Sensitivity and specificity of fluorescence microscopy for diagnosing pulmonary tuberculosis in a high HIV prevalence setting

SETTING

Mulago Hospital, Kampala, Uganda.

OBJECTIVE

To evaluate the diagnostic performance of fluorescence microscopy (FM) for diagnosing pulmonary tuberculosis (TB) in a high human immunodeficiency virus (HIV) prevalence setting.

DESIGN

Consecutive in-patients with cough for >2 weeks submitted two sputum specimens for smear microscopy. Smears were examined by conventional light microscopy (CM) and FM. The performance of the two methods was compared using mycobacterial culture as a reference standard.

RESULTS

A total of 426 patients (82% HIV-infected) were evaluated. FM identified 11% more smear-positive patients than CM (49% vs. 38%, P < 0.001). However, positive FM results were less likely than positive CM results to be confirmed by culture when smears were read as either 'scanty' (54% vs. 90%, P < 0.001) or 1+ (82% vs. 91%, P = 0.02). Compared to CM, the sensitivity of FM was higher (72% vs. 64%, P = 0.005), and the specificity lower (81% vs. 96%, P < 0.001). In receiver operating characteristic analysis, maximum area under the curve for FM was obtained at a threshold of >4 acid-fast bacilli/100 fields (sensitivity 68%, specificity 90%).

CONCLUSION

Although FM increases the sensitivity of sputum smear microscopy, additional data on FM specificity and on the clinical consequences associated with false-positive FM results are needed to guide implementation of this technology in high HIV prevalence settings.

Tradeoffs of integrating real-time tracking into IGRT for prostate cancer treatment

This study investigated the integration of the Calypso real-time tracking system, based on implanted ferromagnetic transponders and a detector array, into the current process for image-guided radiation treatment (IGRT) of prostate cancer at our institution. The current IGRT process includes magnetic resonance imaging (MRI) for prostate delineation, CT simulation for treatment planning, daily on-board kV and CBCT imaging for target alignment, and MRI/MRS for post-treatment assessment. This study assesses (1) magnetic-field-induced displacement and radio-frequency (RF)-induced heating of transponders during MRI at 1.5 T and 3 T, and (2) image artifacts caused by transponders and the detector array in phantom and patient cases with the different imaging systems. A tissue-equivalent phantom mimicking prostate tissue stiffness was constructed and implanted with three operational transponders prior to phantom solidification. The measurements show that the Calypso system is safe with all the imaging systems. Transponder position displacements due to the MR field are minimal (<1.0 mm) for both 1.5 T and 3 T MRI scanners, and the temperature variation due to MRI RF heating is <0.2 degrees C. The visibility of transponders and bony anatomy was not affected on the OBI kV and CT images. Image quality degradation caused by the detector antenna array is observed in the CBCT image. Image artifacts are most significant with the gradient echo sequence in the MR images, producing null signals surrounding the transponders with radii approximately 1.5 cm and length approximately 4 cm. Thus, Calypso transponders can preclude the use of MRI/MRS in post-treatment assessment. Modifications of the clinical flow are required to accommodate and minimize the substantial MRI artifacts induced by the Calypso transponders.

Analysis of image quality for real-time target tracking using simultaneous kV-MV imaging

Real-time tracking can provide high accuracy localization for a moving target and minimize the effect of motion. Simultaneous kV-MV imaging has been proposed as a real-time tracking technique by utilizing the existing kV on-board imager (OBI) and the MV electronic portal device (EPID) mounted on the linear accelerator. The orthogonal pair of kV-MV images acquired simultaneously can provide 3-D localization in real-time. However, the kV and MV beams cross shooting the target interfere with each other with beam scattering, which affects the quality of images. The success of this modality heavily relies on the image quality, especially the visibility of the target, which was investigated in this study. The kV and MV images were acquired for a gold implant marker that was used as a surrogate of the target and placed in an IMRT thorax phantom, a dynamic phantom, and a pelvis phantom to test the image quality in different situations. Contrast-to-noise ration (CNR) was used to quantitatively describe the visibility of the target in the image. CNR can be obtained by statistical calculation from image processing and physics analysis with ion chamber measurement. The difference is described by contrast detection efficiency (CDE). By comparing the ratio (R) of CNR with and without the MV beam on, the MV beam scatter was found to have dramatically reduced the target visibility in the kV images (R=0.47), which was supported by an independent physics analysis that treats beam scatter as a noise. In contrast, the kV scatter effect on the MV images was minor (R=0.93). The effect of tumor motion was visible but tolerable for the target tracking purpose. CNR varied with different tumor sites and was lower for the pelvis than the thorax. Different kV imaging parameters such as kVp, mAs, and exposure time ms were tested for different cases. Considering a threshold of 1.0 CNR as a measure for the target visibility, a range of CNR from 1.3 to 4.2 was reached with appropriate tuning of those imaging parameters. This study has shown that CNR is a key parameter that can be used for assessing the visibility of the target in digital imaging and the quality of kV/MV images. It has also been shown that reasonable target visibility can be obtained using simultaneous kV-MV imaging for real-time target tracking.

Antioxidant effect of ethyl pyruvate in respiring neonatal cerebrocortical slices after H(2)O(2) stress

Administration of ethyl pyruvate, which is formed from pyruvate and ethanol, has been found capable of rescuing cells injured by oxidative stress. In one perspective the rescue has been postulated to be metabolic, with the resulting intracellular delivery of pyruvate seen as providing substrate for the TCA Cycle, making it possible to counteract sequela of poly(ADP-ribose)ribosylation, such as depletion of cytosolic NAD(+), glycolytic arrest, and mitochondrial deprivation of pyruvate. The rescue has also been attributed to radical scavenging via the carbonyl groups in ethyl pyruvate and pyruvate. In a previous study we exposed superfused neonatal (P7) brain slices for 60min to 2mM H(2)O(2) and found evidence for both rescue mechanisms. To see if ethyl pyruvate's actions stemmed more from being an antioxidant than from being a nutrient we conducted six new experiments using the same H(2)O(2) protocol, but with two new rescue solutions: [10mM] glucose (glc) plus one of the following: ethyl pyruvate [20mM], or the nonmetabolizable radical scavenger N-tert-butyl-alpha-phenylnitrone (PBN, 1mM). Final ATP values compared to initial, measured in 14.1T (31)P NMR spectra of PCA extracts, were the same: 0.70+/-0.08 for the former (N=3), and 0.64+/-0.08 for the latter (N=3). Quantifications of this study's (1)H NMR metabolites, also measured at 14.1T, exhibited separate clustering when pooled with data from the previous study and compared in a metabolomic multivariate analyses. Because the addition of ethyl pyruvate provided the same ATP protection as the addition of a nonmetabolizable antioxidant, antioxidant protection was its prominent protective mechanism in the chosen, high glucose protocol. Having distinct clusters in the Scores Plot of a Partial Least Squares-Discriminant Analysis suggests the feasibility of constructing statistical models that are predictive.

Large-scale molecular-dynamics simulation of nanoscale hydrophobic interaction and nanobubble formation

We performed large-scale molecular-dynamics simulation of nanoscale hydrophobic interaction manifested by the formation of nanobubble between nanometer-sized hydrophobic clusters at constrained equilibrium. Particular attention is placed on the tendency of formation and stability of nanobubbles in between model nanoassemblies which are composed of hydrophobic clusters (or patches) embedded in a hydrophilic substrate. On the basis of physical behavior of nanobubble formation, we observed a change from short-range molecular hydrophobic interaction to midrange nanoscopic interaction when the length scale of hydrophobe approaches to about 1 nm. We investigated the behavior of nanobubble formation with several different patterns of nonpolar-site distribution on the nanoassemblies but always keeping a constant ratio of nonpolar to polar monomer sites. Dynamical properties of confined water molecules in between nanoassemblies are also calculated.

Phase II study of irinotecan based fourth-line chemotherapy for gefitinib therapy-failed non-small cell lung cancer (NSCLC)

18164

Background: Despite the undoubted gains from EGFR TK inhibitor therapy as 2nd or 3rd line chemotherapy, most of them will relapse during treatment. Among these patients, they might be young, with good performance status, and their disease is expressed with only minor symptoms. The objectives of this study were to evaluate the antitumor efficacy and safety of irinotecan based regimen as 4th line therapy for refractory or recurrent to gefitinib treatment. We report our experience with irinotecan-based 4th line chemotherapy. Methods: Eligibility required proven NSCLC refractory or recurrent after 3rd line chemotherapy(gefitinib), measurable lesions by RECIST, and ECOG PS 0–1. Irinotecan (60mg/m2, day 1,8,15) and/or cisplatin (60 mg/m2, day 1) were administered every four week for at least 2 course. We analyzed for time to tumor progression (TTP) for first, response rates and toxicities. Results: Since June 2004, 17 patients (consisting of 9 with squamous cell, 7 with adeno-, and 1 with NSCLC not further specified) with a median age of 61 years were enrolled, with 1 drop out during treatment. Chemotherapy was administered for a median 2 courses (range 2–6). Median TTP was 91 (range 35–210) days. Two pts achieved a PR and 5 pts a SD. Disease control rate was 41.2%. Response rate was 11.8%. Toxicity of grade 3 or 4 consisted of neutropenia (35.3%), anemia (29.4%), thrombocytopenia (17.7%), nausea (17.6%), and diarrhea (23.5%). There were no treatment related deaths. Conclusions: This irinotecan based chemotherapy for EGFR TK inhinbitor therapy failed NSCLC patients showed promising efficacy with tolerable toxicity. Irinotecan based chemotherapy may be considered a potential therapeutic option for 4th line chemotherapy in well selected patients.

No significant financial relationships to disclose.

Low SER versus high SER thoracic radiotherapy in the management of limited-stage small cell lung cancer

18170

Background: Patients with small-cell lung cancer account for about 20% of all lung cancer patients, with only one third of the patients presenting with limited disease. Although the combinations of chemo and radiation therapy have improved the prognosis substantially, the optimal chemoradiotherapy remains controversial in LD-SCLC. There are many reports that the overall duration of the chemoradiotherapy package is the most relevant predictor of the outcome. Therefore we tested SER beginning with the start of any treatment until the end of radiotherapy in patients with LD-SCLC. Methods: We enrolled the patients who were diagnosed as SCLC histologically in Korea University Medical Center from 2003 to 2006. All of them presented with limited disease. We divided them into two groups; the low SER (within 60 days of SER) and the high SER group (over 60 days). The patients were treated with thoracic radiotherapy and platinum based topoisomerase inhibitor. Overall survival was analyzed with a Cox model adjusted for performance and the chemotherapy regimen. Results: Of 29 patients, 16 patients were in low SER and 13 patients were in high SER. Low SER, as compared with high SER, significantly prolonged survival rate (p=0.028). We evaluated the radiation effect by the time between the start of chemotherapy and the start of radiotherapy, below 30 days and above 30 days, but there were no statistically comparable difference in there survival time between the two groups (p=0.176). The survival times of the patients were increased by 3.094 times in the low SER (95% C.I, 1.083 to 8.840, p=0.028) and by 6.901 times in ECOG groups 0 or 1 compared with group 2 (95% C.I, 1.563 to 30.468, p=0.018). There were no statistically significant increases in the side effects: pneumonitis, esophagitis, and BM suppressions. Conclusions: The cumulative survival of the patients in the low SER group is higher than for patients in the high SER group. The SER may facilitate a more rational design of combined-modality treatment in rapidly proliferating tumors.

[Table: see text]

No significant financial relationships to disclose.

Photodarkening in Yb-doped aluminosilicate fibers induced by 488 nm irradiation

Photodarkening of Yb-doped aluminosilicate fibers by continuous wave 488 nm irradiation was investigated. The irradiation induced significant excess loss in the UV-visible spectroscopy (VIS) region in Yb-doped aluminosilicate fibers while pure aluminosilicate fibers showed negligible induced loss. Ultraviolet-VIS-near-infrared spectroscopy revealed an absorption peak at 220 nm in unexposed Yb-doped aluminosilicate fiber preforms. The observed peak was attributed to Yb-associated oxygen deficiency centers (ODCs) and proposed as a precursor of the photodarkening. The proposed model was supported by measurements on oxygen-loaded Yb-doped aluminosilicate fibers. In these, the photodarkening could be significantly reduced, which we attribute to a smaller number of ODCs following oxygen loading.

Multi-species prostate implant treatment plans incorporating Ir192 and I125 using a Greedy Heuristic based 3D optimization algorithm

The goals of interstitial implant brachytherapy include delivery of the target dose in a uniform manner while sparing sensitive structures, and minimizing the number of needles and sources. We investigated the use of a multi-species source arrangement (192Ir with 125I) for treatment in interstitial prostate brachytherapy. The algorithm utilizes an "adjoint ratio," which provides a means of ranking source positions and is the criterion for the Greedy Heuristic optimization. Three cases were compared, each using 0.4 mCi 125I seeds: case I is the base case using 125I alone, case II uses 0.12 mCi 192Ir seeds mixed with 125I, and case III uses 0.25 mCi 192Ir mixed with 125I. Both multi-species cases result in lower exposure of the urethra and central prostate region. Compared with the base case, the exposure to the rectum and normal tissue increases by a significant amount for case III as compared with the increase in case II, signifying the effect of slower dose falloff rate of higher energy gammas of 192Ir in the tissue. The number of seeds and needles decreases in both multi-species cases, with case III requiring fewer seeds and needles than case II. Further, the effect of 192Ir on uniformity was investigated using the 0.12 mCi 192Ir seeds in multi-species implants. An increase in uniformity was observed with an increase in the number of 0.12 mCi 1921r seeds implanted. The effects of prostate size on the evaluation parameters for multi-species implants were investigated using 0.12 mCi 192Ir and 0.4 mCi 125I, and an acceptable treatment plan with increased uniformity was obtained.