One Year Radiographic Response Following Prostrate SBRT: An Exploratory Analysis of a Phase III Randomized Trial

PURPOSE/OBJECTIVE(S)

Radiographic MRI response following prostate radiotherapy, particularly stereotactic body radiotherapy (SBRT), remains poorly understood. Our objective was to describe radiographic changes to the prostate gland and prostate tumor following SBRT of men treated on a prospective, randomized trial.

MATERIALS/METHODS

MIRAGE (NCT04384770) is a single center, randomized phase III trial of patients receiving either CT or MRI guided SBRT for localized prostate cancer. Patients underwent pre-treatment and annual post-treatment MRIs, in addition to routine PSA surveillance. Outcomes reported include percent gland shrinkage, percent PSA response at one year, and presence of residual tumor based on radiographic interpretation. Patient characteristics were compared via two-sample t-test or Fischer's exact test. Both univariate and multivariable logistical analysis were employed to identify potential clinical predictors of residual tumor on 1-year follow up MRI.

RESULTS

This study cohort included 94 eligible patients with baseline characteristics in Table 1. Residual lesions were seen in 13 patients (14%), 5/27 (18.5%) treated without ADT and 8/67 (12%) with ADT. PSA ablation was deep, with a 79% median decrease without ADT and 98% median decrease with ADT. Patients receiving ADT showed more gland shrinkage (17% vs. 34% shrinkage, p = 0.0001), while radiographic non-responders and responders experienced similar gland shrinkage (median 21% vs 29% shrinkage, p > 0.05). No significant clinical predictors of residual tumor were identified on univariate and multivariate analysis. No patient had any clinical or biochemical evidence of failure.

CONCLUSION

A total of 14% of patients were found to have residual tumor detected on MRI one year after SBRT. These data highlight the protracted nature of radiographic tumor response to radiation therapy, even with ablative radiation techniques. The analysis is limited by the lack of biopsy data to quantify whether visualized residual tumor harbor active cancer.

Patient-Reported Urinary and Bowel Quality of Life Outcomes Following External Beam Radiotherapy with or without High-Dose-Rate Brachytherapy Boost: Post-Hoc Analyses of TROG 03.04 (RADAR)

PURPOSE/OBJECTIVE(S)

One of the concerns with combining external beam radiotherapy (EBRT) with a high dose rate brachytherapy boost (HDRBT) for prostate cancer is increased toxicity. We aimed to evaluate long-term urinary and bowel quality of life (QoL) outcomes following EBRT vs EBRT + HDRBT using data from the TROG 03.04 trial.

MATERIALS/METHODS

Men who had dose-escalated EBRT (74 Gy) or EBRT (46 Gy) + HDRBT (19.5 Gy in 3 fractions) were included in this exploratory analysis. QoL outcomes were prospectively collected using the EORTC-QLQ-PR25 at baseline, end of radiotherapy, 12, 18, 24, 36, 60 months, and annually up to 10 years. QoL score was normalized to 0-100 with higher scores representing worse symptom burden. Minimal clinically important differences (MCIDs) were defined as differences in the respective QoL scores ≥0.5 standard deviations of the baseline QoL score. Mixed models for repeated measures were used to evaluate longitudinal changes in the QoL score between EBRT and EBRT + HDRBT arms. Logistic regression was used to evaluate differences in proportion of men with 2xMCID between EBRT and EBRT + HDRBT arms at each time point. Age, baseline QoL score, ECOG performance status, and duration of androgen deprivation therapy use (6 vs. 18 months) were adjusted for in all analyses.

RESULTS

Four hundred ninety-seven men were included in this study: 260 (52%) had EBRT and 237 (48%) had EBRT + HDRBT. The median baseline urinary QoL scores were 12.5 (IQR 4.2-19.0) and 8.3 (IQR 4.2-20.8) for men in EBRT and EBRT + HDRBT arms respectively (P = 0.5). Within the first 24 months, men in the EBRT + HDRBT arm had a slower rate of urinary QoL score resolution compared to men in the EBRT arm (P<0.001). At 12, 18, 24, and 36 months, men who had EBRT + HDRBT were 2.4 times (95% CI = 1.4-4.0; P<0.001), 3.1 times (95% CI = 1.8-5.1; P<0.001), 2.8 times (95% CI = 1.7-4.7; P<0.001), and 2.5 times (95% CI = 1.4-4.5; P = 0.002) more likely to have 2xMCID in urinary QoL scores compared to men who had EBRT alone. Beyond 24 months, there were no significant differences in the rate of urinary QoL score resolution between arms, and beyond 36 months there were no significant differences in the proportion with 2xMCID between arms. The median baseline bowel QoL score was 0 in both arms. There were no differences in the rate of bowel QoL score recovery over time between arms. Men who had EBRT + HDRBT were less likely to have 2xMCID in bowel QoL score in the immediate post-radiotherapy period (OR = 0.66; 95% CI = 0.45-0.97; P = 0.03) and at 60 months (OR = 0.51; 95% CI = 0.33-0.80; P = 0.003) compared to men who had EBRT.

CONCLUSION

EBRT + HDRBT is associated with disturbances in urinary QoL that are of greater magnitude compared to EBRT alone within the first 36 months of treatment, but the differences resolved after 36 months. EBRT + HDRBT is associated with less disturbances in bowel QoL immediately after treatment and at 60 months compared to EBRT alone.

Identification of ARUK2002821 as an isoform-selective PI5P4Kα inhibitor

The phosphatidylinositol 5-phosphate 4-kinases (PI5P4Ks) play a central role in regulating cell signalling pathways and, as such, have become therapeutic targets for diseases such as cancer, neurodegeneration and immunological disorders. Many of the PI5P4Kα inhibitors that have been reported to date have suffered from poor selectivity and/or potency and the availability of better tool molecules would facilitate biological exploration. Herein we report a novel PI5P4Kα inhibitor chemotype that was identified through virtual screening. The series was optimised to deliver ARUK2002821 (36), a potent PI5P4Kα inhibitor (pIC₅₀ = 8.0) which is selective vs. other PI5P4K isoforms and has broad selectivity against lipid and protein kinases. ADMET and target engagement data are provided for this tool molecule and others in the series, as well as an X-ray structure of 36 solved in complex with its PI5P4Kα target.

Postbiotic yeast fermentation product supplementation to lactating goats increases the efficiency of milk production by enhancing fiber digestibility and ruminal propionate, and reduces energy losses in methane

Although in vitro data with mixed ruminal fluid demonstrated positive effects of posbiotic diet (POS) from lactobacilli on measures of fermentation and microbial profiles, there is a paucity of in vivo data with lactating ruminants. The aim of the study was to evaluate the effects of incorporating POS into diets of lactating goats on energy (E) partitioning, carbon (C) and nitrogen (N) balance, and performance. Ten late-lactation Murciano-Granadina goats were used in a crossover design with 26-d periods. Goats in the control diet (CON) were fed daily at the rate of 1 kg alfalfa hay and 1.5 kg concentrate, and the treatment group (POS) was fed CON with the addition of 3.75 g/d of Probisan Ruminants (PENTABIOL S.L., Navarra, Spain). No differences in DMI were detected. However, ruminal fluid propionate and apparent total tract digestibilities of NDF and ADF were greater (18%, 4.7%, and 5.2%, respectively; P < 0.05) in POS compared with the CON diet. Daily partitioning of E to milk and efficiency of ME intake for milk production greater (11% and 3.0%, respectively; P < 0.05) in POS compared with CON. The nonprotein RQ was greater in POS compared with CON due to greater (P < 0.05) oxidation of carbohydrate (213 vs. 115 kJ/kg of BW0.75 per day) compared with fat (362 vs. 486 kJ/kg of BW0.75 per day). Although no differences were found in C balance, goats in POS had lower (P < 0.05) amounts of C in CH4 (1.1 vs. 1.3 g/kg BW0.75 per day) compared with CON. There were no differences in N intake or N in feces or urine, but N in milk was greater (P < 0.05) in POS compared with the CON diet (0.8 vs. 0.7 g/kg BW0.75 per day). Yield of fat-corrected milk (FCM) (3.20 vs. 2.72 kg/d; P < 0.05) and concentration of true protein (3.4 vs. 3.3 kg/d; P < 0.05) and lactose (4.7 vs. 4.5 kg/d; P < 0.05) were greater in POS compared with CON. These responses were accompanied by lower (P < 0.05) urea (12.3 vs. 16.6 mM/L) and ammonia-N (6.6 vs. 8.8 mg/L) without changes in fat concentration (6.1% vs. 6.0%; P > 0.05) in POS compared with the CON diet. Daily amount of CH4 emission did not differ P > 0.05 between diets. However, when expressed relative to unit of edible product, feeding POS reduced (P < 0.05) the amount of CH4 by 46 g/kg of milk fat, 97 g/kg of milk protein, and 3 g/kg of milk compared with CON. Overall, data indicated that feeding a postbiotic in late-lactation increased energy efficiency for milk production partly by reducing CH4 emission.

Development of Selective Phosphatidylinositol 5-Phosphate 4-Kinase γ Inhibitors with a Non-ATP-competitive, Allosteric Binding Mode

Phosphatidylinositol 5-phosphate 4-kinases (PI5P4Ks) are emerging as attractive therapeutic targets in diseases, such as cancer, immunological disorders, and neurodegeneration, owing to their central role in regulating cell signaling pathways that are either dysfunctional or can be modulated to promote cell survival. Different modes of binding may enhance inhibitor selectivity and reduce off-target effects in cells. Here, we describe efforts to improve the physicochemical properties of the selective PI5P4Kγ inhibitor, NIH-12848 (1). These improvements enabled the demonstration that this chemotype engages PI5P4Kγ in intact cells and that compounds from this series do not inhibit PI5P4Kα or PI5P4Kβ. Furthermore, the first X-ray structure of PI5P4Kγ bound to an inhibitor has been determined with this chemotype, confirming an allosteric binding mode. An exemplar from this chemical series adopted two distinct modes of inhibition, including through binding to a putative lipid interaction site which is 18 Å from the ATP pocket.

Exploring phenotypes in hypertrophic cardiomyopathy with machine learning data integration. A multicentric, multimodality pilot study

Background

Interpreting patient phenotypes is a challenge when screening for hypertrophic cardiomyopathy (HCM). Machine learning (ML) can potentially help with advanced data integration - combining information contained in whole-cardiac cycle echo deformation and velocity profiles with standard clinical variables. The aim is to apply an ML approach to integrate whole cardiac cycle echo data with clinical variables to explore HCM phenotypes.

Methods

The cohort consisted of 138 participants from two centres: HCM patients (n=91) and relatives (n=47). Echocardiography was performed, whereas magnetic resonance and genetic testing in 48% and 82%, respectively. Whole cardiac cycle echo data (mitral and aortic velocity profiles, and six regional left ventricular (LV) deformation curves) were combined with clinical variables (age, sex, heart rate, e' medial and e' lateral) and used as the ML input. An unsupervised ML algorithm created a representative space where participants were positioned based on integrated data, blinded to disease status. Clustering was used to determine phenogroups and estimate the average characteristics. Data on family history (FHx), genotype, arrhythmias or syncope, implantable cardioverter-defibrillators (ICD), and late gadolinium enhancement (LGE) were used to interpret the phenogroups. As the LA diameter was not available in the dataset, the HCM risk for sudden cardiac death (SCD) was not calculated, however, the Table shows relevant variables to infer clinical risk.

Results

Clustering divided the participants into 6 phenogroups (P1–6) (Figure). Average echo profiles are shown in the Figure, while the clinical data in the Table. P1/2 was defined by symptomatic patients with a high prevalence of positive genotypes, a positive FHx of SCD, and a burden of comorbidities. Echo findings showed pronounced structural/functional remodeling, and P1 was associated with severe septal hypertrophy and outflow tract obstruction. The high prevalence of ICD devices defined P1/2 as high risk groups. In comparison, patients in P3/4 were younger, with milder LV hypertrophy, but still considerable functional impairment. P3 had a higher burden of FHX and a higher prevalence of pathogenic mutations, whereas P4 a higher incidence of hypertension, high heart rate, mitral inflow fusion and findings of LGE. Finally, P5/6 consisted of younger individuals, predominantly HCM relatives, with a mild phenotype and, thus, low inferred risk. As expected, the majority of patients with the genetic variants of undetermined significance were located in P5.

Conclusion

ML can help derive clinically interpretable phenotypes in HCM based on the automated integration of whole cardiac cycle deformation and velocity data with conventional clinical parameters. The derived phenogroups correspond with established risk profiles in HCM. An expanded dataset is needed to enable further exploration of the phenotype-genotype relations and to define prognostic value.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by the Horizon 2020 European Commission Project H2020-MSCA-ITN

Energy, nitrogen partitioning, and methane emissions in dairy goats differ when an isoenergetic and isoproteic diet contained orange leaves and rice straw crop residues

The aim of this study was to evaluate the effects of incorporating rice straw and orange leaves into the diets for goats. Ten Murciano-Granadina goats at mid lactation weighing 45 ± 0.3 kg were used in a crossover design. Two isoproteic and isoenergetic diets (180 g/kg DM and 17 MJ/kg DM, respectively) with alfalfa hay as forage source (33% of DM) were fed. A control diet (CON) incorporated barley as energy source and soy hulls as fiber component. The experimental diet (ORG) replaced barley and soy hulls with orange leaves (19% on DM basis), rice straw (12%, on DM basis) and soya oil (2%). Peas and horsebeans were the protein source in both diets. Each goat received the 2 treatments in 2 periods. Goats were fed the experimental diets and after 14 d on their respective treatments moved to individual metabolism cages for another 7 d. Subsequently, feed intake, total fecal and urine output and milk yield were recorded daily over the first 5 d. During the next 2 d ruminal fluid and blood samples were collected, and then individual gas-exchange measurements were recorded by a mobile open-circuit indirect calorimetry system using a head box. No differences in dry matter intake were detected, and apparent total-tract digestibility was greater in CON than ORG. Efficiency of metabolizable energy intake for milk and maintenance also was lower in response to ORG (0.65 vs. 0.63), with energy balance being negative (-12 kJ/kg of BW^0.75) due to mobilization of fat (-16 g/animal vs. 68 g/animal for ORG and CON, respectively). Although actual milk yield was lower in goats fed ORG (2.32 vs. 2.06 kg/d, respectively), energy-corrected milk did not differ (2.81 kg/d on average). In terms of milk quality, milk fat content, and concentrations of monounsaturated (18.54 vs. 11.55 g/100 g milk fat) and polyunsaturated fatty acids (5.75 vs. 3.99 g/100 g milk fat) were greater in goats fed ORG. Based on various indices, the milk produced by ORG would be less atherogenic and thrombogenic than CON milk. Compared with CON, enteric CH₄ emission was lower due to feeding ORG (reduction of 38 g CH₄/kg milk fat). Data suggest that greater fat mobilization in goats fed ORG might have been due to the apparent lack of synchrony between degradable protein and carbohydrate and the lipogenic nutrients associated with the lower cereal content of the ORG diet. Thus, goats fed ORG seemed to rely more on fat depots to help meet energy requirements and reach optimal performance. As such, the lower content of glucogenic nutrients in ORG did not favor body fat deposition and partitioning of ME into body tissue. Overall, responses in terms of CH₄ emissions and milk quality suggest that inclusion of rice straw and orange leaves in diets for small ruminants could be a valuable alternative to reuse, recycle and revalue agricultural by-products.

Alterations in Energy Partitioning and Methane Emissions in Murciano-Granadina Goats Fed Orange Leaves and Rice Straw as a Replacement for Beet Pulp and Barley Straw

Considering the huge quantities of crops by-products and pruning waste such as rice straw and citrus leaves produced annually worldwide, and their potential pollution capacity, recycling as feed for livestock is an alternative. The objective was to study these by-products effect on energy balance and methane emissions in 10 Murciano-Granadina goats at maintenance. The control diet (CTR) included barley straw and beet pulp while the experimental diet (ORG) consisted of rice straw and orange leaves. Differences were found for energy intake (248 kJ/kg of BW^0.75 greater for CTR than ORG). The intake of metabolizable energy was 199 kJ/kg of BW^0.75 lower in ORG than CTR, and the energy efficiency was higher with CTR (0.61) than ORG (0.48). Protein retained in the body was 9 g/goat greater with CTR than ORG, and fat retention in the body was approximately 108 g/goat greater with CTR than ORG. Despite more unfavorable energy balance in response to feeding ORG than CTR, the retention of body energy was always positive. Reductions in CH₄ emissions were detected when goats were fed ORG diet (from 22.3 to 20.0 g/d). Overall results suggested that feeding orange leaves and rice straw was effective in reducing CH₄ emissions without adversely affecting energy balance.

Inclusion of lemon leaves and rice straw into compound feed and its effect on nutrient balance, milk yield, and methane emissions in dairy goats

The objective of this experiment was to study the effects of incorporating lemon leaves and rice straw into the compound feed of diets for dairy goats. Ten Murciano-Granadina dairy goats (n = 5 per group) in mid-lactation were used in a crossover design experiment (2 treatments across 2 periods). Goats were fed a mixed ration with barley grain (control, CON) or CON plus lemon leaves [189 g/kg of dry matter (DM)] and rice straw (120 g/kg of DM) in place of barley grain (LRS). Soybean oil (19 g/kg of DM) was added to the LRS diet to make it isoenergetic (17 MJ of gross energy/kg of DM) relative to CON. After 14 d on their respective treatments, goats were allocated to individual metabolism cages for another 7 d. Subsequently, feed intake, total fecal and urine output, and milk yield were recorded daily over the first 5 d. During the last 2 d, ruminal fluid and blood samples were collected, along with individual gas exchange measurements recorded by a mobile open-circuit indirect calorimetry system using a head box. No differences in DM intake were detected, and ME intake in LRS was lower than in CON (1,095 vs. 1,180 kJ/kg of metabolic body weight). No differences were observed in milk production, but milk fat content was greater in LRS (6.4%) than in CON (5.6%). Greater concentrations of monounsaturated (14.94 vs. 11.96 g/100 g of milk fat) and polyunsaturated fatty acids (4.53 vs. 4.03 g/100 g of milk fat) were detected in the milk of goats fed LRS compared with CON. Atherogenicity (2.68 vs.1.91) and thrombogenic (4.58 vs. 2.81) indices were lower with LRS compared with CON. Enteric CH₄ emission was lower in LRS (24.3 g/d) compared with CON (31.1 g/d), probably due to the greater lipid content and unsaturated fatty acid profile of lemon leaves and the soybean oil added in the LRS diet. Overall, data suggest that incorporating lemon leaves and rice straw into lactating goat diets is effective in reducing CH₄ emissions while allowing improvements in milk fat production and milk thrombogenic index without affecting production performance. Thus, their inclusion in compound feeds fed to small ruminants appears warranted and would have multiple positive effects, as on efficiency of nutrient use, human health, and the environment.

RUNX1c Regulates Hematopoietic Differentiation of Human Pluripotent Stem Cells Possibly in Cooperation with Proinflammatory Signaling

Runt-related transcription factor 1 (Runx1) is a master hematopoietic transcription factor essential for hematopoietic stem cell (HSC) emergence. Runx1-deficient mice die during early embryogenesis due to the inability to establish definitive hematopoiesis. Here, we have used human pluripotent stem cells (hPSCs) as model to study the role of RUNX1 in human embryonic hematopoiesis. Although the three RUNX1 isoforms a, b, and c were induced in CD45+ hematopoietic cells, RUNX1c was the only isoform induced in hematoendothelial progenitors (HEPs)/hemogenic endothelium. Constitutive expression of RUNX1c in human embryonic stem cells enhanced the appearance of HEPs, including hemogenic (CD43+) HEPs and promoted subsequent differentiation into blood cells. Conversely, specific deletion of RUNX1c dramatically reduced the generation of hematopoietic cells from HEPs, indicating that RUNX1c is a master regulator of human hematopoietic development. Gene expression profiling of HEPs revealed a RUNX1c-induced proinflammatory molecular signature, supporting previous studies demonstrating proinflammatory signaling as a regulator of HSC emergence. Collectively, RUNX1c orchestrates hematopoietic specification of hPSCs, possibly in cooperation with proinflammatory signaling. Stem Cells 2017;35:2253-2266.

Hoxa9 and EGFP reporter expression in human Embryonic Stem Cells (hESC) as useful tools for studying human development

HoxA9 is an evolutionarily conserved homeobox gene implicated in embryo development. To study the roles of Hoxa9 during human development we generated a transgenic H9 (hESC) line that overexpresses HoxA9 and the Enhanced Green Fluorescent Protein (EGFP), and a control H9 with a stable expression of the EGFP. The resulting H9-HoxA9-EGFP and H9-EGFP cell lines allow an efficient visualization of hESCs by fluorescent microscopy, quantification by flow cytometry and cell differentiation tracking. Both transgenic cell lines maintained the pluripotent phenotype, the ability to differentiate into all three germ layers and a normal karyotype.

Generation of induced pluripotent stem cells (iPSCs) from a Bernard-Soulier syndrome patient carrying a W71R mutation in the GPIX gene

We generated an induced pluripotent stem cell (iPSC) line from a Bernard-Soulier Syndrome (BSS) patient carrying the mutation p.Trp71Arg in the GPIX locus (BSS1-PBMC-iPS4F4). Peripheral blood mononuclear cells (PBMCs) were reprogrammed using heat sensitive non-integrative Sendai viruses containing the reprogramming factors Oct3/4, SOX2, KLF4 and c-MYC. Successful silencing of the exogenous reprogramming factors was checked by RT-PCR. Characterization of BSS1-PBMC-iPS4F4 included mutation analysis of GPIX locus, Short Tandem Repeats (STR) profiling, alkaline phosphatase enzymatic activity, analysis of conventional pluripotency-associated factors at mRNA and protein level and in vivo differentiation studies. BSS1-PBMC-iPS4F4 will provide a powerful tool to study BSS.

Short communication: Drug residues in goat milk after prophylactic use of antibiotics in intravaginal sponges for estrus synchronization

The aim of this study was to determine whether the prophylactic use of antibiotics in intravaginal sponges used for estrus synchronization in goats may result in the presence of inhibitors in milk and, therefore, of positive results by microbial screening tests. Ninety-eight Murciano-Granadina goats were used, divided into 7 groups of 14 animals. Intravaginal sponges were placed in 6 groups using 2 concentrations of 3 different antibiotics: doxycycline, oxytetracycline, and sulfathiazole-framycetin. The sponges of the control group were placed without antibiotics. Milk samples were collected daily until 7 d posttreatment and analyzed using 3 microbial tests. Positive samples were retested by specific receptor-binding assays to confirm the positive results. Vaginal status was evaluated by visual assessment of the external aspect of the sponges after removal. The microbial test response was not affected by either day posttreatment or dose of antibiotic used, except for oxytetracycline at the higher concentration. Moreover, no positive results were obtained using receptor-binding assays, suggesting that residues, if present in milk, did not exceed the regulatory (safety) levels established for these drugs. The occurrence of soiled sponges was higher in the control group. With respect to the dose of antibiotics used, no significant differences were found for the lower dose administered. However, a significant increase in the percentage of clean sponges was observed for the higher dose of doxycycline. We conclude that the prophylactic use of low doses of doxycycline, oxytetracycline, or sulfathiazole in intravaginal sponges used for synchronization of estrus helps to reduce clinical vaginitis in dairy goats and does not seem to be the cause of positive results in microbial inhibitor tests used to detect antibiotics in goat milk.

Generation and characterization of the human iPSC line PBMC1-iPS4F1 from adult peripheral blood mononuclear cells

Here we describe the generation and characterization of the human induced pluripotent stem cell (iPSC) line PBMC1-iPS4F1 from peripheral blood mononuclear cells from a healthy female with Spanish background. We used heat sensitive, non-integrative Sendai viruses containing the reprogramming factors Oct3/4, Sox2, Klf4 and c-Myc, whose expression was silenced in the established iPSC line. Characterization of the PBMC1-iPS4F1 cell line included analysis of typical pluripotency-associated factors at mRNA and protein level, alkaline phosphatase enzymatic activity, and in vivo and in vitro differentiation studies.

"A short trauma course for physicians in a resource-limited setting: Is low-cost simulation effective?"

INTRODUCTION

Morbidity and mortality from intentional and unintentional injury accounts for a high burden of disease in low- and middle-income countries. In addition to prevention measures, interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality. A trauma curriculum tailored to low-resource settings was implemented in Managua, Nicaragua utilising traditional didactic methods and novel low-cost simulation methods. Knowledge gain in attending and senior residents was subsequently assessed by using pre- and post-written tests, and by scoring pre- and post-simulation scenarios.

MATERIALS AND METHODS

A 5-day trauma course was designed for Nicaraguan attending and senior resident physicians who practice at six hospitals in Managua, Nicaragua. On days 1 and 5, participants underwent pre- and post-training evaluations consisting of a 26-question written exam and 2 simulation cases. The written exam questions and simulations were randomly assigned so that no questions or cases were repeated. The Wilcoxon signed-rank test was used to compare pre- and post-training differences in the written exam, and the percentage of critical actions completed in simulations. Time to critical actions was also analyzed using descriptive statistics.

RESULTS

A total of 33 participants attended the course, including 18 (55%) attending and 15 (45%) resident physicians, with a 97% completion rate. After the course, overall written examination scores improved 26.3% with positive mean increase of 15.4% (p<0.001). Overall, simulation scores based on the number of critical actions completed improved by 91.4% with a positive mean increase of 33.67 (p<0.001). The time to critical action for completion of the primary survey and cervical spine immobilisation was reduced by 55.9% and 46.6% respectively.

CONCLUSIONS

A considerable improvement in participants' knowledge of trauma concepts was demonstrated by statistically significant differences in both pre- and post-course written assessments and simulation exercises. The participants showed greatest improvement in trauma simulation scenarios, in which they learned, and subsequently demonstrated, a standardised approach to assessing and managing trauma patients. Low-cost simulation can be a valuable and effective education tool in low- and middle-income countries.

Effect In Vitro of Antiparasitic Drugs on Microbial Inhibitor Test Responses for Screening Antibiotic Residues in Goat's Milk

Microbial inhibitor tests are widely used to screen antibiotic residues in milk; however, these tests are nonspecific and may be affected by various substances capable of inhibiting the growth of the test microorganism. The objective of this study was to determine the effect of antiparasitic drugs in goat's milk on the microbial inhibitor test response. Raw antibiotic-free milk from Murciano-Granadina goats was supplemented with eight concentrations of seven antiparasitic substances (albendazole, 10 to 170 mg/kg; closantel, 1 to 140 mg/kg; diclazuril, 8 to 45 mg/kg; febendazole, 10 to 140 mg/kg; levamisole, 40 to 440 mg/kg; diazinon, 8 to 45 mg/kg; and ivermectin, 40 to 200 mg/kg). Twelve replicates for each concentration were analyzed with three microbial inhibitor tests: BRT MRL, Delvotest SP-NT MSC, and Eclipse 100. The results were interpreted visually (negative or positive). Using a logistic regression model, the concentrations of the antiparasitic drugs producing 5% (IC5), 10% (IC10), and 50% (IC50) positive results were determined. In general, the Eclipse 100 test was less sensitive to the effect of antiparasitic substances; the inhibitory concentrations of almost all the drugs assayed were higher than those for other tests. Conversely, the BRT MRL test was most affected, with high levels of interference at lower antiparasitic drug concentrations. Closantel and diazinon interfered with all microbial tests at lower concentrations than did other drugs (IC5 = 1 to 26 and 12 to 20 mg/kg, respectively), and higher concentrations of levamisole and diclazuril (IC5 = 30 to 240 and 50 to 117 mg/kg, respectively) were required to produce 5% positive results. These findings indicate that microbial inhibitor tests can be affected by elevated concentrations of antiparasitic drugs in goat's milk.

Generation of human iPSC line GRX-MCiPS4F-A2 from adult peripheral blood mononuclear cells (PBMCs) with Spanish genetic background

We have generated iPSCs from peripheral blood mononuclear cells (PBMCs) of a healthy man using heat sensitive and non-integrative Sendai virus containing Sox2, Oct3/4, c-Myc and Klf4. Human GRX-MCiPS4F-A2 cell line was established and characterized through this study.

The Notch ligand DLL4 specifically marks human hematoendothelial progenitors and regulates their hematopoietic fate

Notch signaling is essential for definitive hematopoiesis, but its role in human embryonic hematopoiesis is largely unknown. We show that in hESCs the expression of the Notch ligand DLL4 is induced during hematopoietic differentiation. We found that DLL4 is only expressed in a sub-population of bipotent hematoendothelial progenitors (HEPs) and segregates their hematopoietic versus endothelial potential. We demonstrate at the clonal level and through transcriptome analyses that DLL4(high) HEPs are enriched in endothelial potential, whereas DLL4(low/-) HEPs are committed to the hematopoietic lineage, albeit both populations still contain bipotent cells. Moreover, DLL4 stimulation enhances hematopoietic differentiation of HEPs and increases the amount of clonogenic hematopoietic progenitors. Confocal microscopy analysis of whole differentiating embryoid bodies revealed that DLL4(high) HEPs are located close to DLL4(low/-) HEPs, and at the base of clusters of CD45+ cells, resembling intra-aortic hematopoietic clusters found in mouse embryos. We propose a model for human embryonic hematopoiesis in which DLL4(low/-) cells within hemogenic endothelium receive Notch-activating signals from DLL4(high) cells, resulting in an endothelial-to-hematopoietic transition and their differentiation into CD45+ hematopoietic cells.

Short communication: Goat colostrum quality: litter size and lactation number effects

The quality of colostrum of Murciano-Granadina goats was studied to establish the transition period and the time when milk can be marketed. Forty-three dairy goats were used: 19 primiparous (15 single births; 4 multiple births) and 24 multiparous (10 single births; 14 multiple births). Samples were collected every 12h during the first week postpartum. Physicochemical parameters and somatic cell count were determined. Analysis of variance with repeated measures was used to study the effect of different factors: postpartum time, litter size, lactation number, their interactions, and production level on colostrum. Postpartum time had a significant effect on all parameters studied, which decreased along the first week of lactation, whereas lactose, pH, and conductivity increased. Based on these results, colostrum secretion takes place until 36 h postpartum (hpp). In relation to other factors of variation studied, the lactation number influenced most colostrum components, whereas the litter size only affected the pH value, protein and lactose content. The production level influenced only the protein and dry matter contents, with an inverse relationship. Milk produced during the period between 36 and 96 hpp is considered transition milk, which should not be commercialized. Milk collected after 4d postpartum (96 hpp) could be marketed, ensuring that its composition does not present a risk in the dairy industry.

Evaluation of the Charm maximum residue limit β-lactam and tetracycline test for the detection of antibiotics in ewe and goat milk

The Charm maximum residue limit β-lactam and tetracycline test (Charm MRL BLTET; Charm Sciences Inc., Lawrence, MA) is an immunoreceptor assay utilizing Rapid One-Step Assay lateral flow technology that detects β-lactam or tetracycline drugs in raw commingled cow milk at or below European Union maximum residue levels (EU-MRL). The Charm MRL BLTET test procedure was recently modified (dilution in buffer and longer incubation) by the manufacturers to be used with raw ewe and goat milk. To assess the Charm MRL BLTET test for the detection of β-lactams and tetracyclines in milk of small ruminants, an evaluation study was performed at Instituto de Ciencia y Tecnologia Animal of Universitat Politècnica de València (Spain). The test specificity and detection capability (CCβ) were studied following Commission Decision 2002/657/EC. Specificity results obtained in this study were optimal for individual milk free of antimicrobials from ewes (99.2% for β-lactams and 100% for tetracyclines) and goats (97.9% for β-lactams and 100% for tetracyclines) along the entire lactation period regardless of whether the results were visually or instrumentally interpreted. Moreover, no positive results were obtained when a relatively high concentration of different substances belonging to antimicrobial families other than β-lactams and tetracyclines were present in ewe and goat milk. For both types of milk, the CCβ calculated was lower or equal to EU-MRL for amoxicillin (4 µg/kg), ampicillin (4 µg/kg), benzylpenicillin (≤ 2 µg/kg), dicloxacillin (30 µg/kg), oxacillin (30 µg/kg), cefacetrile (≤ 63 µg/kg), cefalonium (≤ 10 µg/kg), cefapirin (≤ 30 µg/kg), desacetylcefapirin (≤ 30 µg/kg), cefazolin (≤ 25 µg/kg), cefoperazone (≤ 25 µg/kg), cefquinome (20 µg/kg), ceftiofur (≤ 50 µg/kg), desfuroylceftiofur (≤ 50µg/kg), and cephalexin (≤ 50 µg/kg). However, this test could neither detect cloxacillin nor nafcillin at or below EU-MRL (CCβ >30 µg/kg). The CCβ for tetracyclines was also lower than EU-MRL for chlortetracycline (ewe milk: ≤ 50 µg/kg; goat milk: 75 µg/kg), oxytetracycline (≤ 50 µg/kg), and tetracycline (≤ 50 µg/kg). Regarding the 4-epimers of these tetracyclines only 4-epioxytetracycline was detected by the Charm MRL BLTET test below EU-MRL (ewe milk: 75 µg/kg; goat milk: ≤ 50 µg/kg). Acidiol had no effect on the performance of the test. The Charm MRL BLTET test could be used routinely with adapted test procedure for the fast screening of ewe and goat milk.

Impact of education, income and chronic disease risk factors on mortality of adults: does 'a pauper-rich paradox' exist in Latin American societies?

OBJECTIVES

To test the hypothesis that an inverse association exists between socio-economic position and all-cause mortality in a developing country in Latin America.

STUDY DESIGN

Prospective cohort study carried out in Chile using data from a simple random sample of 920 apparently healthy subjects (weighted population 11,600 aged 30-89 years) followed for 8 years.

METHODS

Education level (0-8 years, 9-12 years and > or = 13 years) and income quartiles were established at the outset of the study, along with behavioural and biological risk factors for chronic diseases: smoking, alcohol use, obesity, diabetes, hypertension, lipids and family history of death by cardiovascular disease. Relative risks of all-cause mortality were estimated using age-adjusted Cox regression models.

RESULTS

During the follow-up period, 46 deaths were observed. Adjusting for age, gender, and behavioural and biological risk factors, the mortality risk for increasing categories of education after controlling for income was 1.0, 0.76 and 0.33 (P for trend<0.01). In contrast, the relative risk for increasing levels of income after controlling for education was 1.0, 0.98, 1.33 and 1.17 (P for trend=0.07).

CONCLUSION

While education level had a protective effect on mortality risk of Chilean adults, income had a slightly unfavourable effect on survival. This finding is described as suggestive of a 'pauper-rich paradox', since the higher income quantiles in this study correspond with the lower income levels in most developed countries. Nevertheless, due to the small number of deaths, additional research is required to assess the validity of these findings.

Impact of parity on anthropometric measures of obesity controlling by multiple confounders: a cross-sectional study in Chilean women

AIM

To find out whether there is an association between parity and obesity, evaluated through body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) in Chilean women after controlling for sociodemographic characteristics, health risk and gynaeco-obstetric factors.

DESIGN

Cross-sectional study, using baseline data of the San Francisco Project.

SETTING

San Francisco de Mostazal, located in the central region of Chile, 6512 Chilean-Hispanic women (Spanish heritage with a variable indigenous component).

METHODS

A weighted random sample of 508 women who had their first pregnancy inside the primary child-bearing ages. Data were collected between 1997 and 1999. Statistical associations between parity and different anthropometric measurements of adiposity in multiple linear (MLnR) and logistic regression models (MLtR) were evaluated.

RESULTS

In MLnR a modest parity-related increment in BMI and practically null increment in WC, WHR and WHtR was observed. Covariates that showed a statistically significant association with anthropometric measures of adiposity were age, low education, marital status, employment, smoking, smoking cessation, hypertension, diabetes, dyslipidaemia, parent's obesity, menarche and fetal macrosomia. Crude odds ratio (OR) showed a strong association between parity and anthropometric markers of obesity. Nevertheless, after adjustments in MLtR models, the association remained only for BMI. All the measures of abdominal obesity related to parous women showed OR smaller than 1 (95% confidence intervals 0.57 to 0.96).

CONCLUSIONS

Parity modestly influences BMI, but does not seem to be related to WC, WHR and WHtR after controlling by confounders. Parity can increase adiposity but not necessarily following an abdominal pattern.

[Mixedematous ileus; acute abdomen exacerbate.]

The surgical literature contains few reports about effects of hypothyroidism in patients with acute abdomen; has been reported that a glycoprotein infiltrate the lining of the bowel leading to denervation. We report the case of a woman with acute abdomen secondary to pyosalpynx with uncontrolled hypothyroidism postoperative complications.Hypothyroidism is called "big mimicker"because its clinic spectrum ranges from anasymptomatic subclinical condition to the rare,life-threatening myxedema coma, and thus can bea challenging diagnosis to make. Unrecognized hypothyroidism may lead to unnecessary surgery or even a potentially fatal outcome. A heightened awareness of this not so uncommon entity is mandatory

Inheritable variable sizes of DNA stretches in the human MHC: conserved extended haplotypes and their fragments or blocks

The difference in sizes of conserved stretches of DNA sequence within the major histocompatibility complex (MHC) in human individuals constitutes an underappreciated genetic diversity that has many practical implications. We developed a model to describe the variable sizes of stretches of conserved DNA in the MHC using the known frequencies of four different kinds of small (< 0.2 Mb) blocks of relatively conserved DNA sequence: HLA-Cw/B; TNF; complotype; and HLA-DR/DQ. Each of these small blocks is composed of two or more alleles of closely linked loci inherited as one genetic unit. We updated the concept of the conserved extended haplotype (CEH) using HLA allele identification and TNF microsatellites to show that specific combinations of the four blocks form single genetic units (>/= 1.5 Mb) with a total haplotype frequency in the Caucasian population of 0.30. Some CEHs extend to the HLA-A and -DPB1 loci forming fixed genetic units of up to at least 3.2 Mb of DNA. Finally, intermediate fragments of CEHs also exist, which are, nevertheless, larger than any of the four small blocks. This complexity of genetic fixity at various levels should be taken into account in studies of genetic disease association, immune response control, and human diversity. This knowledge could also be used for matching CEHs and their fragments for patients undergoing allotransplantation.

Linkage disequilibrium of HLA-A11 and A1 with one of the polymorphisms of the gamma-aminobutyric acid receptor type B

The gamma-aminobutyric acid receptor type B 1 (GABA(B) R1) is located approximately at 200 kb telomeric to HLA-A on chromosome 6. It has 11 single-nucleotide polymorphisms (SNPs). We studied the most common of its SNPs (T1974C) in a panel of 118 normal Caucasians from New England and 161 epileptic patients of Caucasian ancestry residing in USA. The frequency of the polymorphism did not differ between patients and controls. Here, we report that the allele C of this SNP in the GABA(B) R1 gene is in linkage disequilibrium with HLA-A11 (P<0.00001) and to a lesser extent with HLA-A1 (P<0.01).

A Multimodality Approach to the Diagnosis of Breast Hamartomas with Atypical Mammographic Appearance

The ultrasonographic appearance of breast hamartomas (BHs) is described and its diagnostic utility is discussed in this study of 27 women with mammographic findings both typical and atypical of BH. The role of computed tomography (CT) in the diagnosis of BH of atypical mammographic appearance is also analyzed. These 27 cases of BH were detected in women submitted to mammographic screening. Ages ranged from 45 to 65 years (mean age 52.6 years). In all cases physical and ultrasonographic examinations were carried out. CT studies were carried out in seven cases. Core biopsy was performed in 18 cases of lesions with a mammographic appearance atypical of BH. Lesions were palpable in 9 cases and nonpalpable in 18. Mammographic appearance was characteristic in nine cases. In 19 cases a hypoechoic solid mass with hyperechoic lines and/or bands was seen. This ultrasonographic image is suspicious of BH. Finally, both CT and core biopsy findings were of great help in the diagnosis of BH in the cases where mammographic and ultrasonographic studies were inconclusive. We consider that a combination of mammography, ultrasonography, CT, and core biopsy is fundamental for the successful diagnosis of breast hamartomas not seen in typical form in mammograms.

[Cardiac rehabilitation as a first step in the secondary prevention of coronary heart disease]

Despite that coronary heart disease is still the major cause of death in the industrialized countries and in some with emerging economies, a steady decline in the mortality for coronary heart disease has been observed in the last 30 years. This has been attributed predominantly to a reduction in smoking and in the cholesterol blood levels, two of the major risks factors for coronary heart disease. Cardiac rehabilitation programs represent today one of the most cost effective interventions to reduce the morbidity and mortality after a coronary event. They offer a unique opportunity to guide a patient immediately after an acute coronary episode through the inpatient care to the outpatient environment. In these programs a strong emphasis is made in the educational aspects of secondary prevention of coronary heart disease as well as in motivating patients to achieve life long lasting behavioral changes impacting on the major risk factors (smoking cessation, regular exercise, weight control, etc). The current subutilization of the Cardiac Rehabilitation Programs appears to be related to a variety of factors that include, among others, financial restraints and cultural values and perceptions with reference to health care.

[Cardiac tamponade as first clinical manifestation of small cell carcinoma]

A 69 year old man was diagnosed of cardiac tamponade. At surgery a large hemopericardias was evacuated, cardiac and pericardial metastasis of an oat cell carcinoma was demonstrated. The patient died 4 weeks later. A review of the literature is done about patients with cardiac tamponade as the first manifestation of a neoplastic process.