Extensive mucocutaneous, oesophageal and otic lichen planus secondary to nivolumab therapy

We report a 73-year-old female with metastatic renal cell carcinoma who developed a widespread lichenoid reaction following nivolumab treatment. The timeline of the reaction strongly correlated with the nivolumab treatment and subsequent cessation. Our patient had cutaneous, mucosal, otic, ophthalmic and oesophageal involvement, demonstrating the potentially extensive nature of lichenoid reactions to anti-programmed cell death receptor-1 (anti-PD1) therapies. Although lichenoid reactions to anti-PD1 therapies are now well recognized, there have been no previous reports of otic or oesophageal involvement in the literature. Although cutaneous lichenoid reactions do not tend to be severe or treatment limiting, more widespread systemic lichenoid reactions are challenging to manage, particularly in the context of malignancy. This very unusual case highlights the importance of considering involvement beyond the skin in all lichenoid skin reactions.

Results from the third Scottish National Prevalence Survey: is a population health approach now needed to prevent healthcare-associated infections?

BACKGROUND

Healthcare-associated infections (HCAIs) are a major public health concern and a significant cause of morbidity and mortality. A robust and current evidence base that is specific to local, national and Europe-wide settings is necessary to inform the development of strategies to reduce HCAI and contain antimicrobial resistance.

AIM

To measure the prevalence of HCAI and antimicrobial prescribing and identify key priority areas for interventions to reduce the burden of infection.

METHODS

A national rolling point-prevalence survey (PPS) in National Health Service (NHS) acute, NHS non-acute, NHS paediatric, and independent hospitals was carried out between September and November 2016 using the European Centre for Disease Prevention and Control protocol designed for the European PPS.

FINDINGS

The prevalence of HCAI was 4.6%, 2.7%, and 3.2% in acute adults, paediatric and non-acute patient groups, respectively. The most frequent HCAI types reported in adult patients were urinary tract infection and pneumonia. The prevalence of antimicrobial prescribing was 35.7%, 29.3%, and 13.8% in acute adults, paediatric, and non-acute patient groups, respectively. Respiratory, skin and soft tissue, gastrointestinal, and urinary tract infections were the most common infections being treated at the time of survey.

CONCLUSION

HCAI continues to be a public health concern in Scotland. Urinary tract infection and pneumonia continue to place a significant burden on patients and on healthcare delivery, including those that develop in the community and require hospital admission. A broader population health approach which focuses on reducing the risk of infection upstream would reduce these infections in both community and hospital settings.

Characterizing ammonia emissions from horses fed different crude protein concentrations

Evaluating impact of animal agriculture on air quality has been the focus of recent research. Ammonia (NH) volatilization occurs when undigested protein in feces and urea in urine is broken down by bacteria and enzymes. Information regarding NH emission from equine facilities is limited, and effects of CP intake on NH emissions have not been investigated. Nine mature geldings were used in a 3 × 3 replicated Latin square design study to determine effects of dietary CP on potential NH losses from feces and urine. We hypothesized feeding horses above the CP requirement would result in an increase in NH emissions from urine and feces and different bedding materials would affect NH emissions from urine. Diets were formulated using different ratios of bahiagrass () and Tifton-85 bermudagrass () hays, and a commercial vitamin mineral supplement to provide 3 different CP concentrations and labeled in relation to each other: LOW-CP, MED-CP, and HIGH-CP (10.6%, 11.5%, and 12%, respectively). Each study period consisted of an 11-d diet adaptation phase, followed by a 3-d total collection of urine and feces. To determine total nitrogen (TN) and urea-N concentrations, samples were pooled by period ( = 9). For in vitro determination of NH concentrations, urine and fecal samples were pooled within period by diet ( = 3) and mixed with either wheat straw or wood shavings. Ammonia emission of these samples was measured using a vessel system with an airflow rate (2.5 L/min) at 20°C over a 7-d period. Concentration of NH in each vessel was measured using a photoacoustic multigas analyzer. Temperature, airflow rate, and NH concentration in each vessel were used to calculate NH emission rate (ER). Data were analyzed using a mixed model ANOVA with repeated measures. Urinary TN and urea-N excretion increased as CP intake increased ( < 0.0001). Vessel urinary NH concentrations were not different across diets ( = 0.1225), ranging from 55.48 ppm (LOW-CP) to 101.14 ppm (HIGH-CP); however, they differed between bedding types ( < 0.0001), with straw higher than shavings (97 vs. 73.5 ppm, respectively). Cumulative urinary NH ER tended to be different across diets ( = 0.0550) ranging from 5.87 g/m to 9.97 g/m and bedding types ( = 0.0129), with straw being higher than shavings (11.1 vs. 6.9 g/m, respectively). Overfeeding CP to horses can lead to increased urinary TN and urea-N excretion, which could lead to greater of NH in the atmosphere.

A closer look at the physical and optical properties of gold nanostars: an experimental and computational study

A combined experimental and computational study was carried out to design a semi-empirical method to determine the volume, surface area, and extinction coefficients of gold nanostars. The values obtained were confirmed by reconstructing the nanostar 3D topography through high-tilt TEM tomography and introducing the finite elements in COMSOL Multiphysics through which we have also calculated the morphology-dependent extinction coefficient. Doing so, we have, for the first time, modeled the heat losses of a real, experimentally synthesized nanostar, and found the plasmon resonances to be in excellent agreement with those obtained experimentally. We believe that our approach could substantially improve the applicability of this remarkable nanomaterial.

Pathways of Acetyl-CoA Metabolism Involved in the Reversal of Palmitate-Induced Glucose Production by Metformin and Salicylate

The pathways through which fatty acids induce insulin resistance have been the subject of much research. We hypothesise that by focussing on the reversal of insulin resistance, novel insights can be made regarding the mechanisms by which insulin resistance can be overcome. Using global gene and lipid expression profiling, we aimed to identify biological pathways altered during the prevention of palmitate-induced glucose production in hepatocytes using metformin and sodium salicylate. FAO hepatoma cells were treated with palmitate (0.075 mM, 48 h) with or without metformin (0.25 mM) and sodium salicylate (2 mM) in the final 24 h of palmitate treatment, and effects on glucose production were determined. RNA microarray measurements followed by gene set enrichment analysis were performed to investigate pathway regulation. Lipidomic analysis and measurement of secreted bile acids and cholesterol were also performed. Reversal of palmitate-induced glucose production by metformin and sodium salicylate was characterised by co-ordinated down-regulated expression of pathways regulating acetyl-CoA to cholesterol and bile acid biosynthesis. All 20 enzymes that regulate the conversion of acetyl-CoA to cholesterol were reduced following metformin and sodium salicylate. Selected findings were confirmed using primary mouse hepatocytes. Although total intracellular levels of diacylglycerol, triacylglycerol and cholesterol esters increased with palmitate, these were not, however, further altered by metformin and sodium salicylate. 6 individual diacylglycerol, triacylglycerol and cholesterol ester species containing 18:0 and 18:1 side-chains were reduced by metformin and sodium salicylate. These results implicate acetyl-CoA metabolism and C18 lipid species as modulators of hepatic glucose production that could be targeted to improve glucose homeostasis.

LARP1 post-transcriptionally regulates mTOR and contributes to cancer progression

RNA-binding proteins (RBPs) bind to and post-transcriptionally regulate the stability of mRNAs. La-related protein 1 (LARP1) is a conserved RBP that interacts with poly-A-binding protein and is known to regulate 5'-terminal oligopyrimidine tract (TOP) mRNA translation. Here, we show that LARP1 is complexed to 3000 mRNAs enriched for cancer pathways. A prominent member of the LARP1 interactome is mTOR whose mRNA transcript is stabilized by LARP1. At a functional level, we show that LARP1 promotes cell migration, invasion, anchorage-independent growth and in vivo tumorigenesis. Furthermore, we show that LARP1 expression is elevated in epithelial cancers such as cervical and non-small cell lung cancers, where its expression correlates with disease progression and adverse prognosis, respectively. We therefore conclude that, through the post-transcriptional regulation of genes such as mTOR within cancer pathways, LARP1 contributes to cancer progression.

Quantitative characterization of the hemodynamic environment in ruptured and unruptured brain aneurysms

BACKGROUND AND PURPOSE

Hemodynamics are thought to play an important role in the mechanisms of aneurysm pathogenesis, progression, and rupture. The purpose of this study was to define quantitative measures related to qualitative flow characteristics previously analyzed and to investigate their relationship to aneurysm rupture.

MATERIALS AND METHODS

The hemodynamic environments in 210 cerebral aneurysms were analyzed by using image-based CFD under different flow conditions. Quantitative hemodynamic variables were defined and extracted from the simulation results. A statistical analysis of the relationship to the previous history of aneurysm rupture was performed, and the variability with flow conditions was assessed.

RESULTS

Ruptured aneurysms were more likely to have larger inflow concentrations, larger MWSS, larger shear concentrations, and lower viscous dissipation ratios than unruptured aneurysms. Areas under low WSS and measures of abnormally low shear force distributions of ruptured and unruptured aneurysms were not statistically different. Although the values of hemodynamic quantities changed with different flow conditions, the statistical differences or ratios between their mean values over the ruptured and unruptured groups were maintained, for both pulsatile and steady flows.

CONCLUSIONS

Concentrated inflow streams and WSS distributions with elevated levels of MWSS and low aneurysmal viscous dissipation are statistically associated with a clinical history of prior aneurysm rupture. In contrast, the area and total viscous shear force applied in the aneurysm region subjected to abnormally low WSS levels are not. This study highlights the potential for image-based CFD for investigating aneurysm-evolution mechanisms and for clinical assessment of aneurysm risks.

Association of hemodynamic characteristics and cerebral aneurysm rupture

BACKGROUND AND PURPOSE

Hemodynamic factors are thought to play an important role in the initiation, growth, and rupture of cerebral aneurysms. This report describes a study of the associations between qualitative intra-aneurysmal hemodynamics and the rupture of cerebral aneurysms.

MATERIALS AND METHODS

Two hundred ten consecutive aneurysms were analyzed by using patient-specific CFD simulations under pulsatile flow conditions. The aneurysms were classified into categories by 2 blinded observers, depending on the complexity and stability of the flow pattern, size of the impingement region, and inflow concentration. A statistical analysis was then performed with respect to the history of previous rupture. Interobserver variability analysis was performed.

RESULTS

Ruptured aneurysms were more likely to have complex flow patterns (83%, P < .001), stable flow patterns (75%, P = .0018), concentrated inflow (66%, P = <.0001), and small impingement regions (76%, P = .0006) compared with unruptured aneurysms. Interobserver variability analyses indicated that all the classifications performed were in very good agreement-that is, well within the 95% CI.

CONCLUSIONS

A qualitative hemodynamic analysis of cerebral aneurysms by using image-based patient-specific geometries has shown that concentrated inflow jets, small impingement regions, complex flow patterns, and unstable flow patterns are correlated with a clinical history of prior aneurysm rupture. These qualitative measures provide a starting point for more sophisticated quantitative analysis aimed at assigning aneurysm risk of future rupture. These analyses highlight the potential for CFD to play an important role in the clinical determination of aneurysm risks.

MMG-EMG cross spectrum and muscle fiber type

The purpose of this study was to investigate fiber type-related differences in the patterns of responses for mechanomyographic-electromyographic (MMG-EMG) cross spectrum mean power frequency (MPF) in resistance-trained and aerobically-trained subjects during a fatiguing muscle action. Five resistance-trained and five aerobically-trained men performed a 45-s isometric muscle action of the dominant leg extensors at 50% MVC while MMG and EMG signals were recorded simultaneously from the vastus lateralis muscle. In addition, a biopsy was taken to determine the myosin heavy chain (MHC) isoform content of the vastus lateralis. The resistance-trained and aerobically-trained subjects demonstrated similar patterns of responses for MMG-EMG cross spectrum MPF during the sustained muscle action. The vastus lateralis of the resistance-trained subjects demonstrated primarily Type II MHC isoform expression, indicative of fast-twitch muscle fibers, while that of the aerobically-trained subjects was composed mostly of Type I MHC isoform expression, indicative of slow-twitch fibers. Thus, the differences in fiber type characteristics were not manifested in the patterns of responses for MMG-EMG cross spectrum MPF.

Fluoroscopy-guided percutaneous lung biopsy: a valuable alternative to computed tomography

BACKGROUND

Computed tomography (CT) fluoroscopy nowadays is the most preferred method of guidance to perform percutaneous lung biopsy of pulmonary masses. Conventional fluoroscopy is an increasingly forgotten technique that still can be used to perform lung biopsies, with many advantages.

PURPOSE

To compare the accuracy, safety, and effective dose (ED) of conventional fluoroscopy-guided needle lung biopsy (FNLB) with CT-guided needle lung biopsy procedures (CTNLB) reported in the literature.

MATERIAL AND METHODS

100 consecutive patients who underwent FNLB were reviewed retrospectively. Using the final histological diagnoses and the clinical and radiological course of the disease as references, the accuracy and sensitivity of FNLB were calculated. The complication rates of FNLB were assessed. Using computer software (XDOSE), the ED was calculated. The accuracy, complication rates, and the ED of FNLB were compared with CTNLB reported in the literature.

RESULTS

The overall accuracy rate and sensitivity of FNLB were both 87%, which are comparable to the range of accuracies reported in the literature for CTNLB (74-97%). The complication rates of FNLB were also comparable to the complication rates reported for CTNLB. The commonest complication was pneumothorax, at a rate of 25%. The ED of FNLB was small, significantly lower than reported in the literature for CT-guided procedures. The mean ED of FNLB was 0.029 mSv, which is approximately equivalent to one chest X-ray.

CONCLUSION

Conventional fluoroscopy is an accurate, safe, and low-dose alternative modality to CT to obtain an image-guided histological diagnosis of pulmonary lesions.

Nasal tip necrosis--an unusual presentation of rheumatoid vasculitis

We describe an unusual case of cutaneous necrosis of the nasal tip presenting to a facial reconstructive surgeon. The patient had developed this painless necrosis over a period of about 10 days. Her past medical history included rheumatoid arthritis. She described an exacerbation of her arthritic symptoms in the weeks preceding the development of the nasal tip necrosis. Her rheumatoid arthritis had been managed with corticosteroid and immunosuppressive therapy for more than 3 years. She had not previously experienced extra-articular manifestations (EAMs). A biopsy was taken and histological analysis identified a lymphocytic vasculitis. She was referred to her rheumatologist, and surgical management of her necrotic nasal tip commenced.

The Effect of Inlet Disturbances on Turbulent Pipe Flow

Disturbances near the entry to a pipe are shown to effect significantly the development of the turbulent velocity profile. The attainment of a ‘fully developed’ profile at a Reynolds number of 4 × 105 takes rather longer than is often assumed. Consequently, some care is required when designing test facilities with entry pipes (or channels) providing inlet conditions for internal flow component investigations.

A stream depletion field experiment

A field experiment was carried out to measure drawdowns in observation wells and stream depletion flows that occurred when water was abstracted from a well beside a stream. The field data is analyzed herein to determine the aquifer transmissivity, T, the aquifer storage coefficient, S, and a streambed leakage parameter, lambda, by comparing measurements with a solution obtained by Hunt (1999). The analysis uses early time drawdowns with a match-point method to determine T and S, and stream depletion measurements at later times are used to determine lambda. The final results are reasonably consistent for measurements taken in four observation wells. The advantages and disadvantages of this approach are discussed, and two alternative ways of estimating lambda are also discussed.

Thoracic lymphatic pumping and the efficacy of influenza vaccination in healthy young and elderly populations

The authors investigated whether thoracic lymphatic pumping (TLP) after FluShield vaccination enhanced the production of anti-influenza immunoglobulins in elderly individuals, who are at particular risk for influenza. Osteopathic students and non-TLP-treated elderly subjects served as controls. Serum antibody titers were quantified with enzyme-linked immunosorbent assay, and hemagglutination inhibition assay, both of which generated comparable results. While approximately 70% of the younger controls had increased anti-influenza immunoglobulin production on vaccination, only 30% to 35% of the aged population had increased antibody production. There was no significant enhancement in anti-influenza immunoglobulin production in the TLP-treated subjects. The authors' findings suggest that TLP in conjunction with influenza vaccination does not enhance immunization against influenza in otherwise healthy and active populations. However, such techniques may be of value when applied in conjunction with vaccination to nonambulatory patients or on actual influenza exposure of at-risk individuals.

Erythrocyte transfusion causes immunosuppression after total hip replacement

A prospective study of 34 patients undergoing total hip replacement was done to determine whether homologous erythrocyte transfusion causes postoperative immunosuppression. In the transfused patient group (14 patients), there was a reduction in CD3+ and CD3+4+ cell numbers at Day 2, returning to preoperative levels by Day 7. In contrast, in the untransfused patient group (20 patients), there was no significant depression in these lymphocyte subgroups at Day 2 and an increase in total lymphocyte, CD3+, CD3+4+, and CD3+4-8- cell numbers at Day 7. In both patient groups there was postoperative leukocytosis, granulocytosis, and monocytosis at Days 2 and 7, with no significant change in postoperative B (CD19+) cell numbers, natural killer cells, or the minor T cell populations of CD3+4+8+ and CD3+25+. The lymphocyte functional test of Candida recall was significantly impaired at Day 7 in the transfused patient group, where Candida recall is a memory T cell response to an antigen extracted from the yeast Candida Albicans. These findings suggest that homologous erythrocyte transfusion after hip replacement surgery causes cell mediated immune suppression. The main clinical implication of the current study is that perioperative homologous erythrocyte transfusion may place patients at greater risk of infectious complications, including infection of the prosthesis.

Mutations in MERTK, the human orthologue of the RCS rat retinal dystrophy gene, cause retinitis pigmentosa

Mutation of a receptor tyrosine kinase gene, Mertk, in the Royal College of Surgeons (RCS) rat results in defective phagocytosis of photoreceptor outer segments by the retinal pigment epithelium (RPE) and retinal degeneration. We screened the human orthologue, MERTK, located at 2q14.1 (ref. 10), in 328 DNA samples from individuals with various retinal dystrophies and found three mutations in three individuals with retinitis pigmentosa (RP). Our findings are the first conclusive evidence implicating the RPE phagocytosis pathway in human retinal disease.

Notch signaling and the emergence of auditory hair cells

OBJECTIVE

Recent insights into the mechanisms that determine a hair cell's fate have emerged from studies on invertebrate sensory organs and the avian inner ear. These mechanisms have important implications for our understanding of the possible therapeutic management of sensorineural deafness. This article reviews the current state of our knowledge regarding mammalian auditory hair cell fate specification.

DESIGN

Data were obtained from the MEDLINE database and data presented at the Molecular Biology of Hearing and Deafness Meeting (Bethesda, Md, October 1998). Articles reporting information about cell fate specification and Notch and its ligands were selected.

MAIN OUTCOME MEASURES

Data pertaining to cell fate mechanisms, Notch and its ligands, and application to hearing were extracted.

RESULTS

The Notch/ligand mechanism is responsible for the specification of the hair cell phenotype.

CONCLUSIONS

Major progress has been made in understanding this fundamental process, and its application to hair cell determination is only now being realized. Possible applications could involve the "switching" of supporting cells to hair cells, thus replenishing those hair cells damaged in sensorineural hearing loss.

Deliberate self-poisoning presenting at a rural hospital in Northern Ireland 1976-1996: relationship to prescribing

PURPOSE

This study reports on a project to monitor deliberate self-poisoning in a rural area of Northern Ireland over a 20-year period. Comparison is made with reports from large urban centres. In addition, a local prescribing database allows assessment of any association between psychotropic drug prescription and use for deliberate self-poisoning.

MATERIALS AND METHODS

Frequency of self-poisoning, demographic details and drugs used were recorded for all episodes of deliberate self-poisoning occurring at Craigavon Area Hospital for the years 1976, 1986, 1991 and 1996. It was possible to compare prescriptions of psychotropic drugs with their use for deliberate self-poisoning between the years 1991 and 1996 in the region served by the hospital, using the Defined Daily Dose (DDD) system.

RESULTS

In this rural area the pattern of deliberate self-poisoning has changed, as in urban centres, with a rise in frequency and the male/female ratio approaching unity. The pattern of drug use has altered, with paracetamol overtaking benzodiazepines as the most commonly used agent. More recently, antidepressants have become the second most frequently used drug class for this purpose. Psychotropic medications used for self-poisoning altered in proportion to their prescription between the years 1991 and 1996.

CONCLUSIONS

In the face of a continuing rise in deliberate self-poisoning, which is effecting both urban and rural areas, care should be taken to prescribe the least toxic agent available as this is associated with likely frequency of self-poisoning for most classes of psychotropic drug.

Mutation of the receptor tyrosine kinase gene Mertk in the retinal dystrophic RCS rat

Vertebrate photoreceptor cells are the basic sensory apparatus of the retina, capable of converting the energy of absorbed photons into neuronal signals. The proximal portions of mammalian photoreceptor outer segments are synthesized daily by cell bodies, and outer segment tips are shed with a circadian rhythm, resulting in a complete turnover of outer segments about every 9 days. The shed outer segments are phagocytosed by adjacent retinal pigment epithelial (RPE) cells, and metabolites are recycled to photoreceptors. The Royal College of Surgeons (RCS) rat is a widely studied, classic model of recessively inherited retinal degeneration in which the RPE fails to phagocytose shed outer segments, and photoreceptor cells subsequently die. We have used a positional cloning approach to study the rdy (retinal dystrophy) locus of the RCS rat. Within a 0.3 cM genetic inclusion interval, we have discovered a small deletion of RCS DNA that disrupts the gene encoding the receptor tyrosine kinase Mertk. The deletion includes the splice acceptor site upstream of the second coding exon of Mertk and results in a shortened transcript that lacks this exon. The aberrant transcript joins the first and third coding exons, leading to a frameshift and a translation termination signal 20 codons after the AUG. The concordance of these and other data indicate that Mertk is probably the gene for rdy. Our results provide genetic evidence for an essential role of a receptor tyrosine kinase in a specialized form of phagocytosis and suggest a molecular model for ingestion of outer segments by RPE cells.

Inflammatory abdominal aortic aneurysms: diagnosis with gadolinium enhanced T1-weighted imaging

AIM

Inflammatory abdominal aortic aneurysms (IAAA) are a variant of abdominal aortic aneurysms, which are associated with an increased morbidity. The diagnosis of IAAA has traditionally been established with a combination of clinical and laboratory findings together with contrast enhanced CT. There is a high incidence of renal impairment in this group, and therefore contrast enhanced CT may be harmful.

PATIENTS AND METHODS

Five patients with IAAA underwent T1-weighted spin echo and gradient echo gadolinium enhanced abdominal MRI. A total of eight examinations were performed, including three patients who underwent repeat MRI following steroid therapy.

RESULTS

The inflammatory cuff was clearly identified following gadolinium administration in all eight examinations. The cuff enhanced homogeneously in all patients with no alteration in appearance following steroid therapy. The intravenous administration of gadolinium DTPA enabled clearer definition of locally involved structures.

CONCLUSION

Gadolinium enhanced MRI readily demonstrates features of IAAA. In view of potential renal impairment in this patient group, we recommend this technique in preference to contrast enhanced CT in the initial investigation of inflammatory abdominal aortic aneurysms.

Identification of differentiating cochlear hair cells in vitro

HYPOTHESIS

The expression of hair cell-specific genes involved in differentiation was studied in the cell line UB/OC-1 (University Bristol/Organ of Corti).

BACKGROUND

Studies of gene expression in cochlear hair cells are restricted by the small number of cells available and by their experimental inaccessibility. The cell line was derived from the H2K(b)tsA58 transgenic mouse, which harbors a conditionally expressed immortalizing gene. Two genes that are characteristic of hair cells were upregulated during differentiation of UB/OC-1 cells in vitro. They are the transcription factor Brn3.1, which is essential for hair cell differentiation, and the alpha9 subunit of the nicotinic acetylcholine receptor that is involved in olivocochlear efferent innervation.

METHODS

The expression of Brn3.1 and alpha9, at different time points under differentiating conditions, was analyzed by semiquantitative reverse-transcription polymerase chain reaction (RT-PCR). Western blot analysis and immunofluorescence analysis were performed on the cell line with anti-Brn3.1 antibody.

RESULTS

Reaction products for alpha9 were detected after 3 to 6 days under differentiating conditions. Low levels of Brn3.1 were detectable under proliferating conditions and increased under differentiating conditions. All cells expressed Brn3.1 under differentiating conditions. This temporal pattern of gene expression is very closely similar to that found in vivo.

CONCLUSION

The cochlear hair cell line UB/OC-1 provides a valuable experimental system because it conditionally expresses genes essential for normal differentiation and electrophysiology. It should prove valuable in the identification and characterization of genes involved in development and may provide material for screening new therapeutic methods of stimulating recovery and regeneration of hair cells.