Vascular persistence following precision micropuncture

OBJECTIVE

The success of engineered tissues continues to be limited by time to vascularization and perfusion. Recently, we described a simple microsurgical approach, termed micropuncture (MP), which could be used to rapidly vascularize an adjacently placed scaffold from the recipient macrovasculature. Here we studied the long-term persistence of the MP-induced microvasculature.

METHODS

Segmental 60 μm diameter MPs were created in the recipient rat femoral artery and vein followed by coverage with a simple Type 1 collagen scaffold. The recipient vasculature and scaffold were then wrapped en bloc with a silicone sheet to isolate intrinsic vascularization. Scaffolds were harvested at 28 days post-implantation for detailed analysis, including using a novel artificial intelligence (AI) approach.

RESULTS

MP scaffolds demonstrated a sustained increase of vascular density compared to internal non-MP control scaffolds (p < 0.05) secondary to increases in both vessel diameters (p < 0.05) and branch counts (p < 0.05). MP scaffolds also demonstrated statistically significant increases in red blood cell (RBC) perfused lumens.

CONCLUSIONS

This study further highlights that the intrinsic MP-induced vasculature continues to persist long-term. Its combination of rapid and stable angiogenesis represents a novel surgical platform for engineered scaffold and graft perfusion.

Limited Efficacy of Empiric Antibiotics for Pediatric Facial Fractures

BACKGROUND

Controversies exist regarding the role of perioperative antibiotic use in pediatric craniomaxillofacial fracture repair.

PURPOSE

This study aims to identify factors associated with antibiotic prescribing patterns and measures the association between antibiotic exposure and postoperative infections.

STUDY DESIGN, SETTING, SAMPLE

In this retrospective cohort study, TriNetX, a research database, was used to gather data on patients under 18 years of age who underwent repair of facial fractures. The records were obtained from 2003 to 2021. Current Procedural Terminology codes for facial fracture procedures were used to identify patients.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Antibiotic use, defined as a binary categorical variable of whether or not patients received perioperative antibiotics. The secondary predictor variable was timing of antibiotic administration, categorized by pre, intra, and postoperative administration.

MAIN OUTCOME VARIABLES

Postoperative infection, determined by International Classification of Diseases, 9th and 10th Revision codes within patient charts.

COVARIATES

Covariates included demographic variables such as age, sex, race, ethnicity, geographic location, and fracture characteristics, such as number of fractures and location of fracture.

ANALYSES

χ2 analyses were used for categorical variables and two sample t tests for quantitative variables. Multivariable logistic regression was used to evaluate patient infection and antibiotic use with adjustment for covariates. P-values were 2-tailed and statistical significance was defined as P < .05.

RESULTS

This cohort included 5,413 patients of which 70.4% were male, 74.4% identified as white, and 83.3% identified as non-Hispanic or Latino. There were no differences in postoperative infections in patients who received antibiotics compared to those who did not (0.9 vs 0.5%, respectively, P = .12). Nevertheless, antibiotic prescriptions have increased over the years. After controlling for relevant covariates, antibiotic use did not decrease the odds of infection (adjusted odds ratio 1.1, 95% CI 0.53 to 2.34, P = .79). There was a significant association between the timing of antibiotic use and infection (P = .044), with increased odds of infection when antibiotics were given postoperatively (adjusted odds ratio 3.8, 95% CI 1.2 to 12.07, P = .023).

CONCLUSION AND RELEVANCE

While antibiotic prescriptions have increased over the years, this study demonstrates there is no difference in postoperative infection rates for pediatric patients prescribed antibiotics and those where were not.

Avian Reovirus in Israel, Variants and Vaccines-A Review

Avian reovirus (ARV) has been determined to be the etiologic agent of viral arthritis/tenosynovitis. In Israel, meat-type chickens, including broilers and breeders, are the most affected. Severe disease symptoms can appear in broiler flocks at a very young age because of early exposure and vertical transmission, causing significant welfare problems. Jewish laws define birds with inflamed, damaged, or torn gastrocnemius and digital flexor tendons as religious condemnations (non-kosher), resulting in severe economic losses for the poultry industry. Vaccination of breeders is a strategy to control the disease by reducing vertical transmission and providing maternal-derived antibodies to the progeny. This review describes Israel's ARV variants and the various vaccines developed over the years. Identification of co-circulating variants triggered the development of multivalent autogenous inactivated vaccines. However, the genotype-matched vaccines failed to provide protection, resulting in an increased prevalence of Cluster II ARV (classified as genotyping cluster 5 in the ARV common world classification). Since 2014, ARV Cluster II has been dominant in Israel. In 2015, the dominant variant s7585 tropism changed the virus pathogenesis and affected broilers with severe clinical signs between 12 and 15 days of age. A new vaccine approach developed in Israel used controlled exposure of the breeding flock to virulent ARV at the age when they are resistant to infection. This approach significantly reduced clinical field cases and reovirus isolations of breeding and broiler flocks between 2020 and 2022.

Regenerative Engineering: Current Applications and Future Perspectives

Many pathologies, congenital defects, and traumatic injuries are untreatable by conventional pharmacologic or surgical interventions. Regenerative engineering represents an ever-growing interdisciplinary field aimed at creating biological replacements for injured tissues and dysfunctional organs. The need for bioengineered replacement parts is ubiquitous among all surgical disciplines. However, to date, clinical translation has been limited to thin, small, and/or acellular structures. Development of thicker tissues continues to be limited by vascularization and other impediments. Nevertheless, currently available materials, methods, and technologies serve as robust platforms for more complex tissue fabrication in the future. This review article highlights the current methodologies, clinical achievements, tenacious barriers, and future perspectives of regenerative engineering.

Surveillance and Genetic Characterization of Virulent Newcastle Disease Virus Subgenotype V.3 in Indigenous Chickens from Backyard Poultry Farms and Live Bird Markets in Kenya

Kenyan poultry consists of ~80% free-range indigenous chickens kept in small flocks (~30 birds) on backyard poultry farms (BPFs) and they are traded via live bird markets (LBMs). Newcastle disease virus (NDV) was detected in samples collected from chickens, wild farm birds, and other domestic poultry species during a 2017–2018 survey conducted at 66 BPFs and 21 LBMs in nine Kenyan counties. NDV nucleic acids were detected by rRT-PCR L-test in 39.5% (641/1621) of 1621 analyzed samples, of which 9.67% (62/641) were NDV-positive by both the L-test and a fusion-test designed to identify the virulent virus, with a majority being at LBMs (64.5%; 40/62) compared to BPFs (25.5%; 22/62). Virus isolation and next-generation sequencing (NGS) on a subset of samples resulted in 32 complete NDV genome sequences with 95.8–100% nucleotide identities amongst themselves and 95.7-98.2% identity with other east African isolates from 2010-2016. These isolates were classified as a new sub-genotype, V.3, and shared 86.5–88.9% and 88.5–91.8% nucleotide identities with subgenotypes V.1 and V.2 viruses, respectively. The putative fusion protein cleavage site (¹¹³R-Q-K-R↓F ¹¹⁷) in all 32 isolates, and a 1.86 ICPI score of an isolate from a BPF chicken that had clinical signs consistent with Newcastle disease, confirmed the high virulence of the NDVs. Compared to genotypes V and VI viruses, the attachment (HN) protein of 18 of the 32 vNDVs had amino acid substitutions in the antigenic sites. A time-scaled phylogeographic analysis suggests a west-to-east dispersal of the NDVs via the live chicken trade, but the virus origins remain unconfirmed due to scarcity of continuous and systematic surveillance data. This study reveals the widespread prevalence of vNDVs in Kenyan backyard poultry, the central role of LBMs in the dispersal and possibly generation of new virus variants, and the need for robust molecular epidemiological surveillance in poultry and non-poultry avian species.

Incidental Papillary Thyroid Cancer Identified During Parathyroidectomy

Current treatment guidelines recommend surgical excision of papillary thyroid carcinoma. However, the precise surgical treatment, including thyroid lobectomy, total thyroidectomy, and the need for neck dissection, is dictated by disease extent and tumor cytology. Incidental papillary thyroid carcinoma discovered during another surgery therefore presents a surgical conundrum due to lack of information. Surgeons must consider short- and long-term surgical morbidities, as well as individual patient factors, when deciding how to treat an unexpected thyroid carcinoma.

Ethanol and isopropanol inactivation of human coronavirus on hard surfaces

BACKGROUND

The coronavirus disease 2019 pandemic has greatly increased the frequency of disinfecting surfaces in public places, causing a strain on the ability to obtain disinfectant solutions. An alternative is to use plain alcohols (EtOH and IPA) or sodium hypochlorite (SH).

AIM

To determine the efficacy of various concentrations of EtOH, IPA and SH on a human coronavirus (HCoV) dried on to surfaces using short contact times.

METHODS

High concentrations of infectious HCoV were dried on to porcelain and ceramic tiles, then treated with various concentrations of the alcohols for contact times of 15 s, 30 s and 1 min. Three concentrations of SH were also tested. Reductions in titres were measured using the tissue culture infectious dose 50 assay.

FINDINGS

Concentrations of EtOH and IPA from 62% to 80% were very efficient at inactivating high concentrations of HCoV dried on to tile surfaces, even with a 15-s contact time. Concentrations of 95% dehydrated the virus, allowing infectious virus to survive. The dilutions of SH recommended by the Centers for Disease Control and Prevention (1/10 and 1/50) were efficient at inactivating high concentrations of HCoV dried on to tile surfaces, whereas a 1/100 dilution had substantially lower activity.

CONCLUSIONS

Multiple concentrations of EtOH, IPA and SH efficiently inactivated infectious HCoV on hard surfaces, typical of those found in public places. Often no remaining infectious HCoV could be detected.

Protection conferred by commercial NDV live attenuated and double recombinant HVT vaccines against virulent California 2018 Newcastle disease virus (NDV) in chickens

Vaccines against virulent Newcastle disease virus (NDV) are widely available and can be protective, but improved vaccination protocols are needed to prevent clinical disease and reduce virus circulation. The present study evaluated the efficacy of two commercial vaccines alone or in combination: a live attenuated NDV vaccine (LV) and a recombinant herpesvirus of turkeys vector expressing the fusion protein of NDV and the virus protein 2 of infectious bursal disease virus (rHVT-ND-IBD). Chickens were vaccinated with one of four vaccination protocols: live vaccine (LV) at 1 and 11 days of age (DOA), rHVT ND-IBD and LV at 1 DOA, rHVT ND-IBD at 1 DOA boosted with an LV at 11 DOA, and rHVT ND-IBD at 1 DOA. The vaccinated birds were challenged at different time points (3 or 4 weeks of age) with the California 2018 virus. The mortality, clinical signs, mean death time (MDT), humoral response before and after vaccination, and virus shedding after challenge were evaluated. All vaccination protocols were able to prevent mortality, reduce virus shedding, and induce antibody levels before the challenge at 3 and 4 weeks-old. Overall, the antibody levels before the challenge at 4 weeks were significantly higher in all groups vaccinated with the rHVT ND-IBD when compared to levels in 3 week old birds. The combination of recombinant rHVT ND-IBD with a live vaccine at one-day-old seems to be a better combination, due to the absence of clinical signs, higher antibody levels pre and post-challenge, and reduced virus shedding at any time point after the challenge at 3 or 4 weeks of age with the California 2018 virus.

Newcastle disease virus: is an updated attenuated vaccine needed?

Newcastle disease virus (NDV) is a major cause of infectious mortality and morbidity in poultry worldwide. It is an enveloped virus with two outer-membrane proteins-haemagglutinin-neuraminidase (HN) and fusion protein (F)-that induce neutralizing antibodies. All NDV strains belong to one serotype. Yet, NDV vaccines, derived from genotype II, do not fully prevent infection or shedding of viruses from other genotypes. The aim of this study was to test if an updated vaccine is required. For this purpose, NDVs isolated from infected, albeit heavily vaccinated, flocks were genetically and immunologically characterized. Amino acid differences in F and HN protein sequences were identified between the vaccine strain and each of the isolates, some specifically at the neutralization sites. Whereas all tested isolates showed similar haemagglutination-inhibition (HI) titres, 100-100,000 times higher antibody-to-virus ratios were needed to neutralize viral propagation in embryos by the field isolates versus the vaccine strain. As a result, a model and an equation were developed to explain the phenomenon of escape in one-serotype viruses and to calculate the HI values needed for protection, depending on variation rate at key positions. In conclusion, to confer full protection against NDVs that differ from the vaccine strain at the neutralizing epitopes, very high levels of antibodies should be raised and maintained to compensate for the reduction in the number of effective epitopes; alternatively, an adjusted attenuated vaccine should be developed-a task made possible in the current era of reverse vaccinology.

Using Technology in Global Otolaryngology

Technology is integral to the diverse diagnostics and interventions of Otolaryngology. Historically, major advances in this field derive from advances of associated technologies. Challenges of visualization and surgical access are increasingly overcome by integrating endoscopic, electronic, and robotic instruments. Otolaryngology is often limited to urban areas and large academic centers, making it difficult to allocate care and resources to many underserved populations. The widespread use of technology has important implications in regards to global access to this field as telemedicine is most effectively applied to specialties that are heavily reliant on data and visuals that may be electronically disseminated.

Optimized polypeptide for a subunit vaccine against avian reovirus

Avian reovirus (ARV) is a disease-causing agent. The disease is prevented by vaccination with a genotype-specific vaccine while many variants of ARV exist in the field worldwide. Production of new attenuated vaccines is a long-term process and in the case of fast-mutating viruses, an impractical one. In the era of molecular biology, vaccines may be produced by using only the relevant protein for induction of neutralizing antibodies, enabling fast adjustment to the emergence of new genetic strains. Sigma C (SC) protein of ARV is a homotrimer that facilitates host-cell attachment and induce the production and secretion of neutralizing antibodies. The aim of this study was to identify the region of SC that will elicit a protective immune response. Full-length (residues 1-326) and two partial fragments of SC (residues 122-326 and 192-326) were produced in Escherichia coli. The SC fragment of residues 122-326 include the globular head, shaft and hinge domains, while eliminating intra-capsular region. This fragment induces significantly higher levels of anti-ARV antibodies than the shorter fragment or full length SC, which neutralized embryos infection by the virulent strain to a higher extent compared with the antibodies produced in response to the whole virus vaccine. Residues 122-326 fragment is assumed to be folded correctly, exposing linear as well as conformational epitopes that are identical to those of the native protein, while possibly excluding suppressor sequences. The results of this study may serve for the development of a recombinant subunit vaccine for ARV.

Wide-range protection against avian reovirus conferred by vaccination with representatives of four defined genotypes

Many isolates of the contagious avian reovirus have been characterized, mainly based on the sequence of their sigma C protein. These isolates have been classified into four genotypes. Currently available vaccines are of limited effectiveness, likely due to the existence of many variants. The aim of this study was to test the efficacy of a vaccine consisting of a mixture of prototypes (representatives) of the four defined genotypic groups of avian reovirus. The prototypes were selected based on their distance from the isolates within each genotype. All prototypes were found to be virulent. Antibodies produced against each of the prototypes neutralized all members of its genotype. Birds were then vaccinated with a mixture of the four prototypes. Results suggest that the 4-valent vaccine can prevent disease and confer broad protection against field isolates of avian reovirus.

Differentiating infected from vaccinated animals, and among virulent prototypes of reovirus

Birds are most susceptible to infection by avian reovirus, genus Orthoreovirus family Reoviridae, at a young age. Although chicks are protected by antibodies transferred from vaccinated maternal flocks, due to the many variants in the field, the efficiency of the vaccines is limited. The level of antibodies against viruses is generally determined by enzyme-linked immunosorbent assay (ELISA), using the whole virus as the antigen. This has some disadvantages: first, the test measures antibodies against all capsid proteins, most of which are irrelevant for neutralizing the virus, and as such does not reflect the real protection status; second, it is impossible to distinguish between vaccine- and infection-derived antibodies. In the case of a virus that changes frequently, a third disadvantage is the inability to distinguish among serotypes. The aim of this study was to develop a test that would address these concerns. Four prototypes of the avian reovirus protein sigma C were used as antigens on the ELISA plate. Sigma C is the main protein inducing neutralizing antibodies and the most variable among strains and isolates, and it is used for reovirus classification. This differentiating ELISA enabled distinguishing between vaccine and field strains of the virus, identifying the infection source, and in the case of vaccination, exclusively determining the level of protective antibodies. Whereas the whole virus detected antibodies against all strains, differentiating ELISA enabled differentiating between infected and vaccinated animals (DIVA) and in most cases, identifying the sigma C genotype. In a field study, a correlation was found between disease symptoms and antibodies identified against virulent strains in the flock. Thus virulent strains can be identified in the field, enabling adjustment of the relevant vaccines.

Genetic and antigenic characterization of sigma C protein from avian reovirus

Avian reovirus (ARV) causes viral arthritis, tenosynovitis, liver infection and immunosuppression in birds. Live-attenuated and inactivated vaccines for ARV are available, but do not efficiently protect against recent variants. Sigma C, which mediates virus attachment to target cells, is the most variable protein in ARV. Antibodies to this protein neutralize viral infection. The purpose of the present study was to characterize sigma C in isolates of ARV from infected birds, as compared with the vaccine strain. Amino acids 27 to 293 of sigma C from 28 Israeli isolates were compared, classified and analysed using bioinformatics tools. Large variations were found among the isolates, and the vaccine strain was shown to differ from most of the studied strains, which could explain the failure of commonly used vaccinations in protecting birds against ARV infection. Based on sigma C protein sequences from all over the world, ARV can be divided into four groups. Isolates from all groups were found in the field simultaneously, possibly explaining the insufficient protection achieved by the vaccine strain, which is represented in one of the groups. The results point out the need and the difficulty in producing a wide-ranging vaccine. Several conserved regions among all reported ARV sigma C proteins were identified. These peptides were further studied for structural and functional properties, and for antigenic characterization. The results of this study shed light on peptide selection for a broad and efficient vaccine.

A novel bispecific antibody (bsMAb) construct for nuclear imaging of pancreatic cancer

4564

Background: The initial diagnosis of pancreatic cancer is difficult at best. We developed MAb-PAM4 reactive with a unique epitope within MUC1 that is expressed in most pancreatic cancers, but not in normal or inflammatory pancreas, nor most other normal and neoplastic tissues. Our current focus is the development of a pretargeting procedure that can greatly enhance targeting sensitivity while retaining the MAb’s high specificity. Methods: TF10 is a novel humanized recombinant bsMAb with divalent binding to PAM4-defined MUC1 and monovalent binding to histamine-succinyl-glycine (HSG). TF10 is a 157 kDa protein having >85% binding to MUC1 and >90% with HSG. Athymic nude mice bearing CaPan1, human pancreatic cancer, were injected with 125I-TF10 to assess biodistribution. Other animals were given varying doses of TF10 followed 16 h later with 111In-IMP-288, a divalent-HSG-peptide. These animals were imaged 3 h after the 111In-IMP-288-injection and then necropsied. Results: 125I-labeled TF10 cleared rapidly from the blood, with blood levels <0.25 ± 0.02 %ID/g at 16 h, and no accumulation in any normal tissues. Tumor uptake was 7.16 ± 1.10, 3.47 ± 0.66, and 1.65 ± 0.57 % ID/g at 6, 16, and 48 hrs, respectively. These data confirmed that for a pretargeted imaging study a 16-h interval is sufficient to clear the blood so that 111In-IMP-288 could be administered. At 3 h, the imaging studies showed intense uptake of radiolabeled peptide within the tumors (avg. 0.5 cm3 - 0.3 g at necropsy) with no evidence of uptake in any normal tissues, while no targeting was seen in animals given the 111In-IMP-288 alone. At necropsy, tumor uptake of the 111In-IMP-288 in the TF10 pretargeted animals was 24.3 ± 1.7 % ID/g, while for 111In-IMP-288 alone tumor uptake was only 0.012 ± 0.002 % ID/g. Tumor/blood, liver, lungs, and kidney ratios averaged 2800:1, 139:1, 184:1, and 14.2:1, respectively, in the pretargeted animals. Conclusions: These results demonstrate that this novel PAM4-based pretargeting agent targets and images xenografted human pancreatic cancer with high signal-to-background ratios. In addition to imaging, TF10 may prove useful for pretargeted therapy of pancreas cancer. (Supported in part by grant CA115755 from the NIH.)

No significant financial relationships to disclose.

TGFbeta-dependent gene expression profile during maturation of dendritic cells

Primary immune response to pathogens involves the maturation of antigen-presenting dendritic cells (DC). Bacterial lipopolysacharride (LPS) is a potent inducer of DC maturation, whereas the transforming growth factor beta (TGFbeta) attenuates much of this process. Here, we analyzed the global gene expression pattern in LPS-treated bone marrow derived DC during inhibition of their maturation process by TGFbeta. Exposure of DC to LPS induces a pronounced cell response, manifested in altered expression of a large number of genes. Interestingly, TGFbeta did not affect most of the LPS responding genes. Nevertheless, analysis identified a subset of genes that did respond to TGFbeta, among them the two inflammatory cytokines interleukin (IL)-12 and IL-18. Expression of IL-12, the major proinflammatory cytokine secreted by mature DC, was downregulated by TGFbeta, whereas the expression level of the proinflammatory cytokine IL-18, known to potentiate the IL-12 effect, was upregulated. Expression of the peroxisome proliferator-activated receptor gamma (PPARgamma) increased in response to TGFbeta, concomitantly with reduced expression of chemokine receptor 7 (CCR7). This finding supports the possibility that TGFbeta-dependent inhibition of CCR7 expression in DC is mediated by PPARgamma.

Phase II trial of repeated carcinoembryonic antigen (CEA) radioimmunotherapy (RAIT) with 131I-Labetuzumab post salvage resection of colorectal metastases in the liver

13572

Background: Complete resection of liver metastases (LM) remains the treatment of choice for colorectal cancer (CRC). As shown recently (Liersch et al., JCO 2005; 23:6763–70), RAIT with a single application of the humanized monoclonal anti-CEA antibody, 131I-labetuzumab, improved both the median overall survival (OS) and 5-yr survival rates significantly in patients post salvage resection of LM. The major adverse side effects (≤ grade 3 CTC) were transient myelosuppression and/or thrombocytopenia in patients receiving 40 to 60 mCi/m2 of 131I-labetuzumab. These encouraging results stimulated the current ongoing Phase-II trial to evaluate the safety of repeated RAIT at doses of 2 × 50 mCi/m2 (3 mos apart), post salvage resection of LM. Methods: At present, 13 patients (primary CRC: 8x UICC stage IV, 1× UICC stage III and 4× UICC stage II) who underwent surgery for LM of CRC (postsalvage mTMN stages: 4× mT4, 2× mT3, 6× mT2, 1× mT1) have received the first dose of 50 mCi/m2 131I-labetuzumab within 2 mos of LM surgery. Three months later, a second infusion of 50 mCi/m2 has already been given to 5 pts. In two, a dose reduction to 40 mCi/m2 was performed. At re-staging CT and PET scans) for the 2nd RAIT, in one patient pulmonary metastases were diagnosed and in another patient a re-resection of hepatic relapse was performed. Results: In the previous trial, at a median follow-up of 67 mos, the median OS from the first liver resection for 19 pts treated with single-dose RAIT was 68.0 mos and median DFS was 18.0 mos. Also, 5-year survival was achieved by 51.3% of RAIT pts independently of bilobar involvement, size and number of LM, or resection margins. In the current study with repeated RAIT, transient grade-4 myelosuppression (2 cases in combination with a myelotoxic thiamazol medication) occurred in 4/13 pts after the first dose (1× grade 4 thrombocytopenia). No cumulative toxicity was seen in 6 of 7 RAIT-re-treated patients. Complete bone marrow recovery was observed in all 6 cases within 5–12 weeks; in one pt severe neutropenia persisted to about week 16 post 2nd RAIT. As of January, 2006, patient compliance was 100%. Conclusion: RAIT re-treatment to-date appears to be safe, feasible, and well accepted. Extended follow-up data are being collected.

[Table: see text]

The impact of an aging population on curriculum development in Canadian undergraduate nursing education

The rise in numbers of persons 65 years of age and older due to increased life expectancy is necessitating a revision in undergraduate nursing education. Since additional qualified nurses will be required to care for this expanding population, nursing programs must include sufficient relevant gerontological content delivered by competent faculty to prepare these practitioners. The authors review pertinent literature, present several surveys outlining the current status of gerontology content in nursing and other allied health programs, and argue for gerontological nursing to be a core component of undergraduate programs.

The RUNX3 gene--sequence, structure and regulated expression

The RUNX3 gene belongs to the runt domain family of transcription factors that act as master regulators of gene expression in major developmental pathways. In mammals the family includes three genes, RUNX1, RUNX2 and RUNX3. Here, we describe a comparative analysis of the human chromosome 1p36.1 encoded RUNX3 and mouse chromosome 4 encoded Runx3 genomic regions. The analysis revealed high similarities between the two genes in the overall size and organization and showed that RUNX3/Runx3 is the smallest in the family, but nevertheless exhibits all the structural elements characterizing the RUNX family. It also revealed that RUNX3/Runx3 bears a high content of the ancient mammalian repeat MIR. Together, these data delineate RUNX3/Runx3 as the evolutionary founder of the mammalian RUNX family. Detailed sequence analysis placed the two genes at a GC-rich H3 isochore with a sharp transition of GC content between the gene sequence and the downstream intergenic region. Two large conserved CpG islands were found within both genes, one around exon 2 and the other at the beginning of exon 6. RUNX1, RUNX2 and RUNX3 gene products bind to the same DNA motif, hence their temporal and spatial expression during development should be tightly regulated. Structure/function analysis showed that two promoter regions, designated P1 and P2, regulate RUNX3 expression in a cell type-specific manner. Transfection experiments demonstrated that both promoters were highly active in the GM1500 B-cell line, which endogenously expresses RUNX3, but were inactive in the K562 myeloid cell line, which does not express RUNX3.

Synergistic necrotizing cellulitis as a complication of peritonsillar abscess

Peritonsillar abscess, a complication of tonsillitis, is not uncommon. The usual treatment consists of needle aspiration or surgical drainage and antibiotic treatment. Tonsillectomy may be used in the management of this condition, either at the time of diagnosis or after an interval period. Severe complications of peritonsillar abscess are rare. Synergistic necrotizing cellulitis is a fulminant infection associated with spread along fascial plains, necrosis of connective tissue and muscle, and high mortality. It is usually otondogenic in origin in the cervicofacial area and occurs in debilitated or immune compromised patients. We discuss cervicofacial-necrotizing soft tissue disease and report an unusual case of extensive synergistic necrotizing cellulitis of the neck, chest, and shoulder as a result of a peritonsillar abscess.

The association between iron-deficiency anemia and recurrent acute otitis media

PURPOSE

This study was designed to examine the association between iron-deficiency anemia and the frequency of recurrent acute otitis media in children, and to evaluate the effect of restoring normal hemoglobin levels on the frequency of acute otitis media attacks.

MATERIALS AND METHODS

A total of 680 children with frequent episodes of acute otitis media were enrolled in the study. The levels of the hemoglobin were measured in both these children and in 200 healthy children with no history of infections. The correlation between hemoglobin level and the frequency of middle ear infections was studied and analyzed. All children with hemoglobin levels lower than 9.5 g/dL received iron supplementation until they reached a level of at least 11 g/dL, and the subsequent frequency of middle ear infections was recorded.

RESULTS

The 680 children had an average of 8.3 +/- 2.7 episodes of acute otitis media per year per child, and an average hemoglobin level of 11.4 +/- 2.7 g/dL, whereas the controls had an average hemoglobin level of 13.1 +/- 2.5 g/dL. Twenty percent had hemoglobin levels below 9.5 g/dL. These children had more episodes of acute otitis media when compared with children with average levels. By increasing the hemoglobin level in these children, the frequency of the episodes of acute otitis media decreased significantly.

CONCLUSIONS

This study confirms that anemic children have higher prevalence of episodes of acute otitis media in comparison to healthy, nonanemic children, and shows that there is a direct relationship between the degree of the anemia and the number of the episodes.

What is chronic fatigue syndrome? Heterogeneity within an international multicentre study

OBJECTIVE

We sought to compare the characteristics of patients presenting with chronic fatigue (CF) and related syndromes in eight international centres and to subclassify these subjects based on symptom profiles. The validity of the subclasses was then tested against clinical data.

METHOD

Subjects with a clinical diagnosis of CF completed a 119-item self-report questionnaire to provide clinical symptom data and other information such as illness course and functional impairment. Subclasses were generated using a principal components-like analysis followed by latent profile analysis (LPA).

RESULTS

744 subjects returned complete data sets (mean age 40.8 years, mean length of illness 7.9 years, female to male ratio 3:1). Overall, the subjects had a high rate of reporting typical CF symptoms (fatigue, neuropsychological dysfunction, sleep disturbance). Using LPA, two subclasses were generated. Class one (68% sample) was characterized by: younger age, lower female to male ratio; shorter episode duration; less premorbid, current and familial psychiatric morbidity; and, less functional disability. Class two subjects (32%) had features more consistent with a somatoform illness. There was substantial variation in subclass prevalences between the study centres (Class two range 6-48%).

CONCLUSIONS

Criteria-based approaches to the diagnosis of CF and related syndromes do not select a homogeneous patient group. While substratification of patients is essential for further aetiological and treatment research, the basis for allocating such subcategories remains controversial.

Epstein-Barr virus and cancers of the head and neck

Denis Burkitt pioneered the association of viruses and cancer in humans with his observations of lymphomatous tumors in children in equatorial Africa. The Epstein-Barr virus (EBV), a human B lymphotrophic herpes virus, is strongly associated with undifferentiated carcinoma of the nasopharynx and African-type Burkitt's lymphoma. More recently, an association of this virus with other epithelial neoplasms, lymphomas, and immunodeficiency-related malignant and nonmalignant conditions has been reported. Since many of these tumors are rare, much of the information is based on sporadic reports and relatively small series of patients. The purpose of this report is to review the literature and examine the growing association of EBV with various head and neck malignancies.

The effects of noise on the vestibular system

PURPOSE

Subjects with noise-induced hearing loss sometimes also complain about balance disorders, but reports of clinical series that give contradictory results are highly controversial. This study was designed to evaluate the effects of intense noise on the vestibular labyrinth, both in subjects with symmetrical hearing loss and in subjects with asymmetrical loss, and to examine the correlation between the subjects' complaints and the results of the vestibular function tests.

METHODS

A total of 258 male military personnel, heavily exposed to various intense noises, were included in the study. They were divided into 2 groups according to their hearing; 134 had a symmetrical high-tone hearing loss, and 124 had asymmetrical losses. Each group was divided into 2 subgroups according to the presence or absence of vestibular complaints. All of the subjects underwent a complete audiological and electronystagmographic evaluation.

RESULTS

We found that vestibular damage caused by intense noise exposure might be expressed clinically in subjects with asymmetrical hearing loss. There was a strong correlation between the subjects' complaints and the results of the vestibular function tests. There was no correlation between the severity of the hearing loss and the vestibular symptomatology and pathology.

CONCLUSIONS

Subjects exposed to intense noise may have evidence of vestibular pathology only when there is an asymmetrical hearing loss. Whenever hearing loss is symmetrical, an equal damage to the vestibular system of both ears is most probably responsible for the absence of abnormal findings on the vestibular function tests. The results of this study have important medicolegal implications for individuals exposed to intense noises.

Malignant tumors of the nose and paranasal sinuses: a retrospective review of 291 cases

Malignant neoplasms of the nose and paranasal sinuses are not common among the general population. We present a retrospective study of 291 cases of malignant tumors of the nose and paranasal sinuses that were diagnosed in a northern Romanian population over a period of 35 years. We review the etiology, diagnosis, prognosis, and treatment of these tumors.

Acute mastoiditis--the antibiotic era: a multicenter study

OBJECTIVES

To evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics.

METHODS

A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis.

SETTING

Nine secondary or tertiary academic or non-academic referral centers.

RESULTS

Prior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy).

CONCLUSIONS

Antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.

Laser partial epiglottidectomy as a treatment for obstructive sleep apnea and laryngomalacia

Obstructive sleep apnea (OSA) and laryngomalacia are two different entities. Occasionally, they may have a common etiology: an elongated, flaccid, and lax epiglottis that is displaced posteriorly during inspiration causing airway obstruction. Twenty-seven adults with a diagnosis of airway obstruction or OSA of various degrees, and 12 infants with severe stridor associated with frequent apneas due to laryngomalacia, who on fiberoptic examination were found to have a posteriorly displaced epiglottis, underwent partial epiglottidectomy with a CO2 laser. Their postoperative recovery was uneventful. Polysomnographic studies performed after operation in the adult patients demonstrated statistically significant improvement in 85% of the patients. In all the cases of laryngomalacia, stridor ceased permanently after surgery, together with complete cessation of the apneic episodes. This study demonstrates that similar pathophysiological mechanisms may be involved in both laryngomalacia and in OSA. Effective and relatively safe treatment can be achieved by partial resection of the epiglottis with a microlaryngoscopic CO2 laser.

Misplaced parotid glands: bilateral agenesis of parotid glands associated with bilateral accessory parotid tissue

Agenesis of the parotid is a rare entity. It is usually unilateral but bilateral cases have been described as a rare cause of xerostomia. Accessory parotid tissue is also uncommon and is not normally associated with aplasia of the parotid gland. The embryological, histological, clinical and radiological findings of these two entities will be discussed in addition to the report of an obscure case of bilateral parotid agenesis together with bilateral accessory parotid tissue.

Tracheotomy complications: a retrospective study of 1130 cases

BACKGROUND

Tracheotomy is one of the most frequently performed surgical procedures in the critically ill patient. It is frequently performed as an elective therapeutic procedure and only rarely as an emergency procedure. Complications occur in 5% to 40% of tracheotomies depending on study design, patient follow-up, and the definition of the different complications. The mortality rate of tracheotomy is less than 2%. Numerous studies demonstrate a greater complication and mortality rate in emergency situations, in severely ill patients, and in small children.

METHODS

A retrospective study of 1130 consecutive tracheotomies performed during 1 decade (January 1987 through December 1996) is presented. We studied the indications for surgery, the major complications of tracheotomy, and their treatment and outcome. We also noted the overall mortality rate and the specific complications that led to these deaths.

RESULTS

In total, 1130 tracheotomies were performed. Major complications occurred in 49 of the cases, and 8 deaths were directly attributed to the tracheotomy. The most common complication was tracheal stenosis, which occurred in 21 cases. Hemorrhage was the second most common complication, which occurred in 9 cases.

CONCLUSION

This is one of the largest series of consecutive tracheotomies compiled. We found a relatively low overall complication and mortality rate compared with other large series. Tracheal stenosis was the most common complication in contrast to other series. Our opinion is that this may reflect tracheal damage originally caused by prolonged intubation before the tracheotomy. We believe that all other complications of tracheotomy may be prevented or minimized by careful surgical technique and postoperative tracheotomy care.

The medical school Web site: medical education's newest tool

There are few technological advancements that have had as much impact on the dissemination of information as the Internet, and especially the worldwide web. It is not surprising then that this tool is also changing the way medicine is studied, taught and practiced today. This impressive infrastructure enables us to teach and study medicine in an entirely different way. The web provides medical students and physicians with access to continuing medical education, patient education services, telemedicine, and unparalleled communication between colleagues via email. The medical school web site may be used as a dynamic newspaper or bulletin board to disseminate information internally among the faculty as well as to the outside world. It can also be the vehicle for virtual learning modules that enhance the medical school core curriculum by including lectures, exercises, tests, etc. In addition, the web allows the student access to medical literature, medical software applications and medical resource depots. To date no work has been published on the medical school web site, its construction process, and its advantages, drawbacks and future. The purpose of this article is to examine the evolution of the web as a tool for medical schools, medical students and associated physicians. We discuss the building of a web site for a medical faculty, and look to the future.

Consortium approach for nurse practitioner education

In 1995, a 10-university consortium approach to deliver a post-baccalaureate primary care nurse practitioner programme funded by the Ontario Ministry of Health was launched throughout Ontario, Canada. A combination of traditional and distance teaching methods, in English and French, were used. A 5-year research project was initiated to evaluate the entire programme, the effect of nurse practitioners on patient and health-care system outcomes and examine practice patterns. Participants included deans and directors (n = 10), regional co-ordinators (n = 5) and course developers, some of whom were also course professors (n = 8). This article is a report of the evaluation of the consortium programme after the first year from the perspective of groups involved in implementation and delivery. Results of qualitative analyses of participant perceptions from researcher-led focus groups and asynchronous electronic interviews provided the framework for the evaluation, and revealed the rationale for the consortium method, strengths, limitations and recommendations. Sharing ideas, resources and delivery and increased student access in remote areas were perceived as positive outcomes. Limitations included the short time period to develop programme content, identify and plan for distance education resources, and too little communication between universities and students. Researchers concluded that the consortium approach was effective for nurse practitioner education. Key factors identified for programme planning were communication, resources, curriculum and workload. Included among the recommendations was to allow sufficient time for role and course development before beginning a similar programme.

Plastipore Implants in the Surgical Treatment of Atrophic Rhinitis: Technique and Results

BACKGROUND: Atrophic rhinitis is a distressing and socially crippling disease. Surgical treatment has been used for patients with severe disease that is unresponsive to medical therapy.

METHODS: Eight patients with primary atrophic rhinitis were treated surgically by narrowing of the nasal fossae with implantation of 2 Plastipore plates per affected side into submucosal pockets into the floor of the nose and septum, thus reducing the volume of the nasal fossae.

RESULTS: Excellent results were obtained in 6 patients, with complete resolution of symptoms and good results and only minor crusting in 2 patients. One implant was extruded spontaneously 18 months after implantation and was reimplanted. Results in this patient before and after reimplantation were excellent. There were no cases of infection and no other complications.

CONCLUSION: We implanted Plastipore, a high-density polyethylene sponge with micropores, which enables tissue ingrowth, anchoring the implants to the surrounding tissue. The surgical technique is performed with the patient under local anesthesia and is relatively easy and avoids complicated flap procedures, allogeneic bone harvesting, and the discomfort of nostril closure for prolonged periods.