Investigation of liver-targeted peripheral focused ultrasound stimulation (pFUS) and its effect on glucose homeostasis and insulin resistance in type 2 diabetes mellitus: a proof of concept, phase 1 trial

BACKGROUND

Mechanical waves produced by ultrasound pulses have been shown to activate mechanosensitive ion channels and modulate peripheral nerves. However, while peripheral ultrasound neuromodulation has been demonstrated in vitro and in pre-clinical models, there have been few reports of clinical tests.

AIM

We modified a diagnostic imaging system for ultrasound neuromodulation in human subjects. We report the first safety and feasibility outcomes in subjects with type 2 diabetes (T2D) mellitus and discuss these outcomes in relation to previous pre-clinical results.

DESIGN

The study was performed as an open label feasibility study to assess the effects of hepatic ultrasound (targeted to the porta hepatis) on glucometabolic parameters in subjects with T2D. Stimulation (peripheral focused ultrasound stimulation treatment) was performed for 3 days (i.e. 15 min per day), preceded by a baseline examination and followed by a 2-week observation period.

METHODS

Multiple metabolic assays were employed including measures of fasting glucose and insulin, insulin resistance and glucose metabolism. The safety and tolerability were also assessed by monitoring adverse events, changes in vital signs, electrocardiogram parameters and clinical laboratory measures.

RESULTS AND CONCLUSION

We report post-pFUS trends in several outcomes that were consistent with previous pre-clinical findings. Fasting insulin was lowered, resulting in a reduction of HOMA-IR scores (P-value 0.01; corrected Wilcoxon signed-rank test). Additional safety and exploratory markers demonstrated no device-related adverse impact of pFUS. Our findings demonstrate that pFUS represents a promising new treatment modality that could be used as a non-pharmaceutical adjunct or even alternative to current drug treatments in diabetes.

A37 EFFICACY AND SAFETY OF RISANKIZUMAB AS MAINTENANCE THERAPY IN PATIENTS WITH CROHN’S DISEASE: 52 WEEK RESULTS FROM THE PHASE 3 FORTIFY STUDY

Background

Risankizumab (RZB), an anti-IL-23 p19 inhibitor, was well-tolerated and superior to placebo (PBO) in inducing clinical remission and endoscopic response in patients (pts) with moderate-to-severe Crohn’s disease (CD) in two phase 3 studies at 12 weeks.

Aims

FORTIFY (NCT03105102), was a 52-week (wk) phase 3 double-blind, re-randomized responder withdrawal study that evaluated the efficacy and safety of continuing RZB as subcutaneous (SC) maintenance therapy versus withdrawal to placebo in pts achieving induction response to RZB

Methods

Week 12 IV RZB responders were re-randomized 1:1:1 to: RZB SC 360mg (N=141), RZB 180mg (N=157), or PBO (withdrawal from IV RZB; N=164) every 8wks for 52wks. Co-primary endpoints were clinical remission (per CD Activity Index [CDAI] (US); or stool frequency/abdominal pain score [SF/APS] (OUS) and endoscopic response at wk52. Other clinical and endoscopic endpoints, inflammatory biomarkers, RZB serum levels, and safety were assessed over time.

Results

Rates of clinical remission (CDAI, SF/APS) and clinical response were similar for RZB and PBO groups through wk24, with rates lower for PBO thereafter. At wk52, clinical remission (CDAI, SF/APS) and endoscopic response rates were significantly higher with RZB 360mg than PBO ( P<0.01); RZB 180mg was superior to PBO for clinical remission per CDAI and endoscopic response ( P<0.01). Endoscopic remission and deep remission rates increased over time with 360mg, remained steady with 180mg, and decreased with PBO. Mean fecal calprotectin (FCP) and C-reactive protein (CRP) levels decreased with SC RZB, but increased with PBO, over 52wks. Exposure-adjusted event rates (per 100 pts-years) of serious adverse event (AE) were generally similar among groups (360mg, 21.0 E/100PY and 180mg, 19.5 E/100PY vs PBO, 19.3 E/100PY), as were AEs leading to drug discontinuation (4.8 E/100PY and 2.4 E/100PY vs 3.7 E/100PY), and serious infections (6.0 E/100PY and 3.0 E/100PY vs 5.0 E/100PY).

Conclusions

In pts with moderate-to-severe CD, a robust pharmacodynamic effect on the IL-23 pathway after 12wks RZB IV induction was maintained with RZB SC maintenance therapy. The durability of RZB was demonstrated with high rates of efficacy over the 52-wk study. RZB was superior to PBO for achieving clinical remission and endoscopic response at wk52. Results for the more stringent endpoints (endoscopic remission\deep remission) and persistent improvements in inflammatory biomarkers are consistent with a dose response relationship. Continued RZB SC maintenance treatment was generally safe and well-tolerated.

Funding Agencies

AbbVie

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Transrectal Subharmonic Ultrasound Imaging for Prostate Cancer Detection

OBJECTIVE

To assess the prostate cancer (CaP) detection rates of contrast-enhanced, transrectal subharmonic ultrasound imaging (SHI).

MATERIALS AND METHODS

This IRB-approved study enrolled 55 subjects. The initial 5 subjects were studied for SHI optimization, while the remaining 50 were evaluated with contrast-enhanced sonography using continuous SHI, color, and power Doppler as well as conventional grayscale, continuous color, and power Doppler and SHI combined with maximum flash replenishment. A maximum of 6 directed biopsy cores were obtained from sites of greatest asymmetrical enhancement, followed by spatially distributed cores in a double sextant distribution. Subharmonic time-intensity parameters, including time to peak intensity, peak intensity, and estimated perfusion were also evaluated for each directed biopsy core. Receiver operating characteristic curve analysis and conditional logistic regression were employed to assess the benefit of each modality and the quantitative SHI parameters.

RESULTS

Cancer was detected in 22 of 50 subjects. Among subjects with clinically significant CaP (n = 11), targeted cores were more likely to be positive (odds ratio 1.39, P = .02). The majority of patients detected by SHI demonstrated significant CaP (5/8); SHI remained an independent marker of malignancy in a multivariate logistic regression model (P = .027). Receiver operating characteristic curve analysis of imaging findings compared to biopsy results yielded diagnostic accuracies ranging from 0.59 to 0.80 for all imaging modalities with the highest being for quantitative subharmonic perfusion estimates.

CONCLUSION

This first-in-humans study provides a preliminary estimate of the diagnostic accuracy of SHI for detection of clinically significant CaP (up to 80%).

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis

OBJECTIVE

Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy.

METHODS

CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention.

RESULTS

Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2  = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable).

CONCLUSION

In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

A multi-perspective service evaluation exploring tuberculosis contact screening attendance among adults at a North London hospital

BACKGROUND

Non-attendance at TB contact screening clinics has been highlighted as a common phenomenon across a number of sites during recruitment to the PREDICT TB Study. This has obvious implications for the safety of patients, their communities and for NHS resources. The objective of this study was to explore why adults who have been in contact with TB do, and do not, attend their screening appointment, thereby allowing identification of interventions to reduce non-attendance.

METHODS

A multi-method approach was taken using 15 questionnaires with adults who attended for screening, 15 telephone questionnaires with adults who did not attend and in-depth interviews with 8 TB nurses. Interviews were coded to trace emerging descriptive themes, then refined through an iterative process of interpretation and recoding.

RESULTS

Findings from the questionnaires and interviews were categorized into three principle themes following analysis: awareness, hospital factors and leadership. These themes deconstruct the complex phenomena of patients' lack of attendance at this TB contact screening service.

CONCLUSION

Recommendations related to issues of leadership, outreach services, flexibility of clinic timing and awareness amongst both the local community and GPs were made.

Remote Giant Multispectral Plasmonic Shifts of Labile Hinged Nanorod Array via Magnetic Field

We report a remotely mediated and fast responsive plasmonic-magnetic nanorod array with extremely large variability in optical appearance (up to 100 nm shifts in scattering maxima) and concurrently for multiple wavelengths in a broad range from UV-vis to near-infrared (at 450, 550, and 670 nm) with an external magnetic field with variable direction. The observed phenomenon demonstrates a rapid, wide-range response controlled via a noninvasive remote stimulus. The remotely controlled system suggested here is a magnetic field-directed assembly of an ordered monolayer array of unipolar oriented magnetic-plasmonic nickel-gold nanorods flexibly hinged to a sticky substrate. The unique geometry of the mobile nanorod array allows for the instant alteration of the surface plasmon polariton modes in the gold segment of the controllably tilting nanorods. This design demonstrates the utility of hybrid bimetallic nanoparticles and gives a novel approach to the design of fast-acting, remotely controlled color-changing nanomaterials for sensing and interfacial transport.

Serotonin concentrations in platelets, plasma, mitral valve leaflet, and left ventricular myocardial tissue in dogs with myxomatous mitral valve disease

HYPOTHESIS/OBJECTIVES

Altered serotonin (5-hydroxytryptamine, 5HT) signaling is postulated in development and progression of canine myxomatous mitral valve disease (MMVD). Little is known regarding platelet, plasma, valvular, or myocardial 5HT concentration ([5HT]) in affected dogs. We quantified [5HT] in platelet-rich plasma (PRP), platelet-poor plasma (PPP), mitral valve leaflets (MV), and left ventricular myocardium (LV).

ANIMALS

Forty-five dogs comprised 4 plasma groups of Cavalier King Charles Spaniels (CKCS) or non-CKCS, either healthy (CON) or MMVD affected: CKCS CON (n = 12); non-CKCS CON (n = 8); CKCS MMVD (n = 14); non-CKCS MMVD (n = 11). Twenty-four dogs comprised 3 tissue groups: MMVD (n = 8); other-HD (heart disease) (n = 7); non-HD, extracardiac disease (n = 9).

METHODS

High-performance liquid chromatography measured PRP, PPP, MV, and LV [5HT].

RESULTS

Platelet-rich plasma platelet [5HT] was greater in CKCS CON (1.83 femtograms/platelet [fg/plt]; range, 0.20-4.76; P = .002), CKCS MMVD (1.58 fg/plt; range, 0.70-4.03; P = .005), and non-CKCS MMVD (1.72 fg/plt; range, 0.85-4.44; P = .003) versus non-CKCS CON (0.92 fg/plt; range, 0.63-1.30). There was no group difference in PPP [5HT]. MV [5HT] was significantly higher in MMVD (32.4 ng/mg; range, 8.4-106.7) versus non-HD (3.6 ng/mg; range, 0-28.3; P = .01) and LV [5HT] was significantly higher in MMVD (11.9 ng/mg; range, 4.0-104.8) versus other-HD (0.9 ng/mg; range, 0-10.1; P = .011) and non-HD (2.5 ng/mg; range, 0-6.9; P = .001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Platelet [5HT] was highest in healthy CKCS and both MMVD groups, but plasma [5HT] showed no group differences. Tissue [5HT] was highest in MV and LV of MMVD-affected dogs, suggesting altered 5HT signaling as a potential feature of MMVD. Interactions of platelet, valvular, and myocardial 5HT signaling warrant further investigation.

OS011. Management of late preterm pregnancy complicated by mildpreeclampsia: A prospective randomized trial

INTRODUCTION

In the absence of properly undertaken prospective randomized clinical trials, the optimal management of late preterm mild preeclampsia for best maternal and perinatal outcomes remains unclear for obstetricians worldwide.

OBJECTIVES

We desired to determine if immediate or expectant management of the late preterm mother presenting with mild preeclampsia was more beneficial to her without compromise to her newborn.

METHODS

This prospective randomized clinical trial of immediate versus expectant delivery for patients presenting with mild preeclampsia between the late preterm period of 34-0/7 to 36-6/7weeks gestation was undertaken using CONSORT guidelines. Patients were randomized to immediate delivery via induction of labor or cesarean delivery or inpatient expectant management with delivery at 37-0/7weeks gestation or earlier at onset of labor or progression to severe preeclampsia. The primary outcome was progression to severe preeclampsia; secondary outcomes were neonatal morbidity and mortality. Data were analyzed by appropriate tests for continuous or categorical outcomes with differences considered significant if p<0.05.

RESULTS

One hundred and sixty nine patients during 2002-2008 satisfied and sustained protocol criteria in the immediate delivery (n=94) or inpatient expectant management (n=75) arms of the study. A third (33%) of expectantly managed patients developed severe preeclampsia during significantly longer hospitalization versus 3% in the immediately delivered patients (p=0.001). Cesarean delivery rates were similar. No significant neonatal morbidity differences were observed between groups; there were no maternal or neonatal deaths. The study was stopped in 2008 at 74% of the enrollment target when hospital policy changed to discourage inpatient hospitalization for uncomplicated mild preterm preeclampsia and in view of growing national concern for increased late preterm/early term neonatal morbidity and cost of care.

CONCLUSION

Proceeding to delivery of the late preterm (⩾34weeks gestation) patient with mild preeclampsia lessens maternal risk without significantly increasing neonatal risk.

Use of a surgically derived nomogram to predict high likelihood of Gleason score upgrading for favorable-risk prostate cancer treated with permanent seed brachytherapy

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Background: Crook et al have reported a 7-year disease-free survival (DFS) of 95.2% in 1,111 men with prostate cancer treated with Iodine-125 permanent seed brachytherapy (BT) at Princess Margaret Hospital. Two nomograms have been developed that estimate the likelihood of Gleason score (GS) upgrading for patients with favorable risk prostate cancer undergoing radical prostatectomy (RP). The purpose of this project was to apply these nomograms to a cohort treated with BT.

Methods: Records were examined for all men receiving prostate BT in 2006-7. 217 had favorable risk disease. The likelihood of GS upgrading was predicted using RP-derived nomograms created by Kulkarni et al (PMH, 2007) and Budaus et al (2010). Clinical and pathologic information were available on 208 patients to allow completion of the Kulkarni nomogram, and on 193 patients for the Budaus nomogram.

Results: The median age of the BT cohort was 62 years (range 44–77), and the median PSA level 4.68 ng/ml. Clinical stage was T1 in 65%, and 47.6% had positive findings on transrectal ultrasound. Median prostate volume was 33.3 cc (15.0–72.3). Uro-pathology review was available for 93%. 84.1% had extended biopsies, with 40.9% showing prostatic intraepithelial neoplasia and 10.1% inflammation. The median % of positive cores was 25%, with a median maximum % involvement per core of 20%. Two men received androgen deprivation therapy for prostate downsizing. The median predicted likelihood of GS upgrading was 51.6% using the Kulkarni nomogram, and 43.6% using the Budaus nomogram. The median PSA after 3.2 years median follow-up is 0.18 ng/mL.

Conclusions: In a population of men with favorable risk prostate cancer treated with BT, the estimated likelihood of GS upgrading using two surgical nomograms was substantial. The study cohort was taken from a larger population of patients treated over 10 years for whom 7-year DFS is 95.2%. This suggests that permanent seed brachytherapy is a highly effective treatment option for patients with favorable risk disease despite unfavorable clinical and pathologic factors. Patients should not be discouraged from brachytherapy on the basis of a high likelihood of GS upgrading.

No significant financial relationships to disclose.

Prenatal infection decreases calbindin, decreases Purkinje cell volume and density and produces long-term motor deficits in Sprague-Dawley rats

The cerebellum is involved in the control of motor functions with Purkinje cells serving as the only output from the cerebellum. Purkinje cells are important targets for toxic substances and are vulnerable to prenatal insults. Intrauterine infection (IUI) has been shown to selectively target the developing cerebral white matter through lesioning, necrosis and inflammatory cytokine activation. Developmental and cognitive delays have been associated with animal models of IUI. The aim of this study was to determine if IUI leads to damage to Purkinje cells in the developing cerebellum and if any damage is associated with decreases in calbindin and motor behaviors in surviving pups. Pregnant rats were injected with Escherichia coli (1 × 10⁵ colony-forming units) or sterile saline at gestational day 17. Beginning at postnatal day (PND) 2, the pups were subjected to a series of developmental tests to examine developmental milestones. At PND 16, some pups were sacrificed and their brains extracted and processed for histology or protein studies. Hematoxylin and eosin (HE) staining was done to examine the general morphology of the Purkinje cells and to examine Purkinje cell density, area and volume. Calbindin expression was examined in the cerebellum via immunohistochemistry and Western blot techniques. The remaining rat pups were used to examine motor coordination and balance on a rotating rotarod at the prepubertal and adult ages. Prenatal E. coli injection did not significantly change birth weight or delivery time, but did delay surface righting and negative geotaxis in pups. Pups in the E. coli group also had a decrease in the number of Purkinje cells, as well as a decrease in Purkinje cell density and volume. HE staining demonstrated a change in Purkinje cell morphology. Calbindin expression was decreased in rats from the E. coli group as well. Locomotor tests indicated that while there were no significant changes in gross motor activity, motor coordination and balance was impaired in both prepubertal and adult rats from the E. coli group. In this model of IUI, we observed changes in Purkinje cell development which were associated with alterations in cerebellum-dependent motor behaviors. The decreases in calbindin and Purkinje cells were associated with developmental delays. These data further support the importance of IUI in brain development.

The effect of immune factors, tumor necrosis factor-alpha, and agonistic autoantibodies to the angiotensin II type I receptor on soluble fms-like tyrosine-1 and soluble endoglin production in response to hypertension during pregnancy

BACKGROUND

Preeclampsia is considered a disease of immunological origin associated with abnormalities in inflammatory cytokines, tumor necrosis factor-alpha (TNF-alpha), and activated lymphocytes secreting autoantibodies to the angiotensin II receptor (AT1-AA). Recent studies have also demonstrated that an imbalance of angiogenic factors, soluble fms-like tyrosine kinase (sFlt-1), and sEndoglin, exists in preeclampsia; however, the mechanisms that initiate their overproduction are unclear.

METHODS

To determine the role of immune regulation of these factors, circulating and placental sFlt-1 and/or sEndoglin was examined from pregnant rats chronically treated with TNF-alpha or AT1-AA. On day 19 of gestation blood pressure was analyzed and serum and tissues were collected. Placental villous explants were excised and cultured on matrigel coated inserts for 24 h and sFlt-1 and sEndoglin was measured from media.

RESULTS

In response to TNF-alpha-induced hypertension, sFlt-1 increased from 180 +/- 5 to 2,907 +/- 412 pg/ml. sFlt-1 was also increased from cultured placental explants of TNF-alpha induced hypertensive pregnant rats (n = 12) (2,544 +/- 1,132 pg/ml) vs. explants from normal pregnant (NP) rats (n = 12) (2,189 +/- 586 pg/ml) where as sEng was undetectable. Circulating sFlt-1 increased from 245 +/- 38 to 3,920 +/- 798 pg/ml in response to AT1-AA induced hypertension. sFlt-1 levels were higher (3,400 +/- 350 vs. 2,480 +/- 900 pg/ml) in placental explants from AT1-AA infused rats (n = 12) than NP rats (n = 7). In addition, sEndoglin increased from 30 +/- 2.7 to 44 +/- 3.3 pg/ml (P < 0.047) in AT1-AA infused rats but was undetectable in the media of the placental explants.

CONCLUSIONS

These data suggest that immune factors may serve as an important stimulus for both sFlt-1 and sEndoglin production in response to placental ischemia.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments.

OBJECTIVES

To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), CINAHL (1982 to January 2007) and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

At least two independent authors performed data extraction for each study. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials.

MAIN RESULTS

Seven published RCTs were included, comparing local cooling treatments (ice packs, cold gel pads or cold/iced baths) with no treatment, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam [Epifoam] or warm baths. The RCTs reported on a total of 859 women. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.41 to 0.91). Women preferred the utility of the gel pads compared with ice packs or no treatment, although no differences in pain relief were detected between the treatments. None of our comparisons of treatments resulted in differences detected in perineal oedema or bruising. Women reported more pain (RR 5.60, 95% CI 2.35 to 13.33) and used more additional analgesia (RR 4.00, 95% CI 1.44 to 11.13) following the application of ice packs compared with PET.

AUTHORS' CONCLUSIONS

There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

Gastric nematodes of Nile crocodiles, Crocodylus niloticus Laurenti, 1768, in the Okavango River, Botswana

The ascaridoid nematodes Dujardinascaris madagascariensis Chabaud & Caballero, 1966, Dujardinascaris dujardini (Travassos, 1920), Gedoelstascaris vandenbrandeni (Baylis, 1929) Sprent, 1978 and Multicaecum agile (Wedl, 1861) Baylis, 1923 were recovered from the stomach contents of Crocodylus niloticus Laurenti, 1768 from the Okavango River, Botswana, together with Eustrongylides sp., a dioctophymatoid nematode usually parasitizing piscivorous birds. Dujardinascaris madagascariensis was present in most of the infected hosts, while the remaining species were mostly represented in single collections in one to three hosts. All four ascaridoid nematodes represent new geographic records.

Identification of a high affinity nucleocapsid protein binding element within the Moloney murine leukemia virus Psi-RNA packaging signal: implications for genome recognition

Murine leukemia virus (MLV) is currently the most widely used gene delivery system in gene therapy trials. The simple retrovirus packages two copies of its RNA genome by a mechanism that involves interactions between the nucleocapsid (NC) domain of a virally-encoded Gag polyprotein and a segment of the RNA genome located just upstream of the Gag initiation codon, known as the Psi-site. Previous studies indicated that the MLV Psi-site contains three stem loops (SLB-SLD), and that stem loops SLC and SLD play prominent roles in packaging. We have developed a method for the preparation and purification of large quantities of recombinant Moloney MLV NC protein, and have studied its interactions with a series of oligoribonucleotides that contain one or more of the Psi-RNA stem loops. At RNA concentrations above approximately 0.3 mM, isolated stem loop SLB forms a duplex and stem loops SL-C and SL-D form kissing complexes, as expected from previous studies. However, neither the monomeric nor the dimeric forms of these isolated stem loops binds NC with significant affinity. Longer constructs containing two stem loops (SL-BC and SL-CD) also exhibit low affinities for NC. However, NC binds with high affinity and stoichiometrically to both the monomeric and dimeric forms of an RNA construct that contains all three stem loops (SL-BCD; K(d)=132(+/-55) nM). Titration of SL-BCD with NC also shifts monomer-dimer equilibrium toward the dimer. Mutagenesis experiments demonstrate that the conserved GACG tetraloops of stem loops C and D do not influence the monomer-dimer equilibrium of SL-BCD, that the tetraloop of stem loop B does not participate directly in NC binding, and that the tetraloops of stem loops C and D probably also do not bind to NC. These surprising results differ considerably from those observed for HIV-1, where NC binds to individual stem loops with high affinity via interactions with exposed residues of the tetraloops. The present results indicate that MLV NC binds to a pocket or surface that only exists in the presence of all three stem loops.

Early gene expression profile of human skin to injury using high-density cDNA microarrays

Disturbances in normal wound healing may be traced to perturbations in gene expression following injury. To decipher normal and abnormal genetic responses to cutaneous injury, baseline gene expression of uninjured skin and injured skin must be better defined. Our aim for this study was to determine the gene expression profile of human skin immediately following injury using cDNA microarrays. Samples of normal and injured skin were obtained from 5 healthy females undergoing breast reduction surgery. Specimens of the epidermis and dermis were obtained at 30 minutes and 1 hour after the initial injury. RNA was extracted, reverse transcribed into cDNA and hybridized onto high-density cDNA microarray membranes of 4,000 genes. At 30 minutes, injury resulted in a consistent increase (> 2x) in gene expression of 124 out of 4,000 genes (3%). These genes were primarily involved in transcription and signaling. None of the 4,000 genes were decreased (< 2x) at 30 minutes. At 1 hour only 46 out of the 4,000 genes were increased in expression (1.15%) but 264 out of 4,000 (6.6%) genes were decreased greater than 2 fold, indicating a silencing of many structural genes. We have identified several genes, namely, suppressor of cytokine signaling-1, rho HP1, and BB1, that are highly expressed after injury and may have an unappreciated role in regulating the initial inflammatory response. These data provide an initial high-throughput analysis of gene expression immediately following human skin injury and show the utility and future importance of high-throughput analysis in skin biology and wound repair.

COMPARISON OF NORMAL HUMAN SKIN GENE EXPRESSION USING CDNA MICROARRAYS

Perturbations in normal wound healing may be traced to perturbations in gene expression in uninjured skin. In order to decipher normal and abnormal genetic responses to cutaneous injury, baseline gene expression in uninjured skin must first be defined. There is little data on gene expression profiles of normal human skin, i.e., which genes tend to be variable in expression and which tend to remain comparable. Therefore this study was designed to determine the degree of variability in human skin mRNA expression. Samples of normal skin were obtained from 9 healthy females undergoing breast reduction surgery. RNA was extracted, reverse transcribed into radiolabeled cDNA and hybridized onto cDNA microarrays of approximately 4400 genes. Gene expression intensities from the 9 samples were normalized and compared as a ratio of highest/lowest expression intensity. Deviation greater than 2 standard deviations from the mean of each gene was used as a cut-off. Seventy-one genes (1.7%) were substantially variable in their expression. These included genes coding for transport proteins, gene transcription, cell signaling proteins, and cell surface proteins. We found minimal variability in the matrix genes, growth factor genes and other groups of genes that are the most often studied in wound healing research. A small but definite variability in gene expression across 9 samples of clinically comparable specimens of normal skin was detected. This is in keeping with clinical observations of the variability in normal skin across individuals. These data provide high-throughput comparison of normal skin gene expression and suggest new molecules that may be studied in skin biology and perhaps, wound repair.

The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial

BACKGROUND

Enteral feeding provides nutrients for patients who require endotracheal tubes and mechanical ventilation. There is a presumed increase in the risk of ventilator-associated pneumonia (VAP) with tube feeding. This has stimulated the development of procedures for duodenal intubation and small intestinal (SI) feeding as primary prophylaxes to prevent VAP.

OBJECTIVE

To investigate the rate of VAP and adequacy of nutrient delivery with gastric (G) vs. SI feeding.

DESIGN

A prospective, randomized, controlled trial.

SETTING

A medical intensive care unit of a county hospital.

PATIENTS

A total of 44 endotracheally intubated, mechanically ventilated patients requiring enteral nutrition.

INTERVENTION

Subjects were randomized to receive enteral nutrition via G or SI feeding. Protocols directed the placement of the feeding tube and the infusion of enteral nutrition and defined the radiographic and clinical criteria for a diagnosis of VAP.

MEASUREMENTS AND OUTCOMES

The incidence of VAP and the adequacy of nutritional supplementation were prospectively followed. The relative risk of VAP with SI was 1.1 (95% confidence interval 0.96-2.44) compared with G. The SI group received a greater percentage of their caloric requirements (SI 69 +/- 7% vs. G 47 +/- 7%, mean +/- SEM, p < .05). Mortality did not differ between G (26 +/- 9%) and SI (24 +/- 10, p = .86).

CONCLUSIONS

There is no clear difference in the incidence of VAP in SI compared with G enteral nutrition. Patients given feeding into the SI do receive higher calorie and protein intakes.

The pan-neural bHLH proteins DEADPAN and ASENSE regulate mitotic activity and cdk inhibitor dacapo expression in the Drosophila larval optic lobes

Developmental regulators and cell cycle regulators have to interface in order to ensure appropriate cell proliferation during organogenesis. Our analysis of the roles of the pan-neural genes deadpan and asense defines critical roles for these genes in regulation of mitotic activities in the larval optic lobes. Loss of deadpan results in reduced cell proliferation, while ectopic deadpan expression causes over-proliferation. In contrast, loss of asense results in increased proliferation, while ectopic asense expression causes reduced proliferation. Consistent with these observations endogenous Deadpan is expressed in mitotic areas of the optic lobes, and endogenous Asense is expressed in cells that will become quiescent. Altered Deadpan or Asense expression results in altered expression of the cyclin dependent kinase inhibitor gene dacapo. Thus, regulation of mitotic activity during optic lobe development may, at least in part, involve deadpan and asense mediated regulation of the cyclin dependent kinase inhibitor gene dacapo. genesis 26:77-85, 2000.

Phase I study of docetaxel dose escalation in combination with fixed weekly gemcitabine in patients with advanced malignancies

PURPOSE

To determine the maximum-tolerated dose of monthly docetaxel combined with fixed-dose weekly gemcitabine and describe the dose-limiting toxicities (DLTs) of the combination.

PATIENTS AND METHODS

Patients with refractory solid tumors were treated with gemcitabine days 1, 8, and 15 every 4 weeks at a fixed dose of 800 mg/m2. Two docetaxel administration schedules were studied, with the drug administered either day 1 or day 15 at doses of 45, 60, 75, and 100 mg/m2 per cycle.

RESULTS

Forty patients received 132 cycles of chemotherapy. On the day-1 schedule, the maximum-tolerated docetaxel dose was the highest planned dose of 100 mg/m2 with two DLT episodes among 12 patients treated with 34 cycles at this dose level. On the day-15 schedule, delivery of the planned docetaxel doses was not feasible because of thrombocytopenia and hepatic dysfunction. Hematologic toxicities included grade 4 neutropenia in 16 patients, with three episodes of febrile neutropenia; grades 3 to 4 thrombocytopenia in nine patients; and anemia that required RBC transfusions in 10 patients. For patients treated at the highest docetaxel dose level, myelosuppression was not dose limiting and only one of 34 cycles was complicated by febrile neutropenia. The most common nonhematologic toxicities were asthenia, flu-like symptoms, and fluid retention. Antineoplastic activity was noteworthy, with partial responses in nine of 21 patients with pretreated non-small-cell lung cancer (NSCLC; 43%; 95% confidence interval, 22 to 66), in four of seven patients with breast cancer, and in one patient with esophageal adenocarcinoma.

CONCLUSION

Gemcitabine 800 mg/m2 days 1,8, and 15 can be safely combined with docetaxel 100 mg/m2 day 1 of a 28-day cycle. The observed antitumor activity warrants phase II evaluation.

How to diagnose hypopituitarism. Learning the features of secondary hormonal deficiencies

Hypopituitarism has many causes and various clinical presentations. Diagnosis depends on history taking, clinical suspicion, and an understanding of the hypothalamic-pituitary-target organ axes for proper interpretation of laboratory data. In the patient described in the case report, amenorrhea and inability to lactate were early clinical clues to a possible pituitary problem, but she felt otherwise fairly well over the years and did not seek evaluation. Thyroid-function tests showed normal thyrotropin measurements, but they were inappropriately low for the low T4 concentrations, indicating pituitary thyrotropin deficiency. Given the patient's obstetric history and overall clinical course, hypopituitarism resulting from postpartum pituitary necrosis was suspected. Magnetic resonance imaging of the pituitary was performed, and she was treated with glucocorticoids, T4 replacement, and estrogen-progesterone replacement. We expected her to do well. In general, the long-term outlook for patients with hypopituitarism is excellent, once the problem is diagnosed. Clinical signs and symptoms should be completely relieved by adequate hormone-replacement therapy, and with proper long-term follow-up and special attention during intercurrent illness, there should be no adverse outcomes.

Pseudoaneurysm secondary to pancreatitis presenting as GI bleeding

Pseudoaneurysm formation is a rare but potentially dev approximately astating complication of pancreatitis. It can be diag approximately nosed by using various imaging modalities including computer tomography, ultrasound, and angiography and should be entertained in any patient with a history of pancreatitis. We present the imaging findings in three patients with pseudoaneurysm formation secondary to pancreatitis who initially presented with gastrointestinal bleeding.

Thyroid dysfunction: how to manage overt and subclinical disease in older patients

Thyroid dysfunction is relatively common in older patients, but its clinical presentation varies. It may be obvious from the classic presenting symptoms, or it may be asymptomatic and discovered incidentally during routine testing. The clinical diagnosis of hypothyroidism and hyperthyroidism can be difficult in older patients, because many of the usual symptoms may be mistaken for the effects of aging or other medical conditions. Even so, these diseases in their overt forms are always significant and require treatment. On the other hand, subclinical hypo- and hyperthyroidism are often incidental biochemical abnormalities that may or may not require intervention.

Dacapo, a cyclin-dependent kinase inhibitor, stops cell proliferation during Drosophila development

Most cell types in multicellular eukaryotes exit from the mitotic cell cycle before terminal differentiation. We show that the dacapo gene is required to arrest the epidermal cell proliferation at the correct developmental stage during Drosophila embryogenesis. dacapo encodes an inhibitor of cyclin E/cdk2 complexes with similarity to the vertebrate Cip/Kip inhibitors. dacapo is transiently expressed beginning late in the G2 phase preceding the terminal division (mitosis 16). Mutants unable to express the inhibitor fail to arrest cell proliferation after mitosis 16 and progress through an extra division cycle. Conversely, premature dacapo expression in transgenic embryos results in a precocious G1 arrest.

Skeletal response to immobilization in Paget's disease of bone: a case report

The authors discuss a case of Paget's disease of the forearm in which the Pagetic radius and non-Pagetic ulna responded differently to immobilization. The high turnover state of Pagetic bone is more sensitive to physical unloading than normal bone, and thus more rapidly develops osteopenia of immobilization. The different responses to immobilization between Pagetic bone and site controlled normal bone illustrate how physical and metabolic factors interact at a skeletal site to regulate bone remodeling and bone mass.

Factors affecting treatment decisions and satisfaction of owners of cats with cancer

Cancer in cats is being diagnosed with increasing frequency. Euthanasia or an active intervention such as chemotherapy, radiation therapy, or surgery are treatment choices for the owner at diagnosis of the cat's disease. In this study, 2 interviews with cat owners, one soon after diagnosis of cancer in the cat and one 6 months later, were used to identify owner characteristics associated with a decision of euthanasia or intervention, to identify factors associated with an owner's satisfaction with euthanasia or intervention, and to evaluate inappropriate expectations of the owners who selected an intervention. The study included 89 owners from 3 referral hospitals. In logistic regression analysis, significant factors were not found that affected the owner's decision to euthanatize the cat versus intervene. Satisfaction with the decision to euthanatize the cat was associated with the ability of the cat to groom itself, eat, and play at the first interview. Among owners who selected an intervention, 4 combinations of factors were associated with being satisfied. The first combination was clinic of origin (CLIN), having a live cat at the 6-month follow-up interview (LIVE), and understanding the number of return visits required for the intervention. The second was CLIN, LIVE, and type and frequency of adverse effects from the intervention at the 6-month interview. The third was CLIN, LIVE, and feeling guilty at the 6-month interview. The fourth was CLIN, LIVE, and whether the cat had a good or excellent quality of life at the first interview. Thirty percent (21/69) of the owners tended to overestimate their cats' life expectancy. Owners also felt they had reasonably accurate estimations of adverse effects of treatment and number of return visits, but underestimated the costs required for an intervention. For owners who elect an intervention, a reminder from the veterinarian that emotional upheavals may develop even after the decision has been made is important. To provide optimal patient care and client education, veterinarians must find a middle ground between being knowledgeable, practical, and informed, and being compassionate and approachable.

Post-transcriptional stimulation of transforming growth factor beta 1 mRNA by TGF-beta 1 treatment of transformed human osteoblasts

Following exogenous administration of transforming growth factor-beta 1 (TGF-beta 1) polypeptide to the human osteosarcoma cell line TE-85, we observed a 2- to 6-fold stimulation of steady-state TGF-beta 1 mRNA. The stimulation was dose- and time-dependent, as judged from Northern blot hybridization analyses. A 2- to 6-fold increase of the TGF-beta 1 polypeptide was also found in the media of these cells after TGF-beta 1 treatments. The autostimulation of TGF-beta 1 mRNA was nullified by cycloheximide treatment of the cells. The in vitro transcription rates of the TGF-beta 1 gene by isolated nuclei were not altered by TGF-beta 1 treatment. Under conditions of transcriptional inhibition, the stability of TGF-beta 1 mRNA was enhanced nearly two-fold by TGF-beta 1 treatment. Our findings indicate that TGF-beta 1 can stimulate autologous gene expression and subsequent polypeptide translation by a post-transcriptional mechanism requiring protein synthesis in human osteoblast-like cells. The recognized versatility of TGF-beta 1 autostimulation mechanisms (transcriptional and post-transcriptional) in other mesenchymal cells may apply also to skeletal cells, further underscoring the broad and potent activities of this cytokine.

Olfactory performance during childhood. II. Developing a discrimination task for children

OBJECTIVES

(1) To create a match-to-sample odorant discrimination task (MODT) for children and adolescents; (2) to assess whether nonolfactory factors affect olfactory performance more on an identification task than on the MODT; (3) to evaluate subjects with olfactory dysfunction; and (4) to create age-appropriate sets of odorants for use in the MODT format to test children of different ages.

STUDY DESIGN

We tested 75 normal children, aged 2 to 18 years, and 17 other subjects, aged 7 to 53 years, with known or suspected olfactory dysfunction, with the MODT. We compared the age trends in variability of scores on the MODT with those on an odorant identification task, using a weighted linear regression analysis.

RESULTS

The MODT was useful in children aged 5 years and older, but not generally in the 2- to 4-year-old children. There was an appreciable age trend in the variability of the scores on the identification task but not on the MODT. Mean MODT scores for subjects with suspected or known olfactory dysfunction were far below average. Finally, we created four sets of odorants that will likely be sensitive to age-specific changes in olfactory performance.

CONCLUSIONS

The MODT appears to be a suitable test instrument to assess olfaction in children aged 5 and older and is less likely to be influenced by nonolfactory factors than an identification task. According to our preliminary results, it is likely that the MODT will allow us to detect olfactory deficits in children of many ages.

Assessment of an abbreviated odorant identification task for children: a rapid screening device for schools and clinics

To validate the level of olfactory performance of children, we tested 825 volunteers, aged 4-17 years, with an abbreviated form of our pediatric odorant identification task. The test consisted of sniffing and identifying five odorants (baby powder, bubble gum, candy cane, licorice and peach). Mean olfactory scores increased as a function of age, reaching a plateau of about 94-95% correct at 8 years of age. In general, girls out-performed boys. Physicians require a test instrument such as the one we have devised to allow them to diagnose olfactory dysfunction in children. The present task is particularly applicable in screening large numbers of children in clinics or schools because it can be administered easily and rapidly. Adult subjects with olfactory dysfunction also performed poorly on this odorant identification task designed for children. Therefore, we expect that our odorant identification task will also detect children with severe olfactory dysfunction.

Cytogenetic and histologic findings in 17 pulmonary chondroid hamartomas: evidence for a pathogenetic relationship with lipomas and leiomyomas

Pulmonary chondroid hamartomas (PCH) are benign tumors that contain mesenchymal and epithelial components. In this series, we identified clonal chromosome aberrations in mesenchymal cells from 10 of 17 PCH. Chromosome band 12q15 was rearranged most frequently (N = 4), and one case had a t(12;14)(q15;q24) that was identical cytogenetically to the characteristic translocation in uterine leiomyomas. Histologic review revealed diverse mesenchymal populations, including undifferentiated cells, cartilage, adipose tissue, and smooth muscle, in most of the PCH. These findings suggest that PCH result from neoplastic transformation of a primitive mesenchymal cell that differentiates along chondroid, adipose, and smooth muscle pathways.

Gastrointestinal perforation or vascular injury? A diagnostic dilemma for computed tomography in blunt abdominal trauma

The authors describe an unconscious 20-year-old woman with Crohn's disease who was examined after a motor vehicle accident. During dynamic computed tomography after intravenous and oral administration of contrast material, contrast agent was observed in the peritoneal cavity. The source of the free contrast material was active bleeding, but it was initially mistaken for extravasation from the bowel. Exploratory laparotomy revealed transection of the superior mesenteric vein.