The establishment of a multiple myeloma clinical registry in the Asia-Pacific region: The Asia-Pacific Myeloma and Related Diseases Registry (APAC MRDR)

BACKGROUND

Multiple myeloma (MM) is the second most common haematological cancer worldwide. Along with related diseases including monoclonal gammopathy of undetermined significance (MGUS), plasma cell leukaemia (PCL) and plasmacytoma, MM incidence is rising, yet it remains incurable and represents a significant disease burden. Clinical registries can provide important information on management and outcomes, and are vital platforms for clinical trials and other research. The Asia-Pacific Myeloma and Related Diseases Registry (APAC MRDR) was developed to monitor and explore variation in epidemiology, treatment regimens and their impact on clinical outcomes across this region. Here we describe the registry's design and development, initial data, progress and future plans.

METHODS

The APAC MRDR was established in 2018 as a multicentre collaboration across the Asia-Pacific, collecting prospective data on patients newly diagnosed with MM, MGUS, PCL and plasmacytoma in Korea, Singapore, Malaysia and Taiwan, with China recently joining. Development of the registry required a multidisciplinary team of clinicians, researchers, legal and information technology support, and financial resources, as well as local clinical context from key opinion leaders in the APAC region. Written informed consent is obtained and data are routinely collected throughout treatment by hospital staff. Data are stored securely, meeting all local privacy and ethics requirements. Data were collected from October 2018 to March 2024.

RESULTS

Over 1700 patients from 24 hospitals have been enrolled onto the APAC MRDR to date, with the majority (86%) being newly diagnosed with MM. Bortezomib with an immunomodulatory drug was most frequently used in first-line MM therapy, and lenalidomide-based therapy was most common in second-line. Establishment and implementation challenges include regulatory and a range of operational issues.

CONCLUSION

The APAC MRDR is providing 'real-world' data to participating sites, clinicians and policy-makers to explore factors influencing outcomes and survival, and to support high quality studies. It is already a valuable resource that will continue to grow and support research and clinical collaboration in MM and related diseases across the APAC region.

Detection of Feline Coronavirus in Bronchoalveolar Lavage Fluid from Cats with Atypical Lower Airway and Lung Disease: Suspicion of Virus-Associated Pneumonia or Pneumonitis

The premortem understanding of the role of feline coronavirus (FeCoV) in the lungs of cats is limited as viruses are seldom inspected in the bronchoalveolar lavage (BAL) specimens of small animal patients. This study retrospectively analyzed the prevalence of FeCoV in BAL samples from cats with atypical lower airway and lung disease, as well as the clinical characteristics, diagnostic findings, and follow-up information. Of 1162 clinical samples submitted for FeCoV RT-nPCR, 25 were BAL fluid. After excluding 1 case with chronic aspiration, FeCoV was found in 3/24 (13%) BAL specimens, with 2 having immunofluorescence staining confirming the presence of FeCoV within the cytoplasm of alveolar macrophages. The cats with FeCoV in BAL fluid more often had pulmonary nodular lesions (66% vs. 19%, p = 0.14) and multinucleated cells on cytology (100% vs. 48%, p = 0.22) compared to the cats without, but these differences did not reach statistical significance due to the small sample size. Three cats showed an initial positive response to the corticosteroid treatment based on the clinical signs and radiological findings, but the long-term prognosis varied. The clinical suspicion of FeCoV-associated pneumonia or pneumonitis was raised since no other pathogens were found after extensive investigations. Further studies are warranted to investigate the interaction between FeCoV and lung responses in cats.

Gut Microbiome and Metabolic and Immune Indices in Males with or without Evidence of Metabolic Dysregulation

Background

The contributions of the gut microbiota to obesity and metabolic disease represent a potentially modifiable factor that may explain variation in risk between individuals. This study aimed to explore relationships among microbial composition and imputed functional attributes, a range of soluble metabolic and immune indices, and gene expression markers in males with or without evidence of metabolic dysregulation (MetDys).

Methods

This case-control study included healthy males (n=15; 41.9±11.7 years; body mass index [BMI], 22.9±1.2 kg/m2) and males with evidence of MetDys (n=14; 46.6±10.0 years; BMI, 35.1±3.3 kg/m2) who provided blood and faecal samples for assessment of a range of metabolic and immune markers and microbial composition using 16S rRNA gene sequencing. Metagenomic functions were imputed from microbial sequence data for analysis.

Results

In addition to elevated values in a range of traditional metabolic, adipokine and inflammatory indices in the MetDys group, 23 immunomodulatory genes were significantly altered in the MetDys group. Overall microbial diversity did not differ between groups; however, a trend for a higher relative abundance of the Bacteroidetes (P=0.06) and a lower relative abundance of the Verrucomicrobia (P=0.09) phyla was noted in the MetDys group. Using both family- and genera-level classifications, a partial least square discriminant analysis revealed unique microbial signatures between the groups.

Conclusion

These findings confirm the need for ongoing investigations in human clinical cohorts to further resolve the relationships between the gut microbiota and metabolic and immune markers and risk for metabolic disease.

Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial

OBJECTIVES

Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery.

DESIGN

This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022).

SETTINGS

This study was conducted in a single institution, which is an academic university hospital.

PARTICIPANTS

Eighty-six elective cardiac surgical patients with median sternotomy were recruited.

INTERVENTIONS

Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry.

CONCLUSIONS

Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

GPS-Free Wireless Precise Positioning System for Automatic Flying and Landing Application of Shipborne Unmanned Aerial Vehicle

This research is dedicated to developing an automatic landing system for shipborne unmanned aerial vehicles (UAVs) based on wireless precise positioning technology. The application scenario is practical for specific challenging and complex environmental conditions, such as the Global Positioning System (GPS) being disabled during wartime. The primary objective is to establish a precise and real-time dynamic wireless positioning system, ensuring that the UAV can autonomously land on the shipborne platform without relying on GPS. This work addresses several key aspects, including the implementation of an ultra-wideband (UWB) circuit module with a specific antenna design and RF front-end chip to enhance wireless signal reception. These modules play a crucial role in achieving accurate positioning, mitigating the limitations caused by GPS inaccuracy, thereby enhancing the overall performance and reception range of the system. Additionally, the study develops a wireless positioning algorithm to validate the effectiveness of automatic landing on the shipborne platform. The platform's wave vibration is considered to provide a realistic landing system for shipborne UAVs. The UWB modules are practically installed on the shipborne platform, and the UAV and the autonomous three-body vessel are tested simultaneously in the outdoor open water space to verify the functionality, precision, and adaptability of the proposed UAV landing system. Results demonstrate that the UAV can autonomously fly from 200 m, approach, and automatically land on the moving shipborne platform without relying on GPS.

[Visual analysis of the current research status and hotspots of electric burns at home and abroad]

Objective: To analyze the literature on electric burns published at home and abroad, and to explore the research hotspots and frontiers of electric burns. Methods: The bibliometric method was used. The Chinese and English literature related to electric burns published in China National Knowledge Infrastructure, Wanfang database, VIP database and the core collection of Web of Science database from January 1, 2013 to December 31, 2022 were searched respectively, and the CiteSpace 6.2.R2 software was used for analysis. The number of papers, authors, countries, and institutions of Chinese and English literature were counted respectively, and the co-occurrence analysis of keywords and mutation analysis and cluster analysis on the basis of the co-occurrence analysis were conducted, besides, the clustering time line figure was obtained after the keywords were sorted by time to explore the current research status and the evolution process of hotspots in the field of electric burns. Results: A total of 398 English papers were retrieved from the core collection of Web of Science database, and a total of 523 Chinese papers were retrieved from China National Knowledge Infrastructure, Wanfang database, and VIP database after duplicate check. From 2013 to 2022, the number of English literature published in the field of electric burns showed a steadily upward trend, and the number of published Chinese literature showed a downward trend and tended to be stable. In Chinese literature, a total of 302 authors as the first author published papers related to electric burns, with 17 core authors published ≥3 papers; in English literature, a total of 320 authors as the first author published papers related to electric burns. Researches on electric burns were carried out in 65 countries, with United States having the most cooperation with other countries and the largest number of papers published. A total of 512 institutions at home and abroad published papers related to electric burns, and the institutions with the largest number of Chinese and English papers were Shanghai Electric Power Hospital in China (n=14) and Hallym University in Korea (n=11), respectively. A total of 1 176 Chinese keywords and 1 068 English keywords were included for co-occurrence analysis after excluding keywords related to the searching words. The top three keywords in frequency in Chinese literature were surgical flap, wound repair, and nursing, and the top three keywords in frequency in English literature were management, epidemiology, and children. Ten clusters were obtained by keyword analysis in Chinese literature, and the largest cluster was wound healing, followed by clinical effects and surgical flaps. Seven clusters were obtained by keyword analysis in English literature, and the largest cluster was reconstructive surgical procedures, followed by chronic pain and shock. The persistent clusters in Chinese literature were wound healing and clinical outcomes, etc., and the prominent nodes in the recent two years were surgical timing, limb electric burns, and hypertrophic scars; the persistent clusters in English literature were reconstructive surgical procedures and chronic pain, etc., and the prominent nodes in the recent two years were predictors and burn management, etc. In Chinese literature, the keyword with the longest duration of mutation (2017-2021) was wrist electric burns, and the keyword with the highest intensity of mutation was flap repair; in English literature, the keyword with the longest duration of the mutation (2019-2022) was voltage, and the keyword with the highest intensity of mutation was prevention. Conclusions: There are similarities and differences in the research directions and hotspots of electric burns at home and abroad. Surgical flap repair is a common research hotspot at home and abroad. At present, domestic research focuses on wound healing, wrist electric burns, and other aspects, while international research focuses on treatment management, epidemiology, reconstruction, and other aspects.

Tumor Voxel Dose-Response Matrix Prediction Using Deep Learning

PURPOSE/OBJECTIVE(S)

Tumor voxel dose-response matrix (DRM) can be assessed using a series of FDG-PET/CT feedback images acquired during radiotherapy. Predicting the tumor voxel DRM earlier is crucial for effectively implementing adaptive treatment management. However, it is also challenging due to FDG uptake dynamic fluctuation in tumor cells. This study investigated the feasibility of predicting tumor voxel DRM during the early treatment weeks using the advanced deep learning (DL) technique.

MATERIALS/METHODS

Serial FDG-PET/CT images were acquired at the pretreatment (pre-Tx), the 2nd and 4th treatment weeks during standard chemo-radiotherapy (35 × 2 Gy) from each of the 50 patients with head and neck squamous cell carcinomas (HNSCC). The reference value of tumor voxel DRM (DRMref), representing the average metabolic change ratio during the treatment, was determined using a linear regression performed on the standard uptake values (SUV)s obtained at the pre-Tx (SUV0), the 2nd (SUV2) and the 4th (SUV4) treatment weeks following deformable PET/CT image registration. A DL model, 3D residual-Unet with a total of 3.4 million parameters, was trained to predict the tumor voxel DRMref with using the SUV0 and SUV2 matrices as inputs. The performance of the DL model was evaluated using 10-fold cross-validation and was compared to that of a linear regression (LR) model determined on the SUV0 and SUV2 matrices.

RESULTS

The mean (SD) of the tumor voxel DRMref was 0.46 (0.2) over all 34612 tumor voxels. The predicted tumor voxel DRM was 0.5 (0.38) and 0.46 (0.15) for the LR model and the DL model, respectively. For those resistant voxels (23.7% of all tumor voxels) with a DRMref > 0.6, the DRM deviation was 0.13 (0.4) and -0.11 (0.13) for the LR model and the DL model, respectively. For those sensitive voxels (76.3%) with a DRMref ≤ 0.6, the DRM deviation was 0.01 (0.23) and 0.03 (0.08) for the LR model and the DL model, respectively.

CONCLUSION

The proposed DL model can predict the tumor voxel DRM with a single FDG-PET feedback image acquired during the 2nd treatment week of radiotherapy for HNSCC patients. The prediction accuracy was improved compared to that of the LR model with a substantial reduction in the variances of the prediction errors. This work demonstrates the great potential of utilizing DL techniques to improve the efficiency of tumor response assessment and adaptive treatment management.

[Mechanism of intestinal injury induced by WNT2B high-expressed fibroblasts in Crohn's disease]

Objective: To explore the mechanism of intestinal tissue damage induced by macrophages activated by WNT2B high-expressed fibroblasts. Methods: This study involved biological information analysis, pathological tissue research and cell experimental research. The biological information of the colon tissue from the children with inflammatory bowel disease in previous study was analyzed again with single-cell sequencing. The pathological tissues were collected by colonoscopy from 10 children with Crohn's disease treated in the Department of Gastroenterology of Guangzhou Women and Children's Medical Center from July 2022 to September 2022. According to the findings of colonoscopy, tissues with obvious inflammation or ulceration were classified as the inflammatory group, while tissues with slight inflammation and no ulceration were classified as the non-inflammatory group. HE staining was performed to observe the pathological changes of the colon tissues. Macrophage infiltration and CXCL12 expression were detected by immunofluorescence. In terms of cell experiments, fibroblasts transfected with WNT2B plasmid or empty plasmid were co-cultured with salinomycin treated or non-treated macrophages, respectively; the expression of proteins through Wnt classical pathway were detected by western blotting. Macrophages treated with SKL2001 were used as the experimental group, and those with phosphate buffer as the control group. The expression and secretion of CXCL12 in macrophages were detected by quantitative Real-time PCR and enzyme-linked immunosorbent assay (ELISA). T-test or rank sum test were used for the comparison between groups. Results: Single-cell sequencing analysis suggested that macrophages were the main cells in inflammatory bowel disease colon tissue, and there was interaction between WNT2B high-expressed fibroblasts and macrophages. HE staining of the 10 patients ((9.3±3.8) years old, 7 males and 3 females) showed that the pathological score of colon tissue in the inflammatory group was higher than that in the non-inflammatory group (4 (3, 4) vs. 2 (1, 2) points, Z=3.05, P=0.002). Tissue immunofluorescence indicated that the number of infiltrating macrophages in the inflammatory group was significantly higher than that in the non-inflammatory group under high power field of view (72.8±10.4 vs.8.4±3.5, t=25.10, P<0.001), as well as the number of cells expressing CXCL12 (14.0±3.5 vs. 4.7±1.9, t=14.68, P<0.001). In cell experiments, western blotting suggested an elevated level of glycogen synthase kinase-3β phosphorylation in macrophages co-cultured with fibroblast transfected with WNT2B plasmid, and salinmycin could reverse this change. Real-time PCR suggested that the transcription level of CXCL12 in the experimental group was higher than that in the control group (6.42±0.04 vs. 1.00±0.03, t=183.00, P<0.001), as well as the expression and secretion of CXCL12 by ELISA ((465±34) vs. (77±9) ng/L, t=13.21, P=0.006). Conclusion: WNT2B high-expressed fibroblasts can secrete WNT2B protein and activate the Wnt classical signaling pathway thus enhancing the expression and secretion of CXCL12 in macrophages, inducing the development of intestinal inflammation of Crohn's disease.

[Efficacy and safety of endoscopic diaphragm incision in children with congenital duodenal diaphragm]

Objective: To explore the efficacy and safety of endoscopic diaphragm incision in pediatric congenital duodenal diaphragm. Methods: Eight children with duodenal diaphragm treated by endoscopic diaphragm incision in the Department of Gastroenterology of Guangzhou Women and Children's Medical Center from October 2019 to May 2022 were enrolled in this study. Their clinical data including general conditions, clinical manifestations, laboratory and imaging examinations, endoscopic procedures and outcomes were retrospectively analyzed. Results: Among the 8 children, 4 were males and 4 females. The diagnosis was confirmed at the age of 6-20 months; the age of onset was 0-12 months and the course of disease was 6-18 months. The main clinical manifestations were recurrent non-biliary vomiting, abdominal distension and malnutrition. One case complicated with refractory hyponatremia was first diagnosed with atypical congenital adrenal hyperplasia in the endocrinology department. After treatment with hydrocortisone, the blood sodium returned to normal, but vomiting was recurrent. One patient underwent laparoscopic rhomboid duodenal anastomosis in another hospital but had recurred vomiting after the operation, who was diagnosed with double duodenal diaphragm under endoscope. No other malformations were found in all the 8 cases. The duodenal diaphragm was located in the descending part of the duodenum, and the duodenal papilla was located below the diaphragm in all the 8 cases. Three cases had the diaphragm dilated by balloon to explore the diaphragm opening range before diaphragm incision; the other 5 had diaphragm incision performed after probing the diaphragm opening with guide wire. All the 8 cases were successfully treated by endoscopic incision of duodenal diaphragm, with the operation time of 12-30 minutes. There were no complications such as intestinal perforation, active bleeding or duodenal papilla injury. At one month of follow-up, their weight increased by 0.4-1.5 kg, with an increase of 5%-20%. Within the postoperative follow-up period of 2-20 months, all the 8 children had duodenal obstruction relieved, without vomiting or abdominal distension, and all resumed normal feeding. Gastroscopy reviewed at 2-3 months after the operation in 3 cases found no deformation of the duodenal bulbar cavity, and the mucosa of the incision was smooth, with a duodenal diameter of 6-7 mm. Conclusion: Endoscopic diaphragm incision is safe, effective and less invasive in pediatric congenital duodenal diaphragm, with favorable clinical applicability.

Characteristics and Outcomes of Older Patients With Classical Hodgkin Lymphoma: An Australasian Lymphoma Alliance, and Lymphoma and Related Diseases Registry Study

BACKGROUND

There is no standard front-line therapy for older patients with classical Hodgkin lymphoma (cHL). We analyzed the clinical presentation and front-line management of older Australian patients with cHL and explored factors associated with unplanned hospital admission and survival.

METHODS

Patients aged ≥ 61 years and diagnosed between 2011 and 2020, were retrospectively identified through the Lymphoma and Related Diseases Registry (LaRDR) and Australasian Lymphoma Alliance (ALA) institutional databases. Descriptive statistics and Kaplan-Meier survival analyses were performed using STATA-v17.

RESULTS

195 patients were identified, 72 from LaRDR,123 from ALA. Median age of the combined cohort was 72 years (range 61-93); 56.4% male, 35.3% had stage I-II, bulk present in 9.2%, 33.9% had extra-nodal disease and 48.2% had B-symptoms. Chemotherapy was commenced in 91.3% of patients, with an anthracycline-based regimen used in 81%. Median number of cycles given for stage I-II was 2 and for stage III-IV was 6. Radiotherapy was administered in 26.2% of patients. A complete remission to front-line chemotherapy was achieved in 60.7% of patients. During front-line therapy in the ALA cohort, 89 unplanned hospitalizations occurred in 58 patients, with infection accounting for 59.6% of admissions. Treatment-related mortality was 5.2%. Only performance status and anthracycline use correlated with unplanned hospitalizations. Estimated 2-year progression free survival was 63.7% and 2-year overall survival was 71.2%. Anthracycline use and younger age were independently associated with improved survival.

CONCLUSION

The management of older patients with cHL in Australia is diverse but aligns with international data. Anthracycline-based therapy improved survival but resulted in frequent unplanned hospitalizations.

[Analysis of solitary rectal ulcer syndrome in 7 children]

Objective: To analyze the clinical features, treatment and prognosis of solitary rectal ulcer syndrome (SRUS) in children. Methods: The clinical data of 7 children who were diagnosed with SRUS in Department of Gastroenterology in Guangzhou Women and Children' Medical Center from January 2019 to December 2021 were retrospectively analyzed. The clinical data including general demographics, clinical presentations, endoscopic and histologic features, treatment and outcome were extracted from hospital medical records. Results: The 7 patients were all males, and the age of onset was 6-12 years. The course before diagnosis was 2-36 months. The most common symptom was rectal bleeding (6 cases) and most common findings at initial colonoscopy were ulcer in 3 cases and protuberance in 4 cases, both located only in rectum. The intestinal histopathology of 5 cases showed characteristic fibromuscular obliteration of lamina propria. Five children were treated with mesalamine granules or suppositories, and 2 cases underwent local excision. The follow-up lasted for 5-24 months and found symptoms relieved in 5 cases, improved in 1 case, and no remission in 1 case. Colonoscopy after the treatment was performed in 5 children, among whom 2 cases achieved mucosal healing. Conclusions: SRUS in children is mainly presented with rectal bleeding, and has characteristic histological change of ulcer and protuberance in endoscopy. Pathology is crucial for diagnosis and differential diagnosis. Both the medical and surgical treatment are effective for SRUS.

DNA Barcode Technology and Its Application Prospects in Forensic Medicine

Abstract

Traditional species identification has gone through five stages -- morphology, cytology, biochemistry, immunology and molecular biology. At present, the use of DNA technology for species identification has become a research hotspot. In the use of DNA for species identification, the presentation and application of DNA barcode is of epoch-making significance. With the successful application of new technology in species identification, forensic species identification has also made corresponding development, and is expected to play an important role in forensic related fields. This paper briefly describes the general situation and principles of DNA barcode technology as well as its advantages and limitations when applied to biological classification, and discusses the future significance and feasibility of DNA barcode technology in forensic applications, in order to provide new ideas for future forensic identification.

Selection of microbial biomarkers with genetic algorithm and principal component analysis

Background

Principal components analysis (PCA) is often used to find characteristic patterns associated with certain diseases by reducing variable numbers before a predictive model is built, particularly when some variables are correlated. Usually, the first two or three components from PCA are used to determine whether individuals can be clustered into two classification groups based on pre-determined criteria: control and disease group. However, a combination of other components may exist which better distinguish diseased individuals from healthy controls. Genetic algorithms (GAs) can be useful and efficient for searching the best combination of variables to build a prediction model. This study aimed to develop a prediction model that combines PCA and a genetic algorithm (GA) for identifying sets of bacterial species associated with obesity and metabolic syndrome (Mets).

Results

The prediction models built using the combination of principal components (PCs) selected by GA were compared to the models built using the top PCs that explained the most variance in the sample and to models built with selected original variables. The advantages of combining PCA with GA were demonstrated.

Conclusions

The proposed algorithm overcomes the limitation of PCA for data analysis. It offers a new way to build prediction models that may improve the prediction accuracy. The variables included in the PCs that were selected by GA can be combined with flexibility for potential clinical applications. The algorithm can be useful for many biological studies where high dimensional data are collected with highly correlated variables.

A correlation-based network for biomarker discovery in obesity with metabolic syndrome

Background

Obesity is associated with chronic activation of the immune system and an altered gut microbiome, leading to increased risk of chronic disease development. As yet, no biomarker profile has been found to distinguish individuals at greater risk of obesity-related disease. The aim of this study was to explore a correlation-based network approach to identify existing patterns of immune-microbiome interactions in obesity.

Results

The current study performed correlation-based network analysis on five different datasets obtained from 11 obese with metabolic syndrome (MetS) and 12 healthy weight men. These datasets included: anthropometric measures, metabolic measures, immune cell abundance, serum cytokine concentration, and gut microbial composition. The obese with MetS group had a denser network (total number of edges, n = 369) compared to the healthy network (n = 299). Within the obese with MetS network, biomarkers from the immune cell abundance group was found to be correlated to biomarkers from all four other datasets. Conversely in the healthy network, immune cell abundance was only correlated with serum cytokine concentration and gut microbial composition. These observations suggest high involvement of immune cells in obese with MetS individuals. There were also three key hubs found among immune cells in the obese with MetS networks involving regulatory T cells, neutrophil and cytotoxic cell abundance. No hubs were present in the healthy network.

Conclusion

These results suggest a more complex interaction of inflammatory markers in obesity, with high connectivity of immune cells in the obese with MetS network compared to the healthy network. Three key hubs were identified in the obese with MetS network, involving Treg, neutrophils and cytotoxic cell abundance. Compared to a t-test, the network approach offered more meaningful results when comparing obese with MetS and healthy weight individuals, demonstrating its superiority in exploratory analysis.

Associations of health literacy with diabetic foot outcomes: a systematic review and meta-analysis

BACKGROUND

People with diabetes have low health literacy, but the role of the latter in diabetic foot disease is unclear.

AIM

To determine, through a systematic review and meta-analysis, if health literacy is associated with diabetic foot disease, its risk factors, or foot care.

METHODS

We searched PubMed, EMBASE, CINAHL, Web of Science, Scopus and Science Direct. All studies were screened and data extracted by two independent reviewers. Studies in English with valid and reliable measures of health literacy and published tests of association were included. Data were extracted on the associations between the outcomes and health literacy. Meta-analyses were performed using random effects models.

RESULTS

Sixteen articles were included in the systematic review, with 11 in the meta-analysis. In people with inadequate health literacy, the odds of having diabetic foot disease were twice those in people with adequate health literacy, but this was not statistically significant [odds ratio 1.99 (95% CI 0.83, 4.78); two studies in 1278 participants]. There was no statistically significant difference in health literacy levels between people with and without peripheral neuropathy [standardized mean difference -0.14 (95% CI -0.47, 0.18); two studies in 399 participants]. There was no association between health literacy and foot care [correlation coefficient 0.01 (95% CI -0.07, 0.10); seven studies in 1033 participants].

CONCLUSIONS

There were insufficient data to exclude associations between health literacy and diabetic foot disease and its risk factors, but health literacy appears unlikely to have a role in foot care. The contribution of low health literacy to diabetic foot disease requires definitive assessment through robust longitudinal studies.

How deep is the inflammation in chronic rhinosinusitis? Sinus wall thickness and blood eosinophilia

Various factors have been proposed to be related to refractory chronic rhinosinusitis (CRS). Treatment for refractory CRS is challenging for ear, nose, and throat (ENT) surgeons. The aim of the study was to determine the clinical features associated with the severity of CRS that may necessitate revision surgery by eliminating the bias of the surgeons technique using standardizing surgical procedures. Sinus wall thickness and blood eosinophilia, which may represent the depth of inflammation in CRS, are associated with the need for revision surgery. We found that, when the thickness of the postero-lateral maxillary sinus wall is more than 3.03 mm, there is an increased probability for a need for revision surgery. CRS patients with thickened sinus walls were found to have poorer outcomes. Further research is needed in order to justify this type of surgical procedure for CRS.

Effect of salinity on medium- and low-pressure UV disinfection of Vibrio cholerae

The problem of biological invasions attributed to ballast water release is an ongoing problem that threatens ecosystems and human health. Ultraviolet (UV) radiation has been increasingly used for ballast water treatment mainly due to the advantages of short contact time and minimized harmful disinfection by products. In this study, the impact of salinity on the inactivation of Vibrio cholerae (NCTC 7253) was examined, and comparison of inactivation level and disinfection kinetics after medium-pressure (MP) (1 kW) and low-pressure (LP) (10 W) UV irradiation was made. MP UV exposure resulted in higher inactivation efficacy against V. cholerae than LP UV exposure especially at lower UV doses (≤3 mJ cm^-2) and salinity had a negative impact on both MP and LP UV disinfection, especially at higher UV doses (≥3 mJ cm^-2 for MP and ≥4 mJ cm^-2 for LP). To understand the mechanisms of salinity effect on V. cholerae, the enzyme-linked immunosorbent assay (ELISA) was employed to determine the number of cyclobutane pyrimidine dimers (CPDs), one major type of DNA damage. No significant effects of salinity were found at the CPDs level except for 3% artificial seawater after LP UV exposure case. It is imperative that site-specific conditions of salinity be taken into account in the design of UV reactors to treat V. cholerae and other species.

Kernohan-Woltman Notch Phenomenon Caused by Acute Traumatic Subdural Haematoma

A 27-year-old man suffered from right hemiparesis after a closed head injury. Computed tomography (CT) revealed a right hemisphere subdural haematoma with midline structure shifted to the left. The CT finding was believed to be mislabeled because the site of haematoma did not correlate with an ipsilateral hemiparesis. Magnetic resonance imaging revealed a right transtentorial uncal herniation and a small lesion within left cerebral peduncle, suggesting Kernohan-Woltman notch phenomenon (KWNP). KWNP has been rarely seen in patients with acute traumatic subdural haemorrhage. Anatomical small maximum tentorial notch width is the possible anatomical factor predisposing our patient to this phenomenon. (Hong Kong j.emerg.med. 2014;21:116-119)

Cloaking through cancellation of diffusive wave scattering

A new cloaking mechanism, which makes enclosed objects invisible to diffusive photon density waves, is proposed. First, diffusive scattering from a basic core-shell geometry, which represents the cloaked structure, is studied. The conditions of scattering cancellation in a quasi-static scattering regime are derived. These allow for tailoring the diffusivity constant of the shell enclosing the object so that the fields scattered from the shell and the object cancel each other. This means that the photon flow outside the cloak behaves as if the cloaked object were not present. Diffusive light invisibility may have potential applications in hiding hot spots in infrared thermography or tissue imaging.

An unexpected route for otolaryngology bacterial contamination with a Venturi atomizer

BACKGROUND

The Venturi-principle atomizer is a commonly used device in otolaryngology practices. The purpose of this study is to evaluate the possible route of bacterial contamination from the nasal vestibule to the atomizer tip through the jet airflow created during the use of the Venturi atomizer.

METHODS

Thirty nostrils from 15 enrolled volunteers were tested. The aerosols generated by spraying sterilized saline into the nostrils were collected using a specially made aerosol-collecting nozzle cap. The collected samples were sent for bacterial culture, and nasal vestibular swab cultures were performed for comparison.

RESULTS

In the aerosol-exposed group, 18 out of 30 samples (60%) were positive for bacterial growth, confirming the bacterial contamination from the nasal vestibule to the atomizer tip through the reverse jet airflow. The bacteria species in 8 of the 18 positive samples were identical to those from the nasal swab culture results from the same nostril.

CONCLUSION

In ordinary otolaryngology practices, there are significant risks for bacterial contamination from the nasal vestibule to the tip of the Venturi atomizer even without direct contact. Clinicians must be more aware of this pattern of contamination, which has not been reported in the existing literature.

P3-13-09: Impact of Estrogen Receptor Negativity on Clinical Outcomes Following Accelerated Partial Breast Irradiation

Purpose: To determine the impact of estrogen receptor (ER) negativity on clinical outcomes for patients treated with Accelerated Partial Breast Irradiation (APBI).

Materials/Methods(s): We evaluated 506 consecutive patients treated with interstitial brachytherapy (n= 199), balloon-based brachytherapy (n=203), and 3D-CRT (n=104). ER negative (ERN) status was assigned using the traditional definition of an ER nuclear IHC stain &lt; 10%, which corresponds to an Allred/NSABP staining score of &lt; 2. 63 patients (12.5%) were ER negative and 443 (87.5%) were ER positive (ERP). Patient demographics and clinical outcomes (IBTR, RNF, DM, DFS, CSS, OS) were analyzed for each group.

Results: The two groups had similar patient characteristics. Tumor sizes were slightly larger for the ERN group at 11.9mm vs. 10.7mm, although this was not statistically significant (p=0.14). No differences were seen in median age (63 vs. 64 years, p=0.36), rate of HER-2/neu overexpression (83% vs. 91%, p=0.11), or lymph node positivity (6% vs. 9%, p=0.55) between the ERN vs. ERP groups, respectively. There were an equal distribution of invasive ductal carcinoma (ERN n=55, 87%; ERP n=387, 87%) and DCIS (ERN n=8, 13%; ERP n=56, 13%) patients within each group. The use of chemotherapy (55% vs. 15%, p&lt;0.001) and nuclear grade (71% vs. 12%, p&lt;0.001) were higher in the ERN vs. ERP cohort. With a mean follow up of 6.1 years, the 5-year actuarial rates of ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), and distant metastasis (DM) for the entire cohort were 1.8%, 0.6%, and 3.2%. Although this was not statistically significant, ERN patients appear to have an increased rate of local failure than patients with ERP histology (4.0% vs. 1.5%, p=0.13). Rates of RNF and DM were, however, significantly higher for the ERN group (RNF: 4.9% ERN vs. 0% ERP, p&lt;0.001; DM: 12.1% ERN vs. 2.0% ERP, p&lt;0.001). Although there was no difference in overall survival at six years (86% vs. 90%, p=0.67), we observed a shorter disease-free survival (86.4% vs. 96.5%, p= 0.01) and cause-specific survival (90% vs. 98%, p=0.01) for the ERN vs. ERP groups.

Conclusion: The ER negative phenotype of early-stage breast cancer may have a decreased rate of locoregional control. We observed a higher rate of DM with reduced disease-free and cause-specific survival in ER negative cases, emphasizing the importance of systemic therapy and careful, long-term follow up for these patients. Prospective study of this histologic subtype with a larger cohort of patients is needed to substantiate these findings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-09.

Axo-axonal interaction in autonomic regulation of the cerebral circulation

Noradrenaline (NE) and acetylcholine (ACh) released from the sympathetic and parasympathetic neurones in cerebral blood vessels were suggested initially to be the respective vasoconstricting and dilating transmitters. Both substances, however, are extremely weak post-synaptic transmitters. Compelling evidence indicates that nitric oxide (NO) which is co-released with ACh from same parasympathetic nerves is the major transmitter for cerebral vasodilation, and its release is inhibited by ACh. NE released from the sympathetic nerve, acting on presynaptic β2-adrenoceptors located on the neighbouring parasympathetic nitrergic nerves, however, facilitates NO release with enhanced vasodilation. This axo-axonal interaction mediating NE transmission is supported by close apposition between sympathetic and parasympathetic nerve terminals, and has been shown in vivo at the base of the brain and the cortical cerebral circulation. This result reveals the physiological need for increased regional cerebral blood flow in 'fight-or-flight response' during acute stress. Furthermore, α7- and α3β2-nicotinic ACh receptors (nAChRs) on sympathetic nerve terminals mediate release of NE, leading to cerebral nitrergic vasodilation. α7-nAChR-mediated but not α3β2-nAChR-mediated cerebral nitrergic vasodilation is blocked by β-amyloid peptides (Aβs). This may provide an explanation for cerebral hypoperfusion seen in patients with Alzheimer's disease. α7- and α3β2-nAChR-mediated nitrergic vasodilation is blocked by cholinesterase inhibitors (ChEIs) which are widely used for treating Alzheimer's disease, leading to possible cerebral hypoperfusion. This may contribute to the limitation of clinical use of ChEIs. ChEI blockade of nAChR-mediated dilation like that by Aβs is prevented by statins pretreatment, suggesting that efficacy of ChEIs may be improved by concurrent use of statins.

Probing the mechanisms of chronotype using quantitative modeling

The physiological mechanisms underlying interindividual differences in chronotype have yet to be established, although evidence suggests both circadian and homeostatic processes are involved. A physiologically based model is developed by combining models of the sleep-wake switch and circadian pacemaker, providing a means of examining how interactions between these systems affect chronotype. Specifically, chronotype is shown to depend on the relative influences of homeostatic and circadian drives, with a stronger homeostatic drive causing morningness. Changes to intrinsic circadian and homeostatic properties, including homeostatic clearance and production rates, and circadian period and amplitude, are also shown to affect chronotype. These results provide a framework for explaining several experimentally observed phenomena, including age-related morningness, adolescent eveningness, and familial advanced and delayed sleep-phase disorders. Additionally, experimental studies have shown that healthy adults on the extremes of the morningness-eveningness spectrum fall into two subtypes: those whose circadian phase markers are unaffected by chronotype, and those whose circadian phase markers track their chronotype. The model demonstrates that this spectrum likely results from interindividual differences in homeostatic kinetics in the first group, and differences in circadian period in the second group. Physiologically based modeling can thus guide diagnosis of sleep pathologies.

Immunomodulatory activities of a new pentapeptide (Bursopentin) from the chicken bursa of Fabricius

The bursa of Fabricius (BF) is a central immune organ in birds, and some peptides from chicken BF have demonstrated important immune functions. Here, a new 626.27 Da pentapeptide, Bursopentin (BP5, Cys-Lys-Arg-Val-Tyr) was isolated and purified by reverse-phase high-performance liquid chromatography. In this study, we examined the effects of BP5 on antigen-specific immune response in BALB/c mice sensitized with inactivated avian influenza virus (AIV) [A/Duck/Jiangsu/NJ08/05 (AIV H9N2 subtype)]. The results suggested that BP5 enhanced anti-hemagglutinin antibody (IgG, the isotypes IgG1 and IgG2a) production, induced both of Th1- (IL-2 and IFN-γ) and Th2-type (IL-4 and -10) cytokines, increased proliferations of splenic lymphocyte subsets CD4+ T cells (CD3+CD4+), CD8+ T cells (CD3+CD8+) and B cells, and enhanced cytotoxic T-lymphocyte activity of the activated splenocytes against NIH3T3 cells. The effects of BP5 on the proliferation of isolated T- and/or B-cell populations of BALB/c mice were assessed, and the data suggested that BP5 promoted spleen lymphocyte proliferation by activating B cells directly and T cells indirectly. Further analysis revealed that B-lymphocyte proliferation induced by BP5 is mediated by reactive oxygen species generated from thiol auto-oxidation of BP5. Furthermore, our data indicated that protein kinase C, mitogen-activated protein kinase, and nuclear factor kappa B are involved in the signal transductions during the BP5-induced B lymphocyte proliferation. This study indicates that BP5 could be a potential immunomodulator for future immuno-pharmacological use.

Space charge effects in field emission nanodevices

Electron field emission from a single nanoemitter is a barrier tunneling, quantum mechanical process that can, therefore, be described by the well-known Fowler-Nordheim (FN) equation. At high emission current densities, however, the space charge caused by the cathode may affect the current density-voltage (J-V) characteristics predicted by the FN theory. In this study, we theoretically investigated the effect of space charge on FE nanodevices, including diode and triode structures. The J-V characteristics of FE nanodevices were obtained by analytically (diode structures) or numerically (triode structures) solving the coupled FN equation and Poisson's equation. We discuss the behavior of FE nanodiodes and nanotriodes displaying different geometries, dimensions and work functions of their emitter materials. In the high current density region, space charge plays an important role in FE nanodevices; the threshold current density of space-charge limitation is related to the electric field distributions. Besides, our theoretical results are in good agreement with the experimental results reported previously.

Phase I/II study evaluating early tolerance in breast cancer patients undergoing accelerated partial breast irradiation treated with MammoSite balloon breast brachytherapy catheter using a two-day dose schedule

Abstract #5131

Purpose: Initial phase I/II results utilizing balloon brachytherapy to deliver accelerated partial breast irradiation (APBI) in only 2-days in patients with early stage breast cancer are presented.&#x2028; Materials and Methods: From 3/2004 – 8/2007, 45 patients received adjuvant radiation therapy after lumpectomy with balloon brachytherapy in a phase I/II trial delivering 2800 cGy in 4 fractions of 700 cGy to a depth of 1 cm from the applicator surface. Inclusion criteria for the protocol included: (1) patient age &gt; 40 years, (2) pathological confirmation of stage 0/I/II breast carcinoma, (3) &gt; 3 cm tumor size, (4) &lt; 3 pathologically positive lymph nodes, and (5) negative margins (per NSABP criteria). Toxicities were evaluated using the NCI CTAE v3.0 scale and cosmesis (Harvard Criteria) was documented at &gt; 6 months.&#x2028; Results: The median age was 66 years (48-83) and median skin spacing was 12 mm (8-24). The median follow-up was 11.4 months (5.4-48 mo) with 20 patients (44%) followed greater than one year, 11 (24%) greater than 2 years and 6 (13%) greater than 3 years. At &lt; 6 mo (n=45), grade II toxicity rates were 9% radiation dermatitis (n=4), 13% breast pain (n=6), 2% edema (n=1), and 2% hyperpigmentation (n=1). Grade III breast pain was reported in 13% (n=6). At &gt; 6 months (n=43), grade II radiation dermatitis, induration, and hypopigmentation were 2% (n=1), grade III breast pain was reported in 2% (n=1). Infection was 16% (n=7) at &lt; 6 mo and 2% (n=1) at &gt; 6 mo. Of these pts, only 4% (n=2) had a positive culture, whereas the others were treated empirically due to brisk erythema. Persistent seroma &gt; 6 months was 30% (n=13). FN was seen in 9% (n=4), but only 1 pt required treatment. Rib fracture was seen in 5% (n=2). Cosmesis was good/excellent in 96% and fair in 4%.&#x2028; Conclusions: Treatment with balloon brachytherapy using a 2-day dose schedule resulted acceptable rates of grade II/III chronic toxicity rates and similar cosmetic results observed with standard 5-day APBI schedule.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5131.

Synthesis design of artificial magnetic metamaterials using a genetic algorithm

In this article, we present a genetic algorithm (GA) as one branch of artificial intelligence (AI) for the optimization-design of the artificial magnetic metamaterial whose structure is automatically generated by computer through the filling element methodology. A representative design example, metamaterials with permeability of negative unity, is investigated and the optimized structures found by the GA are presented. It is also demonstrated that our approach is effective for the synthesis of functional magnetic and electric metamaterials with optimal structures. This GA-based optimization-design technique shows great versatility and applicability in the design of functional metamaterials.

Low-loss propagation in Cr4+:YAG double-clad crystal fiber fabricated by sapphire tube assisted CDLHPG technique

Cr4+:YAG double-clad crystal fiber with an uniform 10-microm core was fabricated by using a sapphire tube as a heat capacitor to stabilize the power fluctuation of the CO2 laser in the co-drawing laser-heated pedestal growth system. The uniformity of the fiber core showed a factor of 3 improvement compared to that without the use of sapphire tube. The variation of the core diameter is within the +/-1.35-degree adiabatic criterion and has a autocorrelation length of 1.7 mm. The measured propagation loss is only 0.02 dB/cm. The sapphire tube also reduces the vertical temperature gradient during the crystal fiber growth process so the 10-microm crystal core exhibits a smooth perimeter. The sapphire tube assisted system can be applied to the growth of many other optical crystal materials.

Optimal design of integrally gated CNT field-emission devices using a genetic algorithm

A method to optimize the focusing quality of integrally gated CNT field-emission (FE) devices by combining field-emission modeling and a computational intelligence technique, genetic algorithm (GA), is proposed and demonstrated. In this work, the e-beam shape, as a characteristic parameter of electron-optical properties, is calculated by field-emission simulation modeling. Using a design tool that combines GA and physical modeling, a set of structural and electrical parameters for four FE device groups, including double-gate, triple-gate, quadruple-gate and quintuple-gate type, were optimized. The resultant FE devices exhibit satisfactory e-beam focusabilities and the extracted parameters with the best performance for each type of FE device were represented to be fabricated by a VLSI technique. The GA-based automatic design parameter extraction will significantly benefit the design of integrated electron-optical systems for versatile vacuum micro- and nano-electronic applications.

Improved field emission properties of thiolated multi-wall carbon nanotubes on a flexible carbon cloth substrate

In this paper we report the observation of enhanced field emission properties from thiolated multi-wall carbon nanotubes (MWCNTs) produced by a simple and effective two-step chemical surface modification technique. This technique implements carboxylation and thiolation on the MWCNTs synthesized by microwave plasma chemical vapor deposition (MPCVD) on the flexible carbon cloth substrate. The resulting thiolated MWCNTs were found to have a very low threshold field value of 1.25 V µm(-1) and a rather high field enhancement factor of 1.93 × 10(4), which are crucial for applications in versatile vacuum microelectronics.

Depression and Somatic Symptoms within the Farming Community

The relationship between somatic symptoms and depression was investigated in a population of farm operators and their spouses. The sample consisted of principal farm operators and their spouses from northeastern Colorado. There were a total of 709 participants who completed data relevant for our analyses. Exploratory and confirmatory factor analyses were conducted on the symptom inventory, and suggested a two-factor structure. One of the factors consisted of symptoms of a psychological nature, and the other consisted of physical symptoms. While both of the factors were significantly correlated with depression, the factor with psychological items was more strongly related to depression. Gender differences in the symptom factor structure were investigated, and only a few minor differences were found. Gender differences in relationships between the somatic symptom factors and depression were also investigated and were not found. Implications for farm operators, spouses, and rural healthcare providers were discussed.

Mixed cystic gliosarcoma and primitive neuroectodermal tumor: a case report

The clinical and pathologic features of a mixed (composite) gliosarcoma and primitive neuroectodermal tumor occurring in a 54-year-old male are presented. A large cyst and the presence of Rosenthal fibers are also unusual features of this tumor. To our knowledge, such a morphologically variegated tumor has not previously been reported.

The prevalence and spectrum of alpha and beta thalassaemia in Guangdong Province: implications for the future health burden and population screening

AIM

Thalassaemia is a good candidate disease for control by preventive genetic programmes in developing countries. Accurate population frequency data are needed for planning the control of thalassaemia in the high risk Guangdong Province of southern China.

METHODS

In total, 13397 consecutive samples from five geographical areas of Guangdong Province were analysed for both haematological and molecular parameters.

RESULTS

There was a high prevalence of carriers of alpha thalassaemia (8.53%), beta thalassaemia (2.54%), and both alpha and beta thalassaemia (0.26%). Overall, 11.07% of the population in this area were heterozygous carriers of alpha and beta thalassaemia. The mutation spectrum of alpha and beta thalassaemia and its constitution were fully described in this area. This study reports the true prevalence of silent alpha thalassaemia in the southern China population for the first time. In addition, two novel mutations that give rise to alpha thalassaemia, one deletion resulting in beta thalassaemia, and a rare deletion (--(THAI) allele) previously unreported in mainland China were detected. The frequency of the most common mutation, the Southeast Asian type of deletion (--(SEA), accounting for 48.54% of all alpha thalassaemias) was similar to the total of two alpha(+) thalassaemia deletions (-alpha(3.7) and -alpha(4.2), accounting for 47.49% of alpha thalassaemia).

CONCLUSION

Both alpha and beta thalassaemia are widely distributed in Guangdong Province of China. The knowledge gained in this study will enable the projected number of pregnancies at risk to be estimated and a screening strategy for control of thalassaemia to be designed in this area.

Cardiac complications of enterovirus rhombencephalitis

BACKGROUND

Epidemics of enterovirus 71 infection have caused the death of many children throughout the world. Rhombencephalitis, brain stem encephalitis, and heart failure were present in all of the fatal cases. However, no evidence of myocarditis was noted in the heart specimens, and the mechanism of heart failure remains unknown.

AIMS

To characterise the presentation of cardiac complications in children with enterovirus rhombencephalitis and discuss its pathogenesis.

METHODS

Ninety one consecutive patients with enterovirus rhombencephalitis underwent echocardiography. Of these, 17 patients (nine male, eight female; median age 14 months, range 4-57 months) with left ventricular dysfunction were studied.

RESULTS

Tachycardia was noted in all patients and systemic hypertension in 12. Muscle-brain fraction of creatine kinase was >5% in 14 patients. Plasma norepinephrine and epinephrine levels were significantly raised in the three patients in whom these were analysed. Electrocardiographic abnormalities were noted in eight patients. Pulmonary oedema was complicated in 15 patients. The initial ejection fraction of the left ventricle was 22-58% (mean 37%, SD 11%). All patients deteriorated to hypotensive shock within 12 hours and 13 died. Heart specimens from seven patients showed no evidence of myocarditis, but significant coagulative myocytolysis, myofibrillar degeneration, and cardiomyocyte apoptosis were observed.

CONCLUSIONS

Acute heart failure was noted in 19% of patients with enterovirus rhombencephalitis, which had a fatality rate of 77%. It was not caused by myocarditis but possibly by neurogenic cardiac damage.

Causal inference on the difference of the restricted mean lifetime between two groups

When comparing survival times between two treatment groups, it may be more appropriate to compare the restricted mean lifetime, i.e., the expectation of lifetime restricted to a time L, rather than mean lifetime in order to accommodate censoring. When the treatments are not assigned to patients randomly, as in observational studies, we also need to account for treatment imbalances in confounding factors. In this article, we propose estimators for the difference of the restricted mean lifetime between two groups that account for treatment imbalances in prognostic factors assuming a proportional hazards relationship. Large-sample properties of our estimators based on martingale theory for counting processes are also derived. Simulation studies were conducted to compare these estimators and to assess the adequacy of the large-sample approximations. Our methods are also applied to an observational database of acute coronary syndrome patients from Duke University Medical Center to estimate the treatment effect on the restricted mean lifetime over 5 years.

The role of a beta-bulge in the folding of the beta-hairpin structure in ubiquitin

It is known that the peptide corresponding to the N-terminal beta-hairpin of ubiquitin, U(1-17), can populate the monomeric beta-hairpin conformation in aqueous solution. In this study, we show that the Gly-10 that forms the bulge of the beta-turn in this hairpin is very important to the stability of the hairpin. The deletion of this residue to desG10(1-16) unfolds the structure of the peptide in water. Even under denaturing conditions, this bulge appears to be important in maintaining the residual structure of ubiquitin, which involves tertiary interactions within the sequence 1 to 34 in the denatured state. We surmise that this residual structure functions as one of the nucleation centers in the folding process and is important in stabilizing the transition state. In accordance with this idea, deleting Gly-10 slows down the refolding and unfolding rate by about one half.

Effects of turn residues in directing the formation of the beta-sheet and in the stability of the beta-sheet

The designed peptide (denoted 20-mer, sequence VFITS(D)PGKTYTEV(D)PGOKILQ) has been shown to form a three-strand antiparallel beta-sheet. It is generally believed that the (D)Pro-Gly segment has the propensity to adopt a type II' beta-turn, thereby promoting the formation of this beta-sheet. Here, we replaced (D)Pro-Gly with Asp-Gly, which should favor a type I' turn, to examine the influence of different type of turns on the stability of the beta-sheet. Contrary to our expectation, the mutant peptide, denoted P6D, forms a five-residue type I turn plus a beta-bulge between the first two strands due to a one amino-acid frameshift in the hydrogen bonding network and side-chain inversion of the first beta-strand. In contrast, the same kind of substitution at (D)Pro-14 in the double mutant, denoted P6DP14D, does not yield the same effect. These observations suggest that the SDGK sequence disfavors the type I' conformation while the VDGO sequence favors a type I' turn, and that the frameshift in the first strand provides a way for the peptide to accommodate a disfavored turn sequence by protruding a bulge in the formation of the beta-hairpin. Thus, different types of turns can affect the stability of a beta-structure.

Intraocular lens implantation after penetrating keratoplasty

PURPOSE

We evaluated the clinical results of nonsimultaneous penetrating keratoplasty, cataract extraction, and intraocular lens (IOL) implantation (two-stage surgery) for combined corneal disease and cataract.

METHODS

Twenty-six eyes of 24 patients with an average age of 46 years who underwent two-stage surgery were studied retrospectively. Variables included visual acuity, refractive status, specular microscopy before and after IOL implantation (6 months), and the occurrence of graft failure. Astigmatism was corrected by suture removal and relaxing incision. The mean follow-up after IOL placement was 16 months.

RESULTS

Unaided visual acuity was 20/100 or better in 22 (83%) eyes after the second procedure. Twenty-one (81%) eyes had an aided visual acuity of at least 20/40. The mean refractive and absolute errors were -1.49 +/- 1.39 diopters (D) and 1.55 +/- 1.30 D, respectively. The mean keratometric and refractive cylinders were 3.50 D and 2.26 D, respectively. Nineteen (73%) eyes had a spherical equivalent refraction within 2 D of emmetropia. Anisometropia (> or =3 D) occurred in four (15%) eyes. The endothelial cell density, the coefficient of variation, and the percentage of hexagonal cells documented by specular microscopy were not significantly different before and after IOL implantation. Complications included three rejections, two cases of herpetic recurrence, and one late decompensation. Two graft failures (8%) occurred after secondary surgery.

CONCLUSION

The two-stage surgery is a safe and effective modality.

The use of high-dose-rate brachytherapy alone after lumpectomy in patients with early-stage breast cancer treated with breast-conserving therapy

PURPOSE

We present the preliminary results of our in-house protocol using outpatient high-dose-rate (HDR) brachytherapy as the sole radiation modality following lumpectomy in patients with early-stage breast cancer.

METHODS AND MATERIALS

Thirty-seven patients with 38 Stage I-II breast cancers received radiation to the lumpectomy cavity alone using an HDR interstitial implant with (192)Ir. A minimum dose of 32 Gy was delivered on an outpatient basis in 8 fractions of 4 Gy to the lumpectomy cavity plus a 1- to 2-cm margin over consecutive 4 days.

RESULTS

Median follow-up is 31 months. There has been one ipsilateral breast recurrence for a crude failure rate of 2.6% and no regional or distant failures. Wound healing was not impaired in patients undergoing an open-cavity implant. Three minor breast infections occurred, and all resolved with oral antibiotics. The cosmetic outcome was good to excellent in all patients.

CONCLUSION

In selected patients with early-stage breast cancer, treatment of the lumpectomy cavity alone with outpatient HDR brachytherapy is both technically feasible and well tolerated. Early results are encouraging, however, longer follow-up is necessary before equivalence to standard whole-breast irradiation can be established and to determine the most optimal radiation therapy technique to be employed.

Accelerated treatment of breast cancer

PURPOSE

Radiation therapy (RT) restricted to the tumor bed, by means of an interstitial implant, and lasting 4 to 5 days after lumpectomy was prospectively evaluated in early-stage breast cancer patients treated with breast-conserving therapy (BCT). The goals of the study were to determine whether treatment time can be reduced and whether elective treatment of the entire breast is necessary.

MATERIALS AND METHODS

Between January 1993 and January 2000, 174 cases of early-stage breast cancer were managed with lumpectomy followed by RT restricted to the tumor bed using an interstitial implant. Each brachytherapy patient was matched with one external-beam RT (ERT) patient derived from a reference group of 1,388 patients treated with standard BCT. Patients were matched for age, tumor size, histology, margins of excision, absence of an extensive intraductal component, nodal status, estrogen receptor status, and tamoxifen use. Median follow-up for both the ERT and brachytherapy groups was 36 months.

RESULTS

No statistically significant differences were noted in the 5-year actuarial rates of ipsilateral breast treatment failure or locoregional failure between ERT and brachytherapy patients (1% v 0%, P =.31 and 2% v 1%, P =.63, respectively). In addition, there were no statistically significant differences noted in rates of distant metastasis (6% v 3%, P =.24), disease-free survival (87% v 91%, P =.55), overall survival (90% v 93%, P =.66), or cause-specific survival (97% v 99%, P =.28).

CONCLUSION

Accelerated treatment of breast cancer using an interstitial implant to deliver radiation to the tumor bed alone over 4 to 5 days seems to produce 5-year results equivalent to those achieved with conventional ERT. Extended follow-up will be required to determine the long-term efficacy of this treatment approach.

Impact of boost technique on outcome in early-stage breast cancer patients treated with breast-conserving therapy

We reviewed our institution's experience treating early-stage breast cancer patients with breast-conserving therapy (BCT) to determine the impact of boost technique on outcome. A total of 552 patients with stage I and II breast cancer were managed with BCT. All patients were treated with a partial mastectomy and radiation therapy (RT). RT consisted of 45 Gy to 50 Gy external beam irradiation to the whole breast followed by a boost to the tumor bed using either electrons (232 patients), photons (15 patients), or an interstitial implant (316 patients). Local control and cosmetic outcome was compared among three patient groups based on the type of boost used. Forty-one patients had a recurrence of cancer in the treated breast for 5-, 10-, and 13-year actuarial local recurrence rates of 2.8%, 7.5%, and 11.2%, respectively. There were no significant differences in the local recurrence rates or cosmetic outcome using electrons, photons, or an interstitial implant. On multivariate analysis, only young age and margin status were associated with local recurrence. Stage I and II breast cancer patients undergoing BCT can be effectively managed with electron, photon, or interstitial implant boost techniques. Long-term local control and cosmetic outcome are excellent regardless of which boost technique is used.

Neonatal fungemia caused by Hansenula anomala: a case report

Hansenula anomala, an ascosporogenous yeast of the class Ascomycetes, is a free-living organism isolated from the environment. It is also a part of the normal or transient flora of the human throat and alimentary tract. It has been recognized as an opportunistic pathogen and its infection is very rare. A premature infant, a victim of right femoral osteomyelitis and right hip arthritis caused by oxacillin-resistant Staphylococcus aureus, was found to have developed H. anomala fungemia just before the initiation of the antimicrobial therapy with teicoplanin. Antifungal agents (fluconazole and amphotericin B) were prescribed for 10 days despite the absence of clinical sign of systemic fungal infection. His general condition remained good, with a subsequent sterile blood culture. The patient was discharged after completing 5 weeks of antimicrobial therapy, and he remained well during follow-up at our outpatient clinics. Here, we also review the risk factors, the clinical presentations, and the therapeutic strategies of H. anomala infection in the literature.

Structural characterization of a mutant peptide derived from ubiquitin: implications for protein folding

The formation of the N-terminal beta-hairpin of ubiquitin is thought to be an early event in the folding of this small protein. Previously, we have shown that a peptide corresponding to residues 1-17 of ubiquitin folds autonomously and is likely to have a native-like hairpin register. To investigate the causes of the stability of this fold, we have made mutations in the amino acids at the apex of the turn. We find that in a peptide where Thr9 is replaced by Asp, U(1-17)T9D, the native conformation is stabilized with respect to the wild-type sequence, so much so that we are able to characterize the structure of the mutant peptide fully by NMR spectroscopy. The data indicate that U(1-17)T9D peptide does indeed form a hairpin with a native-like register and a type I turn with a G1 beta-bulge, as in the full-length protein. The reason for the greater stability of the U(1-17)T9D mutant remains uncertain, but there are nuclear Overhauser effects between the side chains of Asp9 and Lys 11, which may indicate that a charge-charge interaction between these residues is responsible.