Externally-induced shear waves in the right ventricular free wall throughout the cardiac cycle

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1. NWO STW/Dutch Heart foundation 2. NWO Vidi TTW

Background

The right ventricular (RV) size and function have prognostic value, not only in right heart conditions (pulmonary hypertension, congenital heart disease), but also in left ventricular (LV) disease states. There is currently no noninvasive method for measuring the elastic properties of the RV walls. Increased RV diastolic stiffness however, as determined invasively, is linked to adverse prognosis in pulmonary arterial hypertension. In the LV, new high frame rate (HFR) echocardiography applications have been used in order to determine the propagation speed of naturally-occurring or externally-induced shear waves (SW) in the septum, which is related to myocardial stiffness.

Purpose

We show for the first time that SWs in the RV free wall (RVFW) can be externally induced and imaged transthoracically with ultrasound.

Methods

SW imaging was performed using a linear array with a programmable research ultrasound system, aimed at the parasternal long-axis view of a 5-weeks-old Yorkshire-Landrace pig (Fig. 1a). SWs were induced by a high intensity focused beam (f0 = 4.5 MHz) on the RVFW (Fig. 1a). This push beam generates a downwards force at the focus, which induces SWs that propagate left and right from the focus along the RVFW, visible on tissue Doppler images (TDI) shown in Figure 1b-c. SW propagation was imaged (f0 = 5.2 MHz) using HFR ultrasound (Fig. 1b, frame rate = 3 kHz). Three acquisitions of 1 second were performed, where 14 SWs were sequentially induced during each acquisition. ECG signal was captured simultaneously and synchronized offline. SW speeds were estimated using a custom, semi-automatic pipeline that includes TDI calculation, and SW speed estimation along a manually traced spline on the RVFW. This was repeated two times to include variability due to the manual processes. Up to four SW speed estimates were made after each push beam. SW speed estimation was repeated for all push pulses throughout the cardiac cycle, and the mean and standard deviation of the estimates were plotted (Fig. 2).

Results

At least 85% of the waves were tracked successfully for all acquisitions. Diastole and systole were identified using the ECG signal (Fig. 2a). The average SW speed was 0.6 ± 0.1 m/s at end-diastole (Fig. 2b). The measured speeds ranged from 0.5 ± 0.1 m/s during diastole to 1.9 ± 0.3 m/s during systole. The changes in SW speeds correspond to the expected variation in muscle stiffness during the heart cycle as the RV relaxes and contracts.

Conclusions

We demonstrate for the first time the induction and tracking of shear waves in the RVFW of a closed-chest pig. The possibility to noninvasively quantify RV wall stiffness opens a large field of translational research, with direct applications in pulmonary hypertension, congenital heart disease and heart failure in general. Pathological increase in stiffness should be further investigated in longitudinal case/control studies. Abstract Figure. Fig1: Induction and tracking of RV SW  Abstract Figure. Fig2: SW speeds during cardiac cycle

Left ventricular high frame rate echo-particle image velocimetry: feasibility and comparison with conventional echocardiography

Funding Acknowledgements

Type of funding sources: None.

Introduction

Echo-Particle Image Velocimetry (echoPIV) tracks speckle patterns from ultrasound contrast agent (UCA) microbubbles injected intravenously, being less angle-sensitive than colour Doppler. One limitation of conventional echoPIV is the inability to accurately resolve high velocities, because of relatively low frame rates.  In contrast, high frame rate (HFR) echoPIV enables tracking of fast flow in the left ventricle (LV).

Purpose

To investigate the feasibility and precision of HFR echoPIV in patients.

Methods

19 heart failure patients were included. UCA was infused with a dedicated pump. HFR contrast images were acquired, in apical long axis view (ALAX, ensuring simultaneous visualization of LV inflow and outflow), using a fully-programmable research ultrasound system, with a phased array probe. In the same session, complete echocardiographic studies were obtained using a clinical ultrasound system, with a matrix array probe, including LV UCA. Non-contrast pulsed-wave (PW) Doppler were also obtained in ALAX (Figure 1) from the mitral valve tips (inflow) and the LV outflow tract (outflow). HFR echoPIV image quality and tracking were assessed offline by two independent observers. The peak velocity of the inflow and outflow were determined by the automated tracking algorithm of the HFR echoPIV, and measured by the peak modal velocity of the conventional PW. These velocities were compared using Pearson’s correlations and Bland-Altman plots. All patients gave their informed consent. The study was approved by the institutional review board.

Results

Conventional echo image quality was good in 12 (63%), medium in 5 (26%) and bad in 2 (11%). EchoPIV tracking was good in 12 (63%), medium in 2 (10%) and bad in 5 (26%). In the 12 patients where echoPIV tracking was good, the direction and velocity of intracavitary vortices could be visualized (Figure 1). The inflow velocity could be determined by echoPIV  in 17/19 (89%), and outflow in 14/19 (74%). EchoPIV tended to underestimate the maximal velocity as determined by PW (Figure 2), with a bias of 0.19 m/s (inflow) and 0.28 m/s (outflow). This negative bias is expected as the PW is assessing maximum velocity in the interrogation kernel whereas echoPIV returns the mean velocity. The correlation of the two methods was good for the inflow (R2 = 0.77, p < 0.001) and moderate for the outflow (R2 = 0.54, p < 0.001). This may be explained by the position of the LV outflow tract deeper in the image, leading to increased attenuation, clutter and reduced lateral resolution.

Conclusion

HFR echoPIV has comparable feasibility to routine echocardiography, and the ability to correctly estimate intraventricular flow velocity. It can provide in one acquisition all the functional information that can be detected by routine echocardiography, PW and color Doppler, as well as contrast. It succeeds in surpassing the shortcomings of Doppler (angle dependency) and classical contrast imaging (low frame rate). Abstract Figure 1: HFR echoPIV in study patients  Abstract Figure 2: study results

On the interplay of loading, myocardial stiffness and contractility in transthoracic acoustic radiation force-induced shear wave measurements in pigs

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Research Foundation Flanders (FWO grant number 1211620N) & TTW-Dutch Heart Foundation partnership program "Early recognition of cardiovascular diseases" (project number 14740)

Background

Acoustic radiation force-based shear wave elastography (SWE) is a promising technique to non-invasively assess mechanical properties of the heart based on the propagation speed of acoustically induced shear waves. However, the interpretation of cardiac SWE measurements remains complex, and it is unclear how other factors such as loading affect shear wave propagation speed (SWS) measurements in diastole and systole.

Purpose

We applied transthoracic SWE in a pig model to investigate the dependencies of diastolic and systolic SWS on pressure-volume (PV) loop derived indices of loading, myocardial stiffness and contractility.

Methods

In 7 pigs, loading conditions were altered (increasing or decreasing preload; increasing afterload) and myocardial stiffness was changed (LAD occlusion for 60-100 minutes followed by 40 minutes of reperfusion). For each intervention, transthoracic SWE measurements were performed in a parasternal long-axis view with a high frame rate ultrasound system (> 6.2 kHz). Recordings of 28 ms were repeated at 34 Hz during 1.5 s to track shear waves throughout the cardiac cycle. To determine systolic and diastolic SWS in a robust manner, a piecewise linear model was fitted to the SWS data of each intervention representing multiple acquisitions, heartbeats and M-lines (fig. 1a). PV loops were recorded simultaneously with SWE measurements to estimate end-diastolic pressure (EDP), end-systolic pressure (ESP), end-diastolic pressure volume relation (EDPVR with exponential coefficient β in fig. 1b) and preload-recruitable stroke work (PRSW). Passive chamber stiffness was evaluated as the local slope of the EDPVR, i.e. β·EDP. Linear regressions and Pearson’s correlation coefficients were calculated.

Results

  Diastolic SWS was significantly correlated to EDP when altering loading (blue in fig. 2a: R = 0.55; p < 0.01) and stiffness (orange in fig. 2a: R = 0.66; p < 0.01). A similar correlation is found between SWS and passive chamber stiffness β·EDP (fig. 2b). Diastolic SWS is more sensitive to changes in stiffness than in loading, as reflected by the larger slope of the regression line (0.79 vs. 0.28 in fig. 2b). Furthermore, systolic SWS significantly correlated with measures of contractility during loading alterations: ESP in fig. 2c (R = 0.69; p < 0.001) and PRSW in fig. 2d (R = 0.63; p = 0.02). However, no significant correlation was found between systolic SWS and contractility during infarct/reperfusion.

Conclusion

This study shows that diastolic SWS reflects the instantaneous stiffness of the myocardium, but is not a load-independent measure of the intrinsic passive mechanical properties of the heart. Instantaneous stiffness, and thus diastolic SWS, might be altered by loading (due to material non-linearity) or intrinsic mechanical changes. Furthermore, loading experiments suggest that systolic SWS is related to contractility. The relation between SWS and contractility in the presence of myocardial infarct deserves further study. Abstract Figure. Fig. 1: SWS and PV analysis.  Abstract Figure. Fig. 2: SWS vs. PV-derived indices.

A spatial and temporal characterisation of single proton acoustic waves in proton beam cancer therapy

An in vivo range verification technology for proton beam cancer therapy, preferably in real-time and with submillimeter resolution, is desired to reduce the present uncertainty in dose localization. Acoustical imaging technologies exploiting possible local interactions between protons and microbubbles or nanodroplets might be an interesting option. Unfortunately, a theoretical model capable of characterising the acoustical field generated by an individual proton on nanometer and micrometer scales is still missing. In this work, such a model is presented. The proton acoustic field is generated by the adiabatic expansion of a region that is locally heated by a passing proton. To model the proton heat deposition, secondary electron production due to protons has been quantified using a semi-empirical model based on Rutherford's scattering theory, which reproduces experimentally obtained electronic stopping power values for protons in water within 10% over the full energy range. The electrons transfer energy into heat via electron-phonon coupling to atoms along the proton track. The resulting temperature increase is calculated using an inelastic thermal spike model. Heat deposition can be regarded as instantaneous, thus, stress confinement is ensured and acoustical initial conditions are set. The resulting thermoacoustic field in the nanometer and micrometer range from the single proton track is computed by solving the thermoacoustic wave equation using k-space Green's functions, yielding the characteristic amplitudes and frequencies present in the acoustic signal generated by a single proton in an aqueous medium. Wavefield expansion and asymptotic approximations are used to extend the spatial and temporal ranges of the proton acoustic field.

Tapering of the interventricular septum can affect ultrasound shear wave elastography: An in vitro and in silico study

Shear wave elastography (SWE) has the potential to determine cardiac tissue stiffness from non-invasive shear wave speed measurements, important, e.g., for predicting heart failure. Previous studies showed that waves traveling in the interventricular septum (IVS) may display Lamb-like dispersive behaviour, introducing a thickness-frequency dependency in the wave speed. However, the IVS tapers across its length, which complicates wave speed estimation by introducing an additional variable to account for. The goal of this work is to assess the impact of tapering thickness on SWE. The investigation is performed by combining in vitro experiments with acoustic radiation force (ARF) and 2D finite element simulations, to isolate the effect of the tapering curve on ARF-induced and natural waves in the heart. The experiments show a 11% deceleration during propagation from the thick to the thin end of an IVS-mimicking tapered phantom plate. The numerical analysis shows that neglecting the thickness variation in the wavenumber-frequency domain can introduce errors of more than 30% in the estimation of the shear modulus, and that the exact tapering curve, rather than the overall thickness reduction, determines the dispersive behaviour of the wave. These results suggest that septal geometry should be accounted for when deriving cardiac stiffness with SWE.

Natural shear wave propagation speed is influenced by both changes in myocardial structural properties as well as loading conditions

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation - Flanders (FWO)

Background

Shear wave elastography (SWE) is a promising tool for the non-invasive assessment of myocardial stiffness. It is based on the evaluation of the propagation speed of shear waves by high frame rate echocardiography. These waves can be induced by for instance mitral valve closure (MVC) and the speed at which they travel is related to the instantaneous stiffness of the myocardium. Myocardial stiffness is defined by the local slope of the stress-strain relation and can therefore be altered by both changes in structural properties of the myocardium as well as loading conditions.

Purpose

The aim of this study was to investigate how changes in myocardial structural properties as well as loading conditions affect shear wave speed after MVC.

Methods

Until now, 8 pigs (weight: 33.6 ± 5.4 kg) were included. The following interventions were performed: 1) preload was reduced by balloon occlusion of the vena cava inferior, 2) afterload was increased by balloon occlusion of descending aorta, 3) preload was increased by intravenous administration of 500 ml of saline and 4) ischemia/reperfusion injury (I/R injury) was induced in the septal wall by balloon occlusion of the LAD for 90 min. with subsequent reperfusion for 40 min. Echocardiographic and left ventricular pressure recordings were simultaneously obtained during each intervention. Left ventricular parasternal long-axis views were acquired with an experimental high frame rate ultrasound scanner (average frame rate: 1279 ± 148 Hz). Shear waves were visualized on tissue acceleration maps by drawing an M-mode line along the interventricular septum. Shear wave propagation speed after MVC was calculated by assessing the slope of the wave pattern on the tissue acceleration map (Figure A).

Results

The change in left ventricular end-diastolic pressure (LVEDP) and shear wave speed after MVC between baseline and each intervention are shown in Figure B and C, respectively. Preload reduction resulted in significant lower LVEDP compared to baseline (p < 0.01), while the other loading changes did not have a significant effect. Shear wave speed after MVC significantly increased by afterload and preload increase (p < 0.01). I/R injury resulted in increased shear wave speed (p < 0.01) without significantly altering LVEDP. There was a good positive correlation between the change in LVEDP and the change in shear wave speed induced by loading changes (r = 0.76; p < 0.001) (Figure D). However, the correlation became less strong if data of I/R injury was taken into account as well (r = 0.63; p < 0.001).

Conclusion

Our results suggest that SWE is capable to characterize myocardial tissue properties and besides has the potential as a novel method for the estimation of left ventricular filling pressures. However, in the presence of structural changes of the myocardium, care should be taken when estimating filling pressures based on shear wave propagation speed.

Abstract Figure.

Closed-chest measurement of diastolic and systolic shear wave speed to assess myocardial stiffness

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Research Foundation Flanders (FWO): grant 1211620N TTW – Dutch Heart Foundation partnership program "Earlier recognition of cardiovascular diseases": project number 14740

Background

Echocardiographic shear wave elastography (SWE) encompasses all ultrasound techniques tracking shear wave (SW) motion in the cardiac wall, of which the propagation speed is linked to the intrinsic mechanical properties. SWs can be induced naturally, for example by valve closure, or externally by using an acoustic radiation force (ARF). Although the latter is technically more demanding, it enables instantaneous stiffness assessment throughout the entire cardiac cycle (fig. a). However, it is unknown how factors such as cardiac loading and contractility, next to intrinsic mechanical properties, affect ARF-based SW speeds.

Purpose

We performed transthoracic SWE measurements in pigs to study the effects of hemodynamic alterations, inotropic state and myocardial infarction (MI) on diastolic and systolic SW speeds.

Methods

Different cardiac conditions were considered in three pigs: (i) baseline (BL), (ii) preload decrease (PD), (iii) afterload increase (AI), (iv) preload increase (PI), (v) administration of dobutamine (DOB), (vi) BL2, (vii) MI through 60-100 min. occlusion of the LAD and (viii) 40 min. reperfusion (REP). For each condition, transthoracic high frame rate ARF-based SWE acquisitions were taken in a parasternal long-axis view with a research ultrasound system. SWs were induced in the septum at 34 Hz during 1.5 s to track SW speeds throughout the cardiac cycle (fig. a&b). Systolic and diastolic SW speeds were determined from the 10% highest and lowest median values per condition, respectively. Left ventricular pressure-volume (PV) loops were recorded to estimate end-diastolic pressure (EDP), end-systolic pressure (ESP) and passive chamber stiffness (dPdV). dPdV was determined as the slope of the tangent to the fitted end-diastolic PV relationship at mean ED volume. Linear regressions and Pearson’s correlation coefficients were computed.

Results

Diastolic SW speed was correlated to EDP for conditions with changes in loading, and to dPdV for conditions with changes in chamber stiffness (fig. c).  Both relationships were significant, with a moderate positive correlation for EDP (R = 0.48, p = 0.02) and a strong positive correlation for dPdV (R = 0.76, p < 0.01). Furthermore, the observed change in diastolic SW speed was smaller when altering EDP compared to dPdV (0.4 m/s vs. 1.0 m/s). For systolic SW speed, very strong positive correlations were found with ESP (R = 0.91, p < 0.01), and with dPdV (R = 0.81, p < 0.01) in fig. d.

Conclusion

This study shows that both diastolic and systolic SW speed are related to passive chamber stiffness. Moreover, loading also influenced systolic SW speed and, to a lesser extent, diastolic SW speed, presumably because of material nonlinearity. Systolic SW speed is linked to contractility as well. Thus, while SWs after valve closure occur at a certain moment in the cardiac cycle, the timing of ARF-based SWs can be chosen such to assess specific aspects of the cardiac (structural and functional) status.

Abstract Figure.

Fundamental modeling of wave propagation in temporally relaxing media with applications to cardiac shear wave elastography

Shear wave elastography (SWE) might allow non-invasive assessment of cardiac stiffness by relating shear wave propagation speed to material properties. However, after aortic valve closure, when natural shear waves occur in the septal wall, the stiffness of the muscle decreases significantly, and the effects of such temporal variation of medium properties on shear wave propagation have not been investigated yet. The goal of this work is to fundamentally investigate these effects. To this aim, qualitative results were first obtained experimentally using a mechanical setup, and were then combined with quantitative results from finite difference simulations. The results show that the amplitude and period of the waves increase during propagation, proportional to the relaxation of the medium, and that reflected waves can originate from the temporal stiffness variation. These general results, applied to literature data on cardiac stiffness throughout the heart cycle, predict as a major effect a period increase of 20% in waves propagating during a healthy diastolic phase, whereas only a 10% increase would result from the impaired relaxation of an infarcted heart. Therefore, cardiac relaxation can affect the propagation of waves used for SWE measurements and might even provide direct information on the correct relaxation of a heart.

[A young man with a painful scrotum]

A 16-year-old male patient with no known medical history presented at the Emergency Department (ED) with a 2-day history of pain and swelling in his right hemiscrotum. He was diagnosed with non-bacterial epididymitis and discharged home with medical advice. Six days after being diagnosed, the pain and swelling worsened and he was seen by a general practitioner who concluded that the symptoms were attributable to the previously diagnosed epididymitis. No further investigations were performed. Two days later he again presented at the ED, at which time colour Doppler echography revealed a testicular torsion of probably two days old. As after operative detorsion the testis was found to be non-vital, an orchidectomy was performed. This case illustrates that the diagnosis of epididymitis should always be reviewed in patients in whom the scrotum once again becomes painful. Early recognition and treatment of torsio testis gives a better chance of keeping the testis and therefore fertility.

Abstract P4-06-16: Analysis of tumor infiltrating lymphocytes in three age categories of luminal B-like breast cancer patients and its correlation with lymph node involvement and systemic immunosenescence/frailty markers

BACKGROUND Immunosenescence, the age-related decrease in immune competence, which is characterized by decreased adaptive immunity and increased low-grade inflammation. It may lead to altered tumor immunity. However, immunosenescence markers have not been correlated yet with tumor infiltrating leukocytes (TILs) nor with clinical frailty.

METHODS This is the first study that investigates how age affects the relation between systemic immunity and tumor microenvironment in early luminal B-like breast cancer (BC) in function of age. Luminal B-like BC was defined as grade II-III, ER+, HER2- on core biopsies at inclusion. Three distinct age categories of BC patients were chosen: 35-45 years (y) (N=15), 55-65y (N=19), ≥70y (N=31). Stromal TILs (sTILs) % were assessed according to published guidelines, on representative tumor sections. Further characterization of the TILs by immunohistochemistry, using the antibodies against CD3, CD4, CD8, CD5, CD20, CD68 and FOXP3, is currently ongoing. Immunosenescence was evaluated by looking at eleven inflammatory plasma cytokines and chemokines, circulating insulin-like growth factor-1 (IGF-1), T-cell p16INK4a expression, PBMC subset profiles and expression levels of twenty immune-related microRNAs. In the old age category, geriatric assessment was performed.

RESULTS With increasing age, sTILs % significantly decreased, concomitant with significantly increased plasma levels of several inflammatory cytokines (IL-1α, IL-6) and chemokines (IP-10, IL-8, MCP-1), intermediate monocytes, as well as T-cell p16INK4a expression. Significant age-related decrease was seen for plasma IGF-1, naïve CD8+ T-cells and CD8+ T-cells expressing CD27 and/or CD28. Four immune-related microRNAs showed significantly different expression levels between the age groups: miR-18a decreased with age, miR-155 increased with age, miR-19b and miR-20a peaked in the middle group. As expected, various correlations exist between the different blood immunosenescence markers. The % of sTILs showed weak negative correlations with IL-6, IL-8, IL-1α, MCP-1 and the % of regulatory T-cells. Additionally the % of sTILs and several makers of immunosenescence (MCP-1, miR-20a, miR-155, intermediate monocytes) correlated with components of the geriatric assessment (activities of daily living (ADL), mini nutritional assessment (MNA), mini–mental state examination (MMSE)) and with the Leuven oncogeriatric frailty score (LOFS) in the oldest group. Conversely, lymph node involvement was not associated with the % of sTILs nor with any blood aging biomarker.

CONCLUSION sTILs % and several blood immunosenescence markers significantly differ between young and older luminal B-like BC patients. Some of these markers correlated with markers of clinical frailty as well. These findings suggest that interactions between tumor cells and immune/inflammatory cells differ with age and therefore applicable immune biomarkers and approaches for immunotherapy may vary depending on patients' age.

Citation Format: Berben L, Hatse S, Kenis C, Dalmasso B, Smeets A, Vos H, Neven P, Floris G, Wildiers H. Analysis of tumor infiltrating lymphocytes in three age categories of luminal B-like breast cancer patients and its correlation with lymph node involvement and systemic immunosenescence/frailty markers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-16.

Abstract P4-06-14: Single-cell RNA sequencing to delineate changes in tumor microenvironment induced by immunotherapy

Introduction: Improved understanding of the interplay between the immune system and cancer would lead to more adequate response prediction to immune-checkpoint blockade (ICB) treatment. Furthermore, insight into immune interactions would allow identifying biomarkers for response to ICB. Single-cell RNA sequencing has emerged as a powerful technology to characterize heterogeneity in a large population of cells and opens up opportunities to predict response to therapy.

Purpose: Tracking the effect of a single dose of Pembrolizumab on the tumor microenvironment through single-cell RNA sequencing.

Methods: Single-cell RNA sequencing was performed on tumor tissue of one patient before and 10 days after a 200 mg dose of Pembrolizumab (Keytruda®). Changes in cell (sub)populations were analyzed. Fresh tumor material was obtained from a core needle biopsy at diagnosis and from the resection specimen.Single cell suspensions were converted to barcoded scRNA-seq libraries with the Chromium Single Cell 3' kit with 10X Genomics platform, aiming for an estimated 5,000 cells per library. The libraries were sequenced using HiSeq400. Expression matrices were generated using CellRanger and analyzed by Seurat package. Dimensionality reduction using principle component analysis was applied to identify major cell types and their subtypes.

Results: The analyzed tumor was a grade 3 invasive ductal adenocarcinoma, hormone receptor negative and HER2+ positive, pT2N0M0. Tumor infiltrating lymphocyte (TIL) count was 30% on core biopsy and 50% on resection specimen. We sequenced a total of 9867 transcriptomes at single cell resolution before and after Pembrolizumab treatment, consisting of 5808 and 4049 cells, respectively. Major cell types of the tumor microenvironment were identified by leveraging single-cell transcriptomics analysis. We observed a sharp decrease in cancer cells after treatment (74% versus 25%), which was accompanied by an increase of tumor infiltrating T cells (18% versus 50%). The residual cancer cells after immunotherapy showed a higher expression of the major histocompatibility complex (MHC), MHC-II in particular. In addition, we found enrichment of B-cells and endothelial cells and a downregulation of fibroblasts and myeloid cells. Furthermore, we analyzed subtypes of each cell type. We found a marked increase in cytotoxic CD4 (6% versus 18%) and cytotoxic CD8 cells (4% versus 12%) in the T cell population. These cytotoxic CD8 cells clearly expressed higher PD-1 after immunotherapy. A decrease in CD4 Tregs, naïve CD4 and intermediate CD8 cells was observed and the B cell enrichment after treatment was mainly driven by the increase of follicular B-cells. The increase of endothelial cells was driven by capillary tumor endothelial but not tip cell population, suggesting vessel normalization rather than neo-vascularization.

Conclusion: Single-cell RNA sequencing provides a powerful tool in detecting changes in the tumor microenvironment induced by immunotherapy, and thus offers new opportunities to predict response to immunotherapy. Thirty-three additional patient samples will be analyzed in the near future, with a special focus on T- and B- cell receptor repertoire.

Citation Format: Vos H, Qian J, Floris G, Nevelsteen I, Lambein K, Berben L, Neven P, Wildiers H, Lambrechts D, Smeets A. Single-cell RNA sequencing to delineate changes in tumor microenvironment induced by immunotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-14.

Abstract P3-05-15: PD-1 expression and its correlation with tumour infiltrating lymphocytes and Ki67 in patients with breast cancer

Introduction: Immunotherapy targeting the programmed death-1 (PD-1) checkpoint has resulted in good outcomes in patients with melanoma, non-small cell lung cancer and head and neck cancer. Recent data have showed that patients with ER/PR negative breast cancer might benefit from immunotherapy as well. We investigated PD-1 expression on tumour infiltrating lymphocytes (TILs), the presence of TILs and Ki67. Furthermore, the association of PD-1, TILs and Ki67 with time to metastasis was statistically determined.

Methods: Resection specimens of 284 patients with an ER/PR negative invasive ductal adenocarcinoma of at least 2 cm were analysed. Haematoxylin-eosin staining was performed to determine the percentage of TILs. Subsequently these percentages were divided into three groups: less than 10%, 10%-30% and more than 30% which matches with respectively 30%, 50% and 20% of the patients. PD-1 expression on the TILs of 116 patients and Ki67 expression of 185 patients were assessed using immunohistochemistry.

Results: An increase in the fraction of TILs was significantly associated with a lower risk of metastasis (hazard ratio [HR] = 0.7, 95% CI = 0.6-0.9). PD-1 expression on TILs was observed in 97% of the patients. Three patients had no expression of PD-1, this lack of PD-1 expression significantly increased the risk of metastasis (HR = 5.541, 95% CI = 1.2-25.0). No association could be noted between PD-1 expression and the amount of TILs or Ki67 (p-values of respectively 0.272 and 0.637). Similarly, no association could be noted between Ki67 and the amount of TILs (p-value = 0.1954)

Conclusion: PD-1 was expressed on TILs in patients with breast cancer. Surprisingly, no correlation was found between PD-1 expression and TILs or Ki67. However, an increased amount of TILs was significantly associated with a lower risk of metastasis.

Citation Format: Vos H, Lambein K, Floris G, Nevelsteen I, Smeets A. PD-1 expression and its correlation with tumour infiltrating lymphocytes and Ki67 in patients with breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-15.

[Social issues in the doctor's clinic]

Doctors are confronted with issues that arise in society. These social issues can affect patients' health. Solving these problems requires more than just prescribing a pill, as illustrated by the cases of three patients. The first patient is a 42-year-old male with cardiac symptoms, chronic lower back pain and an excessive use of tranquillizers. The welfare worker intervened and his demand for health care and use of tranquillizers diminished. The second patient is a 53-year-old female with symptoms of chronic back pain, migraine and depression. A labour dispute concerning her health eventually led to a referral to a project named 'social hospital', but actual assistance never took place due to the patient's alleged lack of time to participate. The third case concerns an 86-year-old female with postherpetic neuralgia who also suffered from loneliness. The patient's named welfare worker tried to get in touch with her, but the patient kept her at a distance. These three cases illustrate that it is very important to get to know the social network in a community in order to refer patients with social issues to the right person or place. Furthermore, prevention and early intervention strategies should be applied where possible. Doctors and local governments must act together in order to succeed in solving patient ill health as a result of social issues.

P1138Cardiac shear wave velocity in healthy individuals

Background

The closure of the valves generates shear waves in the heart walls. The propagation velocity of shear waves relates to stiffness. This could potentially be used to estimate the stiffness of the myocardium, with huge potential implications in pathologies characterized by a deterioration of the diastolic properties of the left ventricle. In an earlier phantom study we already validated shear wave tracking with a clinical ultrasound system in cardiac mode.

Purpose

In this study we aimed to measure the shear waves velocity in normal individuals.

Methods

12 healthy volunteers, mean age=37±10, 33% females, were investigated using a clinical scanner (Philips iE33), equipped with a S5-1 probe, using a clinical tissue Doppler (TDI) application. ECG and phonocardiogram (PCG) were synchronously recorded. We achieved a TDI frame rate of >500Hz by carefully tuning normal system settings. Data were processed offline in Philips Qlab 8 to extract tissue velocity along a virtual M-mode line in the basal third of the interventricular septum, in parasternal long axis view. This tissue velocity showed a propagating wave pattern after closure of the valves. The slope of the wave front velocity in a space-time panel was measured to obtain the shear wave propagation velocity. The velocity of the shear waves induced by the closure of the mitral valve (1st heart sound) and aortic valve (2nd heart sound) was averaged over 4 heartbeats for every subject.

Results

Shear waves were visible after each closure of the heart valves, synchronous to the heart sounds. The figure shows one heart cycle of a subject, with the mean velocity along a virtual M-mode line in the upper panel, synchronous to the ECG signal (green line) and phonocardiogram (yellow line) in the lower panel. The slope of the shear waves is marked with dotted lines and the onset of the heart sounds with white lines. In our healthy volunteer group the mean velocity of the shear wave induced by mitral valve closure was 4.8±0.7m/s, standard error of 0.14 m/s. The mean velocity after aortic valve closure was 3.4±0.5m/s, standard error of 0.09 m/s. We consistently found that for any subject the velocity after mitral valve closure was higher than after aortic valve closure.

Conclusion

The velocity of the shear waves generated by the closure of the heart valves can be measured in normal individuals using a clinical TDI application. The shear wave induced after mitral valve closure was consistently faster than after aortic valve closure. Abstract P1138 Figure.

Abstract P1138 Figure.

Tolerance of combined submergence and salinity in the halophytic stem-succulent Tecticornia pergranulata

BACKGROUND AND AIMS

Habitats occupied by many halophytes are not only saline, but are also prone to flooding. Few studies have evaluated submergence tolerance in halophytes.

METHODS

Responses to submergence, at a range of salinity levels, were studied for the halophytic stem-succulent Tecticornia pergranulata subsp. pergranulata (syn. Halosarcia pergranulata subsp. pergranulata). Growth and total sugars in succulent stems were assessed as a function of time after submergence. Underwater net photosynthesis, dark respiration, total sugars, glycinebetaine, Na(+), Cl(-) and K(+), in succulent stems, were assessed in a NaCl dose-response experiment.

KEY RESULTS

Submerged plants ceased to grow, and tissue sugars declined. Photosynthesis by succulent stems was reduced markedly when underwater, as compared with in air. Capacity for underwater net photosynthesis (P(N)) was not affected by 10-400 mM NaCl, but it was reduced by 30 % at 800 mM. Dark respiration, underwater, increased in succulent stems at 200-800 mM NaCl, as compared with those at 10 mM NaCl. On an ethanol-insoluble dry mass basis, K(+) concentration in succulent stems of submerged plants was equal to that in drained controls, across all NaCl treatments. Na(+) and Cl(-) concentrations, however, were elevated in stems of submerged plants, but so was glycinebetaine. Submerged stems increased in succulence, so solutes would have been 'diluted' on a tissue-water basis.

CONCLUSIONS

Tecticornia pergranulata tolerates complete submergence, even in waters of high salinity. A 'quiescence response', i.e. no shoot growth, would conserve carbohydrates, but tissue sugars still declined with time. A low K(+) : Na(+) ratio, typical for tissues of succulent halophytes, was tolerated even during prolonged submergence, as evidenced by maintenance of underwater P(N) at up to 400 mM NaCl. Underwater P(N) provides O(2) and sugars, and thus should enhance survival of submerged plants.

Nonspherical vibrations of microbubbles in contact with a wall: a pilot study at low mechanical index

Radially oscillating microbubbles can deform when in contact with a wall. These nonspherical shapes have a preferential orientation perpendicular to the wall. Conventional microscope setups for microbubble studies have their optical axis perpendicular to the wall (top view); consequently they have a limited view of the deformation of the bubble. We developed a method to image the bubble in a side view by integrating a mirror in the microscope setup. The image was recorded at 14.5 million frames per second by a high-speed camera. When insonified by a 1-MHz, 140-kPa ultrasound pulse, a 9-microm diameter coated bubble appeared spherical in the top view, but strongly nonspherical in the side view. Its shape was alternatively oblate and prolate, with maximum second order spherical harmonic amplitude equal to the radius.

Oxygen dynamics during submergence in the halophytic stem succulent Halosarcia pergranulata

This study elucidated O2 dynamics in shoots and roots of submerged Halosarcia pergranulata (Salicornioideae), a perennial halophytic stem succulent that grows on floodprone mudflats of salt lakes. Oxygen within shoots and roots was measured using microelectrodes, for plants when waterlogged or completely submerged, with shoots in light or in darkness, in a controlled environment. Net photosynthesis (PN) when underwater, at a range of dissolved CO2 concentrations, was measured by monitoring O2 production rates by excised stems. The bulky nature and apparently low volume of gas-filled spaces of the succulent stems resulted in relatively high radial resistance to gas diffusion. At ambient CO2, quasi-steady state rates of PN by excised succulent stems were estimated to be close to zero; nevertheless, in intact plants, underwater photosynthesis provided O2 to tissues and led to radial O2 loss (ROL) from the roots, at least during the first several hours (the time period measured) after submergence or when light periods followed darkness. The influence of light on tissue O2 dynamics was confirmed in an experiment on a submerged plant in a salt lake in south-western Australia. In the late afternoon, partial pressure of O2 (pO2) in the succulent stem was 23.2 kPa (i.e. approximately 10% above that in the air), while in the roots, it was 6.2-9.8 kPa. Upon sunset, the pO2 in the succulent stems declined within 1 h to below detection, but then showed some fluctuations with the pO2 increasing to at most 2.5 kPa during the night. At night, pO2 in the roots remained higher than in the succulent stems, especially for a root with the basal portion in the floodwater. At sunrise, the pO2 increased in the succulent stems within minutes. In the roots, changes in the pO2 lagged behind those in the succulent stems. In summary, photosynthesis in stems of submerged plants increased the pO2 in the shoots and roots so that tissues experience diurnal changes in the pO2, but O2 from the H2O column also entered submerged plants.

[Extreme dietary selectivity following liver transplantation in a 5-year-old girl; management via behavior therapy]

In a 5.1-year-old girl who had been treated by surgical correction of biliary atresia and total orthotopic liver transplantation, extreme dietary selectivity was noted; this was treated by behaviour therapy. On entry in the rehabilitation centre, she manifested malnutrition along with a variety of gastro-enterologic complaints. The treatment consisted of a set of behavioural procedures such as stepwise expansion of the diet, verbal prompting, intermittent contingent attention and a list of agreements with a system of rewards; this led to the elimination of the dietary selectivity and to the consumption of a varied diet in a normal tempo.

Fetal development in the pig in relation to genetic merit for piglet survival

The objective of this study was to investigate if litters with different genetic merit for piglet survival differ in late fetal development. In total, 507 fetuses from 46 litters were delivered by Caesarean section at, on average, d 111 of gestation. All litters had known estimated breeding values for piglet survival (EBVps). The obtained range of EBVps of the litters was continuous, and the difference between litters with the lowest and highest EBVps was 16.4%. Analysis of relationships between fetal characteristics and EBVps was performed with litter averages, using linear regression analysis with inclusion of EBVps as a covariate. An increase in EBVps of the litter was associated with decreases in average placental weight (P = 0.01) and within-litter variation in placental weight (P = 0.02), and an increase in average placental efficiency (P = 0.08). Average fetal length decreased with increasing EBVps (P = 0.04), but weights of liver (P = 0.02), adrenals (P = 0.0001), and small intestine (P = 0.01) showed relative increases with increasing EBVps. Average serum cortisol concentrations increased with increasing EBVps (P = 0.0001), but the other blood characteristics (hematocrit, glucose, fructose, albumin, estradiol-17beta) were not related to EBVps. Glycogen concentrations in liver (P = 0.07) and longissimus dorsi muscle (P = 0.04) and total liver glycogen content (P = 0.05) increased with increasing EBVps, whereas heart glycogen concentration decreased with increasing EBVps (P = 0.005). The percentage of carcass fat increased with increasing EBVps (P = 0.05). Relationships of relative liver weight, relative small intestinal weight, and liver and muscle glycogen levels with EBVps were absent after adjustment for differences in cortisol levels between litters. The observed differences in fetal development in relation to EBVps suggest a higher degree of physiological maturity in litters with high EBVps. Differences in fetal cortisol most likely accounted for most of these maturational differences. The results imply that selection for improved piglet survival will lead to slightly smaller piglets that nevertheless have an improved ability to cope with hazards during birth or within the first days of life.

The association of Sweet's syndrome with sarcoidosis

We report a 43-year-old woman with biopsy proven Sweet's syndrome with massive mediastinal lymphadenopathy. No other clinical signs compatible with sarcoidosis were present. Mediastinoscopy was performed to establish a diagnosis. Histological evaluation revealed non-caseating granulomas compatible with sarcoidosis. We review the association of Sweet's syndrome and (haematological) malignancies, and eight other cases of Sweet's syndrome and sarcoidosis. All but one presented with erythema nodosum, making the diagnosis of acute sarcoidosis (Löfgren's syndrome) more likely than malignancy.

A minimax procedure in the context of sequential testing problems in psychodiagnostics

The purpose of this paper is to derive optimal rules for sequential testing problems in psychodiagnostics. In sequential psychodiagnostic testing, each time a patient is exposed to a new treatment, the decision then is to declare this new treatment effective, ineffective, or to continue testing and exposing the new treatment to another random patient suffering from the same mental health problem. The framework of minimax sequential decision theory is proposed for solving such testing problems; that is, optimal rules are obtained by minimizing the maximum expected losses associated with all possible decision rules at each stage of testing. The main advantage of this approach is that costs of testing can be explicitly taken into account. The sequential testing procedure is applied to an empirical example for determining the effectiveness of a cognitive-analytic therapy for patients suffering from anorexia nervosa. For a given maximum number of patients to be tested, the appropriate action is indicated at each stage of testing for different numbers of positive reactions to the cognitive-analytic therapy. The paper concludes with a simulation study, in which the minimax sequential strategy is compared for the anorexia nervosa example with other procedures that exist for similar classification decision problems in the literature in terms of average number of patients to be tested, classification accuracy and average loss.

Community reaction to aircraft noise: time-of-day penalty and tradeoff between levels of overflights

A decrease in the level of sound events can compensate for an increase in the level of other events, but noise metrics assume different tradeoffs. Noise metrics also differ in the penalty applied to noise in the evening and to noise in the night, and in the definition of these periods. These two aspects of noise metrics, i.e., the tradeoff and the penalty for the nighttime (23-7h), are investigated. A general model of the relation between SELs of sound events (aircraft overflights) and noise annoyance is presented which allows for a wide range of tradeoffs and time-of-day penalties. The (tradeoff and time-of-day penalty) parameters of the model are fitted to the data from an aircraft noise study conducted around Amsterdam Airport Schiphol, which is especially suited for investigating the tradeoff and time-of-day penalties. It was found that in this study the tradeoff between the levels of events in metrics based on L(Aeq)'s, such as L(Aeq)(24 h), DNL, and DENL, is approximately correct for the prediction of noise annoyance. Furthermore, it was found that the strongest correlation with annoyance is obtained with a nighttime penalty of circa 10 dB. No suitable data were available for further tests of the tradeoff. The result with respect to the nighttime penalty was weakly further supported by the outcome of analyses of the original data from four other aircraft noise surveys (one survey conducted around British airports, and three coordinated surveys carried out around Paris Orly, Amsterdam Schiphol, and Glasgow Abbotsinch).

Exposure-response relationships for transportation noise

This article presents synthesis curves for the relationship between DNL and percentage highly annoyed for three transportation noise sources. The results are based on all 21 datasets examined by Schultz [J. Acoust. Soc. Am. 64, 377-405 (1978)] and Fidell et al. [J. Acoust. Soc. Am. 89, 221-233 (1991)] for which acceptable DNL and percentage highly annoyed measure could be derived, augmented with 34 datasets. Separate, nonidentical curves were found for aircraft, road traffic, and railway noise. A difference between sources was found using data for all studies combined and for only those studies in which respondents evaluated two sources. The latter outcome strengthens the conclusion that the differences between sources cannot be explained by differences in study methodology.

Induction of protective immunity to Theileria annulata using two major merozoite surface antigens presented by different delivery systems

Allelic forms (Tams1-1 and Tams1-2) of the major merozoite surface antigen gene of Theileria annulata have recently been expressed in Escherichia coli and in Salmonella typhimurium aroA vaccine strain SL3261. To test the potential of subunit vaccines against T. annulata infection, we immunized four groups of three calves with either recombinant (re-) (Tams1-1 and Tams1-2) proteins or naked DNA encoding these antigens. Group I was immunized intramuscularly with both re-proteins incorporated into immunostimulating complexes (ISCOMs). Group II was inoculated intramuscularly with naked plasmid DNA encoding Tams1-1 and Tams1-2. Groups III and IV received S. typhimurium SL3261 [pSTams1-1][pIP5] and SL3261 [pSTams1-2] [pIP5] subcutaneously and orally, respectively. A final group of three animals (Group V) served as an unimmunized control group. Four weeks after the last immunization all calves were challenged with a T. annulata stabilate generated from blood of an infected animal with 30% piroplasm parasitaemia. All calves vaccinated with ISCOMs proved to be protected from T. annulata infection and had generated antibodies against both re-(Tams1-1 and Tams1-2) at the time of challenge. In two of these animals the antibody had a surface binding profile by IFAT. Two of three calves immunized with naked DNA also proved to be protected, but none of the animals had generated any detectable antibodies against the recombinants. Salmonella-based delivery of the recombinants did not induce any protection; two of six animals died of theileriosis and there was no difference between subcutaneous or oral administration. These preliminary results show that re-(Tams1-1 and/or Tams1-2) may elicit protective immune responses in cattle, depending on the antigen delivery system.

A Simultaneous Approach to Optimizing Treatment Assignments with Mastery Scores

A model for simultaneous optimization of combinations of test-based decisions in psychology and education is proposed using Bayesian decision theory. The decision problem addressed consists of a combination of a placement and a mastery decision. Weak and strong decision rules are distinguished. As opposed to strong rules, weak rules are allowed to take prior test scores in the series of decisions into account. The introduction of weak rules makes the placement-mastery problem a multivariate decision problem. Conditions for optimal rules to take monotone forms are derived. Results from an empirical example of instructional decision making are presented to illustrate the differences between a simultaneous and a separate approach.

Age-related disease in recurrent outbreak of phocid herpesvirus type-1 infections in a seal rehabilitation centre: evaluation of diagnostic methods

The prevalence and clinical signs of phocid herpesvirus type-1 (PhHV-1) infections among harbour seals (Phoca vitulina) in a seal rehabilitation centre in the Netherlands were monitored between June and September 1993 and 1994 when 34 and 36 seals, respectively, were rehabilitated. In both years PhHV-1-related disease outbreaks occurred in the pupping season. PhHV-1 infections were diagnosed by the demonstration of a more than four-fold increase in virus neutralising serum antibodies in paired serum samples, by the isolation of the virus from swab samples in primary seal kidney cells, and by the detection of PhHV-1 DNA with a polymerase chain reaction (PCR) assay in swab samples. This assay targets a 290 bp fragment of the glycoprotein D (gD) gene equivalent of PhHV-1. The PCR assay when combined with Southern blotting (PCR-SB) was approximately 1000 times more sensitive than virus isolation when tested with serially diluted samples from PhHV-1-infected cell cultures. In contrast with virus isolation, the PCR-SB scored as positive all the animals with serological evidence of PhHV-1 infection. The majority of seals present in the centre during the outbreaks contracted the infection and developed benign upper respiratory disease. However, the severity of PhHV-1-related disease was inversely correlated with age and fatal generalised infections occurred only in neonates.

Canine distemper virus from diseased large felids: biological properties and phylogenetic relationships

Specific pathogen free (SPF) domestic cats were inoculated with tissue homogenate obtained from a Chinese leopard (Panthera pardus japonensis) that had died in a North American zoo from a natural infection with canine distemper virus (CDV). The cats developed a transient cell-associated CDV viraemia along with pronounced lymphopenia but did not show any clinical symptoms. Plasma neutralizing-antibody titres against the homologous CDV (A92-27/4, isolated from the Chinese leopard) were consistently higher than against the CDV vaccine strain 'Bussell'. The Chinese leopard CDV isolate showed in vitro biological properties reminiscent of virulent, wild-type CDV strains. Sequence analysis of the H gene of two large felid CDV isolates from the USA (A92-27/4 and A92-6) revealed up to 10% amino acid changes including up to four additional potential N-linked glycosylation sites in the extra-cytoplasmic domain as compared to CDV vaccine strains. Phylogenetic analysis was performed using the entire coding region of the H gene and a 388 bp fragment of the P gene of several morbillivirus species. Evidence was obtained that recent CDV isolates from different species in the United States (including isolates from large felids), Europe and Africa are significantly distinct from CDV vaccine strains. All wild-type CDV isolates analysed clustered according to geographical distribution rather than to host species origin. By sequence analysis a CDV epizootic among large felids in a Californian safari park was linked to a virus which most likely originated from feral non-felid carnivores.

Characterization of phocid herpesvirus-1 and -2 as putative alpha- and gammaherpesviruses of North American and European pinnipeds

To study the relationships between herpesvirus recently isolated from different pinniped species, antigenic and genetic analyses were performed. First, herpesviruses isolated from North American harbour seals (Phoca vitulina), a Californian sea lion (Zalophus californianus) and a European grey seal (Halichoerus grypus) were examined in an enzyme immunoassay (EIA) with a panel of monoclonal antibodies which had previously been shown to allow typing of herpesviruses from European harbour seals into two distinct virus types: phocid herpesvirus type-1 and type-2 (PhHV-1 and PhHV-2). The EIA data showed that all but one of the isolates from seals ranging in United States coastal waters were PhHV-2-like while the European grey seal herpesvirus was PhHV-1-like. Genetic characterization was facilitated by PCR analysis using primers based on conserved regions of the glycoprotein B and D (gB and gD) genes of the antigenically closely related canid (CHV) and felid (FHV) herpesvirus. Specific amplified products were obtained with five isolates antigenically characterized as PhHV-1-like but not with five PhHV-2-like isolates. Sequence analysis of the PCR products confirmed greatest similarity to members of the genus Varicellovirus of the Alphaherpesvirinae and in particular to CHV. Sequence analysis of two EcoRI fragments of the PhHV-2 genome (European isolate 7848) revealed greatest similarity to gammaherpesviruses and in particular equine herpesvirus-2. Although an unambiguous subgrouping was not feasible, this is the first evidence that PhHV-2 may be a putative gammaherpesvirus of pinnipeds.

Mechanisms and patient compliance of dust-mite avoidance regimens in dwellings of mite-allergic rhinitic patients

We report on the mechanisms, the environmental changes and patient compliance with regard to conventional and new dust and mite avoidance measures to prevent allergic symptoms caused by mite allergens, taking into account both allergen contamination and the developmental success of pyroglyphid Acari. Twenty patients with persisting rhinitic complaints were selected and matched. Although the patients had performed some conventional dust and mite avoidance measures (patient compliance was 90%), the dwellings proved to be a stimulus for mite development. Moisture problems due to faulty construction and excessive moisture production were common. Since humidity conditions could not be changed at short notice, the 20 homes were subjected to the new variants of mite allergen avoidance based on intensive cleaning without (control) and with an acaricide incorporated (acaricidal cleaner [Acarosan]). After the carrying out of conventional avoidance measures, these patients still had allergic symptoms, and dust from only 23 to 52% of their textile objects was under the proposed guanine (mite faeces indicator) risk level. Only the acaricidal cleaner was able to decrease the allergenic mite load (and the burden of the patients) significantly in this 12 month period. With respect to mite-extermination, acaricidal cleaning was 88% better than intensive cleaning. Reduction of guanine was 38% better in the Acarosan treatment group. Clinical results have been reported elsewhere. A significant difference in favour of the acaricidal cleaning was seen in both subjective (as regards symptoms) and in objective data (total IgE). Another 50 patients were questioned.(ABSTRACT TRUNCATED AT 250 WORDS)

Tissue distribution of the C3d/EBV-receptor: CD21 monoclonal antibodies reactive with a variety of epithelial cells, medullary thymocytes, and peripheral T-cells

The CD21 antigen has been described to represent CR2, the receptor for the complement fragment C3d and also the receptor for the Epstein-Barr virus (EBV). Monoclonal antibodies B2, HB5, and B-ly4 belong to the CD21 cluster, recognizing different epitopes of the CD21-molecule. Immunohistology of lymphoid tissues employing these antibodies showed the known staining of B cells and dendritic reticulum cells. Surprisingly, B2, but not HB5 or B-ly4, stained a distinct spot in the cytoplasm of a major proportion of medullary thymocytes, in almost all peripheral blood lymphocytes, and in a substantial amount of cells in T-cell areas of peripheral lymphoid tissues. This distinct cytoplasmic B2 staining was confirmed by immuno-electronmicroscopy. A similar B2+ cytoplasmic dot was observed in B-lymphoblastic lymphomas. Staining of non-lymphoid tissues showed reactivity with all three CD21 mAb with epithelial cells of skin, lung, esophagus, jejunum, colon, pancreas, tonsil, adrenal cortex, renal tubuli, and parotid glands, and with hepatocytes and tongue muscle. In addition, endothelial cells of small vessels showed B2 staining. One possible explanation for our results is, that apart from the presence of B cells and follicular dendritic cells, a CD21-molecule may be expressed by other cell types. However, a maybe more likely explanation may be that the recognized epitopes are not exclusively associated with the C3d/EBV-receptor, but also with other structures. In particular should the possibility be recognized of cross-reactivity with CR2-related proteins, encoded by the large gene family, to which CR2 belongs.

Clinical evaluation of a double-blind dust-mite avoidance trial with mite-allergic rhinitic patients

Inheritance and allergen exposure are key factors in the development and the course of atopic allergy, expressed as conjunctivitis, rhinitis, asthma or dermatitis. This study concerns the clinical significance of mite and mite-allergen avoidance measures based on intensive cleaning with acaricide (solidified benzylbenzoate) added (10 dwellings), and without biocidal activity (10 other homes) as a control in a double-blind trial with matched pairs. Twenty subjects with persisting rhinitic complaints were selected. They lived in 20 different dwellings and were all sensitized to pyroglyphid mites; 12 of them were also sensitized to stored product mites (Acari). Daily symptoms and medication score, guanine and dust exposure, total and mite-specific IgE in serum, eosinophilia in the blood and in the nasal smear, intracutaneous tests with house dust mite and storage mite extracts were compared in both pairs and groups. Acarological data, physiochemical aspects and exposure assessment are discussed in detail elsewhere. Symptom scores dropped significantly, as did the total IgE and exposure to dust and mite products in the acaricidal cleaner treatment group. After 1 year, the daily symptoms median was 47% (P = 0.025), total IgE was 38% (P = 0.0049), and exposure to dust and mite products (guanine exposure) was 53% (P = 0.0449) better or lower than in the controls. Intensive cleaning, without acaricidal treatment performed twice a year, resulted in clinical improvement in four out of 10 subjects, of whom none became free of complaints. In the Acarosan treatment group (cleaning + benzylbenzoate) eight out of 10 subjects improved, in three cases subjective symptoms disappeared.(ABSTRACT TRUNCATED AT 250 WORDS)

Countercurrent multistage fluidized bed reactor for immobilized biocatalysts: II. Operation of a laboratory-scale reactor

In Part I of this series,(1) we derived a model and made simulations for a multistage fluidized bed reactor (MFBR). It was concluded that the MFBR can be an attractive alternative for a fixed bed reactor when operated with a deactivating biocatalyst. In Part II of this series, the design of a laboratory-scale MFBR and its evaluation to investigate the practical feasibility of this reactor type, will be described. Experiments with a duration as long as 10 days were carried out successfully using immobilized glucose isomerase as a model reaction system. The results predicted by the model are in good agreement with the measured glucose concentration and biocatalyst activity gradients, indicating perfect mixing of the particles in the reactor compartments.The diameters of the biocatalyst particles used in the experiments showed a large spread, with the largest being 1.7 times the smallest. Therefore, an additional check was carried out, to make sure that the particles were not segregating according to size. Particles withdrawn from the reactor compartments were investigated using an image analyzer. Histograms of particle size distribution do not indicate segregation and it is concluded that the particles used have been mixed completely within the compartments. As a result, transport of biocatalyst is nearly plug flow.

Setting standards and evaluating nursing performance with a single tool

Establishing standards for the desired quality of nursing care requires identifying clear expectations for professional practice and evaluating related performance by objective, quantifiable criteria. The authors describe development of a job description/evaluation tool, the analysis of that process, and the initial findings of pilot testing.

Monoclonal antibodies reactive with hairy cell leukemia

Monoclonal antibodies reactive with hairy cell leukemia were developed to aid in the diagnosis of this subtype of B cell chronic lymphocytic leukemia and to gain better insight into the origin of hairy cells. Three antibodies were found to be of value in the diagnosis of hairy cell leukemia. Antibody B-ly 2 can be considered a pan-B cell reagent and generally reacts similar to CD22 antibodies. Antibody B-ly 6 is reactive with the same antigen as CD11c (p150/95), an antigen that is present on hairy cell leukemia, macrophages, and a minor subpopulation of lymphocytes. Antibody B-ly 7 is a unique antibody reactive with 144 Kd antigen present only on hairy cell leukemia and a very small population of normal B lymphocytes. This subpopulation may be the counterpart of hairy cells.

Use of fiber-optic pressure transducer for intracranial pressure measurements: a preliminary report

Invasive monitoring of intracranial pressure (ICP) is becoming the standard of care for management of acute neurologic and neurosurgical patients. As a result of improved fiber-optic technology, a new disposable 4 French fiber-optic transducer-tipped catheter (FTC) has been introduced for facilitating measurement of intracranial pressure. Placement of the FTC can be intraventricular, subarachnoid, subdural, or intraparenchymal. Sensitivity and linearity of each catheter are manufacturer calibrated and not adjustable. Zero or atmospheric balance is done only once before insertion. Because the transducer is the catheter tip, no leveling to an anatomic point is necessary. The system appears to eliminate some of the difficulties inherent in fluid-filled catheter monitoring. In clinical trials, the comparison of FTC with subdural and ventriculostomy waveforms and pressures showed essentially no difference. Pressure recordings tracked well except during transient periods of increased ICP, when FTC showed higher peak pressures. Use of the FTC requires education regarding placement and maintenance techniques. Although staff experience with the catheter can practically eliminate the problem, the FTC catheters need special handling because of potential for fiber breakage.