Acute coronary event (ACE) prediction following breast radiotherapy by features extracted from 3D CT, dose, and cardiac structures

PURPOSE

Heart toxicity, such as major acute coronary events (ACE), following breast radiation therapy (RT) is of utmost concern. Thus, many studies have been investigating the effect of mean heart dose (MHD) and dose received in heart sub-structures on toxicity. Most studies focused on the dose thresholds in the heart and its sub-structures, while few studies adopted such computational methods as deep neural networks (DNN) and radiomics. This work aims to construct a feature-driven predictive model for ACE after breast RT.

METHODS

A recently proposed two-step predictive model that extracts a number of features from a deep auto-segmentation network and processes the selected features for prediction was adopted. This work refined the auto-segmenting network and feature processing algorithms to enhance performance in cardiac toxicity prediction. In the predictive model, the deep convolutional neural network (CNN) extracted features from 3D computed tomography (CT) images and dose distributions in three automatically segmented heart sub-structures, including the left anterior descending artery (LAD), right coronary artery (RCA), and left ventricle (LV). The optimal feature processing workflow for the extracted features was explored to enhance the prediction accuracy. The regions associated with toxicity were visualized using a class activation map (CAM)-based technique. Our proposed model was validated against a conventional DNN (convolutional and fully connected layers) and radiomics with a patient cohort of 84 cases, including 29 and 55 patient cases with and without ACE. Of the entire 84 cases, 12 randomly chosen cases (5 toxicity and 7 non-toxicity cases) were set aside for independent test, and the remaining 72 cases were applied to 4-fold stratified cross-validation.

RESULTS

Our predictive model outperformed the conventional DNN by 38% and 10% and radiomics-based predictive models by 9% and 10% in AUC for 4-fold cross-validations and independent test, respectively. The degree of enhancement was greater when incorporating dose information and heart sub-structures into feature extraction. The model whose inputs were CT, dose, and three sub-structures (LV, LAD, and RCA) reached 96% prediction accuracy on average and 0.94 area under the curve (AUC) on average in the cross-validation, and also achieved prediction accuracy of 83% and AUC of 0.83 in the independent test. On 10 correctly predicted cases out of 12 for the independent test, the activation maps implied that for cases of ACE toxicity, the higher intensity was more likely to be observed inside the LV.

CONCLUSIONS

The proposed model characterized by modifications in model input with dose distributions and cardiac sub-structures, and serial processing of feature extraction and feature selection techniques can improve the predictive performance in ACE following breast RT.

Early Experience of Online Adaptive Radiation Therapy for Definitive Radiation of Patients With Head and Neck Cancer

Purpose

The advent of cone beam computed tomography-based online adaptive radiation therapy (oART) has dramatically reduced the barriers of adaptation. We present the first prospective oART experience data in radiation of head and neck cancers (HNC).

Methods and Materials

Patients with HNC receiving definitive standard fractionation (chemo)radiation who underwent at least 1 oART session were enrolled in a prospective registry study. The frequency of adaptations was at the discretion of the treating physician. Physicians were given the option of delivering 1 of 2 plans during adaptation: the original radiation plan transposed onto the cone beam computed tomography with adapted contours (scheduled), and a new adapted plan generated from the updated contours (adapted). A paired t test was used to compare the mean doses between scheduled and adapted plans.

Results

Twenty-one patients (15 oropharynx, 4 larynx/hypopharynx, 2 other) underwent 43 adaptation sessions (median, 2). The median ART process time was 23 minutes, median physician time at the console was 27 minutes, and median patient time in the vault was 43.5 minutes. The adapted plan was chosen 93% of the time. The mean volume in each planned target volume (PTV) receiving 100% of the prescription dose for the scheduled versus adapted plan for high-risk PTVs was 87.8% versus 95% (P < .01), intermediate-risk PTVs was 87.3% versus 97.9% (P < .01), and low-risk PTVs was 94% versus 97.8% (P < .01), respectively. The mean hotspot was also lower with adaptation: 108.8% versus 106.4% (P < .01). All but 1 organ at risk (11/12) saw a decrease in their dose with the adapted plans, with the mean ipsilateral parotid (P = .013), mean larynx (P < .01), maximum point spinal cord (P < .01), and maximum point brain stem (P = .035) reaching statistical significance.

Conclusions

Online ART is feasible for HNC, with significant improvement in target coverage and homogeneity and a modest decrease in doses to several organs at risk.

Ensemble learning and personalized training for the improvement of unsupervised deep learning-based synthetic CT reconstruction

BACKGROUND

The growing adoption of magnetic resonance imaging (MRI)-guided radiation therapy (RT) platforms and a focus on MRI-only RT workflows have brought the technical challenge of synthetic computed tomography (sCT) reconstruction to the forefront. Unpaired-data deep learning-based approaches to the problem offer the attractive characteristic of not requiring paired training data, but the gap between paired- and unpaired-data results can be limiting.

PURPOSE

We present two distinct approaches aimed at improving unpaired-data sCT reconstruction results: a cascade ensemble that combines multiple models and a personalized training strategy originally designed for the paired-data setting.

METHODS

Comparisons are made between the following models: (1) the paired-data fully convolutional DenseNet (FCDN), (2) the FCDN with the Intentional Deep Overfit Learning (IDOL) personalized training strategy, (3) the unpaired-data CycleGAN, (4) the CycleGAN with the IDOL training strategy, and (5) the CycleGAN as an intermediate model in a cascade ensemble approach. Evaluation of the various models over 25 total patients is carried out using a five-fold cross-validation scheme, with the patient-specific IDOL models being trained for the five patients of fold 3, chosen at random.

RESULTS

In both the paired- and unpaired-data settings, adopting the IDOL training strategy led to improvements in the mean absolute error (MAE) between true CT images and sCT outputs within the body contour (mean improvement, paired- and unpaired-data approaches, respectively: 38%, 9%) and in regions of bone (52%, 5%), the peak signal-to-noise ratio (PSNR; 15%, 7%), and the structural similarity index (SSIM; 6%, <1%). The ensemble approach offered additional benefits over the IDOL approach in all three metrics (mean improvement over unpaired-data approach in fold 3; MAE: 20%; bone MAE: 16%; PSNR: 10%; SSIM: 2%), and differences in body MAE between the ensemble approach and the paired-data approach are statistically insignificant.

CONCLUSIONS

We have demonstrated that both a cascade ensemble approach and a personalized training strategy designed initially for the paired-data setting offer significant improvements in image quality metrics for the unpaired-data sCT reconstruction task. Closing the gap between paired- and unpaired-data approaches is a step toward fully enabling these powerful and attractive unpaired-data frameworks.

Acute exacerbation of chronic obstructive pulmonary disease in a slaughterhouse

We describe the case of a 52-year-old male who presented with two episodes of acute exacerbations (AE) of chronic obstructive pulmonary disease (COPD) during work, while suspending live chickens for slaughter. The patient was exposed to high levels of bioaerosols, including endotoxins and microorganisms. Endotoxins can induce bronchoconstriction and airway inflammation, and COPD patients are more vulnerable to airway infections caused by microorganisms inhaled with bioaerosols. This study suggests that a high level of bioaerosols may induce airway infections, resulting in acute exacerbations of COPD.

Abdominal synthetic CT reconstruction with intensity projection prior for MRI-only adaptive radiotherapy

Objective. Owing to the superior soft tissue contrast of MRI, MRI-guided adaptive radiotherapy (ART) is well-suited to managing interfractional changes in anatomy. An MRI-only workflow is desirable, but producing synthetic CT (sCT) data through paired data-driven deep learning (DL) for abdominal dose calculations remains a challenge due to the highly variable presence of intestinal gas. We present the preliminary dosimetric evaluation of our novel approach to sCT reconstruction that is well suited to handling intestinal gas in abdominal MRI-only ART.Approach. We utilize a paired data DL approach enabled by the intensity projection prior, in which well-matching training pairs are created by propagating air from MRI to corresponding CT scans. Evaluations focus on two classes: patients with (1) little involvement of intestinal gas, and (2) notable differences in intestinal gas presence between corresponding scans. Comparisons between sCT-based plans and CT-based clinical plans for both classes are made at the first treatment fraction to highlight the dosimetric impact of the variable presence of intestinal gas.Main results. Class 1 patients (n= 13) demonstrate differences in prescribed dose coverage of the PTV of 1.3 ± 2.1% between clinical plans and sCT-based plans. Mean DVH differences in all structures for Class 1 patients are found to be statistically insignificant. In Class 2 (n= 20), target coverage is 13.3 ± 11.0% higher in the clinical plans and mean DVH differences are found to be statistically significant.Significance. Significant deviations in calculated doses arising from the variable presence of intestinal gas in corresponding CT and MRI scans result in uncertainty in high-dose regions that may limit the effectiveness of adaptive dose escalation efforts. We have proposed a paired data-driven DL approach to sCT reconstruction for accurate dose calculations in abdominal ART enabled by the creation of a clinically unavailable training data set with well-matching representations of intestinal gas.

Determining the Degree of Dopaminergic Denervation Based on the Loss of Nigral Hyperintensity on SMWI in Parkinsonism

BACKGROUND AND PURPOSE

Nigrostriatal dopaminergic function in patients with Parkinson disease can be assessed using ¹²³I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl)-nortropan dopamine transporter (¹²³I-FP-CIT) SPECT, and a good correlation has been demonstrated between nigral status on SWI and dopaminergic denervation on ¹²³I-FP-CIT SPECT. Here, we aim to correlate quantified dopamine transporter attenuation on ¹²³I-FP-CIT SPECT with nigrosome-1 status using susceptibility map-weighted imaging (SMWI).

MATERIALS AND METHODS

Between May 2017 and January 2018, consecutive patients with idiopathic Parkinson disease (n = 109) and control participants (n = 29) who underwent ¹²³I-FP-CIT SPECT with concurrent 3T SWI were included. SMWI was generated from SWI. Two neuroradiologists evaluated nigral hyperintensity from nigrosome-1 on each side of the substantia nigra. Using consensus reading, we compared the ¹²³I-FP-CIT-specific binding ratio according to nigral hyperintensity status and the ¹²³I-FP-CIT specific binding ratio threshold to confirm the loss of nigral hyperintensity was determined using receiver operating characteristic curve analysis.

RESULTS

The concordance rate between SMWI and ¹²³I-FP-CIT SPECT was 65.9%. The ¹²³I-FP-CIT-specific binding ratios in the striatum, caudate nucleus, and putamen were significantly lower when nigral hyperintensity in the ipsilateral substantia nigra was absent than when present (all, P < .001). The ¹²³I-FP-CIT-specific binding ratio threshold values for the determination of nigral hyperintensity loss were 2.56 in the striatum (area under the curve, 0.890), 3.07 in the caudate nucleus (0.830), and 2.36 in the putamen (0.887).

CONCLUSIONS

Nigral hyperintensity on SMWI showed high positive predictive value and low negative predictive value with dopaminergic degeneration on ¹²³I-FP-CIT SPECT. In patients with Parkinson disease, the loss of nigral hyperintensity is prominent in patients with lower striatal specific binding ratios.

Clinical feasibility of deep learning-based auto-segmentation of target volumes and organs-at-risk in breast cancer patients after breast-conserving surgery

Background

In breast cancer patients receiving radiotherapy (RT), accurate target delineation and reduction of radiation doses to the nearby normal organs is important. However, manual clinical target volume (CTV) and organs-at-risk (OARs) segmentation for treatment planning increases physicians’ workload and inter-physician variability considerably. In this study, we evaluated the potential benefits of deep learning-based auto-segmented contours by comparing them to manually delineated contours for breast cancer patients.

Methods

CTVs for bilateral breasts, regional lymph nodes, and OARs (including the heart, lungs, esophagus, spinal cord, and thyroid) were manually delineated on planning computed tomography scans of 111 breast cancer patients who received breast-conserving surgery. Subsequently, a two-stage convolutional neural network algorithm was used. Quantitative metrics, including the Dice similarity coefficient (DSC) and 95% Hausdorff distance, and qualitative scoring by two panels from 10 institutions were used for analysis. Inter-observer variability and delineation time were assessed; furthermore, dose-volume histograms and dosimetric parameters were also analyzed using another set of patient data.

Results

The correlation between the auto-segmented and manual contours was acceptable for OARs, with a mean DSC higher than 0.80 for all OARs. In addition, the CTVs showed favorable results, with mean DSCs higher than 0.70 for all breast and regional lymph node CTVs. Furthermore, qualitative subjective scoring showed that the results were acceptable for all CTVs and OARs, with a median score of at least 8 (possible range: 0–10) for (1) the differences between manual and auto-segmented contours and (2) the extent to which auto-segmentation would assist physicians in clinical practice. The differences in dosimetric parameters between the auto-segmented and manual contours were minimal.

Conclusions

The feasibility of deep learning-based auto-segmentation in breast RT planning was demonstrated. Although deep learning-based auto-segmentation cannot be a substitute for radiation oncologists, it is a useful tool with excellent potential in assisting radiation oncologists in the future.

Trial registration Retrospectively registered.

MRI-Based Assessment of the Pharyngeal Constrictor Muscle as a Predictor of Surgical Margin after Transoral Robotic Surgery in HPV-Positive Tonsillar Cancer

BACKGROUND AND PURPOSE

Transoral robotic surgery is an emerging strategy for treating human papillomavirus-positive cancers, but the role of MR imaging in predicting the surgical outcome has not been established. We aimed to identify preoperative MR imaging characteristics that predispose the outcome of transoral robotic surgery toward an insecure (positive or close) surgical margin in human papillomavirus-positive tonsillar squamous cell carcinoma.

MATERIALS AND METHODS

Between December 2012 and May 2019, sixty-nine patients underwent transoral robotic surgery at our institution. Among these, 29 who were diagnosed with human papillomavirus-positive tonsillar squamous cell carcinoma, did not receive neoadjuvant treatment, underwent preoperative 3T MR imaging, and had postoperative pathologic reports and were included in this retrospective study. Two neuroradiologists evaluated the preoperative MR imaging scans to determine the tumor spread through the pharyngeal constrictor muscle using a 5-point scale: 1, normal constrictor; 2, bulging constrictor; 3, thinning constrictor; 4, obscured constrictor; and 5, tumor protrusion into the parapharyngeal fat. The risk of an insecure surgical margin (involved or <1 mm) according to the MR imaging scores was predicted using logistic regression with the Firth correction.

RESULTS

The interobserver agreement for the MR imaging scores was excellent (κ = 0.955, P < .001). A score of ≥4 could predict an insecure margin with 87.5% sensitivity and 92.3% specificity (area under the curve = 0.899) and was the only significant factor associated with an insecure margin in the multivariable analysis (OR, 6.59; 95% CI, 3.11-22.28; P < .001).

CONCLUSIONS

The pre-transoral robotic surgery MR imaging scoring system for the pharyngeal constrictor muscle is a promising predictor of the surgical margin in human papillomavirus-positive tonsillar squamous cell carcinoma.

Progression of Osteoporosis After Kidney Transplantation in Patients With End-Stage Renal Disease

BACKGROUND

This study investigated the prevalence of osteoporosis and the risk factors for its progression in kidney transplant recipients (KTRs).

METHODS

Dual energy X-ray absorptiometry was used to prospectively measure changes in bone mineral density (BMD) before kidney transplantation (KT) and 1 year after transplantation in 207 individuals. We also analyzed the risk factors of osteoporosis progression during this period.

RESULTS

Prior to KT, the mean BMD score (T-score of the femur neck area) was -2.1 ± 1.2, and the prevalence of osteoporosis was 41.5% (86/207). At 1 year post-transplantation, the mean BMD score significantly decreased to -2.3 ± 1.1 (P < .001), and the prevalence of osteoporosis increased to 47.3% (98/207; P = .277). The BMD score worsened over the study period in 69.1% (143/207) of patients, improved in 24.1% (50/207), and showed no change in 6.8% (14/207). Minimal intact parathyroid hormone (iPTH) improvement after KT was found to be an independent risk factor of osteoporosis progression.

CONCLUSIONS

This study demonstrates progressive loss of BMD after KT and sustained secondary hyperparathyroidism might influence the progression of osteoporosis.

Feasibility of Permanent Stenting with Solitaire FR as a Rescue Treatment for the Reperfusion of Acute Intracranial Artery Occlusion

BACKGROUND AND PURPOSE

The Solitaire FR can be used not only as a tool for mechanical thrombectomy but also as a detachable permanent stent. Our aim was to assess the feasibility and safety of permanent stent placement with the Solitaire FR compared with other self-expanding stents for intracranial artery recanalization for acute ischemic stroke.

MATERIALS AND METHODS

From January 2011 through January 2016, we retrospectively selected 2979 patients with acute ischemic stroke. Among them, 27 patients who underwent permanent stent placement (13 patients with the Solitaire FR [Solitaire group] and 14 patients with other self-expanding stents [other stent group]) were enrolled. The postprocedural modified TICI grade and angiographic and clinical outcomes were assessed. The safety and efficacy of permanent stent placement of the Solitaire FR for acute large-artery occlusion were evaluated.

RESULTS

Stent placement was successful in all cases. Modified TICI 2b-3 reperfusion was noted in 84.6% of the Solitaire group and in 78.6% of the other stent group. Procedural time was significantly shorter in the Solitaire group than in the other stent group (P = .022). Shorter procedural time was correlated with favorable outcome (ρ = 0.46, P = .035). No significant differences were found in the modified TICI grade, NIHSS score, mRS, and hemorrhagic transformation rate between the 2 groups. The acute in-stent thrombosis rate at discharge was significantly lower when a glycoprotein IIb/IIIa inhibitor was injected during the procedure (P = .013).

CONCLUSIONS

Permanent stent placement with the Solitaire FR compared with other self-expanding stents appears to be feasible and safe as a rescue tool for refractory intra-arterial therapy.

Diffusion-Weighted Imaging of the Head and Neck: Influence of Fat-Suppression Technique and Multishot 2D Navigated Interleaved Acquisitions

BACKGROUND AND PURPOSE

DWI of the head and neck can reveal valuable information, but the effects of fat suppression and multishot acquisition on image quality have not been thoroughly investigated. We aimed to comprehensively compare the quality of head and neck DWI at 3T using 2 fat-suppression techniques, STIR, and spectral presaturation with inversion recovery, which were used with both single- and multishot EPI.

MATERIALS AND METHODS

Sixty-five study participants underwent 3 DWI sequences of single-shot EPI-STIR, single-shot EPI-spectral presaturation with inversion recovery, and multishot EPI-spectral presaturation with inversion recovery of the head and neck. In multiple anatomic regions, 2 independent readers assessed 5-point visual scores for fat-suppression uniformity and image distortion, and 1 reader measured the contrast-to-noise ratio and ADC.

RESULTS

The mean visual score for fat-suppression uniformity was higher in single-shot EPI-STIR than in other sequences (all regions except for the orbital region, P < .05). The mean visual score for image distortion was higher in multishot EPI-spectral presaturation with inversion recovery than in single-shot EPI sequences (all regions, P < .001). Contrast-to-noise ratio was mostly lower in single-shot EPI-STIR than in other sequences (P < .001), and ADC was significantly higher in multishot EPI-spectral presaturation with inversion recovery than in single-shot EPI sequences (P ≤ .001).

CONCLUSIONS

Overall, multishot EPI-spectral presaturation with inversion recovery provided the best image quality, with relatively homogeneous fat suppression, less image distortion than single-shot EPI sequences, and higher contrast-to-noise ratio than single-shot EPI-STIR. The measured ADC values can be higher in multishot EPI-spectral presaturation with inversion recovery, which necessitates cautious application of the previously reported ADC values to clinical settings.

The Role of MRI in Diagnosing Neurovascular Compression of the Cochlear Nerve Resulting in Typewriter Tinnitus

BACKGROUND AND PURPOSE

Typewriter tinnitus, a symptom characterized by paroxysmal attacks of staccato sounds, has been thought to be caused by neurovascular compression of the cochlear nerve, but the correlation between radiologic evidence of neurovascular compression of the cochlear nerve and symptom presentation has not been thoroughly investigated. The purpose of this study was to examine whether radiologic evidence of neurovascular compression of the cochlear nerve is pathognomonic in typewriter tinnitus.

MATERIALS AND METHODS

Fifteen carbamazepine-responding patients with typewriter tinnitus and 8 control subjects were evaluated with a 3D T2-weighted volume isotropic turbo spin-echo acquisition sequence. Groups 1 (16 symptomatic sides), 2 (14 asymptomatic sides), and 3 (16 control sides) were compared with regard to the anatomic relation between the vascular loop and the internal auditory canal and the presence of neurovascular compression of the cochlear nerve with/without angulation/indentation.

RESULTS

The anatomic location of the vascular loop was not significantly different among the 3 groups (all, P > .05). Meanwhile, neurovascular compression of the cochlear nerve on MR imaging was significantly higher in group 1 than in group 3 (P = .032). However, considerable false-positive (no symptoms with neurovascular compression of the cochlear nerve on MR imaging) and false-negative (typewriter tinnitus without demonstrable neurovascular compression of the cochlear nerve) findings were also observed.

CONCLUSIONS

Neurovascular compression of the cochlear nerve was more frequently detected on the symptomatic side of patients with typewriter tinnitus compared with the asymptomatic side of these patients or on both sides of control subjects on MR imaging. However, considering false-positive and false-negative findings, meticulous history-taking and the response to the initial carbamazepine trial should be regarded as more reliable diagnostic clues than radiologic evidence of neurovascular compression of the cochlear nerve.

The Revascularization Scales Dilemma: Is It Right to Apply the Treatment in Cerebral Ischemia Scale in Posterior Circulation Stroke?

BACKGROUND AND PURPOSE

Although various revascularization scales are used in the angiographic evaluation of acute ischemic stroke, observer reliability tests of these scales have been rarely performed for posterior circulation stroke. We aimed to evaluate inter- and intraobserver variability of 2 scales, the modified Treatment in Cerebral Ischemia and the Arterial Occlusive Lesion, in posterior circulation stroke.

MATERIALS AND METHODS

Three independent readers interpreted pre- and postthrombolytic angiographies of 62 patients with posterior circulation stroke by using the modified Treatment in Cerebral Ischemia and Arterial Occlusive Lesion scales. The κ statistic was used to measure observer agreement for both scales, and κ > 0.6 was considered substantial agreement.

RESULTS

For the Arterial Occlusive Lesion scale, inter- and intraobserver agreement was >0.6. While intraobserver agreement of the modified Treatment in Cerebral Ischemia scale was >0.6 except for 1 reader, interobserver agreement was lower in dichotomized and original scales. In 49 cases with solely basilar artery occlusion, inter- and intraobserver agreement of both scales was similar to that in all 62 patients with posterior circulation stroke. In 2 consecutive readings, there was a significant decrease in the proportion of mTICI 2a reads (22.58% in the first versus 13.44% in the second session, P < .03) and a reciprocal increase in the sum of proportions for modified Treatment in Cerebral Ischemia 2b and modified Treatment in Cerebral Ischemia 3 reads (62.37% in the first versus 72.58% in the second session, P < .046).

CONCLUSIONS

In angiographic assessment of posterior circulation stroke, inter- and intraobserver agreement for the Arterial Occlusive Lesion scale was reliable, while the modified Treatment in Cerebral Ischemia failed to achieve substantial interobserver agreement. The clinical impact of this result needs to be validated in future studies.

The clinical outcome of end-stage renal disease patients who return to peritoneal dialysis after renal allograft failure

BACKGROUND

With the increased numbers of kidney transplantations, more patients return to dialysis after graft loss (DAGL). The aim of this study was to investigate the safety and efficacy of peritoneal dialysis (PD) after graft loss compared with transplant-naive PD patients (TN-PD).

METHOD

This study was conducted on 715 patients who started PD between 1988 and 2009, including 47 who started PD after allograft loss (DAGL-PD) and 668 in the (TN-PD) group.

RESULT

The mean ages were 40.8 ± 10.7 in DAGL-PD group and 51.03 ± 14.20 in TN-PD group (P < .01). The most common cause of end-stage renal disease in DAGL was primary glomerulonephritis (76.6%), but it was diabetes mellitus (38.9%) in the TN-PD group (P < .05). Patient survival rates at 1, 5, and 10 years were not different: 100%, 86%, and 57% versus 91%, 70%, and 62%, respectively. PD survival rate at 1, 5, and 10 years did not show significant differences: 98%, 95%, and 88% versus 95%, 80%, and 66%, respectively. The most common causes of death in both groups were infection (DAGL, 26.7%; TN-PD, 24.5%) followed by cardiovascular disease (DAGL, 20.0%; TN-PD, 19.6%); the distribution of causes did not differ significantly (P > .05).

CONCLUSION

The clinical outcomes of PD in DAGL group were comparable with those of TN-PD patients. Therefore, PD could be considered as a dialysis modality for patients who experience allograft failure.

Contrast-enhanced magnetic resonance angiography in the early period after kidney transplantation

Our objective was to evaluate the usefulness of three-dimensional (3-D) contrast-enhanced (CE) magnetic resonance angiography (MRA) to assess renal parenchyma, arterial inflow stenosis, and peritransplant fluid collections in the early period after kidney transplantation (KT). Between January 2010 and April 2011, we examined a consecutive series of 144 renal transplants using 3-D CE MRA at 14 days after KT. MRA showed parenchyma infarctions (n = 17, 11.8%), arterial inflow stenoses (n = 23, 16%), lymphoceles (n = 14, 9.7%), and hematomas (n = 6, 4.2%). The degree of renal transplant artery inflow stenosis was graded qualitatively based on diameter criterion; <50% = mild, 50% to 70% = moderate, and >70% = severe in 10 (6.9%), 5 (3.5%), and 8 (5.6%) subjects, respectively. The study recipients were divided into 3 groups according to the degree of renal artery inflow stenosis (group I: normal; group II: mild and moderate, <70%; group III: severe, >70%). Among group III patients who underwent digital subtraction angiography, 5 had percutaneous transluminal angioplasty or stenting performed after 1 month. Their mean resume creatinine levels at 1, 6, and 12 months after transplantation were not significantly different from those in the other groups (P = .391, .447, .110). The prevalence of graft loss (n = 2) was high in group III (P = .012), although the frequency of acute rejection episodes was not different among the groups (P = .890). The incidences of renal parenchyma infarction, peritransplant fluid collection and arterial inflow stenosis were unexpectedly high in the early period after KT. Thus, 3-D CE MRA provided a rapid global assessment of the renal parenchyma, transplant arterial system, and peritransplant fluid collection that can be helpful to detect or exclude many causes of renal transplant dysfunction.

Glyco-engineered anti-EGFR mAb elicits ADCC by NK cells from colorectal cancer patients irrespective of chemotherapy

Background:

The epidermal growth factor receptor (EGFR) is overexpressed in colorectal cancer (CRC), and is correlated with poor prognosis, making it an attractive target for monoclonal antibody (mAb) therapy. A component of the therapeutic efficacy of IgG1 mAbs is their stimulation of antibody-dependent cellular cytotoxicity (ADCC) by natural killer (NK) cells bearing the CD16 receptor. As NK cells are functionally impaired in cancer patients and may be further compromised upon chemotherapy, it is crucial to assess whether immunotherapeutic strategies aimed at further enhancing ADCC are viable.

Methods:

CRC patients before, during and after chemotherapy were immunophenotyped by flow cytometry for major white blood cell populations. ADCC-independent NK cell functionality was assessed in cytotoxicity assays against K562 cells. ADCC-dependent killing of EGFR⁺ A431 cancer cells by NK cells was measured with a degranulation assay where ADCC was induced by GA201, an anti-EGFR mAb glyco-engineered to enhance ADCC.

Results:

Here, we confirm the observation that NK cells in cancer patients are dysfunctional. However, GA201 was able to induce robust NK cell-dependent cytotoxicity in CRC patient NK cells, effectively overcoming their impairment.

Conclusions:

These findings support the evaluation of the therapeutic potential of GA201 in combination with chemotherapy in CRC patients.

Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign

BACKGROUND AND PURPOSE

Absence of the MCA susceptibility vessel sign (negative MCA susceptibility vessel sign) on gradient recalled-echo MR imaging in acute stroke is commonly associated with in situ stenosis and thrombotic occlusion. We evaluated the effectiveness and safety of the Solitaire stent as the first-line device for the recanalization of MCA occlusion with a negative MCA susceptibility vessel sign.

MATERIALS AND METHODS

Thirty-eight consecutive patients presenting with acute ischemic stroke due to MCA occlusion were treated by using the Solitaire AB stent alone or combined with thrombolytic drugs. Among these patients, 11 (7 men and 4 women; median age, 70 years; range, 49-89 years) who underwent multimodal stroke MR imaging before the endovascular procedure and had no MCA susceptibility vessel sign on the initial gradient recalled-echo MR imaging were included in this study. The primary end point was the recanalization of the occluded artery evaluated by the arterial occlusive lesion score. Clinical outcome was assessed at discharge and 90 days, as was the degree of residual MCA stenosis or reocclusion.

RESULTS

Successful recanalization (arterial occlusive lesion score ≥ II) without balloon angioplasty was obtained in 9 patients (81.8%). Six patients (54.5%) had an mRS score of ≤2 at 90 days. After a median of 147 days, no patient showed reocclusion on follow-up imaging. There were no symptomatic intracerebral hemorrhages.

CONCLUSIONS

The Solitaire stent is a feasible tool as the first-line device for multimodal endovascular recanalization therapy in acute ischemic stroke with a negative MCA susceptibility vessel sign. It has a good rate of successful and complete recanalization and is a fast yet safe procedure.

Combined use of rituximab and plasmapheresis pre-transplant increases post-transplant infections in renal transplant recipients with basiliximab induction therapy

INTRODUCTION

We investigated the effect of combined use of rituximab (RTX) and plasmapheresis (PP) pre-transplant on post-transplant infection.

METHODS

A total of 196 patients undergoing living-donor kidney transplantation at Seoul St. Mary's Hospital, all of whom underwent basiliximab induction therapy, were included in the study. They were divided into 3 groups: RTX/PP/intravenous immune globulin (IVIG) (the RPI group; n = 53), RTX monotherapy (the RTX group; n = 14), and control (the CONT group; n = 129). We compared the post-transplant infections in the 3 groups.

RESULTS

The overall prevalence of infection was significantly higher, and the infection-free survival rate was lower, in the RPI group compared with the RTX or CONT groups (P < 0.05). A trend toward more severe bacterial infections was seen in the RPI group compared with the other groups, and fungal infections developed only in the RPI group. After anti-rejection therapy, a significantly higher rate of infection developed in the RPI group than in the other groups (P < 0.05). In addition, the RPI group was an independent risk factor for the development of infection.

CONCLUSION

Our results show that in the setting of basiliximab induction, the use of combined RTX and PP therapy pre-transplant significantly increases the risk for post-transplant infection.

Predictors of renal relapse in Korean patients with lupus nephritis who achieved remission six months following induction therapy

Renal relapse in patients with lupus nephritis (LN) is a risk factor for poor renal function. Therefore, there is a need to identify clinical and serological risk factors for renal relapse. A total of 108 patients with LN were enrolled in this study. All the subjects had achieved complete remission or partial remission following six months of induction therapy. We retrospectively analyzed their clinical and laboratory indices, final renal function, and kidney biopsy findings. The median follow-up period after LN diagnosis was 81 months. Renal relapse had occurred in 36 patients; it occurred in 38% and 46% of patients within five and 10 years after achievement of renal remission, respectively. There was no difference between the relapsed rate in patients with complete remission and that in those with partial remission. Clinical variables at LN onset and renal biopsy findings in the patients with sustained remission and relapsed patients were also not different. The probability of renal relapse was significantly higher in patients with an earlier age of onset of systemic lupus erythematosus (SLE) (≤ 28 years versus >28 years; HR 7.308, P = 0.001), seronegativity for anti-Ro antibody (seronegativity versus seropositivity; HR 3.514, P = 0.007), and seropositivity for anti-dsDNA antibody at six months after initiation of induction therapy (HR 8.269, P = 0.001). Our study demonstrated that early onset of SLE, seronegativity for anti-Ro antibody and increased anti-dsDNA antibody following six months of induction therapy independently predict renal relapse among the LN patients.

Resveratrol prevents renal lipotoxicity and inhibits mesangial cell glucotoxicity in a manner dependent on the AMPK-SIRT1-PGC1α axis in db/db mice

AIMS/HYPOTHESIS

Many of the effects of resveratrol are consistent with the activation of AMP-activated protein kinase (AMPK), silent information regulator T1 (SIRT1) and peroxisome proliferator-activated receptor (PPAR)γ co-activator 1α (PGC-1α), which play key roles in the regulation of lipid and glucose homeostasis, and in the control of oxidative stress. We investigated whether resveratrol has protective effects on the kidney in type 2 diabetes.

METHODS

Four groups of male C57BLKS/J db/m and db/db mice were used in this study. Resveratrol was administered via gavage to diabetic and non-diabetic mice, starting at 8 weeks of age, for 12 weeks.

RESULTS

The db/db mice treated with resveratrol had decreased albuminuria. Resveratrol ameliorated glomerular matrix expansion and inflammation. Resveratrol also lowered the NEFA and triacylglycerol content of the kidney, and this action was related to increases in the phosphorylation of AMPK and the activation of SIRT1-PGC-1α signalling and of the key downstream effectors, the PPARα-oestrogen-related receptor (ERR)-1α-sterol regulatory element-binding protein 1 (SREBP1). Furthermore, resveratrol decreased the activity of phosphatidylinositol-3 kinase (PI3K)-Akt phosphorylation and class O forkhead box (FOXO)3a phosphorylation, which resulted in a decrease in B cell leukaemia/lymphoma 2 (BCL-2)-associated X protein (BAX) and increases in BCL-2, superoxide dismutase (SOD)1 and SOD2 production. Consequently, resveratrol reversed the increase in renal apoptotic cells and oxidative stress, as reflected by renal 8-hydroxy-deoxyguanosine (8-OH-dG), urinary 8-OH-dG and isoprostane concentrations. Resveratrol prevented high-glucose-induced oxidative stress and apoptosis in cultured mesangial cells through the phosphorylation of AMPK and activation of SIRT1-PGC-1α signalling and the downstream effectors, PPARα-ERR-1α-SREBP1.

CONCLUSIONS/INTERPRETATION

The results suggest that resveratrol prevents diabetic nephropathy in db/db mice by the phosphorylation of AMPK and activation of SIRT1-PGC-1α signalling, which appear to prevent lipotoxicity-related apoptosis and oxidative stress in the kidney.

Long-term risk of hypertension and chronic kidney disease in living kidney donors

OBJECTIVE

The aim of this study was to assess the long-term risks of chronic kidney disease and arterial hypertension in living kidney donors.

METHODS

Donors who were followed for more than 1 year after nephrectomy were included. We assessed each donor's blood pressure, urine protein, and estimated glomerular filtration rate (eGFR).

RESULTS

The follow-up rate was 11% (154 out of 1,356 donors), only 19% of whom were followed by nephrologists. Blood pressure had increased from 113/75 to 116/77 mm Hg (P < .01), urinary protein excretion after donation did not increase, and renal function was well preserved after donor nephrectomy. However, 33 patients (21.4%) showed a decreased eGFR of <60 mL/min/1.73 m(2), and 3 donors developed end-stage renal disease that required renal replacement therapy.

CONCLUSIONS

The follow-up rate of living donors after donation was low, and we observed an increased risk of developing chronic kidney disease after donation.

Clinical usefulness of 3-dimensional computerized tomographic renal angiography to detect transplant renal artery stenosis

OBJECTIVE

The aim of this study was to evaluate whether 3-dimensional computerized tomographic angiography (3D-CTA) is useful to detect transplant renal artery stenosis (TRAS).

METHODS

Fourteen patients with clinically suspected TRAS underwent color Doppler ultrasonography (CDU) and 3D-CTA before renal angiography. We compared 3D-CTA and CDU for accuracy based on the results of renal angiography. The safety of 3D-CTA was investigated by measuring the estimated glomerular filtration rate (eGFR) before and after the 3D-CTA examination.

RESULTS

The 10 men and 4 women who participated in this study showed a mean eGFR of 75 mL/min/1.73 m(2) (range 60-94). Of these, 9 patients were diagnosed with TRAS. 3D-CTA detected stenoses in all 9 patients, but CDU failed to detect it in 3, including, 2 with end-to-side arterial anastomoses, which may be more challenging to detect compared with end-to-end anastomoses. The stenotic area in 3D-CTA was similar to that detected by renal angiography (70 ± 12 vs 68 ± 11). The eGFR did not differ significantly before versus after the 3D-CTA examination; 72 ± 13 vs 69 ± 14 mL/min/1.73 m(2).

CONCLUSIONS

3D-CTA was an effective safe method to detect renal artery stenosis among transplant recipients with an eGFR >60 mL/min/1.73 m(2).

Does donor kidney to recipient body weight ratio influence long-term outcomes of living-donor kidney transplantation?

This study evaluated the effect of the donor kidney to recipient body weight (Kw/Rw) ratio on long-term graft function and survival. We investigated retrospectively whether there was any association between Kw/Rw ratio and long-term graft survival and function after a follow-up of >10 years. We studied a consecutive series of 123 adult-to-adult living kidney transplants. According to the Kw/Rw ratio, patients were divided into 3 groups: "low" (Kw/Rw <2.85; n = 29), "medium" (2.85 ≤ Kw/Rw < 4.04; n = 63), and "high" (≥4.04; n = 31). Among the 3 groups, the mean serum creatinine levels at 1 and 6 months as well as 1 year after transplantation were significantly lower among patients with a high Kw/Rw ratio than in those with a medium or low ratio, but serum creatinine levels at 3 and 5 years did not differ significantly (P = .394 and 0.620, respectively). Graft survival rates at 5 and 10 years after transplantation were significantly lower in the "low" group. We observed a significant association between Kw/Rw ratio and graft survival (P = .018). The Kw/Rw ratio is an important factor for long-term graft survival and early graft function. However, it did not significantly affect subsequent renal function.

MR imaging of congenital or developmental neuropathic strabismus: common and uncommon findings

BACKGROUND AND PURPOSE

High-resolution MR imaging enables direct imaging of the ocular motor nerves. The aim of this study was to assess the various causes of congenital or developmental neuropathic strabismus by using high-resolution MR imaging.

MATERIALS AND METHODS

High-resolution MR imaging was performed to evaluate the ocular motor nerves (CNIII, CNIV, CNVI) in 247 consecutive patients with suspected congenital or developmental neuropathic strabismus. These MR images, along with those obtained from conventional MR imaging of the brain and the orbit, were evaluated.

RESULTS

MR imaging abnormalities were found in 112 patients: ocular motor nerve abnormalities in 98 patients (88%), orbital abnormalities in 9 patients (8%), and brain abnormalities in 5 patients (4%). Ocular motor nerve abnormalities were CNIV aplasia (63%), CNVI aplasia or hypoplasia (21%), CNIII aplasia or hypoplasia (3%), and combined CNIII aplasia and CNVI hypoplasia (1%). Orbital abnormalities were EOM hypoplasia (7%), EOM hypertrophy (1%), and fibrotic mass (1%). Brain abnormalities were periventricular leukomalacia (4%) and periventricular heterotopia (1%).

CONCLUSIONS

Various MR imaging abnormalities were associated with congenital and developmental neuropathic strabismus. The most common abnormality was CNIV aplasia.

High-resolution diffusion-weighted imaging increases lesion detectability in patients with transient global amnesia

BACKGROUND AND PURPOSE

DWI can detect small punctate hyperintense lesions of the hippocampus in patients with TGA. We investigated whether small TGA lesions can be detected more often by increasing the resolution of DWI.

MATERIALS AND METHODS

Of 31 consecutive patients with TGA, 27 underwent DWI, twice at the first visit (range 1.5-22 hours; mean 10 hours) and at follow-up (range 50-87 hours; mean 72.5 hours) after the onset of their symptoms. Each DWI included 2 different spatial resolutions with the same b-value (2000 seconds/mm(2)): conventional resolution in a 128 × 128 matrix with 3-mm section thickness and high resolution in a 220 × 220 matrix with 2-mm section thickness. The number and contrast of hyperintense lesions were compared between the 2 resolutions.

RESULTS

Twenty-two of the 27 patients had single or multiple TGA lesions. The total number of lesions detected on conventional and high-resolution DWI was 11 and 22, respectively, at the first visit, and was 24 and 37, respectively, at follow-up. The number of lesions was significantly larger on high-resolution DWI than on conventional resolution at the first visit (P < .01) and at the follow-up (P < .01). Lesion contrast was significantly increased on high-resolution DWI (P < .01).

CONCLUSIONS

Higher DWI resolution increased lesion detectability in patients with TGA. Considering the small size of TGA lesions, the resolution of DWI is an important parameter influencing lesion detectability.

Outcome evaluation of carotid stenting in high-risk patients with symptomatic carotid near occlusion

Management of symptomatic carotid near occlusion especially in high-risk patients is different from outcome analysis of NASCET. We evaluated outcome in high-risk patients with symptomatic near occlusion. For 48 patients with near occlusion out of 166 symptomatic high-risk patients who underwent carotid stenting, we assessed the procedural success defined as residual stenosis <30%, modified Rankin Scale (mRS) at one and six months following stenting, and the 13 cerebrovascular factors related to the outcome. Initial National Institutes of Health Stroke Scale (NIHSS) ≥4, 1-3 and 0 were 13, 14 and 21 patients each. We compared the outcome with patients who underwent CAS (n=118) due to symptomatic stenosis without near occlusion during the same period. Our procedural success rate was 98%. A good outcome (mRS ≤2) was achieved in 44 patients (92%) at six months. There were five events (10%) within six months, i.e. three minor strokes, one major stroke caused by hemorrhage, and one death excluding two deaths not related to stroke. Hyperperfusion (n=4) was the most common cause of events leading to two minor strokes and a major stroke. Although initial NIHSS (P = .012) was related to poor outcome (mRS >2) compared to the CAS group, there was no statistical significance between two groups in the event rate of stroke, death or restenosis. The outcome of carotid stenting in high-risk patients with symptomatic near occlusion did not reveal any difference compared with CAS. Poor outcome was related to the initial NIHSS (≥4). Hyperperfusion tended to be more commonly related to an event occurring after stenting.

High-resolution 3D MR imaging of the trochlear nerve

BACKGROUND AND PURPOSE

The cisternal segment of the trochlear nerve is difficult to identify reliably by routine MR imaging. We investigated the visibility and anatomic features of the trochlear nerve by using high-resolution 3D-bTFE imaging in healthy subjects.

MATERIALS AND METHODS

This study was conducted with 32 healthy subjects without ocular movement disorders. For us to visualize the cisternal segment of the trochlear nerve, all subjects underwent 3D-bTFE imaging at 3T with 2 different resolutions: conventional resolution (voxel size, 0.67 x 0.45 x 1.4 mm) and high resolution (voxel size, 0.3 x 0.3 x 0.25 mm). Visibility of the trochlear nerve was graded with the use of a qualitative scale of certainty as follows: definite, probable, and indeterminate. The diameter of the trochlear nerve was measured.

RESULTS

On conventional-resolution images, the visibility of the trochlear nerve was definite in 3 nerves, probable in 12 nerves, and indeterminate in 49 nerves. On high-resolution images, visibility was definite in 63 nerves and probable in 1 nerve. The mean diameter of the trochlear nerve was 0.54 mm (range, 0.35-0.96 mm).

CONCLUSIONS

The trochlear nerve was visualized 100% of the time on high-resolution imaging with a voxel smaller than the nerve diameter. High-resolution imaging should have an important role in investigating the pathogenic mechanism of neuropathic strabismus, such as congenital superior oblique palsy.

Can a warning leak in a patient with unruptured aneurysm mask an underlying gastrointestinal pathology? A case report

Aggravating headache accompanied by nausea and epigastric discomfort suggesting a warning leak in a 39-year-old woman with a giant thrombosed intracranial aneurysm prompted us to undertake coiling of the aneurysm. After uneventful coil embolization of the aneurysm, collapse of the lung related to bronchospam developed, and was found to have a gastrointestinal pathology which had gone undetected before the procedure. Despite its rarity, gastrointestinal pathology mimicking warning leak should have been considered in a patient with a warning leak sign.

Intracranial stenting of severe symptomatic intracranial stenosis: results of 100 consecutive patients

BACKGROUND AND PURPOSE

There are a few reports regarding the outcome evaluation of balloon-expandable intracranial stent placement (BEICS). The purpose of our study was to evaluate the outcome and factors related to the adverse events (AEs) of BEICS.

MATERIALS AND METHODS

We evaluated 100 consecutive patients who underwent BEICS. We assessed the procedural success (residual stenosis < 50%), AEs (minor strokes, major strokes, and death), clinical outcome, and restenosis (> 50%) at 6 months. We also analyzed 18 factors including symptom patterns related to AE rate. Symptom patterns revealed 1) stable patients (n = 73) with improving, stationary, or resolved symptoms; and 2) unstable patients (n = 27) with gradual worsening or fluctuating symptoms (National Institutes of Health Stroke Scale [NIHSS] > or = 4) within 2 days before stent placement.

RESULTS

The procedural success rate was 99%. Overall, there were 10 (10%) AEs within the 6 months: 4 (4%) minor strokes, 3 (3%) major strokes, and 3 (3%) deaths including a death from myocardial infarction. AE rate was 4.1% in stable and 25.9% in unstable patients. Restenosis at 6 months revealed 0% (0/59). Good outcome (modified Rankin Scale < or = 2) at 6 months was 97% (71/73) in stable and 67% (18/27) in unstable patients. Stepwise logistic regression model revealed that symptom pattern (unstable versus stable) was the only significant risk factor (OR, 8.167; 95% CI, 1.933-34.500; P = .004).

CONCLUSION

BEICS revealed a low AE and good outcome rate at 6 months, especially in the stable patients. Midterm outcome was also favorable in the unstable patient group.

Pretransplant donor-specific interferon-gamma ELISPOT assay predicts acute rejection episodes in renal transplant recipients

Interferon (IFN)-gamma enzyme-linked immunosorbent spot (ELISPOT) assay is a powerful tool for measuring the frequency of alloantigen-specific T cells, reflecting cellular immunity. We correlated the pretransplant frequencies of donor-specific and third-party-specific IFN-gamma ELISPOT tests, with the posttransplant outcomes of 45 recipients of living donor renal transplantations. The mean frequency of pretransplant donor-specific ELISPOT was significantly greater among patients with acute rejection episodes (ARE) than those without ARE (18.0 [12 to 50] versus 8.8 [5 to 30.4]) spots per 200,000 peripheral blood lymphocytes (PBLs; P=.024). A cutoff level of 12 spots per 200,000 PBLs on the donor-specific ELISPOT identified an ARE-positive patient with a sensitivity of 81.8% and a specificity of 64.7%. The recipients with pretransplant donor-specific ELISPOT+showed higher serum creatinine levels and lower glomerular filtration rate (GFR) at 6 posttransplant months (P<.05). Although the pretransplant third-party-specific ELISPOT results correlated with the donor-specific ELISPOT results (r=.783; P<.001), there was no significant difference in the third-party ELISPOT results between the ARE-positive and ARE-negative recipients. In conclusion, an analysis of pretransplant donor-specific IFN-gamma ELISPOT may identify the posttransplant risk of developing ARE and displaying decreased GFR at 6 months.

Detection of Donor-Specific Anti-HLA Class I and II Antibodies Using Antibody Monitoring System

The antibody monitoring system (AMS, GTI Inc) is a solid enzyme-linked immunosorbent assay (ELISA) crossmatch test for the detection of immunoglobulin G (IgG) antibody to donor-specific solubilized HLA class I and class II antigens. The objective of this study was to compare the results of the AMS assay with donor-specific anti-HLA IgG antibodies (DS-HLA Abs), as determined by ELISA panel reactive antibody (PRA) and the flow cytometric crossmatch test (FCXM). A total of 107 sera were screened for the presence of HLA Abs by ELISA PRA (LAT-M, One-Lambda Inc), the DS-HLA Abs were determined in 34 serum samples (31.8%) by an ELISA panel (LAT class I and class II, One-Lambda Inc) and FCXM. The FCXM and AMS assays were performed with matched lymphocytes from 56 donors. There was a significant degree of concordance (89.7%) between the two tests (P < .001). The sensitivity, specificity, positive predictive value, and negative predictive value of AMS assay to detect DS-HLA Abs was 88.2%, 94.5%, 88.2%, and 94.5%, respectively. The AMS is a simple, objective test, which has several advantages over the cell-based crossmatch test, such as elimination of non-HLA antibody reactivity, elimination of non-donor-specific antibody reactivity, no need for viable cells, and preparation of the donor's HLA antigens in advance. In summary, this study suggested that AMS may be useful as a supportive crossmatch test or as a monitoring test after transplantation to detect class I or class II DS-HLA Abs.

Structure of influenza a virus promoter and its implications for viral RNA synthesis

Since the worst worldwide pandemic ever recorded — the 1918 Spanish influenza outbreak that killed more than 20 million people — we have achieved significant advances in understanding the influenza virus. However, the fear of such a pandemic remains strong. For example, in 1997, when a lethal influenza variant afflicted eight people in Hong Kong, contributing to the death of six, officials feared the next wave had begun. They managed to solve the problem quickly, however, by destroying all of the poultry in Hong Kong[1].

SeqA protein aggregation is necessary for SeqA function

The binding of SeqA protein to hemimethylated GATC sequences is important in the negative modulation of chromosomal initiation at oriC, and in the formation of SeqA foci necessary for Escherichia coli chromosome segregation. Using gel-filtration chromotography and glycerol gradient sedimentation, we demonstrate that SeqA exists as a homotetramer. SeqA tetramers are able to aggregate or multimerize in a reversible, concentration-dependent manner. Using a bacterial two-hybrid system, we demonstrate that the N-terminal region of SeqA, especifically the 9th amino acid residue, glutamic acid, is required for functional SeqA-SeqA interaction. Although the SeqA(E9K) mutant protein, containing lysine rather than glutamic acid at the 9th amino acid residue, exists as a tetramer, the mutant protein binds to hemimethylated DNA with altered binding patterns as compared with wild-type SeqA. Aggregates of SeqA(E9K) are defective in hemimethylated DNA binding. Here we demonstrate that proper interaction between SeqA tetramers is required for both hemimethylated DNA binding and formation of active aggregates. SeqA tetramers and aggregates might be involved in the formation of SeqA foci required for the segregation of chromosomal DNA as well as the regulation of chromosomal initiation.

Structural features of an influenza virus promoter and their implications for viral RNA synthesis

The influenza A virus, a severe pandemic pathogen, has a segmented RNA genome consisting of eight single-stranded RNA molecules. The 5' and 3' ends of each RNA segment recognized by the influenza A virus RNA-dependent RNA polymerase direct both transcription and replication of the virus's RNA genome. Promoter binding by the viral RNA polymerase and formation of an active open complex are prerequisites for viral replication and proliferation. Here we describe the solution structure of this promoter as solved by multidimensional, heteronuclear magnetic resonance spectroscopy. Our studies show that the viral promoter has a significant dynamic nature and reveal an unusual displacement of an adenosine that forms a novel (A-A) x U motif and a C-A mismatch stacked in a helix. The characterized structural features of the promoter imply that the specificity of polymerase binding results from an internal RNA loop. In addition, an unexpected bending (46 +/- 10 degrees ) near the initiation site suggests the existence of a promoter recognition mechanism similar to that of DNA-dependent RNA polymerase and a possible regulatory function for the terminal structure during open complex formation.

Holographic optical elements recorded in silver halide sensitized gelatin emulsions. Part I. Transmission holographic optical elements

Silver halide sensitized gelatin (SHSG) holograms are similar to holograms recorded in dichromated gelatin (DCG), the main recording material for holographic optical elements (HOE's). The drawback of DCG is its low sensitivity and limited spectral response. Silver halide materials can be processed in such a way that the final hologram will have properties like a DCG hologram. Recently this technique has become more interesting since the introduction of new ultra-high-resolution silver halide emulsions. An optimized processing technique for transmission HOE's recorded in these materials is introduced. Diffraction efficiencies over 90% can be obtained for transmissive diffraction gratings. Understanding the importance of the selective hardening process has made it possible to obtain results similar to conventional DCG processing. The main advantage of the SHSG process is that high-sensitivity recording can be performed with laser wavelengths anywhere within the visible spectrum. This simplifies the manufacturing of high-quality, large-format HOE's.

Validity and cost-effectiveness of diagnostic procedures in CS2 poisoning

To determine relatively useful diagnostic procedures of carbon disulfide (CS2) poisoning in terms of validity and cost-effectiveness, several diagnostic tests are evaluated on 1,552 people by prevalence ratio (exposed/nonexposed), dose-response relationship, sensitivity and specificity, and the cost of the tests. Several symptoms with high kappa indices are found to be useful in various combinations, showing a consistent dose-response relationship and high exposed-nonexposed ratio. In clinicopathologic tests on functions of the kidney, liver and hematopoietic systems, eight items out of 22 have been shown to have significant dose-response relationship, mostly in liver function tests. A thorough dental examination failed to identify any useful indicator peculiar to the CS2 poisoning. Unlike Western people, the prevalence of coronary heart disease among Koreans was too low to be useful in the diagnosis of CS2 poisoning. Among four elective tests, i.e., Minnesota Multiphasic Personality Inventory (MMPI), Brain magnetic resonance imaging (MRI), nerve conduction velocity (NCV), and fluorescent angiography (FAG), the NCV appeared to be a more sensitive and specific test than the others are. Combinations of the tests improved the probability of diagnosing CS2 poisoning cases when any one test out of four was positive. Addition of other valid tests increased the probability of excluding non-cases. It was concluded that diagnosis of CS2 poisoning could be made validly and inexpensively if the diagnostic tests were carefully chosen step by step.

Synthesis and antimicrobial activity of squalamine analogue

Synthesis and antimicrobial activity of squalamine analogue 2 are reported. The synthesis of 2 was accomplished from bisnoralcohol 3. The spermidine moiety was introduced via reductive amination of an appropriately functionalized 3beta-aminosterol with spermidinyl aldehyde 17 utilizing sodium triacetoxyborohydride as the reducing agent. Compound 2 shows weaker antimicrobial activity than squalamine.

The Dewar photoproduct of thymidylyl(3'-->5')- thymidine (Dewar product) exhibits mutagenic behavior in accordance with the "A rule"

In contrast to the highly mutagenic pyrimidine(6-4)pyrimidone photoproduct, its Dewar valence isomer (Dewar product) has low mutagenic potential and produces a broad range of mutations [LeClerc, J. E., Borden, A. & Lawrence, C. W. (1991) Proc. Natl. Acad. Sci. USA 88, 9685-9689]. To determine the origin of the mutagenic property of the Dewar product, we used experimental NMR restraints and molecular dynamics to determine the solution structure of a Dewar-lesion DNA decamer duplex. This DNA decamer duplex (DW/GA duplex) contains a mismatched base pair between the 3' T residue of the Dewar lesion (T6) and an opposed G residue (G15). The 3' T (T6) of the Dewar lesion formed stable hydrogen bonds with the opposing G15 residue. However, the helical bending and unwinding angles of the DW/GA duplex were much larger than those of a second duplex that contains the Dewar lesion and opposing A15 and A16 residues (DW/AA duplex). The DW/GA duplex showed poorer stacking interactions at the two bases of the Dewar product and at the adjacent A7 small middle dotT14 base pair than did the DW/AA duplex. These structural features imply that no thermal stability or conformational benefit is obtained by incorporating a G instead of an A opposite the 3' T of the Dewar lesion. These properties may thus facilitate the preferential incorporation of an A in accordance with the A rule during translesion replication and lead to the low frequency of 3' T-->C mutations observed at this site.

Solution structure of the DNA decamer duplex containing a 3'-T x T basepair of the cis-syn cyclobutane pyrimidine dimer: implication for the mutagenic property of the cis-syn dimer

The cis - syn dimer is the major DNA photoproduct produced by UV irradiation. In order to determine the origin of the mutagenic property of the cis - syn dimer, we used NMR restraints and molecular dynamics to determine the solution structure of a DNA decamer duplex containing a wobble pair between the 3'-T of the cis - syn dimer and the opposite T residue (CS/TA duplex). The solution structure of the CS/TA duplex revealed that the 3'-T x T base pair of the cis - syn dimer had base pair geometry that was significantly different from the canonical Watson-Crick base pair and caused destabilization and conformational distortion of its 3'-region. However, a 3'-T x A base pair at the cis - syn dimer within this related DNA decamer maintains the normal Watson-Crick base pair geometry and causes little distortion in the conformation of its 3'-side. Our results show that in spite of its stable hydrogen bonding, the insertion of a T residue opposite the 3'-T of the cis - syn dimer is inhibited by structural distortion caused by the 3'-T x T base pair. This may explain why the frequency of the 3'-T-->A transversion, which is the major mutation produced by the cis - syn dimer, is only 4%.

Structures of ovine corticotropin-releasing factor and its Ala32 mutant as studied by CD and NMR techniques

The corticotropin-releasing factor (CRF) is a 41-amino acid peptide-amide hormone, which mediates a general stress-response. It has been reported that the substitution of His-32 in the ovine CRF (oCRF) with Ala brings about a 4.5-fold increase in activity [Kornreich et al. (1992) J. Med. Chem. 35, 1870-76]. Here, we have determined the secondary structure of this Ala-substituted ovine CRF ([Ala32]oCRF) and compare it with that of oCRF using circular dichroism (CD) and NMR techniques in trifluoroethanol (TFE) solution, which is known to stabilize the alpha-helix formation. In contrast to an earlier report, it was observed the alpha-helical structure extends to the C-terminus of oCRF. By analyzing the CalphaH and NH chemical shifts, the properties of local structures of oCRF were elucidated. The oCRF and [Ala32]oCRF have stable alpha-helical structures in the middle region, regardless of pH and temperature, and the alpha-helix initiation regions of these peptides are stabilized as the pH is decreased. However, the [Ala32]oCRF has a more stable alpha-helical structure than oCRF in the vicinity of the substitution region, and it is thought that this is the cause of the increased activity of [Ala32]oCRF.

Structural and functional implications of a proline residue in the antimicrobial peptide gaegurin

Although it is commonly known as a helix breaker, proline residues have been found in the alpha-helical regions of many peptides and proteins. The antimicrobial peptide gaegurin displays alpha-helical structure and has a central proline residue (P14). The structure and activity of gaegurin and its alanine derivative (P14A) were determined by various spectroscopic methods, restrained molecular dynamics, and biological assays. Both P14 and P14A exhibited cooperative helix formation in solution, but the helical stability of P14 was reduced substantially when compared to that of P14A. Chemical-shift analysis indicated that both of the peptides formed curved helices and that P14 showed diminished stability in the region around the central proline. However, hydrogen-exchange data revealed remarkable differences in the location of stable amide protons. P14 showed a stable region in the concave side of the curved helix, while P14A exhibited a stable region in the central turn of the helix. The model structure of P14 exhibited a pronounced kink, in contrast to the uniform helix of P14A. Both peptides showed comparable binding affinities for negatively charged lipids, while P14 had a considerably reduced affinity for a neutral lipid. With its destabilized alpha-helix, P14 exhibited greater antibacterial activity than did P14A. Hence, electrostatic interaction between helical peptides and lipid membranes is believed to be the dominant factor for antibacterial activity. Moreover, helical stability can modulate peptide binding to membranes that is driven by electrostatic interactions. The observation that P14 is a more potent antibacterial agent than P14A implies that the helical kink of P14 plays an important role in the disruption of bacterial membranes.

Antifungal activities of recombinant antifungal protein by conjugation with polyethylene glycol

Tenecin 3, an antifungal protein isolated from coleopteran insect Tenebrio molitor larvae, inhibited growth of the fungus Candida albicans. We have previously reported that tenecin 3 has a propensity of random structure with very loose turn-like elements by circular dichroism (CD) analysis and 2D nuclear overhauser effect spectroscopy [Lee et al. (1999)]. However, the antifungal mechanism of tenecin-3 has not yet been studied due to its very low availability from natural sources. As an initial step to study the antifungal mechanism of tenecin 3, recombinant tenecin 3 (RT-3) obtained from an expression system in Escherichia coli showed antifungal activity against C. albicans as did natural tenecin 3. To elucidate the antifungal mechanism of RT-3 and to explore the possibility of preparing polyethylene glycol (PEG) conjugated derivative, we synthesized PEG conjugated RT-3 (RT-3-PEG) and examined its antifungal activity against C. albicans in vitro. RT-3-PEG showed greater antifungal activity against C. albicans than RT-3 alone at the same dose. When C. albicans was treated with RT-3-PEG in vitro, K+ in the C. albicans cell was leaked out rapidly compared to the C. albicans treated with RT-3 alone. When the morphological change of RT-3-PEG treated C. albicans was examined by scanning electron microscopy, string-like substances, which may have been derived from the fungus, were stacked around the cell whose wall was damaged. Also, no appreciable hemolysis of mouse erythrocytes was detected under conditions in which 1% melittin caused 100% hemolysis. These results suggested that the RT-3-PEG derivative probably does not interact with mammalian cell appreciably, although it has antifungal activity.

Solution structure of a DNA decamer duplex containing the stable 3' T.G base pair of the pyrimidine(6-4)pyrimidone photoproduct [(6-4) adduct]: implications for the highly specific 3' T --> C transition of the (6-4) adduct

The pyrimidine(6-4)pyrimidone photoproduct [(6-4) adduct] is one of the major photoproducts induced by UV irradiation of DNA and occurs at TpT sites. The (6-4) adduct is highly mutagenic and leads most often to a 3' T --> C transition with 85% replicating error frequency [LeClerc, J. E., Borden, A. & Lawrence, C. W. (1991) Proc. Natl. Acad. Sci. USA 88, 9685-9689]. To determine the origin of the specific 3' T --> C transition of the (6-4) adduct, we have used experimental NMR restraints and molecular dynamics to determine the solution structure of a (6-4)-lesion DNA decamer duplex that contains a mismatched base pair between the 3' T residue and an opposed G residue. Normal Watson-Crick-type hydrogen bonding is retained at the 5' T of the lesion site. The O2 carbonyl of the 3' T residue forms hydrogen bonds with the imino and amino protons of the opposed G residue. This potential hydrogen bonding stabilizes the overall helix and restores the highly distorted conformation of the (6-4) adduct to the typical B-form-like DNA structure. This structural feature can explain the marked preference for the insertion of an A residue opposite the 5' T and a G residue opposite the 3' T of the (6-4) lesion during trans-lesion synthesis. Thus these insertions yield the predominant 3' T --> C transition.

Inhibition of poly(ADP-ribose)polymerase binding to DNA by thymidine dimer

The ability of poly(ADP-ribose)polymerase to bind damaged DNA was assessed by electrophoretic mobility shift assay. DNA binding domain of poly(ADP-ribose)polymerase (PARPDBD) binds to synthetic deoxyribonucleotide duplex 10-mer. However, the synthetic deoxyribonucleotide duplex containing cys-syn thymidine dimer which produces the unwinding of DNA helix structure lost its affinity to PARPDBD. It was shown that the binding of PARPDBD to the synthetic deoxyribonucleotide duplex was not affected by O6-Me-dG which causes only minor distortion of DNA helix structure. This study suggests that the stabilized DNA helix structure is important for poly(ADP-ribose)polymerase binding to DNA breaks, which are known to stimulate catalytic activity of poly(ADP-ribose)polymerase.

Chemical shift perturbation studies of the interactions of the second RNA-binding domain of the Drosophila sex-lethal protein with the transformer pre-mRNA polyuridine tract and 3' splice-site sequences

The interactions of the second RNA-binding domain of the Drosophila melanogaster Sex-lethal protein (Sxl RBD2) with the oligoribonucleotides, GUUUUUUUU (GU8) and CUAGUG, representing the sequences surrounding an alternative 3'-splicing site of the transformer pre-mRNA (GU8CUAGUG), were studied using heteronuclear two-dimensional NMR techniques. The 1H and 15N chemical shifts of the backbone amide resonances upon titration of Sxl RBD2 with each of these RNAs were recorded. It was found that Sxl RBD2 can bind not only to the polyuridine tract, GU8, but also to the downstream 3' splice-site sequence, CUAGUG, with similar affinities. In contrast, a nonspecific sequence, C8, did not bind to Sxl RBD2. This result is consistent with previous in vitro RNA-selection and UV-cross-linking results which indicated that the Sex-lethal protein binds to the uridine stretch and the AG dinucleotide in the consensus sequence, AUnNnAGU. In both cases, the chemical-shift perturbations were significant for almost the same amino acid residues, including the two central beta-strands formed by the RNP2-motif and RNP1-motif with the two highly conserved aromatic residues (Y214 and F256) in the middle. As the first RNA-binding domain of Sex-lethal (Sxl RBD1) has a characteristic aliphatic residue at one of the two corresponding positions (I128 and F170), Y214 of Sxl RBD2 was replaced by Ile using site-directed mutagenesis. On the one hand, the 1H and 15N chemical-shift perturbations indicated that GU8 binds to the same interface of mutant Sxl RBD2 as of wild-type Sxl RBD2, although its binding affinity was decreased significantly. On the other hand, the specific binding of Sxl RBD2 to CUAGUG was abolished almost completely by the Y-->I mutation. Taken together, the present results indicate that the interface residues that bind with GU8 and CUAGUG are much the same, but the role of the Y214 residue is clearly different between these two target sequences.

Structural characteristics of tenecin 3, an insect antifungal protein

Tenecin 3, an antifungal protein, previously isolated from the insect Tenebrio molitor, inhibits growth of the fungus Candida albicans. However, the antifungal mechanism and functions of tenecin 3 remain unknown. As an initial step to study the mechanism and functions, physical and structural properties of tenecin 3 were examined by circular dichroism (CD) analysis and 2D nuclear overhauser effect spectroscopy. These analyses suggest that tenecin 3 has a propensity of random structure with very loose turn-like elements. The CD results also indicate that this random structural propensity is not significantly affected by temperature, pH, and by the presence of organic solvents or sodium dodecyl sulfate (SDS) micelles. However, the hydrodynamic studies suggest that tenecin 3 is not in extended form in spite of its random structural feature.

Structure of influenza virus panhandle RNA studied by NMR spectroscopy and molecular modeling

The structure of a 34 nucleotide RNA molecule in solution, which contains the conserved panhandle sequences, was determined by NMR spectroscopy and molecular modeling. The partially double-strandedpanhandle structure of the influenza virus RNA serves to regulate initiation and termination of viral transcription as well as polyadenylation. The panhandle RNA consists of internal loop flanked by short helices. The nucleotides at or near the internal loop are crucial for polymerase binding and transcriptional activity. They show more flexible conformational character than the Watson-Crick base-paired region, especially for the backbone torsion angles of alpha, gamma and delta. Although residues A10 and A12 are stacked in the helix, the phosphodiester backbones are distorted. Residues A12, A13 and G25 show dynamic sugar conformations and the backbone conformations of these nucleotides are flexible. This backbone conformation and its associated flexibility may be important for protein-RNA interactions as well as base-specific interactions.

Bacterial expression of tenecin 3, an insect antifungal protein isolated from Tenebrio molitor, and its efficient purification

Tenecin 3, an antifungal protein isolated from the insect Tenebrio molitor larvae, inhibits growth of the fungus Candida albicans. However, the antifungal mechanism and functions of tenecin 3 have not yet been studied due to its very low availability from the natural source. Here we report an expression system of the recombinant tenecin 3 in E. coli, whose amino acid composition is the same with that of the natural tenecin 3. We also devised a simple and easy procedure to isolate the recombinant protein from the bacterial cell extracts. The recombinant tenecin 3 showed an antifungal activity against C. albicans as the natural tenecin 3 did. Therefore large quantities of tenecin 3 can be easily obtained by the expression and purification system of tenecin 3 described in this report.