Live tissue intrinsic emission microscopy using multiphoton-excited native fluorescence and second harmonic generation

Multicolor nonlinear microscopy of living tissue using two- and three-photon-excited intrinsic fluorescence combined with second harmonic generation by supermolecular structures produces images with the resolution and detail of standard histology without the use of exogenous stains. Imaging of intrinsic indicators within tissue, such as nicotinamide adenine dinucleotide, retinol, indoleamines, and collagen provides crucial information for physiology and pathology. The efficient application of multiphoton microscopy to intrinsic imaging requires knowledge of the nonlinear optical properties of specific cell and tissue components. Here we compile and demonstrate applications involving a range of intrinsic molecules and molecular assemblies that enable direct visualization of tissue morphology, cell metabolism, and disease states such as Alzheimer's disease and cancer.

Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact

WHAT IS KNOWN AND OBJECTIVE

Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults.

METHODS

We performed a systematic review of studies from relevant biomedical databases and grey literature sources published from January 2007 to January 2012. We searched citation and reference lists and contacted content experts to identify additional studies. Two authors independently selected studies using a predefined protocol. We did not restrict selection to particular study designs; however, non-English studies were excluded during the selection process. Independent extraction of articles by two authors used predefined data fields. For randomized controlled trials and observational studies comparing STOPP/START to other explicit criteria, we assessed risk of bias using an adapted tool.

RESULTS AND DISCUSSION

We included 13 studies: a single randomized controlled trial and 12 observational studies. We performed a descriptive analysis as heterogeneity of study populations, interventions and study design precluded meta-analysis. All observational studies reported the prevalence of PIP; however, the application of the criteria was not consistent across all studies. Seven of the observational studies compared STOPP/START with other explicit criteria. The STOPP/START criteria were reported to be more sensitive than the more-frequently-cited Beers criteria in six studies, but less sensitive than a set of criteria developed in Australia. The STOPP criteria identified more medications associated with adverse drug events than the 2002 version of the Beers criteria. Patients with PIP, as identified by STOPP, had an 85% increased risk of adverse drug events in one study (OR = 1·85, 95% CI: 1·51-2·26; P < 0·001). There was limited evidence that the application of STOPP/START criteria optimized prescribing. Research involving the application of STOPP/START on the impact on the quality of life was not found. The direct costs of PIP were documented in three studies from Ireland, but more extensive analyses on the economic impact or studies from other jurisdictions were not found.

WHAT IS NEW AND CONCLUSION

The STOPP/START criteria have been used to review the medication profiles of community-dwelling, acute care and long-term care older patients in Europe, Asia and North America. Observational studies have reported the prevalence and predictors of PIP. The STOPP/START criteria appear to be more sensitive than the 2002 version of the Beers criteria. Limited evidence was found related to the clinical and economic impact of the STOPP/START criteria.

Structural and functional disruption of vascular smooth muscle cells in a transgenic mouse model of amyloid angiopathy

The deposition of amyloid Abeta peptide in the wall of cerebral vessels (cerebral amyloid angiopathy), can lead to weakness and rupture of the vessel wall, resulting in hemorrhagic stroke. The Tg2576 transgenic mouse line, overexpressing mutant amyloid precursor protein in an age-dependent manner, forms amyloid angiopathy morphologically similar to that seen in the human. We report here the structural and functional disruption of smooth muscle cells (SMCs) in the walls of pial vessels affected by amyloid deposition in the Tg2576 mouse. We demonstrate, using multiphoton imaging, that the arrangement of SMCs becomes disorganized before the onset of cell death, and that these disorganized SMCs are unable to respond appropriately to application of endothelial-dependent and endothelial-independent vasodilators in a closed-cranial window preparation.

Laparoscopic excision of distal pancreas including insulinoma

A case of sporadic occult insulinoma treated by laparoscopic distal pancreatectomy using a laparoscopic ultrasound probe to facilitate localization of the insulinoma and a laparoscopic surgical stapler to transect the pancreas is presented. This is believed to be the first case description of a laparoscopic pancreatic resection.

Lesch-Nyhan disease: clinical experience with nineteen patients

The clinical phenotype in Lesch-Nyhan disease has been analyzed in 19 patients studied in hospital. In each case the diagnosis was made on the basis of inactivity of the enzyme hypoxanthine guanine phosphoribosyltransferase in erythrocyte lysates. All had hyperuricemia, and the presence of 'orange sand' in the diaper was a prominent early complaint. All had self-mutilative behavior, of which the most characteristic form was biting the fingers or lips. All had the neurological syndrome of spasticity and choreoathetoid involuntary movements. All but one had less-than-normal intelligence.

Aggregation and disaggregation of senile plaques in Alzheimer disease

We quantitatively analyzed, using laser scanning confocal microscopy, the three-dimensional structure of individual senile plaques in Alzheimer disease. We carried out the quantitative analysis using statistical methods to gain insights about the processes that govern Abeta peptide deposition. Our results show that plaques are complex porous structures with characteristic pore sizes. We interpret plaque morphology in the context of a new dynamical model based on competing aggregation and disaggregation processes in kinetic steady-state equilibrium with an additional diffusion process allowing Abeta deposits to diffuse over the surface of plaques.

Anatomic and physiologic characteristics of venous ulceration

PURPOSE

The purpose of this study was to describe the combination of physiologic and anatomic changes present in limbs with venous ulceration.

METHODS

Limbs with venous ulceration (chronic venous insufficiency [CVI] class 3) were assessed prospectively by air plethysmography and color-flow duplex scanning. Findings were compared with clinically normal contralateral limbs and normal control limbs (CVI class 0), as well as with limbs without skin changes (CVI class 1).

RESULTS

Of the 120 ulcerated limbs studied, only 28% had deep system incompetence. Reflux at the saphenofemoral or saphenopopliteal junctions without perforator incompetence was present in 40%. Raised venous filling indexes (> 2 ml/s) and high residual volume fractions (> 20%) were present in 90% and 95%, respectively. Although levels of these parameters were significantly different from the other groups (p < 0.05), absolute ejection volumes and outflow parameters were the same (p > 0.05). One third of contralateral "normal" limbs (class 0) had abnormal duplex scanning findings. The ratio of venous filling time to residual volume fraction produced a useful discriminating index for the ulcerated limb.

CONCLUSION

The ulcerated limb was characterized by high rates of reflux and high residual volumes that were independent of the site of reflux. This study highlights the important association of venous ulceration and isolated superficial venous system incompetence.

Recurrent varicose veins: patterns of reflux and clinical severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Modeling the spread of methicillin-resistant Staphylococcus aureus (MRSA) outbreaks throughout the hospitals in Orange County, California

BACKGROUND

Since hospitals in a region often share patients, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection in one hospital could affect other hospitals.

METHODS

Using extensive data collected from Orange County (OC), California, we developed a detailed agent-based model to represent patient movement among all OC hospitals. Experiments simulated MRSA outbreaks in various wards, institutions, and regions. Sensitivity analysis varied lengths of stay, intraward transmission coefficients (β), MRSA loss rate, probability of patient transfer or readmission, and time to readmission.

RESULTS

Each simulated outbreak eventually affected all of the hospitals in the network, with effects depending on the outbreak size and location. Increasing MRSA prevalence at a single hospital (from 5% to 15%) resulted in a 2.9% average increase in relative prevalence at all other hospitals (ranging from no effect to 46.4%). Single-hospital intensive care unit outbreaks (modeled increase from 5% to 15%) caused a 1.4% average relative increase in all other OC hospitals (ranging from no effect to 12.7%).

CONCLUSION

MRSA outbreaks may rarely be confined to a single hospital but instead may affect all of the hospitals in a region. This suggests that prevention and control strategies and policies should account for the interconnectedness of health care facilities.

Assessment of nutritional status and fluid deficits in advanced cancer

Malnutrition and cachexia are frequent manifestations of cancer and are major contributors to morbidity and mortality. The assessment of nutrition status in cancer patients can be easily accomplished. The first step is to record a complete medical history and to perform a thorough clinical examination to uncover signs of nutritional deficiency. Simple and inexpensive tests are available to assess the body composition, such as: anthropometric measurements, skinfold thickness, arm muscle circumference and area, and weight and body mass index (BMI). Biochemical measurements are also available, such as serum albumin, transferring, and prealbumin.

Fluid deficit is divided into two categories based on pathophysiology (dehydration and volume depletion) and to three subtypes based on plasma sodium concentration (hyponatremic, hypernatremic, and isotonic). Dehydration (total water deficit, especially intracellular) is always hypernatremic, while volume depletion (intravascular water and sodium deficit) is either hyponatremic, hypernatremic, or isotonic. There are no clear clinical differences among the various categories, but a delay of capillary refill, tachycardia, and orthostatic hypotension is more common with volume depletion. Careful clinical assessment and laboratory tests, especially serum sodium, are the keystones for diagnosis and effective management. Bioelectrical impedance (BEI) is an easy way to assess both nutrition status and fluid deficits in advanced cancer and should be used more often than it currently is. This article reviews the subjective and objective methods of assessing fluid deficit and nutrition in advanced cancer.

Prenatal ethanol exposure alters immune capacity and noradrenergic synaptic transmission in lymphoid organs of the adult mouse

Clinical and experimental evidence indicates that exposure to alcohol in utero is associated with altered immune capacity. The mechanisms underlying such abnormalities are not clear. However, the suggestion that reciprocal interactions between the immune and the nervous systems are necessary for a competent immune response may be relevant. This work examined the consequences of prenatal ethanol exposure on cellular immune responses and noradrenergic synaptic transmission in lymphoid organs of the adult C57B1/6 mouse. Pregnant mice were fed a liquid diet containing 25% of the calories as ethanol (4.8% w/v) or pair-fed an isocaloric equivalent of this diet throughout gestation, followed by foster-nursing the neonates on normal dams. As young adults, mice exposed to ethanol prenatally displayed immunologic and selective neurochemical changes: (1) depressed ability to produce cellular immune responses, including contact hypersensitivity and a local graft-vs-host response, and (2) altered noradrenergic synaptic transmission, including enhanced norepinephrine turnover, and a reduction in norepinephrine levels and beta-adrenoceptor density in the thymus and spleen, but not the heart. However, both the integrity and compartmentation of noradrenergic nerve fibres in the spleen were intact. It is suggested that altered noradrenergic synaptic transmission selectively in lymphoid organs may contribute to the impaired immune capacity associated with fetal alcohol exposure.

Modeling the regional spread and control of vancomycin-resistant enterococci

BACKGROUND

Because patients can remain colonized with vancomycin-resistant enterococci (VRE) for long periods of time, VRE may spread from one health care facility to another.

METHODS

Using the Regional Healthcare Ecosystem Analyst, an agent-based model of patient flow among all Orange County, California, hospitals and communities, we quantified the degree and speed at which changes in VRE colonization prevalence in a hospital may affect prevalence in other Orange County hospitals.

RESULTS

A sustained 10% increase in VRE colonization prevalence in any 1 hospital caused a 2.8% (none to 62%) average relative increase in VRE prevalence in all other hospitals. Effects took from 1.5 to >10 years to fully manifest. Larger hospitals tended to have greater affect on other hospitals.

CONCLUSIONS

When monitoring and controlling VRE, decision makers may want to account for regional effects. Knowing a hospital's connections with other health care facilities via patient sharing can help determine which hospitals to include in a surveillance or control program.

Analytical study of a Rift Valley fever epidemic

Three epidemiological investigations were carried out during and after the 1987 Rift Valley fever (RVF) epidemic in South Mauritania: a case control study, a cross-sectional study in the town of Rosso and a cross-sectional study of villages and encampments around Rosso. The case control study showed an association between epizootic and epidemic outbreaks. The study in Rosso town showed housing and district effects. Also, a medical survey of hospital staff showed the absence of interhuman contamination. The cross-sectional study of villages and encampments around Rosso showed heterogeneity corresponding to a village and ethnic effect. The human epidemic was linked to epizootic disease, but the "vectors" of the disease are not as yet known.

Lack of association of trinucleotide repeat polymorphisms in very-low-density lipoprotein receptor gene with Alzheimer's disease

Inheritance of the apolipoprotein E epsilon 4 allele is a risk factor for Alzheimer's disease (AD). A recent report studying Japanese patients suggested that a polymorphism of a trinucleotide repeat in the 5' untranslated region of an apolipoprotein E receptor, the very-low-density lipoprotein receptor, is genetically associated with AD, with overrepresentation of the allele containing five copies of the repeat. We determined the allele frequencies of the very-low-density lipoprotein receptor in 3 white populations totaling 469 individuals. In contrast to the previous report, we found no differences in allele frequencies between case patients and control subjects. The discrepancy could be due to differences in Japanese and white populations. Nonetheless, these data weaken the likelihood that this polymorphism in the very-low-density lipoprotein receptor gene is strongly associated with AD.

The use of video image analysis for the measurement of venous ulcers

The accurate measurement of the size of skin wounds and ulceration is important for comparing the efficiency of treatment modalities and for monitoring progress in the individual patient. Although various methods of differing sophistication are in use, many of the common simpler techniques lack accuracy and reliability. We describe a new technique of ulcer measurement which uses video image recording, capture and computer analysis. A method of correcting for limb convexity in a two-dimensional image is presented. The method has an overall accuracy of 1.82% and a clinical precision of 3.41%, both of which are significantly better than acetate tracings or photographic methods. The technique is simple and rapid, and once established it incurs minimal ongoing costs.

Scimitar syndrome

Three patients with the scimitar syndrome represented an incidence at the King Faisal Specialist Hospital and Research Centre of one per cent of patients who underwent cardiac catheterization. In one of the patients the anomalous pulmonary venous return and the pulmonary hypoplasia was on the left. The syndrome is usually benign. Its recognition may save the patient from unnecessary additional diagnostic procedures.

Authoritarianism and Mental Rigidity: The Einstellung Problem Revisited

As with many issues in psychology, after decades of research no consensus was reached regarding the relationship between authoritarianism and mental rigidity. In particular, the literature describing experiments on authoritarianism and Einstellung rigidity left the basic question unresolved. The present study, based on Christie's review of this literature, used his recommendations for improvements in experimental methodology. An experiment with 101 college undergraduates found greater rigidity among high authoritarians only under conditions designed to produce ego involvement. These results were bolstered by the finding that low humanism, as measured by Tomkins's Polarity Scale, also predicted rigidity. The second dimension of polarity theory (normativism) did not predict rigidity. The present findings suggest that the rigidity of authoritarians may result from arousal produced by ego involvement.

The SPARC DRC: Building a Resource for the Autonomic Nervous System Community

The Data and Resource Center (DRC) of the NIH-funded SPARC program is developing databases, connectivity maps, and simulation tools for the mammalian autonomic nervous system. The experimental data and mathematical models supplied to the DRC by the SPARC consortium are curated, annotated and semantically linked via a single knowledgebase. A data portal has been developed that allows discovery of data and models both via semantic search and via an interface that includes Google Map-like 2D flatmaps for displaying connectivity, and 3D anatomical organ scaffolds that provide a common coordinate framework for cross-species comparisons. We discuss examples that illustrate the data pipeline, which includes data upload, curation, segmentation (for image data), registration against the flatmaps and scaffolds, and finally display via the web portal, including the link to freely available online computational facilities that will enable neuromodulation hypotheses to be investigated by the autonomic neuroscience community and device manufacturers.

Factor V Leiden: how great is the risk of venous thromboembolism?

The factor V Leiden mutation, the most common inherited cause of thrombophilia, causes a mild hypercoagulable state. We describe a 29-year-old man, heterozygous for factor V Leiden, who developed extensive pulmonary emboli with concomitant bilateral deep venous thrombosis, likely provoked by prolonged immobility during a car trip. We then review the diagnosis, therapy, screening, and prognosis of venous thromboembolism related to factor V Leiden.