Safety and Efficacy of Stereotactic Radiosurgery with Concurrent Targeted Systemic Therapy for Brain Metastases

PURPOSE/OBJECTIVE(S)

Data describing the safety and efficacy of central nervous system (CNS)-active targeted systemic therapies in combination with stereotactic radiosurgery (SRS, 1 fraction) and/or radiotherapy (SRT, 3-5 fractions) for brain metastases are emerging but limited. We report rates of local and intracranial failure and radiation necrosis in patients receiving CNS-active targeted systemic therapy and SRS/SRT.

MATERIALS/METHODS

We retrospectively identified patients with intact brain metastases at two institutions from 2009-2022 who were treated with SRS/SRT and CNS-active targeted systemic therapy in any sequence. Patients were followed for a minimum of 3 months after SRS/SRT with brain MRI. Patients typically stopped the targeted agent 2-4 days prior to radiation and resumed 2-4 days after. Targeted therapies included inhibitors of ALK/ROS1 (Alectinib, Ceritinib, Crizotinib, Lorlatinib), EGFR (Afatinib, Erlotinib, Gefitinib, Osimertinib), BRAF (Dabrafenib, Encorafenib, Vemurafenib), MEK (Binimetinib, Trametinib), CDK 4/6 (Abemaciclib, Palbociclib, Ribociclib), HER2 (Afatinib, Lapatinib, Neratinib, Pertuzumab, Trastuzumab, T-DM1, T-DXd, Tucatinib), KRAS (Adagrasib and Sotorasib), PARP (Niraparib, Olaparib), VEGF(R) (Axitinib, Bevacizumab, Ramucirumab), and less-selective tyrosine (receptor) kinase inhibitors (Bosutinib, Brigatinib, Entrectinib, Lenvatinib, Pazopanib, Sorafenib, Sunitinib). Local failure (LF) and radiation necrosis were determined radiographically with clinical impression (grade 2 (symptomatic) or higher (G2+)) and compared between different systemic agents.

RESULTS

The study included 95 patients with 310 metastases (SRS 246, SRT 64 metastases). Most common primary histologies were non-small cell lung cancer (36% 34/95), breast cancer (28% 27/95), and melanoma (16% 15/95). Overall survival at 1 and 2 years was 80% (76/95) and 55% (52/95), respectively. Median follow-up was 16.6 (range 3-91) months. Median tumor size was 7mm (range 1-75mm). Median number of brain metastases per patient was 2.5 (range 1-12). The G2+ radiation necrosis rate was 5.8% (18/310) while the LF rate was 9.7% (30/310) per metastasis. There was no significant difference in G2+ radiation necrosis by class of targeted therapy. Sixty-two percent (59/95) of patients experienced distant intracranial failure. Median intracranial progression free survival (PFS) was 8.0 (range 0.4-61.4) months.

CONCLUSION

Although heterogeneous, patients treated with SRS/SRT and ongoing CNS-active targeted systemic therapies have on average >6 month intracranial PFS and little evidence of significant toxicity. We observed <6% G2+ radiation necrosis for this cohort, and no particular class of agent was associated with a significantly higher rate of G2+ radiation necrosis.

Neurologic Events and Outcomes in Patients Receiving Proton and Photon Reirradiation for High Grade Non-Codeleted Gliomas

PURPOSE/OBJECTIVE(S)

Patients undergoing reirradiation (ReRT) for high grade glioma are at risk for tumor progression, pseudoprogression, and radiation necrosis. We investigated factors associated with neurologic events and disease control after re-irradiation with protons and photons at a single academic center.

MATERIALS/METHODS

We reviewed records and MRIs of patients receiving scanning beam proton (since center opening in 2016) and photon (since 2015) reirradiation in ≥10 fractions for grade 3 anaplastic astrocytoma (AA) and grade 4 glioblastoma (GBM), excluding 1p19q co-deleted oligodendrogliomas and extensive multifocal/leptomeningeal disease. The primary endpoint was time from ReRT to ≥ grade 2 pseudoprogression or radiation necrosis (PsP/RN, grade 2: moderate symptoms requiring outpatient steroids/bevacizumab, grade 3: severe symptoms leading to admission or surgical intervention). Dose was converted to EQD2 using a/b = 3. Cox proportional hazards model was used to calculate survival and time to PsP/RN.

RESULTS

A total of 53 patients were included (26 protons, 27 photons, median KPS 80). Patients receiving protons had more favorable features. Compared to the photons, the proton group was younger (48 vs. 58) and more likely to have AA (46% vs. 22%) and resection within 3 months (42% vs 26%). The proton group also had a longer interval from prior RT (57 vs. 39 months) and were less likely to receive bevacizumab at reRT (15% vs. 59%). CTV was 130 cc for protons vs 99 cc for photons, and most had active disease at time of ReRT identified on planning MRI (76% protons, 85% photons). Median OS was 10.5 months (14.1 months protons, 8.1 months photons), with time from initial RT the only significant factor on multivariate analysis. Median PFS was 9.4 months (9.8 months protons, 6.2 months photons). 9 patients (18%) had ≥ grade 3 PsP/RN (8 proton, 1 photon) and 21 patients (41%) had ≥ grade 2 PsP/RN (16 proton, 5 photon). Grade 3 events included 1 seizure (photon group), 1 hemorrhage, 1 thalamic stroke, 1 shunt placement, 1 re-resection, and PSP4 4 PsP/RN requiring admission. Protons were associated shorter time to ≥ grade 2 PsP/RN (4 months vs. not reached, p = 0.027). When accounting for bevacizumab use at time of reRT, the association between protons and PsP/RN lost significance but there remained a trend (grade 2, p = 0.095, HR 2.4; grade 3, p = 0.105, HR 5.8). CTV, MGMT status, EQD2, and interval from prior RT were not associated with PsP/RN.

CONCLUSION

High grade neurologic events were common in patients with predominantly active, unresected high grade gliomas receiving ReRT. Though ascertainment and survival bias are significant limitations, pseudoprogression and necrosis appeared to be more prominent in patients receiving protons. These results contribute to ongoing efforts to both optimize ReRT for high grade glioma and investigate biologic effects of proton therapy.

OC-030 EARLY OUTCOMES OF ROBOTIC TAPP HERNIA REPAIR FOR INGUINAL HERNIA: A SINGLE SURGEON'S EXPERIENCE

Aim

The aim of this study was to evaluate the early outcomes of robotic TAPP (trans abdominal pre-peritoneal) inguinal hernia repair in a tertiary hospital.

Material & methods

This is a retrospective analysis of patients who underwent robotic TAPP by a single surgeon from November 2019 to May 2022. Three-arm, 4-port technique of robotic TAPP was performed. The patient cart was advanced depending upon laterality of the hernia. Three ports were placed in a linear fashion at the level of umbilicus, and the fourth port or assistant port was taken on the side opposite to the cart, triangulated from the umbilical and lateral ports.

Results

37 male patients were included, of which, 16 had unilateral hernias and 11 had bilateral hernias. Mean age was 46.2 (SD 16.5) years. One patient had a recurrent groin hernia after open repair. Mean operating time was 137.6 (SD 33.2) minutes. Operating time for the first ten cases was 158.2 (SD 25.1) min, and that of the last ten cases was 127 (SD 42.2) minutes, showing a steady decrease over time. One patient had intraoperative injury of the vas deferens, which was repaired. Mean hospital stay was 1.4 (SD 0.8) days. One patient had seroma. None of the patients had recurrence or mesh infection.

Conclusions

Robotic TAPP is a safe and effective procedure for the repair of inguinal hernias. Placing of assistant port near the umbilicus offers ergonomic advantage over linear port placement.

Tallo: A global tree allometry and crown architecture database

Data capturing multiple axes of tree size and shape, such as a tree's stem diameter, height and crown size, underpin a wide range of ecological research-from developing and testing theory on forest structure and dynamics, to estimating forest carbon stocks and their uncertainties, and integrating remote sensing imagery into forest monitoring programmes. However, these data can be surprisingly hard to come by, particularly for certain regions of the world and for specific taxonomic groups, posing a real barrier to progress in these fields. To overcome this challenge, we developed the Tallo database, a collection of 498,838 georeferenced and taxonomically standardized records of individual trees for which stem diameter, height and/or crown radius have been measured. These data were collected at 61,856 globally distributed sites, spanning all major forested and non-forested biomes. The majority of trees in the database are identified to species (88%), and collectively Tallo includes data for 5163 species distributed across 1453 genera and 187 plant families. The database is publicly archived under a CC-BY 4.0 licence and can be access from: https://doi.org/10.5281/zenodo.6637599. To demonstrate its value, here we present three case studies that highlight how the Tallo database can be used to address a range of theoretical and applied questions in ecology-from testing the predictions of metabolic scaling theory, to exploring the limits of tree allometric plasticity along environmental gradients and modelling global variation in maximum attainable tree height. In doing so, we provide a key resource for field ecologists, remote sensing researchers and the modelling community working together to better understand the role that trees play in regulating the terrestrial carbon cycle.

A Comparative Study of Rapid SARS-Cov-2 Antigen Detection Assay against RT-PCR Assay for Diagnosis of COVID-19 in a Tertiary Hospital of Kathmandu

Background The Coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2) has spread worldwide since its first recorded case in the city of Wuhan, China, in December 2019. SARS-CoV-2 infection causes asymptomatic to sever pneumonia. Severe cases may develop acute respiratory disease symdrome (ARDS), with an average mortality rate of 6.9%. Real Time Reverse Transcriptase Polymerase Chain Reaction (rRT-PCR) assay is the current reference standard laboratory method for the diagnosis of SARS-CoV-2 infection. However, it takes around 6-8 hours to get the result and is time consuming. Therefore, rapid and accurate tests for SARS-CoV-2 screening are essential to expedite disease prevention and control. Lateral flow immunoassay using monoclonal anti SARS-CoV-2 antibodies which target for SARS-CoV-2 antigen can be complimentary screening test if their accuracy were comparable to that of the real time reverse transcriptionpolymerase chain reaction (RT-PCR) assay. Objective To find the sensitivity and specificity of a rapid antigentest kit in comparison to reverse transcription-polymerase chain reaction (RT-PCR). Method A cross-sectional hospital based study was carried out at Shree Birendra Army Hospital, Kathmandu for a period of four months. Result Our finding shows sensitivity and specificity of rapid diagnostic tests (RDT) Ag kit as 60.6% and 96.4% respectively. Positive and negative predictive value was 83.7% and 89.0%. Likewise, positive and negative likelihood ratio was 17.0 and 0.4. The overall accuracy of the antigen kit was 88.1% in comparison to reverse transcriptionpolymerase chain reaction (RT-PCR) as the gold standard. Conclusion Our study concluded the use of rapid antigen kit is mainly useful for screening purposes.

Assessment of Body Fat Percentage Using B-Mode Ultrasound Technique versus Skinfold Caliper in Obese Healthy Volunteers

Background and aims

The measurement of the skinfold thickness at various sites with the calipers has remained the traditional method for estimation of body fat percentage (%BF) in clinical practice. Although this technique is relatively inexpensive and easy to learn, there are more chances of errors while measuring the skinfold thickness by this method. Therefore, no single standard prediction formula for the determination of body fat could be fixed. The aim of our study was to use B-mode ultrasound (US) for measuring the subcutaneous fat thickness and the calipers for skinfold thickness, and then compare, correlate, and derive the prediction equations for estimation of %BF by both the techniques.

Methods

This cross-sectional, observational, monocentric study was conducted on 43 Indian male volunteers aged 18 to 40 years. After collecting anthropometric data (age, height, weight, body mass index, waist circumference, hip circumference, waist-to-hip ratio [WHR], etc.), the skinfold thickness was measured at four standard sites (biceps, triceps, subscapular region, and suprailiac region) with skinfold caliper (SFC) and then B-mode US. The data were analyzed for distribution, and independent t-test was applied to compare the difference between two means of a %BF estimated by both the methods. The prediction equations were developed from anthropometric and skinfold thickness data obtained from both the methods, i.e., SFC and US, by applying stepwise multiple linear regression.

Results

It was observed that mean values of all the skinfold thicknesses along with the %BF measured by SFC were far more than those measured by US. The %BF measured by US technique (%BF US) was significantly lesser, i.e., 20.69 (SD: 3.126; p < 0.0002), than that of the SFC method (%BF SFC), i.e., 30.38 (SD: 4.634), which is 0.68 % higher. The best prediction equation for the %BF by SFC method was [%BF SFC = -26.154 + 0.208 SFss + 0.374 age + 0.354 SFbi + 32.066 WHR] (R² = 84.8), where SFss and SFbi are skin fold thicknesses at subscapular and biceps regions, respectively, measured with SFCs, and that by the US method was [%BF US = 0.713 + 0.351 USsi + 0.232 age + 0.248 USss + 0.448 USbi] (R² = 84.6), where USsi and USss are skinfold measurements at suprailiac and subscapular regions, respectively, measured by US technique.

Conclusion

In our study, we arrived to the conclusion that even though the estimated %BF by both the methods were found to have a significant correlation with each other, the values were very less in case of the US method. In the prediction equations, it was found that the skinfold thickness at the suprailiac region was not found to be the significant determining factor for estimation of %BF by SFC method as that by the US method. Looking at the lesser sample size with all participants being males, we do not recommend the prediction equations to be used in clinical practice in spite of the high R² values.

Burden of Silicosis among stone crushing workers in India

BACKGROUND

In North India, the mining industry is disorganized and profit-driven. It predisposes its workers towards the development of silicosis. Haryana, a major North Indian state, has developed a compensation-rehabilitation policy for mining workers.

AIMS

This study is the review of the policy's functioning and limitation from the first 4 years of implementation.

METHOD

The labour department does surveillance of workers in the mining industry. All suspected cases of silicosis are evaluated by a multidisciplinary team. Based on the final diagnosis, the compensation is decided.

RESULT

Nearly 5000 workers were screened, and 729 appeared before the medical board. Of these 729, 465 were having silicosis, and their data are presented here (data of 7 patients were missing). All workers were males. The mean age was 44.54 ± 9.6 years, and the mean exposure (work experience) was 17.25 ± 6.7 years. Most of the workers were between the age of 40 and 50 years and had exposure for 10-20 years. Chest radiography examination showed that progressive massive fibrosis (large size type C opacities) was the most common type of presentation (23%). Smaller opacities (p, q, r and s, t, u) were combined for further analysis, given their similar prognostic significance. It was found that age and experience both had a linear and significant correlation with the severity of lung involvement.

CONCLUSIONS

Nearly a quarter of subjects were suffering from the worst type of lung involvement at screening itself. The policy has laid a foundation for the welfare of workers, but there is still a long way to go.

National level E-Resource Centre for Tobacco Control (E-RCTC): One stop solution to information on tobacco control in India

The existing information on tobacco control, though highly valuable, is lying scattered at different sources. Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh in collaboration and technical support of International Union against TB and Lung Diseases (The Union) undertook an initiative to start a national level E-Resource Centre for Tobacco Control (E-RCTC) with an aim to provide relevant information on tobacco control under one roof thereby countering the misleading facts on tobacco control which exist on various web engines. The national level E-Resource Centre for Tobacco Control was developed in three stages. In the span of less than 3 years, the portal is open in public domain with over 2,36,019 visitors from around 80+ countries (as on 23rd July 2020), and growing. The portal showcases an array of valuable and vital information related to tobacco control initiatives under various heads like: Policies and Legislations, Circulars and Orders, National Tobacco Control Programme (NTCP), Publications and IEC Materials. India's first national level Resource Centre for Tobacco Control has proved to be a much-needed step in the country for facilitating speedy implementation of World Health Organization- Framework Convention on Tobacco Control (WHO-FCTC), MPOWER and other tobacco control interventions. Even with its limitations like absence of an interactive mechanism among a few others, the Resource Centre is nothing less than a storehouse of knowledge as it showcases content that are immensely helpful for the tobacco control community. Constant efforts are being made to improve the national level E-Resource Centre for Tobacco Control website and minimize the drawbacks.

Effect of Breastfeeding on Relieving Pain during Immunization in Infant

Background Advantages due to immunization are numerous and cannot be avoided but at the same time pain inflicted on babies needs to be addressed when possible. Pain associated with immunization injections has often been overlooked when remedies are available. Objective To find out the effect of breastfeeding on relieving pain during immunization injection in infants. Method An experimental study was conducted at Immunization clinic of B.P. Koirala Institute of Health Sciences (BPKIHS). Total 124 subjects were divided randomly into two groups. Experimental subjects were allowed to breastfeed for 5-10 minutes before immunization while control group was immunized without breastfeeding. Interview Questionnaire was used to obtain demographic variables and measurements were obtained. Measures of pain was recorded using duration of cry and Modified Behavior Pain Scale, by Taddio et al. Data was analyzed by using SPSS 20.0 where variables were assessed with frequency tables, Pearson's Chi-Square test, independent t test and Mann Whitney U test. Result The mean pain score in experimental group was 7.10 and in control group 7.56 which was statistically significant (p=0.001). The median duration of cry was significantly shorter in experimental group i.e. 25 seconds (IQR: 20-30) than control group 42.5 seconds (IQR: 30-61.5) (p < 0.001). Conclusion Breastfeeding before immunization is effective in reducing pain in infants.

Abstract AP19: COLLAGEN ALTERATIONS IN HUMAN OVARIAN CANCER PROBED BY SECOND HARMONIC GENERATION (SHG) IMAGING MICROSCOPY

PURPOSE: Significant remodeling of the extracellular matrix (ECM) occurs in human ovarian cancer and has been observed in both high grade and low grade tumors as well as ovaries from high risk patients with BRCA mutations. Uniquely quantifying alterations in the tumor microenvironment (TME) could be used as a new diagnostic tool, e.g. to complement histology; provide insight into disease etiology; and assess treatment efficacy through minimally invasive in vivo imaging. Current clinical modalities (CT, MRI, PET) lack the resolution for this purpose. Our efforts have focused on examining collagen alterations across a spectrum of human ovarian tumors, where the changes can serve as quantitative biomarkers. Alterations can be reflected in increased collagen concentration, changes in alignment of collagen molecules within fibrils and/or fibers and/or up-regulation of different collagen isoforms, e.g. Col III.

METHODS AND RESULTS: We used the collagen specific/sensitive Second Harmonic Generation (SHG) imaging microscopy to probe collagen architecture over size scales that range from the macromolecular structural properties to fibril/fiber morphology. First, we used SHG polarization analyses to probe collagen macromolecular/supramolecular properties to discriminate ex vivo human tissues (normal stroma, benign tumors, and high grade serous tumors) by determination of: i) collagen alpha helical pitch angle, ii) alignment of collagen molecules within fibrils, and iii) collagen helical chirality via SHG circular dichroism (SHG-CD). The largest differences were between normal stroma and benign tumors, consistent with gene expression data showing Col III is up-regulated in the latter. The different tissues also displayed differing collagen alignment within fibrils and SHG-CD responses, consistent with either Col III incorporation or randomization of Col I alignment within benign and high-grade tumors fibrils. These results collectively indicate the fibril assemblies are distinct in all tissues and likely result from synthesis of new collagen rather than remodeling of existing collagen. Importantly, these techniques do not require exogenous labels, and additionally, provide sub-resolution structural information previously obtained through ultrastructural analysis that cannot be performed on intact tissues.

We next implemented a novel form of 3D texture analysis and machine learning to delineate the fibrillar morphology observed in SHG images of normal stroma, high risk stroma, benign tumors, and a spectrum of malignant tumors (high grade serous, low grade serous, and endometrioid). We extracted textural features in the 3D image sets to build statistical models of each class and we achieved clinically significant 83-91% classification accuracies for the six classes. Importantly, the 3D analysis significantly outperformed our prior 2D methods. This classification based on collagen morphology will complement conventional classification based on genetic profiles and can serve as an additional biomarker.

CONCLUSIONS: Taken together, the combination of the macro/supramolecular probes and the fiber morphology classification will greatly increase our understanding of the TME evolution in human ovarian cancer. These methods and their findings have clinical translational significance in terms of understanding disease etiology, and also by enhancing prognostic and diagnostic capabilities.

Citation Format: Kirby R. Campbell, Rajeev Chaudhary, Julia Handel, Bruce Wen, Vikas Singh, Manish Patankar and Paul J. Campagnola. COLLAGEN ALTERATIONS IN HUMAN OVARIAN CANCER PROBED BY SECOND HARMONIC GENERATION (SHG) IMAGING MICROSCOPY [abstract]. In: Proceedings of the 12th Biennial Ovarian Cancer Research Symposium; Sep 13-15, 2018; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2019;25(22 Suppl):Abstract nr AP19.

Feasibility of a modified Atkins diet in glioma patients during radiation and its effect on radiation sensitization

Background

Gliomas are the most dreaded primary brain tumour because of their dismal cure rates. Ketogenic-type diets (kds) are high-fat, low-protein, and low-carbohydrate diets; the modified Atkins diet (mad) is a less-stringent version of a kd that still generates serum ketones in patients. The purpose of the present study was to retrospectively examine the feasibility of attaining ketosis and the safety of the mad in patients undergoing radiation and chemotherapy treatment for glioma. The rate of pseudoprogression (psp) after treatment was also assessed as a marker of radiation sensitization. To our knowledge, this dataset is the largest published relating to patients with glioma undergoing kd during radiation and chemotherapy.

Methods

We retrospectively studied 29 patients with grades ii-iv astrocytoma following the mad during standard radiation and chemotherapy. Feasibility of attaining ketosis was assessed though levels of beta hydroxybutyrate in blood. Pre- and post-radiation magnetic resonance images were evaluated for psp by a neuroradiologist blinded to patient data.

Results

In the 29 patients who started the mad during radiation, ketosis was achieved in all 29 (100%). No serious adverse events occurred secondary to the mad. Of those 29 patients, 19 had glioblastoma multiforme. Of the latter 19 patients, 11 (58%) showed psp after mad and radiation and temozolomide therapy.

Conclusions

A modified Atkins diet is feasible and safe for glioma patients during radiation and chemotherapy treatment. The mad and resulting ketosis could play a role as a radiation sensitizer.

Second-harmonic generation microscopy analysis reveals proteoglycan decorin is necessary for proper collagen organization in prostate

Collagen remodeling occurs in many prostate pathologies; however, the underlying structural architecture in both normal and diseased prostatic tissues is largely unexplored. Here, we use second-harmonic generation (SHG) microscopy to specifically probe the role of the proteoglycan decorin (Dcn) on collagen assembly in a wild type (wt) and Dcn null mouse (Dcn  -    /    -  ). Dcn is required for proper organization of collagen fibrils as it regulates size by forming an arch-like structure at the end of the fibril. We have utilized SHG metrics based on emission directionality (forward-backward ratio) and relative conversion efficiency, which are both related to the SHG coherence length, and found more disordered fibril organization in the Dcn  -    /    -  . We have also used image analysis readouts based on entropy, multifractal dimension, and wavelet transforms to compare the collagen fibril/fiber architecture in the two models, where all these showed that the Dcn  -    /    -   prostate comprised smaller and more disorganized collagen structures. All these SHG metrics are consistent with decreased SHG phase matching in the Dcn  -    /    -   and are further consistent with ultrastructural analysis of collagen in this model in other tissues, which show a more random distribution of fibril sizes and their packing into fibers. As Dcn is a known tumor suppressor, this work forms the basis for future studies of collagen remodeling in both malignant and benign prostate disease.

Polarization-resolved second harmonic generation imaging of human ovarian cancer

Remodeling of the extracellular matrix in human ovarian cancer can be manifested in increased collagen concentration, changes in alignment within fibrils/fibers and/or up-regulation of different collagen isoforms. We used pixel-based second harmonic generation (SHG) polarization microscopy analyses to probe these molecular changes in human ovarian tissues [normal stroma, benign tumors, and high-grade serous (HGS) tumors] by: (i) determination of the α-helical pitch angle via the single-axis molecular model, (ii) collagen alignment within fibrils via SHG anisotropy, and (iii) chirality via SHG circular dichroism (SHG-CD). Pixel approaches are required due to the complex structure of the matrix that lacks a high degree of fiber alignment. The largest differences in the helical pitch angle were between normal stroma and benign tumors, consistent with gene expression showing the Col III isoform is up-regulated in the latter. The data were not consistent with up-regulation of Col III in HGS tumors as previous reports have suggested. The different tissues also displayed differing SHG anisotropies and SHG-CD responses, consistent with either Col III incorporation or randomization of Col I alignment within benign and malignant tumors. Additionally, the high-grade tumors displayed higher collagen concentration, where this desmoplasia is consistent with the higher fiber density in these tissues. These results collectively indicate that the fibril assemblies are distinct in all tissues, where these differences likely result from the synthesis of collagen rather than remodeling of existing collagen. Importantly, these analyses are label-free and interrogate subresolution collagen structure on intact tissues, without the need for conventional structural biology tools.

Maternal Diets Deficient in Vitamin D Increase the Risk of Kyphosis in Offspring: A Novel Kyphotic Porcine Model

BACKGROUND

The purpose of this study was to explore the role of perinatal vitamin-D intake on the development and characterization of hyperkyphosis in a porcine model.

METHODS

The spines of 16 pigs were assessed at 9, 13, and 17 weeks of age with radiography and at 17 weeks with computed tomography (CT), magnetic resonance imaging (MRI), histology, and bone-density testing. An additional 169 pigs exposed to 1 of 3 maternal dietary vitamin-D levels from conception through the entire lactation period were fed 1 of 4 nursery diets supplying different levels of vitamin D, calcium, and phosphorus. When the animals were 13 weeks of age, upright lateral spinal radiography was performed with use of a custom porcine lift and sagittal Cobb angles were measured in triplicate to determine the degree of kyphosis in each pig.

RESULTS

The experimental animals had significantly greater kyphotic sagittal Cobb angles at all time points when compared with the control animals. These hyperkyphotic deformities demonstrated no significant differences in Hounsfield units, contained a slightly lower ash content (46.7% ± 1.1% compared with 50.9% ± 1.6%; p < 0.001), and demonstrated more physeal irregularities. Linear mixed model analysis of the measured kyphosis demonstrated that maternal diet had a greater effect on sagittal Cobb angle than did nursery diet and that postnatal supplementation did not completely eliminate the risk of hyperkyphosis.

CONCLUSIONS

Maternal diets deficient in vitamin D increased the development of hyperkyphosis in offspring in this model.

CLINICAL RELEVANCE

This study demonstrates that decreased maternal dietary vitamin-D intake during pregnancy increases the risk of spinal deformity in offspring. In addition, these data show the feasibility of generating a large-animal spinal-deformity model through dietary manipulation alone.

Risk factor profiling and study of atherosclerotic coronary plaque burden and morphology with coronary computed tomography angiography in coronary artery disease among young Indians

BACKGROUND

With a decade earlier manifestation of coronary artery disease (CAD) and paucity of data characterizing coronary plaque with coronary computed tomography angiography (CTA) among CAD patients in India, the study aimed to analyze patient characteristics and coronary plaque burden and morphology in young Indian patients with CAD.

METHODS

Serial coronary CTA was performed in 96 CAD patients. Among 60 patients ≤40years, risk factor and coronary plaque analysis done using a 256- slice CT in 33 patients with acute coronary syndrome (ACS) was compared with 27 patients with chronic stable angina (CSA). Univariate and multivariate analysis was performed, for factors predicting ACS as an outcome among young CAD patients. In addition, quantitative and morphologic plaque characteristics were compared among those ≤40years and >40years.

RESULTS

Among 60 subjects ≤40years of age, 77% had dyslipidemia, 70% high lipoprotein(a), 53.33% elevated hs-CRP and 73.33% raised homocysteine. hs-CRP (9.33 vs. 3.33, p value=0.01) and serum triglycerides (178.67 vs. 141.42, p value=0.03) were markedly raised in patients with ACS. Statistically significant number of patients in the ACS group had positive remodelling (ACS, 69.7% vs. CSA, 14.8%; p value<0.001), low attenuation plaque (ACS, 63.6% vs. CSA, 11.1%; p value<0.001), spotty calcification (ACS, 36.4% vs. CSA, 3.7%; p=0.002) and non-calcified plaque (ACS, 69.7% vs. CSA, 11.1%; p<0.001). On multivariate analysis, only lipoprotein (a) >30mg/dL and composite vulnerability score maintained a predictive value for ACS in patients ≤40years. Statistically significant number of patients in the younger age group had higher mean total plaque volume (66.17±41.31mm³ vs. 44.94±49.07mm³; p=0.03), remodelling index (1.5±0.27 vs. 1.08±0.38; p=0.0001). Comparing culprit lesion characteristics of ACS patients in the two age groups, positive remodelling (95.8% vs. 70.5%, p=0.02), spotty calcification (50% vs. 11.7%, p=0.01) and non-calcified plaque (95.8% vs. 70.5%, p=0.02) were significantly more frequent in patients ≤40years.

CONCLUSION

ACS in young Indians is characterized by a higher prevalence of both conventional and newer risk factors. In addition, culprit lesions in young ACS patients are more frequently characterized by coronary plaques with high risk morphological features. This may have implications in terms of preventive strategies to identify this high-risk group.

Advanced quantitative imaging and biomechanical analyses of periosteal fibers in accelerated bone growth

PURPOSE

The accepted mechanism explaining the accelerated growth following periosteal resection is that the periosteum serves as a mechanical restraint to restrict physeal growth. To test the veracity of this mechanism we first utilized Second Harmonic Generation (SHG) imaging to measure differences of periosteal fiber alignment at various strains. Additionally, we measured changes in periosteal growth factor transcription. Next we utilized SHG imaging to assess the alignment of the periosteal fibers on the bone both before and after periosteal resection. Based on the currently accepted mechanism, we hypothesized that the periosteal fibers adjacent to the physis should be more aligned (under tension) during growth and become less aligned (more relaxed) following metaphyseal periosteal resection. In addition, we measured the changes in periosteal micro- and macro-scale mechanics.

METHODS

30 seven-week old New Zealand White rabbits were sacrificed. The periosteum was imaged on the bone at five regions using SHG imaging. One centimeter periosteal resections were then performed at the proximal tibial metaphyses. The resected periosteal strips were stretched to different strains in a materials testing system (MTS), fixed, and imaged using SHG microscopy. Collagen fiber alignment at each strain was then determined computationally using CurveAlign. In addition, periosteal strips underwent biomechanical testing in both circumferential and axial directions to determine modulus, failure stress, and failure strain. Relative mRNA expression of growth factors: TGFβ-1, -2, -3, Ihh, PTHrP, Gli, and Patched were measured following loading of the periosteal strips at physiological strains in a bioreactor. The periosteum adjacent to the physis of six tibiae was imaged on the bone, before and after, metaphyseal periosteal resection, and fiber alignment was computed. One-way ANOVA statistics were performed on all data.

RESULTS

Imaging of the periosteum at different regions of the bone demonstrated complex regional differences in fiber orientation. Increasing periosteal strain on the resected strips increased periosteal fiber alignment (p<0.0001). The only exception to this pattern was the 10% strain on the tibial periosteum, which may indicate fiber rupture at this non-physiologic strain. Periosteal fiber alignment adjacent to the resection became less aligned while those adjacent to the physes remained relatively unchanged before and after periosteal resection. Increasing periosteal strain on the resected strips increased periosteal fiber alignment (p<0.0001). The only exception to this pattern was the 10% strain on the tibial periosteum, which may indicate fiber rupture (and consequent retraction) at this non-physiologic strain. Increasing periosteal strain revealed a significant increase in relative mRNA expression for Ihh, PTHrP, Gli, and Patched, respectively.

CONCLUSION

Periosteal fibers adjacent to the growth plate do not appear under tension in the growing limb, and the alignments of these fibers remain unchanged following periosteal resection.

SIGNIFICANCE

The results of this study call into question the long-accepted role of the periosteum acting as a simple mechanical tether restricting growth at the physis.

Accuracy of model-based tracking of knee kinematics and cartilage contact measured by dynamic volumetric MRI

The purpose of this study was to determine the accuracy of knee kinematics and cartilage contact measured by volumetric dynamic MRI. A motor-actuated phantom drove femoral and tibial bone segments through cyclic 3D motion patterns. Volumetric images were continuously acquired using a 3D radially undersampled cine spoiled gradient echo sequence (SPGR-VIPR). Image data was binned based on position measured via a MRI-compatible rotary encoder. High-resolution static images were segmented to create bone models. Model-based tracking was performed by optimally registering the bone models to the volumetric images at each frame of the SPGR-VIPR series. 3D tibiofemoral translations and orientations were reconstructed, and compared to kinematics obtained by tracking fiducial markers. Imaging was repeated on a healthy subject who performed cyclic knee flexion-extension. Cartilage contact for the subject was assessed by measuring the overlap between articular cartilage surfaces. Model-based tracking was able to track tibiofemoral angles and translations with precisions less than 0.8° and 0.5mm. These precisions resulted in an uncertainty of less than 0.5mm in cartilage contact location. Dynamic SPGR-VIPR imaging can accurately assess in vivo knee kinematics and cartilage contact during voluntary knee motion performed in a MRI scanner. This technology could facilitate the quantitative investigation of links between joint mechanics and the development of osteoarthritis.

Multicomponent T2 analysis of articular cartilage with synovial fluid partial volume correction

PURPOSE

To investigate the use of a three-pool model to account for the confounding effects of synovial fluid on multicomponent T2 analysis of articular cartilage using Multicomponent Driven Equilibrium Single Shot Observation of T1 and T2 (mcDESPOT).

MATERIALS AND METHODS

mcDESPOT was performed on the knee of eight asymptomatic volunteers and eight patients with osteoarthritis at 3.0T with multicomponent T2 maps created using the two-pool model and a three-pool model containing a nonexchanging synovial fluid water pool. The fraction of the fast-relaxing water component (FF ) and the T2 relaxation times for the fast-relaxing (T2F ) and slow-relaxing (T2S ) water components were measured in the superficial and deep layers of patellar cartilage using the two-pool and three-pool models in asymptomatic volunteers and patients with osteoarthritis and were compared using Wilcoxon signed rank tests.

RESULTS

Within the superficial layer of patellar cartilage, FF was 22.5% and 25.6% for asymptomatic volunteers and 21.3% and 22.8% for patients with osteoarthritis when using the two-pool and three-pool models, respectively, while T2S was 73.9 msec and 62.0 msec for asymptomatic volunteers and 72.0 msec and 63.1 msec for patients with osteoarthritis when using the two-pool and three-pool models, respectively. For both asymptomatic volunteers and patients with osteoarthritis, the two-pool model provided significantly (P < 0.05) lower FF and higher T2S than the three-pool model, likely due to the effects of synovial fluid partial volume averaging.

CONCLUSION

The effects of partial volume averaging between superficial cartilage and synovial fluid may result in biased multicomponent T2 measurements that can be corrected using an mcDESPOT three-pool model containing a nonexchanging synovial fluid water pool.

Detection of ST772 Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus (Bengal Bay clone) and ST22 S. aureus isolates with a genetic variant of elastin binding protein in Nepal

Genetic characteristics were analysed for recent clinical isolates of methicillin-resistant and -susceptible Staphylococcus aureus (MRSA and MSSA respectively) in Kathmandu, Nepal. MRSA isolates harbouring Panton-Valentine leukocidin (PVL) genes were classified into ST1, ST22 and ST88 with SCCmec-IV and ST772 with SCCmec-V (Bengal Bay clone), while PVL-positive MSSA into ST22, ST30 and ST772. ST22 isolates (PVL-positive MRSA and MSSA, PVL-negative MRSA) possessed a variant of elastin binding protein gene (ebpS) with an internal deletion of 180 bp, which was similar to that reported for ST121 S. aureus previously outside Nepal. Phylogenetic analysis indicated that the ebpS variant in ST22 might have occurred independently of ST121 strains. This is the first report of ST772 PVL-positive MRSA in Nepal and detection of the deletion variant of ebpS in ST22 S. aureus.

Articular cartilage zonal differentiation via 3D Second-Harmonic Generation imaging microscopy

PURPOSE

The collagen structure throughout the patella has not been thoroughly investigated by 3D imaging, where the majority of the existing data come from histological cross sections. It is important to have a better understanding of the architecture in normal tissues, where this could then be applied to imaging of diseased states.

METHODS

To address this shortcoming, we investigated the combined use of collagen-specific Second-Harmonic Generation (SHG) imaging and measurement of bulk optical properties to characterize collagen fiber orientations of the histologically defined zones of bovine articular cartilage. Forward and backward SHG intensities of sections from superficial, middle and deep zones were collected as a function of depth and analyzed by Monte Carlo simulations to extract the SHG creation direction, which is related to the fibrillar assembly.

RESULTS

Our results revealed differences in SHG forward-backward response between the three zones, where these are consistent with a previously developed model of SHG emission. Some of the findings are consistent with that from other modalities; however, SHG analysis showed the middle zone had the most organized fibril assembly. While not distinct, we also report bulk optical property values for these different zones within the patella.

CONCLUSIONS

Collectively, these results provide quantitative measurements of structural changes at both the fiber and fibril assembly of the different cartilage zones and reveals structural information not possible by other microscope modalities. This can provide quantitative insight to the collagen fiber network in normal cartilage, which may ultimately be developed as a biomarker for osteoarthritis.

The role of computerised tomography in predicting visual outcome in ocular trauma patients

PURPOSE

Ocular blast injuries in the military setting are particularly associated with significant maxillofacial trauma and/or brain injury. The opportunity to perform a comprehensive ophthalmic evaluation is frequently limited in the acute multiple trauma scenario. We aim to describe the relationship between the clinical effects of acute ocular and orbital blast trauma with the findings on computerised tomography (CT).

METHODS

This was a retrospective consecutive case series of all soldiers with facial and/or suspected ocular injuries. A total of 80 eyes that had suffered blast injuries of varying severity were studied. Assessment of orbital and ocular CT images were performed by military consultant radiologists. A comparison was made with actual clinical findings. Statistical analysis was performed using Fisher's exact test.

RESULTS

No pathological findings were described in 37 of the 80 eyes imaged by orbital and ocular CT scans. Clinically, these eyes and orbits were all found to be intact, or had minor trauma. All foreign bodies and penetrating eye injuries were successfully diagnosed by CT. Absence of an orbital fracture did not rule out a globe injury. However, a corneal or scleral defect was less likely when an orbital fracture was absent.

CONCLUSION

The eye is a delicate structure prone to injury that requires urgent repair if breached. It is difficult to assess thoroughly in the unconscious or distressed patient. In this context, CT imaging is invaluable to be able to make a relatively confident prediction of clinical findings and decide upon the necessity for acute ophthalmic surgical intervention.

Quantitative magnetic resonance imaging of the articular cartilage of the knee joint

Osteoarthritis is characterized by a decrease in the proteoglycan content and disruption of the highly organized collagen fiber network of articular cartilage. Various quantitative magnetic resonance imaging techniques have been developed for noninvasive assessment of the proteoglycan and collagen components of cartilage. These techniques have been extensively used in clinical practice to detect early cartilage degeneration and in osteoarthritis research studies to monitor disease-related and treatment-related changes in cartilage over time. This article reviews the role of quantitative magnetic resonance imaging in evaluating the composition and ultrastructure of the articular cartilage of the knee joint.

Demonstration of IgG subclass (IgG1 and IgG3) in patients with positive direct antiglobulin tests

Serologic characterization of autoantibodies helps in the management and monitoring of the course of autoimmune hemolytic anemia (AIHA). The purpose of this study was to evaluate gel centrifugation test (GCT) cards for immunoglobulin G (IgG) titer and determination of IgG subclasses IgG1 and IgG3 and their influence on hemolysis. Eighty direct antiglobulin test (DAT)-positive patients were examined with the help of GCT cards for IgG titer and IgG subclasses. The results were correlated with the presence and absence of hemolysis. A statistically significant (p < 0.005) association of hemolysis with increasing anti-IgG titer was observed. When IgG titer was 30 or less, 28 (50.91%) patients had no hemolysis, whereas 15 (93.75%) patients had features of hemolysis when titer was at least 300. Statistically significant (p < 0.005) association of subclass of IgG (IgG1, IgG3) coating the red blood cells with intravascular hemolysis was also seen. Twenty-nine (80.56%) patients had evidence of hemolysis when IgG1 or IgGl-IgG3 both were present. Gel technology is helpful to demonstrate red blood cell-bound autoantibodies and their characterization with regard to class, subclass, and titer. This information is useful to identify patients with AIHA who are at risk of severe hemolysis with adverse prognosis.

Rapid multicomponent T2 analysis of the articular cartilage of the human knee joint at 3.0T

PURPOSE

To determine the feasibility of using multicomponent-driven equilibrium single-shot observation of T1 and T2 (mcDESPOT) for evaluating the human knee joint at 3.0T and to investigate depth-dependent and regional-dependent variations in multicomponent T2 parameters within articular cartilage.

MATERIALS AND METHODS

mcDESPOT was performed on the knee joint of 10 asymptomatic volunteers at 3.0T. Single-component T2 relaxation time (T2single ), multicomponent T2 relaxation time for water tightly bound to proteoglycan (T2PG ) and bulk water loosely bound to the macromolecular matrix (T2BW ), and fraction of water tightly bound to proteoglycan (FPG ) were measured in eight cartilage subsections and within the superficial and deep layers of patellar cartilage. Statistical analysis was used to investigate depth-dependent and regional-dependent variations in parameters.

RESULTS

There was lower (P = 0.001) T2single and T2PG and higher (P < 0.001) FPG in the deep than superficial layer of patellar cartilage. There was higher (P < 0.001) FPG on the weight-bearing surfaces than nonweight-bearing surfaces. There was higher (P < 0.001) T2single , T2PG , and T2BW on the trochlea and posterior medial and lateral femoral condyles than the patella, central medial and lateral femoral condyles, and medial and lateral tibia plateaus.

CONCLUSION

Multicomponent T2 parameters of the articular cartilage of the human knee joint can be measured at 3.0T using mcDESPOT and show depth-dependent and regional-dependent variations.

Posterior Reversible Encephalopathy Syndrome : A Rare Cause of Sudden Onset Vision Loss in Pregnancy

Posterior Reversible Encephalopathy Syndrome (PRES) is a very rare cause of sudden onset vision loss in pregnancy. There are only few case reports in literature. It is characterized by headache, seizures, altered mental status and visual deficits ranging from visual neglect to cortical blindness. Here a case if PRES has been reported with discussion on its pathophysiology. NJOG 2011 Nov-Dec; 6 (2): 51-52 DOI: http://dx.doi.org/10.3126/njog.v6i2.6759

Remediation of acidic industrial effluents by sulphate reducing bioreactors

This research work was designed to examine the feasibility of sulphate reducing bioreactors with organic substrates, containing manures, and other cellulosic wastes for remediation of acidic industrial wastewater on bench scale. The pH of the wastewater increased from 5.5. to 7.18, alkalinity from 0 to 2566 mg/L as CaCO3, acidity removal was from 357 to 210 mg/L as CaCO3, sulphate removal was 92.7%, lead removal was 97.3%, zinc- 99.8%, copper-97.5%, cobalt-99.4%, manganese-98.9%, nickel- 98.3% and iron 99.5%, were observed in this study after the maximum retention of 106 days. This paper describes bioremediation as a state-of-art for the treatment of wastewater from the industries.

Short ReportGenetic variation at three VNTR loci (D1S80, APOB and D17S5) in two tribal populations of Andhra Pradesh, India

This study reports the genetic variation at three variable number of tandem repeat (VNTR) loci (APOB, D17S5 and D1S80) in two tribes (Thoti and Kolam) of Andhra Pradesh, India. Kolams constitute 1% of the total scheduled tribal population of Andhra Pradesh, while Thoti is a numerically small tribe. All three genetic loci were genotyped using the polymerase chain reaction (PCR) technique and were polymorphic in both populations. At the D1S80 locus, both populations showed higher frequencies of allele *31 (9-14%) than other Indian populations. In the APOB system, Thoti showed a very high frequency of allele *37 (54%) and for D17S5 system allele *4 was the most common in Thoti (32%) and allele *2 in Kolam (28%). Both tribes differed statistically significantly from other tribal populations of the region. The level of gene differentiation was low (GST = 0.038) for Indian tribal populations. The allele frequency distribution, heterozygosity and genetic diversity analysis shows that the observed genetic variation is socially and geographically structured.

Knee range of motion during the first two years after use of posterior cruciate-stabilizing or posterior cruciate-retaining total knee prostheses. A randomized clinical trial

BACKGROUND

The impact of posterior cruciate ligament-substituting and posterior cruciate ligament-retaining devices on the range of motion of the knee following primary total knee arthroplasty is unclear. The primary objective of our study was to compare the range of motion of the knee over the first two postoperative years between subjects who had received the ligament-substituting design and those who had received the ligament-retaining design. Secondarily, pain, function, and health-related quality of life were compared between the two groups.

METHODS

We undertook a prospective randomized study of 100 patients with noninflammatory osteoarthritis who were undergoing primary total knee arthroplasty. Patients were randomized at the time of surgery to receive one of the two study prosthesis designs. They were evaluated preoperatively, at the time of hospital discharge, at three months postoperatively, and at up to two years postoperatively by a physical therapist who was blinded to the group allocation. Active knee flexion and extension, measured with a goniometer, were the primary outcome measures. Self-reported pain, function, and health-related quality of life were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the RAND 36-Item Health Survey (RAND-36). Complications and revision rates were determined through hospital record review and at each patient evaluation.

RESULTS

Eighty percent (seventy-eight) of the ninety-eight available patients returned for the final assessment. At two years postoperatively, the mean difference between the groups with regard to knee flexion was 0.03 degrees (95% confidence interval, -5.9 degrees to 6.0 degrees ) and the mean difference in knee extension was 1.0 degrees (95% confidence interval, -0.36 degrees to 2.4 degrees ). Ninety-one (93%) of the ninety-eight available patients completed questionnaires at the time of the final assessment. The two treatment groups had similar pain, function, and quality-of-life scores and complication rates. One subject in the cruciate-retaining group required revision, secondary to a deep joint infection, and one subject in the cruciate-substituting group required manipulation to address poor knee flexion.

CONCLUSIONS

Overall, the two treatment groups had a similar range of motion of the knee over the initial two-year postoperative time period. A satisfactory range of motion was achieved by three months postoperatively and was maintained at the final assessment.

Cytidine-5-diphosphocholine supplement in early life induces stable increase in dendritic complexity of neurons in the somatosensory cortex of adult rats

Cytidine-5-diphosphocholine (CDP-choline or citicholine) is an essential molecule that is required for biosynthesis of cell membranes. In adult humans it is used as a memory-enhancing drug for treatment of age-related dementia and cerebrovascular conditions. However the effect of CDP-choline on perinatal brain is not known. We administered CDP-choline to Long Evans rats each day from conception (maternal ingestion) to postnatal day 60 (P60). Pyramidal neurons from supragranular layers 2/3, granular layer 4 and infragranular layer 5 of somatosensory cortex were examined with Golgi–Cox staining at P240. CDP-choline treatment significantly increased length and branch points of apical and basal dendrites. Sholl analysis shows that the complexity of apical and basal dendrites of neurons is maximal in layers 2/3 and layer 5. In layer 4 significant increases were seen in basilar dendritic arborization. CDP-choline did not increase the number of primary basal dendrites on neurons in the somatosensory cortex. Primary cultures from somatosensory cortex were treated with CDP-choline to test its effect on neuronal survival. CDP-choline treatment neither enhanced the survival of neurons in culture nor increased the number of neurites. However significant increases in neurite length, branch points and total area occupied by the neurons were observed. We conclude that exogenous supplementation of CDP-choline during development causes stable changes in neuronal morphology. Significant increase in dendritic growth and branching of pyramidal neurons from the somatosensory cortex resulted in enlarging the surface area occupied by the neurons which we speculate will augment processing of sensory information.

Localization of the citrate synthase (CS) gene to the p12-p13 bands of chromosome 5 in pigs by in situ hybridization

Citrate synthase (CS) is a key enzyme of the Krebs tricarboxylic acid cycle. A 1.4 kb porcine CS cDNA probe was used to chromosomally localize the CS gene in pigs by in situ hybridization. Two in situ hybridization experiments were conducted. Although the first experiment indicated a distinct signal on the 5p12-p13 bands, a secondary signal was observed on the 13q24-q32 bands. Hence, a second in situ hybridization experiment was conducted at higher stringency. The results demonstrated a consistent signal on the 5p12-p13 bands, and the signal on chromosome 13 was scattered with no prominent secondary peak. The CS gene was therefore assigned to the p12-p13 bands of chromosome 5 in pigs.