Fully Automatic Fine-Grained Grading of Lumbar Intervertebral Disc Degeneration Using Regional Feature Recalibration Network

Accurate fine-grained grading of lumbar intervertebral disc (LIVD) degeneration is essential for the diagnosis and treatment design of high-incidence low back pain. However, the grading accuracy is still challenged by lacking the fine-grained degenerative details, which is mainly due to the existing grading methods are easily dominated by the salient nucleus pulposus regions in LIVD, overlooking the inconspicuous degeneration changes of the surrounding structures. In this study, a novel regional feature recalibration network (RFRecNet) is proposed to achieve accurate and reliable LIVD degeneration grading. Detection transformer (DETR) is first utilized to detect all LIVDs and then input to the proposed RFRecNet for the fine-grained grading. To obtain sufficient features from both the salient nucleus pulposus and the surrounding regions, a regional cube-based feature boosting and suppression (RC-FBS) module is designed to adaptively recalibrate the feature extraction and utilization from the various regions in LIVD, and a feature diversification (FD) module is proposed to capture the complementary semantic information from the multi-scale features for the comprehensive fine-grained degeneration grading. Extensive experiments were conducted on a clinically collected dataset, which consists of 500 MR scans with a total of 10225 LIVDs. An average grading accuracy of 90.5%, specificity of 97.5%, sensitivity of 90.8%, and Cohen's kappa correlation coefficient of 0.876 are obtained, which indicate that the proposed framework is promising to provide doctors with reliable and consistent fine-grained quantitative evaluation results of the LIVD degeneration conditions for the optimal surgical plan design.

Visual interpretable MRI fine grading of meniscus injury for intelligent assisted diagnosis and treatment

Meniscal injury represents a common type of knee injury, accounting for over 50% of all knee injuries. The clinical diagnosis and treatment of meniscal injury heavily rely on magnetic resonance imaging (MRI). However, accurately diagnosing the meniscus from a comprehensive knee MRI is challenging due to its limited and weak signal, significantly impeding the precise grading of meniscal injuries. In this study, a visual interpretable fine grading (VIFG) diagnosis model has been developed to facilitate intelligent and quantified grading of meniscal injuries. Leveraging a multilevel transfer learning framework, it extracts comprehensive features and incorporates an attributional attention module to precisely locate the injured positions. Moreover, the attention-enhancing feedback module effectively concentrates on and distinguishes regions with similar grades of injury. The proposed method underwent validation on FastMRI_Knee and Xijing_Knee dataset, achieving mean grading accuracies of 0.8631 and 0.8502, surpassing the state-of-the-art grading methods notably in error-prone Grade 1 and Grade 2 cases. Additionally, the visually interpretable heatmaps generated by VIFG provide accurate depictions of actual or potential meniscus injury areas beyond human visual capability. Building upon this, a novel fine grading criterion was introduced for subtypes of meniscal injury, further classifying Grade 2 into 2a, 2b, and 2c, aligning with the anatomical knowledge of meniscal blood supply. It can provide enhanced injury-specific details, facilitating the development of more precise surgical strategies. The efficacy of this subtype classification was evidenced in 20 arthroscopic cases, underscoring the potential enhancement brought by intelligent-assisted diagnosis and treatment for meniscal injuries.

Robust and efficient abdominal CT segmentation using shape constrained multi-scale attention network

PURPOSE

Although many deep learning-based abdominal multi-organ segmentation networks have been proposed, the various intensity distributions and organ shapes of the CT images from multi-center, multi-phase with various diseases introduce new challenges for robust abdominal CT segmentation. To achieve robust and efficient abdominal multi-organ segmentation, a new two-stage method is presented in this study.

METHODS

A binary segmentation network is used for coarse localization, followed by a multi-scale attention network for the fine segmentation of liver, kidney, spleen, and pancreas. To constrain the organ shapes produced by the fine segmentation network, an additional network is pre-trained to learn the shape features of the organs with serious diseases and then employed to constrain the training of the fine segmentation network.

RESULTS

The performance of the presented segmentation method was extensively evaluated on the multi-center data set from the Fast and Low GPU Memory Abdominal oRgan sEgmentation (FLARE) challenge, which was held in conjunction with International Conference on Medical Image Computing and Computer Assisted Intervention (MICCAI) 2021. Dice Similarity Coefficient (DSC) and Normalized Surface Dice (NSD) were calculated to quantitatively evaluate the segmentation accuracy and efficiency. An average DSC and NSD of 83.7% and 64.4% were achieved, and our method finally won the second place among more than 90 participating teams.

CONCLUSIONS

The evaluation results on the public challenge demonstrate that our method shows promising performance in robustness and efficiency, which may promote the clinical application of the automatic abdominal multi-organ segmentation.

Urinary complement proteins and risk of end-stage renal disease: quantitative urinary proteomics in patients with type 2 diabetes and biopsy-proven diabetic nephropathy

PURPOSE

To investigate the association between urinary complement proteins and renal outcome in biopsy-proven diabetic nephropathy (DN).

METHODS

Untargeted proteomic and Kyoto Encyclopedia of Genes and Genomes (KEGG) functional analyses and targeted proteomic analysis using parallel reaction-monitoring (PRM)-mass spectrometry was performed to determine the abundance of urinary complement proteins in healthy controls, type 2 diabetes mellitus (T2DM) patients, and patients with T2DM and biopsy-proven DN. The abundance of each urinary complement protein was individually included in Cox proportional hazards models for predicting progression to end-stage renal disease (ESRD).

RESULTS

Untargeted proteomic and functional analysis using the KEGG showed that differentially expressed urinary proteins were primarily associated with the complement and coagulation cascades. Subsequent urinary complement proteins quantification using PRM showed that urinary abundances of C3, C9, and complement factor H (CFAH) correlated negatively with annual estimated glomerular filtration rate (eGFR) decline, while urinary abundances of C5, decay-accelerating factor (DAF), and CD59 correlated positively with annual rate of eGFR decline. Furthermore, higher urinary abundance of CFAH and lower urinary abundance of DAF were independently associated with greater risk of progression to ESRD. Urinary abundance of CFAH and DAF had a larger area under the curve (AUC) than that of eGFR, proteinuria, or any pathological parameter. Moreover, the model that included CFAH or DAF had a larger AUC than that with only clinical or pathological parameters.

CONCLUSION

Urinary abundance of complement proteins was significantly associated with ESRD in patients with T2DM and biopsy-proven DN, indicating that therapeutically targeting the complement pathway may alleviate progression of DN.

Automatic segmentation and grading of ankylosing spondylitis on MR images via lightweight hybrid multi-scale convolutional neural network with reinforcement learning

Objective.Ankylosing spondylitis (AS) is a disabling systemic disease that seriously threatens the patient's quality of life. Magnetic resonance imaging (MRI) is highly preferred in clinical diagnosis due to its high contrast and tissue resolution. However, since the uncertainty and intensity inhomogeneous of the AS lesions in MRI, it is still challenging and time-consuming for doctors to quantify the lesions to determine the grade of the patient's condition. Thus, an automatic AS grading method is presented in this study, which integrates the lesion segmentation and grading in a pipeline.Approach. To tackle the large variations in lesion shapes, sizes, and intensity distributions, a lightweight hybrid multi-scale convolutional neural network with reinforcement learning (LHR-Net) is proposed for the AS lesion segmentation. Specifically, the proposed LHR-Net is equipped with the newly proposed hybrid multi-scale module, which consists of multiply convolution layers with different kernel sizes and dilation rates for extracting sufficient multi-scale features. Additionally, a reinforcement learning-based data augmentation module is utilized to deal with the subjects with diffuse and fuzzy lesions that are difficult to segment. Furthermore, to resolve the incomplete segmentation results caused by the inhomogeneous intensity distributions of the AS lesions in MR images, a voxel constraint strategy is proposed to weigh the training voxel labels in the lesion regions. With the accurately segmented AS lesions, automatic AS grading is then performed by a ResNet-50-based classification network.Main results. The performance of the proposed LHR-Net was extensively evaluated on a clinically collected AS MRI dataset, which includes 100 subjects. Dice similarity coefficient (DSC), average surface distance, Hausdorff Distance at95thpercentile (HD95), predicted positive volume, and sensitivity were employed to quantitatively evaluate the segmentation results. The average DSC of the proposed LHR-Net on the AS dataset reached 0.71 on the test set, which outperforms the other state-of-the-art segmentation method by 0.04.Significance. With the accurately segmented lesions, 31 subjects in the test set (38 subjects) were correctly graded, which demonstrates that the proposed LHR-Net might provide a potential automatic method for reproducible computer-assisted diagnosis of AS grading.

Using neural networks to extend cropped medical images for deformable registration among images with differing scan extents

PURPOSE

Missing or discrepant imaging volume is a common challenge in deformable image registration (DIR). To minimize the adverse impact, we train a neural network to synthesize cropped portions of head and neck CT's and then test its use in DIR.

METHODS

Using a training dataset of 409 head and neck CT's, we trained a generative adversarial network to take in a cropped 3D image and output an image with synthesized anatomy in the cropped region. The network used a 3D U-Net generator along with Visual Geometry Group (VGG) deep feature losses. To test our technique, for each of the 53 test volumes, we used Elastix to deformably register combinations of a randomly cropped, full, and synthetically full volume to a single cropped, full, and synthetically full target volume. We additionally tested our method's robustness to crop extent by progressively increasing the amount of cropping, synthesizing the missing anatomy using our network, and then performing the same registration combinations. Registration performance was measured using 95% Hausdorff distance across 16 contours.

RESULTS

We successfully trained a network to synthesize missing anatomy in superiorly and inferiorly cropped images. The network can estimate large regions in an incomplete image, far from the cropping boundary. Registration using our estimated full images was not significantly different from registration using the original full images. The average contour matching error for full image registration was 9.9 mm, whereas our method was 11.6, 12.1, and 13.6 mm for synthesized-to-full, full-to-synthesized, and synthesized-to-synthesized registrations, respectively. In comparison, registration using the cropped images had errors of 31.7 mm and higher. Plotting the registered image contour error as a function of initial preregistered error shows that our method is robust to registration difficulty. Synthesized-to-full registration was statistically independent of cropping extent up to 18.7 cm superiorly cropped. Synthesized-to-synthesized registration was nearly independent, with a -0.04 mm of change in average contour error for every additional millimeter of cropping.

CONCLUSIONS

Different or inadequate in scan extent is a major cause of DIR inaccuracies. We address this challenge by training a neural network to complete cropped 3D images. We show that with image completion, the source of DIR inaccuracy is eliminated, and the method is robust to varying crop extent.

Multi-task edge-recalibrated network for male pelvic multi-organ segmentation on CT images

Automated male pelvic multi-organ segmentation on CT images is highly desired for applications, including radiotherapy planning. To further improve the performance and efficiency of existing automated segmentation methods, in this study, we propose a multi-task edge-recalibrated network (MTER-Net), which aims to overcome the challenges, including blurry boundaries, large inter-patient appearance variations, and low soft-tissue contrast. The proposed MTER-Net is equipped with the following novel components. (a) To exploit the saliency and stability of femoral heads, we employed a light-weight localization module to locate the target region and efficiently remove the complex background. (b) We add an edge stream to the regular segmentation stream to focus on processing the edge-related information, distinguish the organs with blurry boundaries, and then boost the overall segmentation performance. Between the regular segmentation stream and edge stream, we introduce an edge recalibration module at each resolution level to connect the intermediate layers and deliver the higher-level activations from the regular stream to the edge stream to denoise the irrelevant activations. (c) Finally, using a 3D Atrous Spatial Pyramid Pooling (ASPP) feature fusion module, we fuse the features at different scales in the regular stream and the predictions from the edge stream to form the final segmentation result. The proposed segmentation network was evaluated on 200 prostate cancer patient CT images with manually delineated contours of bladder, rectum, seminal vesicle, and prostate. The segmentation performance of the proposed method was quantitatively evaluated using three metrics including Dice similarity coefficient (DSC), average surface distance (ASD), and 95% surface distance (95SD). The proposed MTER-Net achieves average DSC of 86.35%, ASD of 1.09 mm, and 95SD of 3.53 mm on the four organs, which outperforms the state-of-the-art segmentation networks by a large margin. Specifically, the quantitative DSC evaluation results of the four organs are 96.49% (bladder), 86.39% (rectum), 76.38% (seminal vesicle), and 86.14% (prostate), respectively. In conclusion, we demonstrate that the proposed MTER-Net efficiently attains superior performance to state-of-the-art pelvic organ segmentation methods.

Self-channel-and-spatial-attention neural network for automated multi-organ segmentation on head and neck CT images

Accurate segmentation of organs at risk (OARs) is necessary for adaptive head and neck (H&N) cancer treatment planning, but manual delineation is tedious, slow, and inconsistent. A self-channel-and-spatial-attention neural network (SCSA-Net) is developed for H&N OAR segmentation on CT images. To simultaneously ease the training and improve the segmentation performance, the proposed SCSA-Net utilizes the self-attention ability of the network. Spatial and channel-wise attention learning mechanisms are both employed to adaptively force the network to emphasize the meaningful features and weaken the irrelevant features simultaneously. The proposed network was first evaluated on a public dataset, which includes 48 patients, then on a separate serial CT dataset, which contains ten patients who received weekly diagnostic fan-beam CT scans. On the second dataset, the accuracy of using SCSA-Net to track the parotid and submandibular gland volume changes during radiotherapy treatment was quantified. The Dice similarity coefficient (DSC), positive predictive value (PPV), sensitivity (SEN), average surface distance (ASD), and 95% maximum surface distance (95SD) were calculated on the brainstem, optic chiasm, optic nerves, mandible, parotid glands, and submandibular glands to evaluate the proposed SCSA-Net. The proposed SCSA-Net consistently outperforms the state-of-the-art methods on the public dataset. Specifically, compared with Res-Net and SE-Net, which is constructed from squeeze-and-excitation block equipped residual blocks, the DSC of the optic nerves and submandibular glands is improved by 0.06, 0.03 and 0.05, 0.04 by the SCSA-Net. Moreover, the proposed method achieves statistically significant improvements in terms of DSC on all and eight of nine OARs over Res-Net and SE-Net, respectively. The trained network was able to achieve good segmentation results on the serial dataset, but the results were further improved after fine-tuning of the model using the simulation CT images. For the parotids and submandibular glands, the volume changes of individual patients are highly consistent between the automated and manual segmentation (Pearson's correlation 0.97-0.99). The proposed SCSA-Net is computationally efficient to perform segmentation (sim 2 s/CT).

The association of hematuria on kidney clinicopathologic features and renal outcome in patients with diabetic nephropathy: a biopsy-based study

PURPOSE

To investigate the relationships between hematuria, clinicopathological features and renal outcomes in patients with biopsy-proven diabetic nephropathy (DN).

METHODS

This cohort study included 261 patients with DN. Participants were divided into two groups according to number of red blood cells per high-power field (RBC/hpf) in urine sediment: the hematuria (-) group (≤ 3 RBC/hpf) and the hematuria (+) group (> 3 RBC/hpf). Basic clinical parameters were measured at the time of renal biopsy; relationships between hematuria and clinicopathological features and renal outcomes were analyzed.

RESULTS

Patients in the hematuria (+) group often had overt proteinuria. Interstitial inflammation was more severe in the hematuria (+) group than in the hematuria (-) group. Glomerular arteriolar hyalinosis, interstitial fibrosis and tubular atrophy were comparable between groups. For patients with early DN (eGFR ≥ 60 ml/min/1.73 m²), urinary RBC/hpf at baseline was positively correlated with glomerular classification, interstitial fibrosis/tubular atrophy scores and interstitial inflammation scores. In prognostic analysis, hematuria was associated with a higher risk of progression to end-stage renal disease. Hematuria remained an independent predictor after adjustment for confounding factors such as sex, age, duration of diabetes, serum glucose level, hypertension, cholesterol, eGFR and urine protein excretion, especially in patients with early DN and in male patients.

CONCLUSION

In this study, hematuria was associated with more severe renal pathologic lesions in patients with DN. The presence of hematuria could be an independent predictor of renal outcome in patients with early DN.

Self-paced DenseNet with boundary constraint for automated multi-organ segmentation on abdominal CT images

Automated multi-organ segmentation on abdominal CT images may replace or complement manual segmentation for clinical applications including image-guided radiation therapy. However, the accuracy of auto-segmentation is challenged by low image contrast, large spatial and inter-patient anatomical variations. In this study, we propose an end-to-end segmentation network, termed self-paced DenseNet, for improved multi-organ segmentation performance, especially for the difficult-to-segment organs. Specifically, a learning-based attention mechanism and dense connection block are seamlessly integrated into the proposed self-paced DenseNet to improve the learning capability and efficiency of the backbone network. To heavily focus on the organs showing low soft-tissue contrast and motion artifacts, a boundary condition is utilized to constrain the network optimization. Additionally, to ease the large learning pace discrepancies of individual organs, a task-wise self-paced-learning strategy is employed to adaptively control the learning paces of individual organs. The proposed self-paced DenseNet was trained and evaluated on a public abdominal CT data set consisting of 90 subjects with manually labeled ground truths of eight organs (including spleen, left kidney, esophagus, gallbladder, stomach, liver, pancreas, and duodenum). For quantitative evaluation, the Dice similarity coefficient (DSC) and average surface distance (ASD) were calculated. An average DSC of 84.46% and ASD of 1.82 mm were achieved on the eight organs, which outperforms the state-of-the-art segmentation methods 2.96% on DSC under the same experimental configuration. Moreover, the proposed segmentation method shows notable improvements on the duodenum and gallbladder, obtaining an average DSC of 69.26% and 80.94% and ASD of 2.14 mm and 2.24 mm, respectively. The results are markedly superior to the average DSC of 63.12% and 76.35% and average ASD of 3.87 mm and 4.33 mm using the vanilla DenseNet, respectively, for the two organs. We demonstrated the effectiveness of the proposed self-paced DenseNet to automatically segment abdominal organs with low boundary conspicuity. The self-paced DenseNet achieved consistently superior segmentation performance on eight abdominal organs with varying segmentation difficulties. The demonstrated computational efficiency (<2 s/CT) makes it well-suited for online applications.

Five-year Survival Rate of Bonded Dental Restorations in Frail Older Adults

INTRODUCTION

Frail older adults residing in long-term care (LTC) facilities are among the most vulnerable to dental caries due to poor oral hygiene (OH), medication-related salivary hypofunction, carbohydrate-rich diets, and limited access to dental care. Providing dental restorations for LTC patients is challenging, and there are few studies investigating the longevity of restorations in this cohort. Multiple restorative materials have been used to restore tooth anatomy as well as address caries prevention using fluoride-based materials.

OBJECTIVES

This study examined the longevity of bonded direct restorations placed in LTC patients. Specifically, we examined whether a difference in survival exists between resin composite (RC) and glass ionomer cement (GIC) direct restorations in frail older adults residing in LTC.

METHODS

Tooth-colored restorations placed in LTC patients between 2007 and 2012, within the University of British Columbia Geriatric Dentistry Program, were followed annually up to 5 y or until they incurred an event (i.e., re-restoration or tooth extraction) or the patient was lost to follow-up or deceased. Restoration status was documented within the Clinical Oral Disorder in Elders (CODE) Index annual oral health assessments. Mixed-effect logistic regression was calculated to determine hazard ratios, address within-patient correlation, and measure the effect size of multiple covariates.

RESULTS

A total of 3,201 dental restorations placed in 846 LTC patients were followed. This cohort of patients had a mean age of 86 y and high levels of oral and systemic disease. Over half were wheelchair bound and had compromised ability to perform OH. The overall 5-y survival rate was 60.3%, and there was no statistically significant difference in survival between RC and GIC.

CONCLUSION

Tooth-colored restorations had reasonable longevity in LTC patients and had comparable survival to restorations placed in functionally independent, community-dwelling geriatric populations. No difference between RC and GIC was found with regards to restoration longevity in this population.

KNOWLEDGE TRANSFER STATEMENT

Direct restorations provided to frail older adults residing in LTC have reasonable longevity and should be expected to survive for the remainder of the patient's life. As no detectable difference exists in survival rates between RC and GIC, operators should select appropriate restorative materials based on clinical conditions, patient factors, physical properties, and personal preference.

Shape constrained fully convolutional DenseNet with adversarial training for multiorgan segmentation on head and neck CT and low-field MR images

PURPOSE

Image-guided radiotherapy provides images not only for patient positioning but also for online adaptive radiotherapy. Accurate delineation of organs-at-risk (OARs) on Head and Neck (H&N) CT and MR images is valuable to both initial treatment planning and adaptive planning, but manual contouring is laborious and inconsistent. A novel method based on the generative adversarial network (GAN) with shape constraint (SC-GAN) is developed for fully automated H&N OARs segmentation on CT and low-field MRI.

METHODS AND MATERIAL

A deep supervised fully convolutional DenseNet is employed as the segmentation network for voxel-wise prediction. A convolutional neural network (CNN)-based discriminator network is then utilized to correct predicted errors and image-level inconsistency between the prediction and ground truth. An additional shape representation loss between the prediction and ground truth in the latent shape space is integrated into the segmentation and adversarial loss functions to reduce false positivity and constrain the predicted shapes. The proposed segmentation method was first benchmarked on a public H&N CT database including 32 patients, and then on 25 0.35T MR images obtained from an MR-guided radiotherapy system. The OARs include brainstem, optical chiasm, larynx (MR only), mandible, pharynx (MR only), parotid glands (both left and right), optical nerves (both left and right), and submandibular glands (both left and right, CT only). The performance of the proposed SC-GAN was compared with GAN alone and GAN with the shape constraint (SC) but without the DenseNet (SC-GAN-ResNet) to quantify the contributions of shape constraint and DenseNet in the deep neural network segmentation.

RESULTS

The proposed SC-GAN slightly but consistently improve the segmentation accuracy on the benchmark H&N CT images compared with our previous deep segmentation network, which outperformed other published methods on the same or similar CT H&N dataset. On the low-field MR dataset, the following average Dice's indices were obtained using improved SC-GAN: 0.916 (brainstem), 0.589 (optical chiasm), 0.816 (mandible), 0.703 (optical nerves), 0.799 (larynx), 0.706 (pharynx), and 0.845 (parotid glands). The average surface distances ranged from 0.68 mm (brainstem) to 1.70 mm (larynx). The 95% surface distance ranged from 1.48 mm (left optical nerve) to 3.92 mm (larynx). Compared with CT, using 95% surface distance evaluation, the automated segmentation accuracy is higher on MR for the brainstem, optical chiasm, optical nerves and parotids, and lower for the mandible. The SC-GAN performance is superior to SC-GAN-ResNet, which is more accurate than GAN alone on both the CT and MR datasets. The segmentation time for one patient is 14 seconds using a single GPU.

CONCLUSION

The performance of our previous shape constrained fully CNNs for H&N segmentation is further improved by incorporating GAN and DenseNet. With the novel segmentation method, we showed that the low-field MR images acquired on a MR-guided radiation radiotherapy system can support accurate and fully automated segmentation of both bony and soft tissue OARs for adaptive radiotherapy.

Fully automatic multi-organ segmentation for head and neck cancer radiotherapy using shape representation model constrained fully convolutional neural networks

PURPOSE

Intensity modulated radiation therapy (IMRT) is commonly employed for treating head and neck (H&N) cancer with uniform tumor dose and conformal critical organ sparing. Accurate delineation of organs-at-risk (OARs) on H&N CT images is thus essential to treatment quality. Manual contouring used in current clinical practice is tedious, time-consuming, and can produce inconsistent results. Existing automated segmentation methods are challenged by the substantial inter-patient anatomical variation and low CT soft tissue contrast. To overcome the challenges, we developed a novel automated H&N OARs segmentation method that combines a fully convolutional neural network (FCNN) with a shape representation model (SRM).

METHODS

Based on manually segmented H&N CT, the SRM and FCNN were trained in two steps: (a) SRM learned the latent shape representation of H&N OARs from the training dataset; (b) the pre-trained SRM with fixed parameters were used to constrain the FCNN training. The combined segmentation network was then used to delineate nine OARs including the brainstem, optic chiasm, mandible, optical nerves, parotids, and submandibular glands on unseen H&N CT images. Twenty-two and 10 H&N CT scans provided by the Public Domain Database for Computational Anatomy (PDDCA) were utilized for training and validation, respectively. Dice similarity coefficient (DSC), positive predictive value (PPV), sensitivity (SEN), average surface distance (ASD), and 95% maximum surface distance (95%SD) were calculated to quantitatively evaluate the segmentation accuracy of the proposed method. The proposed method was compared with an active appearance model that won the 2015 MICCAI H&N Segmentation Grand Challenge based on the same dataset, an atlas method and a deep learning method based on different patient datasets.

RESULTS

An average DSC = 0.870 (brainstem), DSC = 0.583 (optic chiasm), DSC = 0.937 (mandible), DSC = 0.653 (left optic nerve), DSC = 0.689 (right optic nerve), DSC = 0.835 (left parotid), DSC = 0.832 (right parotid), DSC = 0.755 (left submandibular), and DSC = 0.813 (right submandibular) were achieved. The segmentation results are consistently superior to the results of atlas and statistical shape based methods as well as a patch-wise convolutional neural network method. Once the networks are trained off-line, the average time to segment all 9 OARs for an unseen CT scan is 9.5 s.

CONCLUSION

Experiments on clinical datasets of H&N patients demonstrated the effectiveness of the proposed deep neural network segmentation method for multi-organ segmentation on volumetric CT scans. The accuracy and robustness of the segmentation were further increased by incorporating shape priors using SMR. The proposed method showed competitive performance and took shorter time to segment multiple organs in comparison to state of the art methods.

A novel homozygous mutation in the solute carrier family 12 member 3 gene in a Chinese family with Gitelman syndrome

Loss of function of mutated solute carrier family 12 member 3 (SLC12A3) gene is the most frequent etiology for Gitelman syndrome (GS), which is mainly manifested by hypokalemia, hypomagnesemia and hypocalciuria. We report the genetic characteristics of one suspicious Chinese GS pedigree by gene sequencing. Complete sequencing analysis of the SLC12A3 gene revealed that both the proband and his elder sister had a novel homozygous SLC12A3 mutation: c.2099T>C and p.Leu700Pro. Moreover, the SLC12A3 genes of his mother and daughter encoded the same mutated heterozygote. It was noted that in this pedigree, only the proband complained about recurrent episodes of bilateral lower limb weakness over 8 years, while his elder sister, mother and daughter did not present symptoms. The inconsistent clinical features of this pedigree implied that besides diverse phenotypes possibly originated from the same genotype, gender difference may also dominate the variant GS phenotypes. Further genetic and proteomic research are needed to investigate the precise mechanisms of GS, including the study of specific ethnicities.

A novel SLC12A3 gene homozygous mutation of Gitelman syndrome in an Asian pedigree and literature review

OBJECTIVES

Gitelman syndrome (GS) is an autosomal recessive disease characterized by hypokalemic metabolic alkalosis in combination with significant hypomagnesemia and hypocalciuria which is caused by mutations in the SLC12A3 gene. In this study, we reported a case of GS pedigree and reviewed pertinent literature so as to explore the relationship between clinical characteristics and genotype meanwhile provide recommendations for the diagnosis and treatment of GS.

DESIGN AND METHODS

This is a pedigree-based genetic study of GS and 11 members from one family were included. We summarized their clinical features, analyzed laboratory parameters related to GS and SLC12A3 gene.

RESULTS

The proband experienced intermittent severe symptoms of weakness accompanied by significant hypokalemia, hypomagnesemia and hypocalciuria in laboratory test with poor treatments. His mother had more slight symptoms of weakness than him with mild hypokalemia and hypocalciuria. Mild hypomagnesemia was also observed in his sister with occasional weakness. All other pedigree members had normal laboratory test with no GS-related symptoms. A homozygous mutation of SLC12A3 gene (c.488C > T) was detected by genetic testing in three members, and six were carriers of this mutation.

CONCLUSIONS

Genotype and phenotype vary significantly among GS patients. Male patients tend to experience more severe symptoms and poor treatment effect. Further large-scale population, animal, and molecular biology experiments are required to investigate the complexity of GS and to find a better treatment regimen for this disease.

Adipose afferent reflex response to insulin is mediated by melanocortin 4 type receptors in the paraventricular nucleus in insulin resistance rats

BACKGROUND

Adipose afferent reflex (AAR) contributes to sympathetic activation and hypertension. Paraventricular nucleus (PVN) plays an important role in AAR and sympathetic outflow. The aim of the present study was to determine whether PVN mediates AAR response to insulin in a rat model of insulin resistance (IR).

METHODS

Male Sprague-Dawley rats were randomly divided into Control and IR groups. Insulin resistance was induced by supplementing fructose (125 g L(-1) , 12 weeks) in the drinking water. Renal sympathetic nerve activity (RSNA) and mean arterial pressure (MAP) were recorded in anesthetized rats. AAR was evaluated by the RSNA and MAP responses to injection of capsaicin into four sites of right inguinal white adipose tissue.

RESULTS

Rats in IR group showed a rise in plasma noradrenaline (NE), glucose, insulin and triglyceride levels, left ventricular weight, systolic blood pressure, homeostasis model assessment of insulin resistance (HOMA-IR) and PVN glucose and insulin levels, melanocortin 4 type receptors (MC4Rs) protein expression, but not MC3Rs and insulin receptors. Compared with Control group, AAR in IR group was significantly enhanced, which contributed to the elevation of NE level; and insulin microinjection into the PVN or the third ventricle significantly strengthened AAR, which was attenuated by pre-treatment with MC4Rs antagonist HS024 and anti-insulin affibody, respectively, but not insulin receptors antagonist S961.

CONCLUSION

The enhanced AAR participates in sympathetic activation in IR, which can be strengthened by PVN insulin. PVN MC4Rs mediate the AAR response to insulin in IR, but not MC3Rs and insulin receptors.

Effect of miR-146a polymorphism on biochemical recurrence risk after radical prostatectomy in southern Chinese population

Evidence has shown that miR-146a is involved in carcinogenesis and a common G/C variant (rs2910164) in the pre-miR-146a gene has been found to be associated with various cancers. We investigated the potential prognostic role of miR-146a polymorphism in prostate cancer after radical prostatectomy. Seventy-two southern Chinese with prostate cancer undergoing radical prostatectomy were included in this study. miR-146a polymorphism was analyzed by PCR-RFLP. Its prognostic role in biochemical recurrence was assessed using Kaplan-Meier analysis and Cox regression model. We did not find a significant association between miR-146a polymorphism and prostrate-specific antigen failure in the Chinese population [HR (95%CI): 0.83 (0.30-2.32) for CC vs GG/GC]. However, high Gleason score (over 8) was associated with increased biochemical recurrence and poorer PSA-free survival. This study was limited by the length of follow-up. Future studies with longer follow-up would allow evaluation of more direct metrics, such as disease-specific survival, metastasis-free survival, and overall survival.

Acarbose monotherapy and weight loss in Eastern and Western populations with hyperglycaemia: an ethnicity-specific meta-analysis

OBJECTIVE

To demonstrate if weight loss achieved with acarbose in individuals with hyperglycaemia differs between Eastern and Western populations.

METHODS

Databases and reference lists of clinical trials on acarbose were searched. Eligible studies were randomised controlled trials of acarbose monotherapy in populations with hyperglycaemia of more than 12-week duration that provided data on body weight (BW) or body mass index (BMI).

RESULTS

A total of 34 trials (6082 participants) were included. The effect of acarbose on BW was superior to that of placebo [weighted mean difference (WMD) = -0.52, 95% confidence interval (CI) -0.78 to -0.25], nateglinide (WMD = -1.33, 95% CI -1.51 to -0.75) and metformin (WMD = -0.67, 95% CI -1.14 to -0.20). Compared with placebo, there was a significantly greater weight loss of 0.92 kg (p < 0.05, I(2)  = 88.8%) with acarbose in Eastern populations (WMD = -1.20, 95% CI -1.51 to -0.75) than that in Western populations (WMD = -0.28, 95% CI -0.59 to 0.03). Across all studies, the acarbose group achieved a significantly larger absolute weight loss of (change from baseline) 1.35 kg (p < 0.05, I(2)  = 94.3%) in Eastern populations (WMD = -2.26, 95% CI -2.70 to -1.81) than in Western populations (WMD = -0.91, 95% CI -1.36 to -0.47). Nevertheless, the possible risk of bias in Eastern studies may influence the results.

CONCLUSION

The effect of acarbose on weight loss seems to be more pronounced in Eastern than in Western populations with hyperglycaemia, and is superior to that of placebo, nateglinide and metformin across both ethnicities.

The MTMR9 rs2293855 polymorphism is associated with glucose tolerance, insulin secretion, insulin sensitivity and increased risk of prediabetes

BACKGROUND

Polymorphism of rs2293855 in gene MTMR9 has been associated with obesity and metabolic syndrome. We aim to study the association of rs2293855 with type 2 diabetes mellitus (T2DM) intermediate phenotypes in a Han Chinese population.

METHODS

The polymorphism was genotyped in 838 Han Chinese individuals using Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS); all participants underwent a 75 g oral glucose tolerance test (OGTT); associations between the polymorphism and glucose tolerance, indices of insulin secretion and indices of insulin sensitivity were analyzed.

RESULTS

The frequency of genotypes and alleles differed significantly between normal glucose tolerance and prediabetes (P=0.043 and P=0.009, respectively). The GG homozygous presented higher fasting plasma glucose (P=0.009), higher 2-hour plasma glucose (P=0.024) and higher glucose area under the curve (AUC, P=0.01). Moreover, the G allele of rs2293855 was associated with glucose intolerance (fasting glucose, P=0.012; glucose AUC, P=0.006; 2-h glucose, P=0.024); it is also associated with decreased indices of insulin sensitivity (fasting insulin, P=0.043; insulin sensitivity index composite, P=0.009; homeostasis model assessment of insulin resistance, HOMA-IR, P=0.008) and decreased indices of insulin secretion (HOMA of beta cell function, HOMA-B, P=0.028; insulinogenic index, P=0.003). In addition, the minor allele G was also associated with increased risk of prediabetes (OR=1.463, 95%CI: 1.066-2.009, P=0.018).

CONCLUSIONS

Polymorphism of rs2293855 in MTMR9 is associated with measures of glucose tolerance, indices of insulin secretion and indices of insulin sensitivity. We also suggest that allele G is likely to increase the risk of prediabetes by influencing both insulin secretion and insulin sensitivity.

Berberine attenuates doxorubicin-induced cardiotoxicity in mice

This study investigated the effects of berberine, a natural alkaloid, on doxorubicin-induced cardiotoxicity in mice. Mice were injected intraperitoneally with saline 10 ml/kg (n = 10), doxorubicin 2.5 mg/kg (n = 10), 60 mg/kg berberine 1 h before doxorubicin 2.5 mg/kg (n = 10), or 60 mg/kg berberine alone (n = 10) every other day for 14 days. Body weight, general condition and mortality were recorded over the 14-day study period. Electro cardiography was performed before the start of treatment and after 14 days and plasma lactate dehydrogenase (LDH) activity was measured after 14 days. At the end of the study period the heart was excised and examined histologically. An increase in mortality, an initial decrease in body weight, increased LDH activity, prolongation of QRS duration and increased myocardial injury were seen in the doxorubicin-treated group compared with the saline control group. These changes were significantly attenuated by pretreatment with berberine. The study suggests that berberine may have a potential protective role against doxorubicin-induced cardiotoxicity in mice.

ELAC2 polymorphisms and prostate cancer risk: a meta-analysis based on 18 case-control studies

Polymorphisms in the elaC homolog-2 (ELAC2)/HPC2 gene have been hypothesized to alter the risk of prostate cancer. However, the results of the related published studies remained conflicting. We performed a meta-analysis of 18 studies evaluating the association between ELAC2 Ser217Leu and Ala541Thr polymorphisms and prostate cancer risk. Overall, ELAC2 Leu217 allele was associated with increased prostate cancer risk as compared with the Ser217 allele (odds ratio (OR)=1.13, 95% confidence interval (CI): 1.03–1.24, P=0.019 for heterogeneity), as well as in the heterozygote comparison (OR=1.21, 95% CI: 1.07–1.36, P=0.034 for heterogeneity) and the dominant genetic model (OR=1.20, 95% CI: 1.07–1.35, P=0.025 for heterogeneity). Furthermore, the ELAC2 Thr541 allele was associated with increased prostate cancer risk as compared with the Ala541 allele (OR=1.22, 95% CI: 1.00–0.48, P=0.131 for heterogeneity). In the stratified analyses for Ser217Leu polymorphism, there was significantly increased prostate cancer risk in Asian and Caucasian populations, and studies using sporadic and familial prostate cancer cases. Similar result was found in the Asian population in the stratified analyses for Ala541Thr polymorphism. This meta-analysis showed evidence that ELAC2 Ser217Leu and Ala541Thr polymorphisms were associated with prostate cancer risk, and might be low-penetrance susceptibility markers of prostate cancer.

Emergency intubation for acutely ill and injured patients

BACKGROUND

Emergency intubation has been widely advocated as a life saving procedure in severe acute illness and injury associated with real or potential compromises to the patient's airway and ventilation. However, some initial data have suggested a lack of observed benefit.

OBJECTIVES

To determine in acutely ill and injured patients who have real or anticipated problems in maintaining an adequate airway whether emergency endotracheal intubation, as opposed to other airway management techniques, improves the outcome in terms of survival, degree of disability at discharge or length of stay and complications occurring in hospital.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register (December 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (1950 to November 2006), EMBASE (1980 to week 50, December 2006), National Research Register (Issue 4, 2006), CINAHL (1980 to December 2006), BIDS (to December 2006) and ICNARC (to December 2006). We also examined reference lists of articles for relevant material and contacted experts in the field. Non-English language publications were searched for and examined.

SELECTION CRITERIA

All randomised (RCTs) or controlled clinical trials involving the emergency use of endotracheal intubation in the injured or acutely ill patient were examined.

DATA COLLECTION AND ANALYSIS

The full texts of 452 studies were reviewed independently by two authors using a standard form. Where the review authors felt a study may be relevant for inclusion in the final review or disagreed, the authors examined the study and a collective decision was made regarding its inclusion or exclusion from the review. The results were not combined in a meta-analysis due to the heterogeneity of patients, practitioners and alternatives to intubation that were used.

MAIN RESULTS

We identified three eligible RCTs carried out in urban environments. Two trials involved adults with non-traumatic out-of-hospital cardiac arrest. One of these trials found a non-significant survival disadvantage in patients randomised to receive a physician-operated intubation versus a combi-tube (RR 0.44, 95% CI 0.09 to 1.99). The second trial detected a non-significant survival disadvantage in patients randomised to paramedic intubation versus an oesophageal gastric airway (RR 0.86, 95% CI 0.39 to 1.90). The third included study was a trial of children requiring airway intervention in the prehospital environment. The results indicated no difference in survival (OR 0.82, 95% CI 0.61 to 1.11) or neurologic outcome (OR 0.87, 95% CI 0.62 to 1.22) between paramedic intubation versus bag-valve-mask ventilation and later hospital intubation by emergency physicians; however, only 42% of the children randomised to paramedic endotracheal intubation actually received it.

AUTHORS' CONCLUSIONS

The efficacy of emergency intubation as currently practised has not been rigorously studied. The skill level of the operator may be key in determining efficacy. In non-traumatic cardiac arrest, it is unlikely that intubation carries the same life saving benefit as early defibrillation and bystander cardiopulmonary resuscitation (CPR). In trauma and paediatric patients, the current evidence base provides no imperative to extend the practice of prehospital intubation in urban systems. It would be ethical and pertinent to initiate a large, high quality randomised trial comparing the efficacy of competently practised emergency intubation with basic bag-valve-mask manoeuvres (BVM) in urban adult out-of-hospital non-traumatic cardiac arrest.

Muscle infarction involving muscles of abdominal and thoracic walls in diabetes

AIMS

This paper presents two cases of muscle infarction involving four major muscles of the anterior abdominal wall (case 1) and pectoralis major (case 2) in individuals with diabetes.

METHODS

Erythrocyte sedimentation rate (ESR) and creatine kinase (CK) were measured and Doppler ultrasound, an open muscle biopsy (case 1) and magnetic resonance imaging (MRI) (case 2) were performed.

RESULT

The diagnosis of muscle infarction was made by histological findings and MRI images with hyper-intensive signals on a gadolinium-enhanced T2-weighted sequence, respectively. Both patients were treated with bed rest, immobilization of the involved extremities, analgesia and intensive insulin therapy. In addition, anticoagulant drugs such as low molecular weight heparin sodium and cilostazol, and some traditional Chinese medicines such as ligustrazine and salvia miltiorrhiza were administered. The symptoms of both patients resolved gradually after 3 weeks. However, muscle infarction reoccurred in case 1 on the opposite side of the abdomen and recovered after 40 days.

CONCLUSIONS

This is the first report of muscle infarction involving the muscles of anterior abdominal walls and pectoralis major in diabetes. MRI is the best non-invasive technique and T2-weighted imaging is the most valuable method for the diagnosis. In addition to supportive therapy, administration of anticoagulant agents and some Chinese traditional medicine may be useful in symptom relief.

[Gigantism with low serum level of growth hormone: a case report]

Gigantism with low or normal basal concentrations of growth hormone (GH) is a rare condition, possibly due to abnormal GH secretory patterns, enhanced tissue sensitivity to GH, or the existence of an unidentified growth promoting factor. Here we report an 11 year-old female case of gigantism with a normal pituitary gland. Her height was 181 cm, body weight 77 kg, and bone age 11.1 years. Her basal serum GH levels were lower than 1 ng/ml. The levels of T3, T4, FT3, FT4, TSH, E2, LH, FSH, PRL, PTC and ACTH were normal. Serum GH response to insulin-induced hypoglycemia or arginine stimulation tests was blunted. In this case, non-pulsatile GH secretion and enhanced tissue sensitivity to GH may induce hypersecretion of IGF-1 and the existence of an unidentified growth promoting factor or biologically active anti-GH receptor antibodies may cause clinical gigantism.

[Study on gastric motility and its relevant factors in type 2 diabetes]

OBJECTIVE

In this study radionuclide semi-liquid gastric emptying (GE) study was adopted to test the gastric motility in 129 patients with type 2 diabetes. Further study was made to explore the relationship between gastric motility disorder of diabetes and the influential factors.

METHODS

The variables to be measured and analyzed were age, BMI, duration of illness, level of glycemia, HbAlc, plasma insulin, motilin, gastrin, glucagon and Mg2+.

RESULTS

Of the 129 cases, 80 had delayed GE with an occurrence of 62.02%, and there was a close correlation between gastric motility disorder and the duration of illness, BMI, FPG, PPG, serum insulin, motilin levels and HbAlc as well.

CONCLUSION

These findings imply that gastric motility disorder of diabetes is influenced by multiple factors. The results also suggest that gastric motiligy disorder is much more common than expected, and radionuclide gastric emptying test is a useful aid for the early detection of this clinical entity.

Activation of glycogen synthase kinase 3 beta (GSK-3beta) by platelet activating factor mediates migration and cell death in cerebellar granule neurons

Children with vertically acquired HIV-1 can present with a rapidly progressive encephalopathy and neuronal apoptosis in the first 12-18 months of life. Furthermore, abnormal prenatal platelet activating factor (PAF) signalling may result in lissencephaly, a disorder of neuronal migration. PAF, produced from human immunodeficiency virus type 1 (HIV-1) -infected brain-resident macrophages, induces neuronal apoptosis in cultured cerebellar granule neurons (CGNs) in part by activating glycogen synthase kinase 3 beta (GSK-3beta). However, PAF can also inhibit migration of CGNs that are dispersed and allowed to reaggregate. Therefore, we investigated the biological effects following activation of GSK-3beta by PAF, and whether these effects were dependent on the culture conditions of the CGNs. We show here that activation of neuronal GSK-3beta by PAF is receptor-specific, with similar kinetics of activation in both monolayer cultures of CGNs that have ceased to migrate and reaggregate cultures of CGNs that are actively migrating. However, PAF receptor activation in reaggregated CGNs inhibits neuronal migration and induces approximately half the level of neuronal apoptosis compared with PAF-treated CGN cultures that have ceased to migrate. PAF-mediated inhibition of neuronal migration in reaggregated CGNs or induction of apoptosis in CGNs that have ceased to migrate can be reversed by either PAF receptor antagonists, or the GSK-3beta inhibitors lithium or valproic acid, in a dose-dependent manner. Abnormal PAF signalling that results in GSK-3beta overactivation may represent a common mechanism for pathological defects in neuronal migration in the prenatal period and neuronal apoptosis in the postnatal period.

[A multicenter randomized controlled clinical trial on lipids regulating effects of domestic simvastatin]

OBJECTIVE

This clinical trial was designed to assess the lipids regulating effects of domestic simvastatin (DS, produced by Chengdu Huayu Pharmaceutical Co.) in patients with hyperlipidemia.

METHODS

160 hyperlipidemic patients were randomly divided into 3 groups (A, B and C). Groups A and B were subjected to single-blind trial; group C was for open trial. Group A took DS 10 mg q.n., group B Zocor 10 mg q.n. and group C DS 10 mg q.n. respectively for 8 weeks. All the patients were followed up at the 4th week and 8th week. 155 patients finished the trial with 59 cases in group A, 47 cases in group B and 39 cases in group C.

RESULTS

At the 4th week, serum total cholesterol (TC) in group A, B and C decreased by 16.88%, 19.23% and 14.10%; serum triglycerides (TG) decreased by 19.27%, 15.66% and 17.96%; HDL-C increased by 7.69%, 7.46% and 6.69%; and LDL-C decreased by 23.02%, 27.84% and 24.43%, respectively; there was no significant difference among the three groups (P > 0.05). At the 8th week, serum TC in groups A, B and C decreased by 25.03%, 26.53% and 25.22%. TG decreased by 23.85%, 24.74% and 24.75%; HDL-C increased by 9.23%, 8.95% and 8.39%; and LDL-C decreased by 33.72%, 35.50% and 30.99%, respectively; still, no significant difference among the three groups was observed (P > 0.05). The incidence rates of side effects in the three groups were similar. The clinical effects were more significant at the 8th week than at the 4th week for Zocor and DS.

CONCLUSION

These data suggest that DS is as effective and safe as Zocor in clinical use for lipids regulating serum.

Release of the neuronal glycoprotein ICAM-5 in serum after hypoxic-ischemic injury

Intercellular adhesion molecule (ICAM)-5 (telencephalin) is unique among the ICAMs, because it is only expressed in somatodendritic membranes of telencephalic neurons. To investigate the fate of ICAM-5 during focal brain injury, we induced hypoxia-ischemia (HI) damage in adult mice by right common carotid artery ligation followed by hypoxia. ICAM-5 was detectable in serum within a 48-hour window after HI injury. In HI brain, dendritic ICAM-5 immunore-activity was abolished, but it was present in the neuropil and soma of hippocampal pyramidal, dentate granule, and some cortical and striatal neurons. After HI injury, levels of ICAM-5 protein and messenger RNA initially increased, and ICAM-5 messenger RNA expression then decreased, although protein levels continued to increase. Because HI injury induces microglial activation with increases in CD11a/CD18 (lymphocyte function antigen [LFA]-1) counterreceptors to ICAM-5, we investigated whether modulation of interactions between LFA-1 receptors and brain ICAM-5 during HI injury are associated with changes in levels of serum ICAM-5. Intracerebroventricular administration of lipopolysaccharide to activate microglia before HI injury resulted in elevated serum ICAM-5 levels compared with those in mice with only HI injury. Pretreatment with anti-LFA-1 antibodies before HI injury or LFA-1 receptor knockout mice with HI injury had markedly reduced levels of serum ICAM-5. Lipopolysaccharide levels increased, whereas LFA-1 receptor blockade or LFA-1 knockout decreased HI injury in the first 12 hours. These data suggest that during the necrotic phase of HI injury, serum ICAM-5 may be a potential marker for somatodendritic neuronal damage.

Hospital pharmacy service provision in Australia--1998

The results of a 1998 national survey of pharmaceutical services in hospitals throughout Australia are reported. A self-administered questionnaire was sent to all directors of hospital pharmacy services and senior hospital pharmacy managers to determine the extent of clinical and nonclinical pharmacy services provided by hospitals in Australia. Respondents chose the services their departments provide from a list of 26 commonly provided services. The response rate was 58.5%. Respondents were fairly evenly divided between teaching and nonteaching hospitals, but most of the respondents were from public (versus nongovernment) hospitals. The five most commonly provided services were imprest (a wordstock of frequently used medications that are regularly restocked by the pharmacy department), informal drug education for hospital staff, review of medication charts, control of drug purchasing, and inpatient dispensing. Review of medication charts and provision of drug education for the hospital staff were the most widely provided clinical pharmacy services. The most common services available from hospital pharmacies throughout Australia were imprest, informal drug education for hospital staff, review of medication charts, control of drug purchasing for the hospital, and inpatient dispensing.

Neuronal fractalkine expression in HIV-1 encephalitis: roles for macrophage recruitment and neuroprotection in the central nervous system

HIV-1 infection of the brain results in chronic inflammation, contributing to the neuropathogenesis of HIV-1 associated neurologic disease. HIV-1-infected mononuclear phagocytes (MP) present in inflammatory infiltrates produce neurotoxins that mediate inflammation, dysfunction, and neuronal apoptosis. Neurologic disease is correlated with the relative number of MP in and around inflammatory infiltrates and not viral burden. It is unclear whether these cells also play a neuroprotective role. We show that the chemokine, fractalkine (FKN), is markedly up-regulated in neurons and neuropil in brain tissue from pediatric patients with HIV-1 encephalitis (HIVE) compared with those without HIVE, or that were HIV-1 seronegative. FKN receptors are expressed on both neurons and microglia in patients with HIVE. These receptors are localized to cytoplasmic structures which are characterized by a vesicular appearance in neurons which may be in cell-to-cell contact with MPs. FKN colocalizes with glutamate in these neurons. Similar findings are observed in brain tissue from an adult patient with HIVE. FKN is able to potently induce the migration of primary human monocytes across an endothelial cell/primary human fetal astrocyte trans-well bilayer, and is neuroprotective to cultured neurons when coadministered with either the HIV-1 neurotoxin platelet activating factor (PAF) or the regulatory HIV-1 gene product Tat. Thus focal inflammation in brain tissue with HIVE may up-regulate neuronal FKN levels, which in turn may be a neuroimmune modulator recruiting peripheral macrophages into the brain, and in a paracrine fashion protecting glutamatergic neurons.

Functional interplay between nuclear factor-kappaB and c-Jun integrated by coactivator p300 determines the survival of nerve growth factor-dependent PC12 cells

Nerve growth factor (NGF) activates the transcription factors nuclear factor kappaB (NF-kappaB) and activator protein-1 (AP-1) in sympathetic neurons. Whereas NGF-inducible NF-kappaB is required for the survival of neurons, c-Jun has the ability to promote neuronal death. In this report, we have examined the effect of NGF withdrawal on c-Jun and NF-kappaB transcription factors in PC12 cells differentiated to a neuronal phenotype. We show that the withdrawal of NGF from these cultures results in de novo synthesis of c-Jun, increase in AP-1 activity, and down-regulation of NF-kappaB activity. To investigate how the signal transduction pathways activating c-Jun and NF-kappaB are differentially regulated by NGF, we performed transcriptional analyses. Expression of ReIA (NF-kappaB) suppressed the c-Jun-dependent transcription of c-jun, and this effect was reversed by overexpression of the coactivator p300. RelA's effects on c-Jun transcription were mediated by competitive binding of the carboxy-terminal region of RelA to the CH1 domain of p300, which also binds to c-Jun; deletion of this region abrogated the ability of RelA to inhibit c-Jun activity. Furthermore, the inhibition of endogenous NF-kappaB in NGF-maintained neuronal PC12 cells led to the induction of c-Jun synthesis and a marked increase in cell death. Together, these studies demonstrate a functional interaction between NF-kappaB and c-Jun and suggest a novel mechanism of NF-kappaB-mediated neuroprotection.

[A clinical study of sudden death in patients with type 2 diabetes mellitus]

This study aimed to investigate the clinical characteristics of sudden death (SD) in type 2 diabetes mellitus (DM2). Clinical data from 1988 through 1996 in our hospital showed that 130 hospitalized patients with DM2 died, and 17 of them died of SD (13.08%). These 17 SD patients were pair-matched with 17 DM2 patients who were alive in the same period. The results revealed that the SD group had longer clinical DM duration, more chronic diabetic complications and higher blood pressure. In the direct causes of SD, cardiac SD accounted for 76.47%. The others were non-cardiac factors, including cerebral hemorrhage, hyperkalemia from diabetic nephropathy with renal failure and respiratory tract obstruction from lung infection. The triggering causes included eating, defecting, lung infection, strenuous attempt, hypoglycemia and surgical operation. To reduce the rate of SD in DM2, it is necessary and vital to treat the DM2 itself, and to take positive steps to prevent the onset of SD in high risk patients.

HIV-1 Tat-mediated activation of glycogen synthase kinase-3beta contributes to Tat-mediated neurotoxicity

Human immunodeficiency virus type 1 (HIV-1) Tat induces neuronal apoptosis. To examine the mechanism(s) that contribute to this process, we studied Tat's effects on glycogen synthase kinase-3beta (GSK-3beta), an enzyme that has been implicated in the regulation of apoptosis. Addition of Tat to rat cerebellar granule neurons resulted in an increase in GSK-3beta activity, which was not associated with a change in protein expression and could be abolished by the addition of an inhibitor of GSK-3beta (lithium). Lithium also enhanced neuronal survival following exposure to Tat. Coprecipitation experiments revealed that Tat can associate with GSK-3beta, but direct addition of Tat to purified GSK-3beta had no effect on enzyme activity, suggesting that Tat's effects might be mediated indirectly. As the activation of platelet activating factor (PAF) receptors is critical for the induction of neuronal death by several candidate HIV-1 neurotoxins, we determined whether PAF can also activate GSK-3beta. Application of PAF to neuronal cultures activated GSK-3beta, and coincubation with lithium ameliorated PAF-induced neuronal apoptosis. These findings are consistent with the existence of one or more pathways that can lead to GSK-3beta activation in neurons, and they suggest that the dysregulation of this enzyme could contribute to HIV-induced neuronal apoptosis.

[A pair-matched comparison and follow-up study of patients with euthytroid Graves ophthalmopathy and patients with hyperthyroid graves ophthalmopathy]

This study was intended to acquire a knowledge about the similarity and difference between euthyriod Graves ophthalmopathy (EGO) and hyperthyroid Graves ophthalmopathy (HGO), and about the outcome of the EGO cases. Twenty-seven EGO patients were pair-matched with 27 HGO patients, and 18 of the EGO patients were followed up for 1-6 years. The results showed that the EGO group had markedly more patients with diplopia, failure to close lids, limitation of eyeball movements, cornea involvement, and more patients with a difference of two eyes' exophthalmos degrees > or = 2 mm, but the HGO group had more patients with optic nerve involvement. No significant difference was found between the two groups' ophthalmopathic indexes by using the t-test. Drug therapy of the EGO group was more efficacious than that of the HGO group. The results of follow-up study showed that 61% of the EGO cases had hyperthyroidism and goiter within 5 months to 3 years, but 39% of the cases had no hyperthyroidism up to 6 years. These data suggest that EGO is associated with thyroid diseases and it can stand "alone" as an auto-immune disease.

M protein correlates with the receptor-binding specificity of haemagglutinin protein of reassortant influenza A (H1N1) virus

From the reassortment experiments between A/Aichi/4/92 and A/WSN/33 (WSN) (H1N1) viruses, two different phenotype viruses which contained the haemagglutinin (HA) gene from A/Aichi/4/92 virus and the neuraminidase (NA) gene from WSN virus were obtained. PW13 and PW15 viruses agglutinated chicken red blood cells (CRBC), while PW10 and PW70 viruses did not. However, the expressed HA proteins of these viruses did not adsorb CRBC. The difference in gene constellation between PW13, PW15 and PW10, PW70 viruses was the membrane protein (M) gene. The former two had the M gene from A/Aichi/4/92 virus and the latter two had that from WSN virus. In PW15-infected cells, haemadsorption of CRBC was observed 30 min later than that of goose red blood cells and the M1 protein migrated from the nucleus to the cytoplasm 30 min earlier than adsorption of CRBC was observed. On the other hand, in PW10-infected cells, haemadsorption of CRBC was not observed through the virus replication and the M1 protein stayed in the nucleus after HA and NA activities reached maximum levels. Co-expression of the M and the HA proteins of A/Aichi/4/92 virus did not help the HA protein gain the ability to adsorb CRBC. However, neuraminidase treatment of COS cells expressing the HA protein of A/Aichi/4/92 virus or MDCK cells infected by PW10 virus restored the ability to adsorb CRBC. We discussed the possibility that the M1 protein helped the NA protein in its role to modify the HA protein on the cell surface.

[Changes of serum TNF-alpha level, t-PA activivty and PAI activity in patients with silent myocardial ischemia or silent cerebral ischemia]

Tumor necrosis factor-alpha (TNF-alpha) level, tissue-typed plasminogen activator(t-PA) activity and PA inhibitor (PAI) activity were determined in three groups: (1) 25 NIDDM patients with silent myocardial ischemia (SMI) or silent cerebral ischemia (SCI); (2) 18NIDDM patients without SMI or SCI; (3) 20 age-matched normal controls. Diagnosis of SMI or SCI was based on the finding of ischemic evidence by SPECT of myocardiotomograph or cerebrotomograph. All patients ECG and blood pressure were normal, and they had no history of clinical symptoms and signs of MI or CI. The result showed that the TNF-alpha level and PAI activity in the ischemia group were the highest and the t-PA activity in the ischemia group was the lowest, as compared with those in the other two groups respectively. It suggests that in NIDDM patients who have high TNF-alpha, high PAI activity, low t-PA, and even no symptoms and signs of MI or CI, anticoagulant therapy might be useful to prevent the progression of diabetic macroangiopathies.

[The effects of intensive DMPA regimen in the treatment of Graves' ophthalmopathy]

35 patients with Graves' ophthalmopathy were treated with DMPA regimen which included dexamethasone (D) 20-30 mg and Methotrexate (M) 15-20 mg i.v. once a week and prednisone (P) 20 mg/d p. o. 4 times a week for 4 weeks followed by addition of azathioprine (A) or 6-MP 75-100 mg/d and the increment of prednisone (20 mg/d) to 5 times a week in the fifth and sixth weeks. The full intensive course of therapy lasted for 6 weeks. If necessary, the similar course of therapy might be repeated. Later on, each patient was mintainted on a therapy with P and A or P and 6-MP for another 1-2 months then the P and A or P and 6-MP for another 1-2 months, and then the P and A or 6-MP were tapered and finally discontinued at the end of sixth month. The symptoms and signs of the opthalmopathy were evaluated blindedly at the beginning and the end of the first and second courses of the therapy by two ophthalmologists. The results showed that the symptoms and signs were significantly improved in 33 (94.3%) cases. A decrease of eyeball protrusion of 1.22 +/- 1.15 and 1.28 +/- 1.15 mm in the left and right eyes respectively was shown by eophthalmometry reading (both P < 0.0005, compared with before and after the therapy). The decrease of exophthalmos was more remarkable in the cases with ophthalmopathy for < or = 1 year than that > 1 year. 11/22 patients recovered their ability to close eyes adequately. The diplopia was corrected in 8/15 cases. The mobility of eye ball returned to normal in 5/15 cases. Exposed lesion and/or ulceration of the cornea found in 7 patients were cured. Serious side and/or toxic effects of the drugs were not present during the course of therapy. It is suggested that DMPA regimen is an effective, safe and cheap approach to the treatment of Graves' ophthalmopathy.

[Comparative analysis of clinical features of acute myocardial infarction in diabetic and non-diabetic patients]

We conducted match-control study to make a comparison between 20 diabetic and 20 non-diabetic patients in clinical features of acute myocardial infarction (AMI). There were 16 males and 4 females in each group. The mean age of diabetic group (DM) was 61.95 +/- 9.83 years, and that of non-diabetic group (NDM) was 61.45 +/- 9.38 years. We found the morbidity of silent myocardial infarction (MI) being 45% (DM) versus 10% (NDM); acute pulmonary edema being 40% (DM) versus 10% (NDM); cardiac shock, 35% (DM) versus 0% (NDM); arrhythmia, 70% (DM) versus 30% (NDM); the complication of cerebral infarction being 20% (DM) versus 0% (NDM); and complication of infection, 30% (DM) versus 10% (NDM). These revealed that DM had higher morbidity of silent MI and complications of AMI than NDM. Three diabetic patients had MI in two sites while one diabetic patient had myocardial remfarction, which showed DM had more serious damage in coronary artery than NDM. The mortality rate was 45% in DM and 15% in NDM. Multiple-organ functional failure was the main cause of death in DM.

Identification of the sites for suppressor mutations on the hemagglutinin molecule to temperature-sensitive phenotype of the influenza virus

A temperature-sensitive (ts) mutant of the influenza virus A/WSN/33 strain, ts-134, possessed a defect in intracellular transport at the nonpermissive temperature and marked thermolability of hemagglutinin (HA) activity at 51 C. These were caused by a change at amino acid residue 157 from tyrosine to histidine in the HA protein. We isolated 37 spontaneous revertant clones from ts-134 at the nonpermissive temperature and determined their HA sequences. The deduced amino acid sequences demonstrated that one was a true revertant and the others were revertants with suppressor mutations, each of which had an additional amino acid change besides those of ts-134. The changed amino acids were located at 14 positions on the HA molecule, and eight of them were found in multiple revertants. These were located in five to six distinct regions on the three-dimensional structure of the HA molecule. However, the heat stability of HAs in the revertants was recovered differently depending on the sites of the changed amino acids. The kinetics of transport of the HA protein in the revertants were slightly delayed compared to the wild-type both at permissive and nonpermissive temperatures.

Prospective audit of an aminoglycoside consultative service in a general hospital

OBJECTIVE

To investigate the impact of the introduction of a consultative service on the use, efficiency of dosing and clinical toxicology of the aminoglycoside antibiotics, gentamicin and tobramycin, in a general hospital.

METHODS

Two audits were conducted six months and 18 months after the introduction of the consultative service. The audits reviewed the use of drug assay services, the adequacy of drug administration (as measured by serum antibiotic concentrations), indications for prescription, adverse outcomes (by noting markers of nephrotoxicity) and the antibiotic sensitivity of Gram-negative pathogens. The results were compared with the results of an audit conducted before the consultative service was instituted.

RESULTS

There was a significant (P < 0.001 by chi 2 test) increase in the use of assays, with drug assays performed in 67% (first audit) and 77% (second audit) of aminoglycoside courses compared with 48.2% in the pre-intervention audit. Sample timing was greatly improved, with more than 70% of the samples collected at the appropriate times. Assay wastage in terms of uninterpretable assay results decreased significantly (P < 0.001) from 42.9% of total assays to 6.3% at the first audit and 3.8% at the second audit. The percentage of assay results in the desirable range increased significantly (P < 0.001) from 39.1% to 71.9% (first audit) and 75.4% (second audit). Pharmacokinetic recommendations were made in 39.1% and 64% of all aminoglycoside courses during the first and second audits respectively, with clinician acceptance of dosage recommendations at 83.1% and 82.8% respectively. For aminoglycoside courses prescribed for therapeutic reasons, 97.9% (first audit, n = 325) and 98.6% (second audit, n = 280) of indications for use were judged as clinically appropriate. The incidence of suspected aminoglycoside-induced nephrotoxicity was reduced from 8.9% of patients to 1.6% (first audit, P < 0.001) and 2.4% (second audit). Bacterial sensitivity audits showed that the great majority of clinical isolates of target organisms (n = 3523, Year 1 and n = 3385, Year 2) were sensitive to gentamicin (92.2% and 91.5% respectively) and tobramycin (98.1% and 98.8% respectively); these aminoglycosides exceeded all alternative agents in effectiveness, including first and third generation cephalosporins.

CONCLUSIONS

The overall results indicate that introduction of the consultative service had a positive impact on the effective use of aminoglycosides, with a marked decrease in clinical toxicity. These influences were shown to persist for at least 18 months. The availability of reliable predictive techniques to reduce toxicity allows active promotion of aminoglycosides as the agents of choice on grounds of efficacy and economy.

Dosage adjustment and clinical outcomes of long-term use of high-dose tobramycin in adult cystic fibrosis patients

A two-phase study was undertaken designed to investigate the impact of computer-aided drug monitoring on tobramycin concentrations and clinical outcomes in adult patients with cystic fibrosis. In phase one, a baseline (historical control) study of drug use patterns was performed. During the second phase, patients admitted for intravenous treatment with tobramycin for acute exacerbations of pseudomonal pulmonary infections were randomly allocated to one of two schedules. Group A patients had tobramycin dosage regimens decided by clinicians based on pre-existing protocols using serum tobramycin assay data determined three times weekly. Group B patients had dosage regimens determined by a computerized pharmacokinetic predictive program using both population-based pharmacokinetic parameter estimation and fitting of serum concentration-time data using Bayesian regression. The agreed therapeutic target was a peak serum tobramycin concentration of 8-10 mg/L and a trough concentration of 1-2 mg/L. There was a major difference between the two groups comparing the number of paired trough and peak concentrations within the target concentration ranges (group A-14%; group B-34.7%, chi 2 test, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of gemfibrozil on serum apo C II and C III in diabetic hyperlipidemia]

The effects of gemfibrozil on apolipoproteins C II and C III (apo C II, C III) were observed in 20 NIDDM hyperlipidemic patients. All of the patients continued their anti-diabetic treatment, gemfibrozil 900 mg/day for 4 weeks. The results revealed no significant change in fasting plasma glucose (FPG) and HbA1 before and after the study. But after the treatment with gemfibrozil, the following parameters changed significantly: total cholesterol (TC) decreased by 18.64% (P less than 0.01), total triglyceride (TG) decreased by 65.05% (P less than 0.001), VLDL-C decreased by 63.19% (P less than 0.001), HDL-C increased by 44.23% (P less than 0.001), apo C III decreased by 31.38% (P less than 0.02), and the ratio of apo C III/C II reduced by 35.49% (P less than 0.01). These findings suggest that gemfibrozil has excellent effect on decreasing apo C III and the ratio of apo C III/C II, thus facilitates the metabolism of chylomicron and decreases TG level in hyperlipidemic diabetic patients.