, PASI score, biologic therapy, statin therapy, type 2 diabetes, hyperlipidemia, and subcutaneous adipose tissue volume. Red arrow: represents indirect effect; Beta: standard regression coefficient.

Bone marrow and splenic metabolic activity by 18F-FDG PET/CT are associated with noncalcified coronary burden and lipid-rich necrotic core in psoriasis

Background/Introduction

Psoriasis is an immune-mediated inflammatory skin condition with an increased risk of myocardial infarction (MI). Elevated bone marrow (BM) and splenic hematopoiesis occurs after MI. In stable patients without chronic inflammation, higher splenic hematopoiesis predicts major adverse cardiovascular events (MACE). Nevertheless, studies in humans investigating these relationships in states of chronic inflammation on coronary artery disease features associated with MACE are limited.

Purpose

To investigate the relationships between bone marrow and splenic metabolic activity by [18]-fluorodeoxyglucose (FDG) PET/CT and subclinical cardiovascular disease in psoriasis.

Methods

Healthy participants (N=30) and psoriasis participants (N=210) were age and sex matched. All participants underwent 18FDG PET/CT and CT angiography (Toshiba 320 slice). Coronary artery plaque characteristics were assessed using QAngio CT (Medis, The Netherlands) and lipid rich necrotic core (LRNC) was assessed using vascuCAP (Elucid Bioimaging, Boston, MA). For tissue metabolic activities target-to-background ratio (TBR) was calculated as the ratio of arterial and venous standardized uptake values (SUV).

Results

The psoriasis cohort was middle aged 49.2 (±SD 11.9) years and predominantly male (64%). Those with psoriasis vs. healthy participants had higher BM (1.58 (IQR 1.35–1.89) vs. 1.23 (IQR 1.14–1.35); p&lt;0.001) and splenic (1.40 (IQR 1.21–1.66) vs.1.17 (IQR 1.11–1.26); p&lt;0.001) metabolic activity. After adjustment for cardiovascular risk factors bone marrow metabolic activity was associated with total burden, non-calcified burden (NCB) and LRNC (β=0.36, β=0.39, β=0.26; all p&lt;0.001) respectively. Similar findings were observed for splenic activity (β=0.33, β=0.36, β=0.36; all p&lt;0.001). In ROC analysis, when comparing area under the curve, BM activity better incrementally predicted non-calcified burden and lipid rich necrotic core compared to splenic activity (Figure).

Conclusions

BM and splenic metabolic activity are increased in psoriasis. Both are associated with coronary artery disease but there was a slightly stronger association with BM activity compared to splenic activity, These findings warrant further study to understand immune mechanisms underlying these observations.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung and Blood Institute Intramural Research Program in Bethesda, Maryland Figure 1. Median values of NCB and LRNC were used to convert these continuous variables into dichotomous variables such that values ≤ median were designated as 0 and values &gt;median were designated 1. Bone marrow model compared to base model and splenic model added incremental value in predicting NCB (p&lt;0.0001) and LRNC (p=0.0003). Base model: Framingham risk score, lipid treatment, biologic therapy, homeostasis model assessment as an index of insulin resistance (HOMA-IR), low density lipoprotein (LDL).

Primary colonic squamous cell carcinoma: a case report and review of the literature

Colonic squamous cell carcinoma is extremely rare, with no clear pathogenesis. It usually presents as an emergency. We present the surgical management of a descending colon squamous cell carcinoma, together with a review of the available cases of colonic squamous cell carcinoma in the literature. A 69-year-old woman presented with a palpable mass and abdominal pain. She underwent ultrasound and colonoscopy, which revealed a large obstructing mass at the descending colon, the biopsies of which were not diagnostic. Unfortunately, she was readmitted with bowel obstruction and underwent extended right hemicolectomy with en-bloc excision of attached small bowel and omentum because of local mass expansion. Histopathological analysis demonstrated squamous cell carcinoma with lymph node metastases. Palliative chemotherapy followed, owing to liver and peritoneal deposits. Sixty-six cases of colonic squamous cell carcinoma have been reported in the literature. The most common location is the right colon. Most cases present at a late stage. Several theories for the pathogenesis of colonic squamous cell carcinoma have been reported; the most popular is the squamous transformation of a pluripotent stem cell.

Abstract P6-16-04: A self-administered geriatric assessment tool for Spanish-speaking older women with breast cancer

Background: Almost a quarter of older adults in the United States will identify themselves as Hispanic/Latino by 2060. Our group has previously developed and validated a self-administered geriatric assessment tool which can be used to identify functional, psychological, social and cognitive impairments among older patients with various types of cancer. Among English-speaking older adults, completing this tool using paper/pencil or a tablet takes a median of 15-21 minutes (min), with &lt; 10% needing assistance to answer it (Hurria, JOP 2016). However, the utilization of this tool among Spanish-speaking older adults has not been tested. We assessed the feasibility of administering a translated and validated Spanish version of our geriatric assessment tool for older Hispanic women with breast cancer, and identified their preferred format (tablet or paper/pencil).

Methods: Spanish-speaking women aged ≥ 65 years with a diagnosis of breast cancer completed the geriatric assessment twice on the same day. Patients were randomized into 3 groups: paper/pencil twice; tablet and paper/pencil in random order; and tablet twice. We assessed the proportion of patients requiring assistance to complete the geriatric assessment, the time needed to complete it, and the proportion of patients who thought the geriatric assessment was difficult/very difficult.

Results: 140 older women with breast cancer completed the geriatric assessment twice and were evaluable. Mean age was 71.6 years (SD 5.8), 53% had ≤ 8th grade education, 43% were married, 45% were retired, 32% were homemakers, and 6% were employed. The participants came from 13 different Spanish-speaking countries, although 70% were born in Mexico. For 90%, Spanish was their primary language, and 75% spoke only in Spanish at home. Regarding computer skills, 64% of the patients said they had none. 39% (n = 54) were unable to complete the geriatric assessment on their own; mean time to complete the geriatric assessment was 29 min (range 8-90); and 28% (n = 39) thought the geriatric assessment was difficult/very difficult. The most common reasons for needing assistance were difficulty understanding questions (39%) and visual problems (31%). Patients with ≤ 8th grade education took longer to complete the geriatric assessment (mean 37.2 vs 29.4 min, p &lt; 0.01), and more often needed help completing the assessment (51% vs 19%, p &lt; 0.01) than those with ≥9th grade education. 53% of the participants preferred using a tablet to answer the geriatric assessment, while 47% preferred paper/pencil.

Conclusions: A substantial proportion of Spanish-speaking older women with breast cancer required assistance to complete our self-administered geriatric assessment tool. This may be a consequence of the low educational level we found among this patient population. Tailoring assessments for diverse populations with particular attention to educational level is needed in multicultural settings.

Citation Format: Soto-Perez-de-Celis E, Vazquez J, Kim H, Sun C-L, Somlo G, Yuan Y, Waisman JR, Mortimer JE, Kruper L, Taylor L, Patel NH, Moreno J, Charles K, Roberts E, Uranga C, Levi A, Katheria V, Paredero-Perez I, Mitani D, Hurria A. A self-administered geriatric assessment tool for Spanish-speaking older women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-16-04.

Implication of enterohepatic re-circulation on single dose bioequivalence evaluation of two brands of clonidine hydrochloride tablets in healthy human volunteers

A single dose, crossover bioequivalence study of two different brands of clonidine hydrochloride 25 μg tablets was conducted in 24 (+2 stand by) healthy, adult, male, Indian subjects under fasting conditions to check the implication of enterohepatic re-circulation on assessment of bioequivalence. After an overnight fasting of at least 10 h, the subjects received single oral dose of test or reference product with either of the product as per randomization schedule in each period with a washout period of 10 days. The pre-dose blood sample was collected within a period of one h before dosing. The post-dose blood samples were collected at specified time intervals up to 96 h. The plasma concentrations of clonidine were quantified by validated LCMS/MS method and pharmacokinetic parameters were computed. The 90% confidence intervals of test/reference ratios for C_max and area under the plasma-concentration- time-curve AUC under 0-t were found to be between 0.80 and 1.25 for log-transformed data. Analysis of variance did not show significant difference to these parameters. No meaningful values of K_el and therefore AUC under 0-infinity could be calculated for significant number of subjects due to enterohepatic re-circulation. Based on the results obtained, two different brands of clonidine 25 μg tablets have comparable rate and extent of absorption after oral administration but failed to show bioequivalence as per regulatory requirement of Food and Drugs Administration-united states.

Lophotrochozoa get into the game: the nodal pathway and left/right asymmetry in bilateria

Animals as diverse as humans, flies, crabs, and snails show overall bilateral symmetry, but each species has specific structures and organs that display left/right asymmetry, and the presence of these asymmetries is vital to the organism. Here, we review recent results showing that part of the molecular pathway that sets left/right asymmetry in vertebrates is also conserved in snails, suggesting that left/right asymmetry was present in the common ancestor of all bilaterians. More specifically, we can now predict that the signaling molecule Nodal and the transcription factor Pitx were expressed on the right side of the bilaterian ancestor. These results also allow us to understand how the direction of shell coiling (chirality) is regulated in snails and provides interesting insights into the possible inversion of the dorsoventral axis in the lineage leading to chordates.

On the molecular organization, diversity and functions of desmosomal proteins

After a brief review of epithelial cell junctions, the authors describe a series of observations and experiments directed toward elucidating the molecular organization and functions of the proteins of desmosomes (maculae adherentes). Their immunofluorescence observations reveal differences between the proteins of junctional complex and other desmosomes of the same cells. Quantitative immuno-localization studies are described using protein A-colloidal gold markers and a series of monospecific, polyclonal antibodies directed against cytokeratins and four desmosomal protein families. It is shown that desmoplakin III (about 81 kDa) is restricted to the desmosomal cytoplasmic plaque, which possesses outer and inner dense zones. Desmoplakins I/II (about 240 kDa and 210 kDa) extend across the same range and beyond into the intermediate filament-rich cytoplasm. Two glycoprotein families, desmoglein I (DGI; about 150 kDa) and desmoglein II (DGII; about 97-118 kDa), extend from the desmosomal midline (or beyond) across the desmoglea (intercellular space), through the plasma membrane and across both layers of the plaque, terminating near its cytoplasmic border. Cytokeratins do not extend into the desmosome. With new procedures utilizing guanidine HCl for preparing and fractionating desmosomal proteins, DGII has been purified to homogeneity. DGII, DGI and a third protein are all shown to bind Ca2+, which is known to promote desmosome assembly.

Computerised analysis of auscultatory sounds associated with vascular patency of haemodialysis access

Vascular access for renal dialysis is a lifeline for about 120 000 individuals in the United States. Stethoscope auscultation of vascular sounds has some utility in the assessment of access patency, yet can be highly skill-dependent. The objective of the study was to identify acoustic parameters that are related to changes in vascular access patency. The underlying hypothesis is that stenoses of haemodialysis access vessels or grafts cause vascular sound changes that are detectable using computerised data acquisition and analysis. Eleven patients participated in the study. Their vascular sounds were recorded before and after angiography, which was accompanied by angioplasty in most patients. The sounds were acquired using two electronic stethoscopes and then digitised and analysed on a personal computer. Vessel stenosis changes were found to be associated with changes in acoustic amplitude and/or spectral energy distribution. Certain acoustic parameters correlated well (correlation coefficient = 0.98, p < 0.0001) with the change in the degree of stenosis, suggesting that stenosis severity may be predictable from these parameters. Parameters also appeared to be sensitive to modest diameter changes (> 20%), (p < 0.005, Wilcoxon rank sum test). These results suggest that computerised analysis of vascular sounds may be useful in vessel patency surveillance. Further testing using longitudinal studies may be warranted.

Conservation and divergence in molecular mechanisms of axis formation

Genetic screens in Drosophila melanogaster have helped elucidate the process of axis formation during early embryogenesis. Axis formation in the D. melanogaster embryo involves the use of two fundamentally different mechanisms for generating morphogenetic activity: patterning the anteroposterior axis by diffusion of a transcription factor within the syncytial embryo and specification of the dorsoventral axis through a signal transduction cascade. Identification of Drosophila genes involved in axis formation provides a launch-pad for comparative studies that examine the evolution of axis specification in different insects. Additionally, there is similarity between axial patterning mechanisms elucidated genetically in Drosophila and those demonstrated for chordates such as Xenopus. In this review we examine the postfertilization mechanisms underlying axis specification in Drosophila. Comparative data are then used to ask whether aspects of axis formation might be derived or ancestral.

Hepatic and intestinal cytochrome P450 3A activity in cirrhosis: effects of transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunt (TIPS) is performed to treat some complications of cirrhosis. This study investigated the effects of cirrhosis and TIPS on intestinal and hepatic cytochrome P450 3A (CYP3A) activity. Nine volunteers were cirrhotic patients with TIPS, 9 were cirrhotic controls (matched for sex, age, etiology, and Child-Pugh class), and 9 were sex- and age-matched healthy volunteers. Simultaneous doses of midazolam were given intravenously (0.05 mg/kg) and orally (3 mg of [15N3]midazolam). Peripheral and portal venous blood samples were assayed for midazolam and [15N3]midazolam. The systemic clearance of midazolam was significantly greater (P <.05) in healthy volunteers (0.42 +/- 0.10 L x h(-1) x kg(-1)) compared with cirrhotic controls (0.20 +/- 0.05) and with cirrhotic patients with TIPS (0.21 +/- 0.09). Hepatic availability followed the same trend. The bioavailability of midazolam was significantly higher (P <.05) in cirrhotic patients with TIPS (0.76 +/- 0.20) compared with cirrhotic controls (0.27 +/- 0.14) and with healthy volunteers (0.30 +/- 0.10). The intestinal availability was significantly greater (P <.05) in cirrhotic patients with TIPS (0.83 +/- 0.17) compared with cirrhotic controls (0.32 +/- 0.16) and with healthy volunteers (0.42+/-0.15). As expected, hepatic CYP3A activity was reduced in cirrhosis. However, in cirrhotic patients with TIPS, there was a marked loss in first-pass metabolism of midazolam as a result of diminished intestinal CYP3A activity.

Increase in hepatic arterial blood flow after transjugular intrahepatic portosystemic shunt creation and its potential predictive value of postprocedural encephalopathy and mortality

PURPOSE

To determine (i) whether there is a significant increase in hepatic artery blood flow (HABF) after transjugular intrahepatic portosystemic shunt (TIPS) creation and (ii) whether the extent of incremental increase in HABF is predictive of clinical outcome after TIPS creation.

MATERIALS AND METHODS

Prospective, nonrandomized, nonblinded duplex Doppler ultrasound (US) examinations were performed on 24 consecutive patients (19 men; Child Class A/B/C: 4/12/8, respectively) with a mean age of 52.8 years who were referred for TIPS creation for variceal bleeding. Peak hepatic artery velocity and vessel dimensions were used to calculate the hepatic arterial blood flow (HABF) before and after TIPS creation. Patients were clinically followed in the gastrohepatology clinic and TIPS US surveillance was performed at 1 and 3 months to assess shunt function. The extent of incremental increase in HABF was analyzed as a predictor of post-TIPS encephalopathy and/or death.

RESULTS

The technical success rate of TIPS creation was 100%. The shunt diameters were either 10 mm (n = 11) or 12 mm (n = 13). TIPS resulted in a significant reduction in the portosystemic gradient from 24.3 mm Hg +/- 5.7 to 9.3 mm Hg +/- 2.9 (P <.001). The hepatic artery peak systolic velocity and HABF increased significantly after TIPS creation, from 60.8 cm/sec +/- 26.7 to 121 cm/sec +/- 51.5 (P <.001) and from 254.2 mL/min +/- 142.2 to 507.8 mL/min +/- 261.3 (P <.001), respectively. The average incremental increase in HABF from pre-TIPS to post-TIPS was 253.6 mL/min +/- 174.2 and the average decremental decrease in portosystemic gradient was 15.0 mm Hg +/- 5.3, but there was no significant correlation (r = 0.04; P =.86) between the two. All shunts were patent at 30 and 90 days without sonographic evidence of shunt dysfunction. After TIPS creation, new or worsened encephalopathy developed in five patients at 30 days and in an additional three at 90 days. They were all successfully managed medically. Three patients (12.5%) died within 30 days of the TIPS procedure. The extent of incremental increase in HABF after TIPS was variable and did not correlate with the development of 30-day and 90-day encephalopathy (P =.41 and P =.83, respectively) or 30-day mortality (P =.2).

CONCLUSIONS

HABF increases significantly after TIPS but is not predictive of clinical outcome. The significance of the incremental increase is yet to be determined.

Body patterning

Early patterning of the body during animal development is a fundamental process to subsequent events including cell differentiation, tissue and organ formation, and correct function of the adult body. We focused on two major topics: body segmentation and brain patterning, both of which are essential for conferring a functional complexity to the body, repetition of skeletal elements and complex neural network, respectively.

Grasshopper hunchback expression reveals conserved and novel aspects of axis formation and segmentation

While the expression patterns of segment polarity genes such as engrailed have been shown to be similar in Drosophila melanogaster and Schistocerca americana (grasshopper), the expression patterns of pair-rule genes such as even-skipped are not conserved between these species. This might suggest that the factors upstream of pair-rule gene expression are not conserved across insect species. We find that, despite this, many aspects of the expression of the Drosophila gap gene hunchback are shared with its orthologs in the grasshoppers S. americana and L. migratoria.

We have analyzed both mRNA and protein expression during development, and find that the grasshopper hunchback orthologs appear to have a conserved role in early axial patterning of the germ anlagen and in the specification of gnathal and thoracic primordia. In addition, distinct stepped expression levels of hunchback in the gnathal/thoracic domains suggest that grasshopper hunchback may act in a concentration-dependent fashion (as in Drosophila), although morphogenetic activity is not set up by diffusion to form a smooth gradient.

Axial patterning functions appear to be performed entirely by zygotic hunchback, a fundamental difference from Drosophila in which maternal and zygotic hunchback play redundant roles. In grasshoppers, maternal hunchback activity is provided uniformly to the embryo as protein and, we suggest, serves a distinct role in distinguishing embryonic from extra-embryonic cells along the anteroposterior axis from the outset of development – a distinction made in Drosophila along the dorsoventral axis later in development.

Later hunchback expression in the abdominal segments is conserved, as are patterns in the nervous system, and in both Drosophila and grasshopper, hunchback is expressed in a subset of extra-embryonic cells. Thus, while the expected domains of hunchback expression are conserved in Schistocerca, we have found surprising and fundamental differences in axial patterning, and have identified a previously unreported domain of expression in Drosophila that suggests conservation of a function in extra-embryonic patterning.

Pax group III genes and the evolution of insect pair-rule patterning

Pair-rule genes were identified and named for their role in segmentation in embryos of the long germ insect Drosophila. Among short germ insects these genes exhibit variable expression patterns during segmentation and thus are likely to play divergent roles in this process. Understanding the details of this variation should shed light on the evolution of the genetic hierarchy responsible for segmentation in Drosophila and other insects. We have investigated the expression of homologs of the Drosophila Pax group III genes paired, gooseberry and gooseberry-neuro in short germ flour beetles and grasshoppers. During Drosophila embryogenesis, paired acts as one of several pair-rule genes that define the boundaries of future parasegments and segments, via the regulation of segment polarity genes such as gooseberry, which in turn regulates gooseberry-neuro, a gene expressed later in the developing nervous system. Using a crossreactive antibody, we show that the embryonic expression of Pax group III genes in both the flour beetle Tribolium and the grasshopper Schistocerca is remarkably similar to the pattern in Drosophila. We also show that two Pax group III genes, pairberry1 and pairberry2, are responsible for the observed protein pattern in grasshopper embryos. Both pairberry1 and pairberry2 are expressed in coincident stripes of a one-segment periodicity, in a manner reminiscent of Drosophila gooseberry and gooseberry-neuro. pairberry1, however, is also expressed in stripes of a two-segment periodicity before maturing into its segmental pattern. This early expression of pairberry1 is reminiscent of Drosophila paired and represents the first evidence for pair-rule patterning in short germ grasshoppers or any hemimetabolous insect.

Accuracy of CO(2) angiography in vessel diameter assessment: a comparative study of CO(2) versus iodinated contrast material in a porcine model

PURPOSE

To compare, with use of intravascular ultrasound (IVUS) as an internal reference standard in a porcine model, arterial diameters measured from arteriograms obtained with use of CO(2) to those obtained with use of iodinated contrast material (ICM).

MATERIALS AND METHODS

In nine pigs, digital subtraction angiograms (DSAs) were obtained in the aorta and iliac arteries to compare vessel diameters measured with use of CO(2) to those measured with use of ICM. These measurements were divided by measurements made with use of intravascular ultrasound (IVUS) to yield a DSA/IVUS ratio. Differences between ICM and CO(2) were compared with analysis of variance to assess the effect of location (aorta vs iliac), contrast material used (ICM vs CO(2)), and position (posteroanterior, right anterior oblique, or left anterior oblique). Secondary analysis compared measurements of dependent and nondependent iliac arteries and compared the use of hand-injected CO(2) to that of CO(2) injected by an injector.

RESULTS

The DSA/IVUS ratio was 70.7% +/- 4.4% with ICM use and 69.6% +/- 6.3% with CO(2) use, which did not represent a significant difference (P =.311). Animal position had no effect (P =.477). Underestimation was worse in the iliac arteries than in the aorta (67.4% +/- 1.5% vs 71.4% +/- 1.7%; P =.038). There was no difference in nondependent (P =.163) arteries, but CO(2) underestimated dependent iliac artery size more than ICM did (66.3% +/- 4.8% vs 70.3% +/- 5.4%; P =.051). Vessel diameter was underestimated more with the CO(2) injector than with hand-injected CO(2) (64.3% +/- 2.3% vs 71.7% +/- 1.7%; P <.0001).

CONCLUSION

There is no difference in diameter underestimation between CO(2) and ICM in this animal model. Hand-injection of CO(2) causes less underestimation of vessel diameter than does the CO(2) injector.

Outcome of Polyester Cuff Retention Following Traction Removal of Tunneled Central Venous Catheters

PURPOSE

To elucidate the factors that contribute to cuff retention during traction removal of tunneled catheters, as well as to determine the risk of complication associated with polyester cuff retention.

MATERIALS AND METHODS

A total of 428 tunneled, cuffed catheters were removed with traction and local anesthesia. Polyester cuff retention was recorded when it occurred, and the effects of cuff retention were determined at a mean follow-up of 250 days. Statistical analysis was performed to determine the variables influencing cuff retention.

RESULTS

Traction removal was successful in 428 (100%) patients. Of 428 catheters removed, 41 (10%) cuffs were retained. Silicone 10-F double-lumen and 9.6-F single-lumen catheters had a higher rate of cuff retention (27 [32%] of 84 and nine [39%] of 23, respectively) than did the split-tip polyurethane hemodialysis catheter (two [1%] of 196; P <.001). Cuff retention rates among other catheter types compared with that of the polyurethane catheter were not significantly different. Duration of catheter dwell did not significantly influence cuff retention. Of 41 retained cuffs, three required removal with cutdown for cuff migration to the exit site, which inhibited healing (n = 1); for suspected infection (n = 1); or for cosmetic purposes as requested by the patient (n = 1). The remaining patients had no complications associated with cuff retention.

CONCLUSION

Traction removal of smaller-bore silicone catheters is more likely to result in cuff retention than removal of larger silicone and polyurethane catheters, and cuff retention is usually inconsequential.

Renal Arterial Stenosis in Renal Allografts: Retrospective Study of Predisposing Factors and Outcome after Percutaneous Transluminal Angioplasty

PURPOSE

To determine the predisposing factors to transplant renal arterial stenosis (TRAS) and assess the outcome of percutaneous transluminal angioplasty (PTA) as the primary treatment.

MATERIALS AND METHODS

Of 831 renal allograft recipients (584 cadaveric, 247 living related) between January 1991 and December 1998, 72 had hypertension and/or renal dysfunction. All 72 underwent arteriography, and their medical charts were retrospectively reviewed.

RESULTS

Prevalence of TRAS was 3.1% (26 of 831). Technical success rate of PTA was 94% (16 of 17), and clinical success rate was 82% (14 of 17). Those with renal dysfunction had a mean pre-PTA creatinine value of 2.6 mg/dL (230 micromol/L) +/- 0.5 (SD) versus a 1-week post-PTA value of 1.7 mg/dL (150 micromol/L) +/- 0.3 (P <.001). Of those with hypertension, all but one had substantial improvement in mean diastolic blood pressure. At 26.9 months mean follow-up in 16 patients with successful PTA, two stenoses reoccurred, and two grafts were lost to chronic rejection. TRAS was present in 14 of 45 end-to-side anastomoses and 12 of 27 end-to-end anastomoses (P =.31), and TRAS was more prevalent in cadaveric grafts (24 of 584) than in living related grafts (two of 247). In cadaveric grafts, the mean cold ischemia time was 29.0 hours +/- 6.9 in those with TRAS (n = 24), as compared with 25.5 hours +/- 8.1 in those with no TRAS (n = 39; P = .35). Seven of 17 patients with acute rejection and six of 35 with chronic rejection had TRAS.

CONCLUSION

Primary treatment of TRAS with PTA has good intermediate-term results. TRAS is more prevalent in cadaveric allografts with long cold ischemia time.

Suprarenal intraarterial infusion of alloxan and streptozotocin during balloon occlusion of the juxtarenal abdominal aorta: a simple technique for inducing diabetes mellitus in canines with reduced mortality

RATIONALE AND OBJECTIVES

The authors performed this study to evaluate the mortality and morbidity associated with a simple technique for inducing diabetes in dogs--suprarenal intraarterial infusion of alloxan and streptozotocin during balloon occlusion of the juxtarenal abdominal aorta.

MATERIALS AND METHODS

The authors attempted to induce diabetes in six purpose-bred dogs. After the dogs were fasted for 12 hours, the abdominal aorta at the level of the origin of the renal arteries was occluded with an angioplasty balloon introduced by means of a femoral approach. A 3-F microcatheter (n = 1) or infusion wire (n = 5) was introduced via the percutaneous transluminal angioplasty catheter and positioned at the level of the celiac axis, and a mixture of streptozotocin (20-25 mg/kg) and alloxan (20-25 mg/kg) was infused. Diabetes was considered to have been induced if the dogs experienced sustained hyperglycemia.

RESULTS

There were no deaths during the follow-up period (range, 7 months to 2 1/2 years). A diabetes-like state was induced in five of the six dogs, and no nephrotoxicity was seen. Diabetes was not induced in one dog owing to caudal migration of an undersized balloon during the infusion; this also resulted in reversible renal damage.

CONCLUSION

This simple technique is effective for inducing diabetes in dogs, and morbidity and mortality rates are lower than those reported in the literature with other described techniques.

Vascular access for hemodialysis: an indepth review

A multi-disciplinary approach to vascular access planning, early preoperative surgical assessment and increased use of vascular imaging for surveillance, specialist service and pharmacological prevention of intimal hyperplasia will lead to improved patency rates for both autologous AVF and synthetic grafts.

The role of chemoembolization in the treatment of colorectal hepatic metastases

In this brief review, we discuss the role of transcatheter arterial chemoembolization in the treatment and palliation of hepatic metastases from colorectal tumors. Although surgical resection is the optimal treatment for hepatic colorectal metastases, only a small percentage of these tumors are amenable to resection. A number of other modalities are being evaluated for these patients, of which, transcatheter arterial chemoembolization is the most promising. However, patients should be carefully selected and monitored to study outcomes; preferably these patients should be entered into randomized controlled trials.

Molecular genetics of crustacean feeding appendage development and diversification

Arthropods dominate our seas, land, and air and have done so for hundreds of millions of years. Among the arthropods, crustaceans present us with a rich history of morphological change, much of which is still represented among extant forms. Crustacea largely interact with their environment via their appendages; thus vast amounts of variation exist among the different appendages of a single individual and between appendages from different species. Comparative studies of crustacean appendage development present us with an important story regarding the evolution of morphology over both relatively short (a few million years) and relatively long (a few hundred million years) evolutionary time scales. Recent studies have used the genetic and molecular data from Drosophila development to try to understand the molecular basis for some of the variations seen in crustacean limbs. Here we review some of these data based on the expression patterns of the genes Ultrabithorax, abdominal - A, Sex combs reduced, and Distal-less.

Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome

PURPOSE

The authors report their experience on the treatment of acute extensive iliofemoral deep venous thrombosis (DVT) due to May-Thurner syndrome using endovascular techniques.

MATERIALS AND METHODS

During a 1-year period, 10 symptomatic women (age range, 22-52 years; mean, 35.5 years) were referred for treatment. After ascending venography, an infusion catheter system was placed and urokinase was infused locally into the thrombus burden. After near complete clot dissolution (> or = 95%) or lytic stagnation, the residual left common iliac vein narrowing was treated by means of angioplasty and/or placement of Wallstent endoprosthesis. All patients continued to receive oral warfarin. Patients were followed-up by means of clinic visits, and stent patency was assessed by means of duplex Doppler sonography performed at 1, 3, 6, and 12 months, and then yearly thereafter.

RESULTS

The total dose of urokinase used and the duration of infusion were 5.87 +/- 2.57 million units (range, 3.18-10.7) and 51.95 +/- 21.57 hours (range, 26.5-89), respectively. After completion of thrombolytic therapy, the iliac vein narrowing was successfully treated by deployment of a Wallstent endoprosthesis in all 10 patients because of failure of angioplasty. No major bleeding complications occurred. Initial clinical success was 100%, with complete resolution of symptoms in all patients. One patient, who was hypercoagulable and was receiving chemotherapy for metastatic adenocarcinoma, had recurrent symptomatic acute DVT 1 month after therapy. She underwent successful repeated lysis. The remaining nine patients were asymptomatic, with a mean follow-up of 15.2 months (range, 6-36 months). One asymptomatic patient, at 36-month follow-up ultrasound, had iliac vein occlusion and well-developed venous collaterals. Serial ultrasonography in all 10 patients showed no evidence of valvular insufficiency in the femoral and popliteal veins.

CONCLUSION

Catheter-directed thrombolytic therapy for the treatment of acute extensive iliofemoral DVT due to May-Thurner syndrome is an effective method for restoring venous patency and provides relief of the acute symptoms. The underlying left common iliac vein lesion invariably needs to undergo stent placement.

It's a bug's life

Although the mechanisms of anterior-posterior axis formation are well understood in Drosophila, both embryological and molecular studies suggest significant variation in the mechanisms generating this axis within the Insecta class as a whole.

Hepatic artery embolization: factors predisposing to postembolization pain and nausea

PURPOSE

Analysis of preprocedural factors that may be helpful in predicting the severity of pain and nausea after hepatic arterial embolization (HAE) for liver neoplasms.

MATERIALS AND METHODS

During a 2-year period, 62 patients (33 men, 29 women) underwent 130 palliative lobar HAEs for unresectable liver neoplasms. The hepatic lobe was embolized with 150-250-microm polyvinyl alcohol particulates with or without lipiodol and/or chemotherapeutic agents. Postembolization pain was rated at rest and during movement with use of an 11-point verbal pain scale, and postembolization nausea was assessed with use of a four-point verbal scale, each at two separate time periods. Daily morphine use was also recorded. Primary analysis was made using the first embolization procedure. One-way analysis of variance and Spearman correlation coefficients were used to identify associated predictors. Plots of the outcomes versus the pre-embolization liver function tests and sensitivities and specificities were used to identify the strength of the associations for prediction purposes. A secondary analysis was performed in patients who underwent multiple embolizations.

RESULTS

No strong categorical predictors were found from the ANOVA on the severity of postembolization pain or nausea. There were significant (P < .05) associations between the pre-embolization liver function tests and the pain outcomes only. However, while these laboratory values demonstrate strong associations with resultant pain, they are not strong predictors of pain and morphine requirements for any individual patient. The morphine requirements were highly associated (P < .0001) with the pain scores at rest and with movement. The authors did not find significant differences on any of the pain outcomes or morphine requirements between the first and second embolizations.

CONCLUSION

Laboratory values and patient age are not predictors for the severity of postembolization pain and nausea. Postembolization pain is a significant complication and poses a continuing challenge to the physician with regards to patient management.

Percutaneous transmyocardial intracardiac retroperfusion shunts: technical feasibility in a canine model

PURPOSE

To test the technical feasibility of creating a left ventricle to coronary sinus shunt using endovascular techniques.

MATERIALS AND METHODS

By means of a right jugular vein approach, a needle puncture was made from the coronary sinus to the left ventricle in 10 dogs. The tracts were balloon dilated and lined with 6-mm Wallstents. Shunt patencies, immediate and 4-hours later, were fluoroscopically assessed by contrast material injection into the left ventricle. Blood pressure, pulse, oxygen saturation, and cardiac rhythm were monitored. The dogs were then euthanized. Thoracic cavities and hearts were dissected and inspected.

RESULTS

Technical success and immediate shunt patency were 100%. No cardiac dysrhythmias, electrocardiographic changes, or reduction in voltage potential were seen. Eight (80%) of the shunts were patent at 4 hours, one (10%) had thrombosed, and one dog died. Nine (90%) dogs had no pericardial hematoma and one (10%) had minimal pericardial blood from needle passes into the pericardial sac. The coronary sinuses were intact and no injuries to the valve leaflets or chordae tendineae were seen. The puncture sites were from the coronary sinus, 1-2 mm (mean, 1.3) from its auricular orifice, into the left ventricle, just below the inferior margin of the posterior leaflet of the mitral valve. One dog died at 3 hours with no preceding electrocardiographic evidence of impending demise. Autopsy showed no pericardial hematoma and the heart findings were no different from the other nine dogs.

CONCLUSIONS

Creation of a left ventricle to coronary sinus shunt with use of endovascular techniques is technically feasible. Study of a transmyocardial intracardiac coronary retroperfusion shunt to deliver oxygenated blood to the ischemic myocardium is warranted.

Evidence for stabilizing selection in a eukaryotic enhancer element

Eukaryotic gene expression is mediated by compact cis-regulatory modules, or enhancers, which are bound by specific sets of transcription factors. The combinatorial interaction of these bound transcription factors determines time- and tissue-specific gene activation or repression. The even-skipped stripe 2 element controls the expression of the second transverse stripe of even-skipped messenger RNA in Drosophila melanogaster embryos, and is one of the best characterized eukaryotic enhancers. Although even-skipped stripe 2 expression is strongly conserved in Drosophila, the stripe 2 element itself has undergone considerable evolutionary change in its binding-site sequences and the spacing between them. We have investigated this apparent contradiction, and here we show that two chimaeric enhancers, constructed by swapping the 5' and 3' halves of the native stripe 2 elements of two species, no longer drive expression of a reporter gene in the wildtype pattern. Sequence differences between species have functional consequences, therefore, but they are masked by other co-evolved differences. On the basis of these results, we present a model for the evolution of eukaryotic regulatory sequences.

Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting

BACKGROUND & AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) placement is effective in the treatment of complications of portal hypertension. This study evaluated the predictors of mortality in a group of cirrhotic patients with advanced liver disease after placement of TIPS.

METHODS

A retrospective analysis of all patients undergoing TIPS placement over a 21/2-year period was undertaken.

RESULTS

Fifty-six patients had TIPS placement for variceal hemorrhage, 49 for refractory ascites, and 24 for hepatic hydrothorax (total, 129). Of 21 variables available before TIPS placement, variceal hemorrhage requiring emergent TIPS placement (relative risk [RR], 37.5; 95% confidence interval [CI], 5.4-259) and bilirubin concentration > 3.0 mg/dL (RR, 5.4; 95% CI, 1.4-10.2) were independent predictors of 30-day mortality. Variceal hemorrhage requiring emergent TIPS placement (hazard ratio [HR], 5.1, 95% CI, 2. 2-9.1), alanine aminotransferase level > 100 IU/L (HR, 2.5; 95% CI, 1.2-5.5), bilirubin level > 3.0 mg/dL (HR, 2.6; 95% CI, 1.1-4.6), and pre-TIPS encephalopathy unrelated to bleeding (HR, 2.2; 95% CI, 1.2-4.8) independently predicted death during the follow-up period. A model was developed that separated the patients into 3 groups with significantly different survival rates.

CONCLUSIONS

A clinical index consisting of 4 pre-TIPS variables can reliably predict outcome after TIPS.

Beyond the Hox complex

The Hox complex is an example of a gene cluster created by tandem duplications. Recent findings suggest the Hox complex may be just part of a larger chromosomal assemblage of homeobox-containing genes that existed in the ancestor to all vertebrates.

The origin and evolution of segmentation

Arthropods, annelids and chordates all possess segments. It remains unclear, however, whether the segments of these animals evolved independently or instead were derived from a common ancestor. Considering this question involves examining not only the similarities and differences in the process of segmentation between these phyla, but also how this process varies within phyla, where the homology of segments is generally accepted. This article reviews what is known about the segmentation process and considers various proposals to explain its evolution.

Functional conservation of the wingless-engrailed interaction as shown by a widely applicable baculovirus misexpression system

BACKGROUND

The expression patterns of the segment polarity genes wingless and engrailed are conserved during segmentation in a variety of arthropods, suggesting that the regulatory interactions between these two genes are also evolutionarily conserved. Hypotheses derived from such comparisons of gene expression patterns are difficult to test experimentally as genetic manipulation is currently possible for only a few model organisms.

RESULTS

We have developed a system, using recombinant baculoviruses, that can be applied to a wide variety of organisms to study the effects of ectopic expression of genes. As a first step, we studied the range and type of infection of several reporter viruses in the embryos of two arthropod and one vertebrate species. Using this system to express wingless, we were able to induce expression of engrailed in the anterior half of each parasegment in embryos of the fruit fly Drosophila melanogaster. Virus-mediated wingless expression also caused ectopic naked ventral cuticle formation in wild-type Drosophila larvae. In the flour beetle, Tribolium castaneum, ectopic wingless also induced engrailed expression. As in Drosophila, this expression was only detectable in the anterior half of the parasegment.

CONCLUSIONS

The functional interaction between wingless and engrailed, and the establishment of cells competent to express engrailed, appears to be conserved between Drosophila and Tribolium. The data on the establishment of an engrailed-competent domain also support the idea that prepatterning by pair-rule genes is conserved between these two insects. The recombinant baculovirus technology reported here may help answer other long-standing comparative evolutionary questions.

Neural cell fate in rca1 and cycA mutants: the roles of intrinsic and extrinsic factors in asymmetric division in the Drosophila central nervous system

In the central nervous system (CNS) of Drosophila embryos lacking regulator of cyclin A (rca1) or cyclin A, we observe that several ganglion mother cells (GMCs) fail to divide. Whereas GMCs normally produce two sibling neurons that acquire different fates ('A/B'), non-dividing GMCs differentiate exclusively in the manner of one of their progeny ('B'). In zygotic numb mutants, sibling neuron fate alterations ('A/B' to 'A/A') occur infrequently or do not occur in some sibling pairs; we have determined that depletion of both maternal and zygotic numb causes sibling neurons to acquire equalized fates ('A/A') with near-complete expressivity. In rca1, numb mutant embryos, we observe binary cell fate changes ('B' to 'A') in several GMCs as well. Finally, we have demonstrated that expression of Delta in the mesoderm is sufficient to attain both sibling fates. Our results indicate that the intrinsic determinant Numb is absolutely required to attain differential sibling neuron fates. While the extrinsic factors Notch and Delta are also required to attain both fates, our results indicate that Delta signal can be received from outside the sibling pair.

Tunneled jugular small-bore central catheters as an alternative to peripherally inserted central catheters for intermediate-term venous access in patients with hemodialysis and chronic renal insufficiency

In 34 patients with chronic renal insufficiency or failure, 43 small-bore central catheters were placed via the internal or external jugular veins: right internal jugular vein, 28; left internal jugular vein, 14; right external jugular vein, one. Central venous access was achieved in all patients (mean catheter dwell time, 28 days; range, 3-99 days), with two minor complications (arterial puncture and catheter damage during suturing). Tunneled jugular small-bore central catheters are a vein-preserving alternative to peripherally inserted central catheters in this population.

Hemodialysis graft: use as access for upper and lower extremity arteriography and interventional procedures--initial experience

Functioning hemodialysis grafts were used as access sites for peripheral vascular arteriography and interventional procedures. In 11 patients with end-stage renal disease and ischemia, upper extremity (n = 8) or lower extremity (n = 3) arteriography was performed successfully. Angioplasty and other interventional procedures were performed via the same route in two of the patients. No bleeding complications occurred, and all patients were ambulatory immediately after the procedure.