A quantitative assessment of the number of disease foci in papillary thyroid cancer

AIM

Multifocality is a frequent feature of papillary thyroid carcinoma (PTC). Its prognostic value is controversial although national guidelines recommend treatment intensification if present. However, multifocality is not a binary but discrete variable. This study aimed to examine the association between increasing number of foci and risk of recurrence following treatment.

METHODS

577 patients with PTC were identified with median follow-up of 61 months. Number of foci were taken from pathology reports. Log-rank test was used to assess significance. Multivariate analysis was performed and Hazard Ratios were calculated.

RESULTS

Of 577 patients, 206(35%) had multifocal disease and 36(6%) recurred. 133(23%), 89(15%) and 61(11%) had 3+, 4+ or 5+ foci respectively. The 5-year RFS stratified by number of foci was 95%v93% for 2+foci (p = 0.616), 95%v96% for 3+foci (p = 0.198) and 89%v96% for 4+foci (p = 0.022). The presence of 4 foci was associated with an over 2-fold risk of recurrence (HR 2.296, 95% CI 1.106-4.765, p = 0.026) although this was not independent of TNM staging. Of the 206 multifocal patients, 31(5%) had 4+foci as their sole risk factor for treatment intensification.

CONCLUSION

Although multifocality per se does not confer worse outcome in PTC, finding 4+foci is associated with worse outcome and could therefore be appropriate as a cut-off for treatment intensification. In our cohort, 5% of patients had 4+foci as a sole indication for treatment intensification, suggesting that such a cut off could impact clinical management.

Clinicopathological features of Differentiated Thyroid Cancer presenting in the UK versus internationally: An observational cohort study

INTRODUCTION

Very little data are available regarding differentiated thyroid cancer (DTC) managed in the UK, and no UK patients are included in the evidence base upon which international guidelines are based. Therefore, the aim of this study was to compare the clinicopathological features of patients with DTC presenting in a UK population with international patient cohorts.

PATIENTS AND METHODS

Data were collected from a prospectively held multi-disciplinary team records from January 2009 to December 2016. The local cohort was compared with cohorts from across the world based on clinicopathological features. Ethical approval was obtained by Lothian Caldicott Guardian (Ref 16 133).

RESULTS

444 cases were diagnosed locally with a median age of 48 years (range 16-86 years). 78% of patients were female. 25% of our patients had follicular carcinoma with an overall N1 rate of 20%. Distant disease was recorded in 5% cases. In comparison with international data, our local cohort had a higher rate of follicular thyroid carcinoma. Variation was seen in terms of age, gender distribution, primary tumour size, nodal and distant disease. In Korea, where thyroid cancer screening has been undertaken, smaller tumours, higher rates of nodal disease and lower rates of distant disease are described.

CONCLUSION

In our centre, a higher rate of males is treated with larger primary disease and a higher percentage of follicular carcinoma. The reasons for this geographic variation in clinicopathological features in the UK are unclear. As a result, caution should be applied in translating the international move towards a more conservative approach to DTC in the UK in comparison with other areas of the world.

Oncological outcomes in differentiated thyroid cancer in South East Scotland

BACKGROUND

Differentiated thyroid cancer (DTC) is increasing in incidence but little is known about oncological outcomes for patients treated in the UK. Internationally there is a move toward conservative treatment of DTC. However, this is based on evidence from outside the UK. The aim of this study was to analyse oncological outcomes for a contemporary cohort of patients treated in a UK centre.

METHODS

Review of 470 consecutive prospectively recorded cases of DTC from the South East of Scotland endocrine MDT 2009-2018. Data on patient, tumour and treatment details as well as recurrence and survival details were extracted from the electronic patient record.

RESULTS

Of 470 patients female:male ratio was 3.4:1, median age at presentation was 48 years (range 16-86 years). Overall 193 (41%), 134 (29%), 119 (25%) and 22 (5%) patients were p T1, T2, T3, and p T4 respectively. 385 patients (82%) were pN0, 31 patients (7%) were pN1a and 53 patients (11%) were pN1b. 19 patients (4%) were M1. Of 470 patients 350 (74%) had papillary thyroid carcinoma, 120 patients (26%) had follicular carcinoma. Surgical management was lobectomy, isthumusectomy, total thyroidectomy and lobectomy then completion thyroidectomy in 14%,1%, 41% and 43% cases respectively. 64% patients received radioactive Iodine (RAI) therapy. With a median follow-up of 70 months (range 4-124 months), 5 years overall survival and disease specific survival were 96.7% and 98.5% respectively. The 5 year local recurrence free survival (LRFS), regional recurrence free survival (RRFS), locoregional recurrence free survival (LRRFS), distant recurrence free survival (DRFS) and any recurrence free survivals were 100%, 95.8%, 95.8%, 98.3% and 95% respectively.

CONCLUSION

Oncological outcomes for patients treated with DTC were excellent, in keeping with experience from international groups, suggesting that a move towards conservative treatment in the UK seems reasonable.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Reading Instruction for Students with Emotional Disturbance: A Mixed-Methods Investigation

Although there is a substantial body of observation research investigating the manner in which reading instruction is provided to students with learning disabilities, there is little research in this area involving students with and at risk for emotional disturbance. The purpose of this investigation was to contribute to the limited corpus of observation studies investigating school-based practice in reading for this student population. In this investigation, 11 teachers from two states were systematically observed while providing reading instruction over the course of the 2017-2018 school year. Participating students were also observed over the course of the year and completed two standardized reading assessments at the beginning and end of this investigation. Teachers were also interviewed to identify contextual factors that promote or impede the provision of high quality reading instruction to this student population. Study findings suggest that teachers are in need of additional training, support, and resources to maximize instructional time. Students in this sample tended to make no or minimal progress in reading and were frequently observed displaying low levels of academic engagement across settings. Implications for school practice and areas for future research are discussed.

The impact of completion thyroidectomy

INTRODUCTION

The oncological benefit of completion thyroidectomy (CT) following thyroid lobectomy (TL) is presumed to be similar to that of upfront total thyroidectomy(TT), from a patient's perspective the risk and inconvenience of further surgery adds significantly to the impact of the overall treatment. The aim of this study is to assess the impact of CT in terms of the duration of admission and associated complications.

METHODS

A study of consecutive patients with DTC identified from prospective MDT records of South-East Scotland from 2009 to 2015. Surgical data was extracted from electronic medical record.

RESULTS

Of 361 patients diagnosed with DTC, 161 (45%) had CT. The median postoperative stay was 1 day (range 1-5days). In total 22 patients (14%)suffered complications. Four patients (3%) developed postoperative haematoma. Two (1%) had an identified permanent nerve palsy on the completion side. 13 patients (8%) remained on calcium supplementation for more than 6 months postoperatively and three patients (2%) developed wound complications.

CONCLUSIONS

Our study confirms that CT is regularly performed (45%). Recent changes in international guidelines recognize increasing number of patients as eligible for a conservative approach but recommend CT based on whether upfront TT would have been recommended if the TL pathology were known from the outset. Such an approach fails to consider the additional risk and inconvenience of CT on the overall patient experience. Due to a relatively high rate of complications, only those patients who are most likely to benefit from further surgery to facilitate adjuvant radioactive iodine should be offered additional surgery.

Curbing Our Enthusiasm: An Analysis of the Check-In/Check-Out Literature Using the Council for Exceptional Children's Evidence-Based Practice Standards

Check-in/Check-out (CICO) is an intervention designed to improve behavioral outcomes for students identified as at-risk for school failure. Core principles of the intervention include clearly defined behavioral expectations and rules, precorrections for meeting behavioral expectations, high rates of feedback and reinforcement for demonstration of desired behavior, use of data to monitor outcomes, and a system for school-to- home communication. The purpose of this investigation was to use the 2014 Council for Exceptional Children's quality indicators and standards for establishing evidence-based practices in special education to review the existing research for CICO. Implications regarding the use of different sets of quality indicators to evaluate extant research are provided, and recommendations for future research are discussed.

A Systematic Review of Function-Based Replacement Behavior Interventions for Students With and At Risk for Emotional and Behavioral Disorders

Students with emotional and behavioral disorders and students considered at risk often have social deficits. Although social skills interventions are often provided to this student population, there are some concerns regarding how these interventions are conceived and provided. One possible way to improve the effectiveness of social skills interventions is to use functional behavior assessment data to tailor the interventions to a student’s individual needs and the contexts in which social skills deficits and problem behaviors occur. This approach is commonly referred to as replacement behavior training. In this study, the literature on function-based replacement behavior interventions is systematically reviewed. In addition, studies are evaluated according to the What Works Clearinghouse design and evidence standards for single-case research. Although this research base does not meet the What Works Clearinghouse replication standards, function-based replacement behavior interventions appear to be a promising practice for addressing problem behaviors. Implications for practice, areas for future research, and study limitations are discussed.

Intraventricular flow patterns and stasis in the LVAD-assisted heart

Left ventricular assist device (LVAD) support disrupts the natural blood flow path through the heart, introducing flow patterns associated with thrombosis, especially in the presence of medical devices. The aim of this study was to quantitatively evaluate the flow patterns in the left ventricle (LV) of the LVAD-assisted heart, with a focus on alterations in vortex development and stasis. Particle image velocimetry of a LVAD-supported LV model was performed in a mock circulatory loop. In the Pre-LVAD flow condition, a vortex ring initiating from the LV base migrated toward the apex during diastole and remained in the LV by the end of ejection. During LVAD support, vortex formation was relatively unchanged although vortex circulation and kinetic energy increased with LVAD speed, particularly in systole. However, as pulsatility decreased and aortic valve opening ceased, a region of fluid stasis formed near the left ventricular outflow tract. These findings suggest that LVAD support does not substantially alter vortex dynamics unless cardiac function is minimal. The altered blood flow introduced by the LVAD results in stasis adjacent to the LV outflow tract, which increases the risk of thrombus formation in the heart.

Crosstalk between site-specific modifications on p53 and histone H3

Previously, we have observed a link between p53 expression and histone H3 post-translational modifications. Here, we ask if specific post-translational modifications of p53 impact upon histone H3 modifications in a selective manner. We have also screened for internal co-operative effects within the repertoire of p53 modifications. Exogenous p53 constructs were expressed in HCT116 p53-/- cells. Four mutant p53 constructs were used, with single 'phosphorylation' mutations at serines 15 and 37 (S15A, S15D, S37A and S37D) and compared with exogenously expressed wild-type p53. The results showed that the replacement of serine 15 with either alanine (S15A) or aspartic acid (S15D) induced phosphorylation at S33P, S37P and S46P. In contrast, phosphorylation mutants p53(S37A) and p53(S37D) were not phosphorylated on S33. S46 phosphorylation appeared specifically enhanced by p53(S37D) relative to p53(S37A). Distal induction of S392 phosphorylation was observed for each of the p53 N-terminal phosphorylation mutants. Analysis of endogenous histone H3 (from the transfected cells) revealed loss of di-methylated K9 following expression of wild type and mutant p53 constructs. Expression of p53 (S15A), (S15D) and (S37A) selectively induced acetylation at K9 and K14. In contrast, wt p53 and p53(S37D) had no effect upon K9 or K14 acetylation. K18 acetylation status was unaffected throughout.

A role for matrix metalloproteinases in the pathology and attenuation of Theileria annulata infections

Upon infection with Theileria annulata, bovine leukocytes are induced to express eight novel metalloproteinase activities. In this article, Rachel Adamson and Roger Hall suggest that these enzymes are virulence factors and their presence may explain some of the features of the pathology of the disease. Specifically, they discuss the possibility that the metastatic properties of infected cells, the 'cigarette burn' ulcers and the cachexia characteristic of tropical theileriosis are associated with metalloproteinase expression. Furthermore, they propose that loss of metalloproteinase activity during the generation of a vaccine line could explain the attenuated phenotype.

Assessment of secondary haemorrhage rates following adult tonsillectomy - a telephone survey and literature review

Many previous studies have considered patient re-admission rates alone as the true rate of secondary haemorrhage following adult tonsillectomy. We aimed to determine the true rate of secondary haemorrhage following tonsillectomy in adults by performing a telephone interview with 60 consecutive patients. Whilst 40% (n = 24) of our patients reported a significant episode of bleeding (blood actively flowing from their mouth for more than 1 min) following discharge, only 8% (n = 5) were re-admitted and only 3% (n = 2) required return to theatre. Review of the current literature suggests that return-to-theatre rates are more consistent than hospital re-admission rates in large studies. We would suggest that although secondary haemorrhage can occasionally be very serious, the majority is minor, and it would therefore be more useful when comparing different techniques for tonsillectomy to consider numbers of patients returning to theatre rather than re-admission rates.

Prime-boost: the way forward for recombinant vaccines against apicomplexan parasites. A Theileria perspective

A good CD8+ response is required for immunity to many intracellular pathogens. Traditional antigen delivery using isolated sub-units or killed pathogens and adjuvant stimulates strong antibody responses but weak T-cell reactivity. Attenuated vaccines are usually more effective. The prime-boost delivery system based on immunisation with a naked DNA antigen-gene construct followed by boosting with an attenuated vaccinia virus expressing the same antigen is proving to be a powerful way to stimulate antigen-specific CD8 responses. Success using single epitopes is possible in malaria and we believe this approach holds much promise for other apicomplexan parasites such as Theileria spp.

Transient transfection of Theileria annulata

We have developed a method to transiently transfect infective, uninucleate, Theileria annulata sporozoites. Transfection vectors have been constructed using a number of T. annulata 5' gene flanking sequences linked to the enhanced green fluorescence protein (eGFP) reporter gene. Sporozoites were transfected with these constructs using the lipid transfection agent SuperFect, then allowed to infect purified bovine mononuclear cells (PBMs). Green fluorescence was observed in developing trophozoites, 36-40 h post infection, using constructs containing the upstream regions of the T. annulata Hsp70, T. annulata merozite surface antigen 1 (TamS1) and T. annulata macroschizont-specific AT hook-containing protein2 (TashAT2) genes. A construct with the 5' TamS1 upstream sequence in reverse orientation gave no detectable fluorescence indicating fluorescence was derived by expression from the T. annulata promoter. A cytomegalovirus (CMV) promoter construct showed no activity in this stage of the parasite. However, when this construct was introduced directly into schizont-infected cells by electroporation, fluorescence was observed in the bovine cells but not the schizont. We describe the significance of these results in relation to novel control strategies and the fundamental biology of Theileria parasites.

SEX AND ETHNICITY MAY CHIEFLY INFLUENCE THE INTERACTION OF FLUCONAZOLE WITH CALCINEURIN INHIBITORS12

BACKGROUND

Calcineurin inhibitors (CNI) and azole antifungal agents have been reported to interact in a disparate manner. The azole dose and route and the level of involvement of the liver and intestines have been implicated, although data are limited. A significant interaction may result in CNI toxicity, and withdrawal of the azole may result in subtherapeutic CNI concentrations. Fluconazole, available in both intravenous and oral formulations, is commonly used in transplant recipients and is ideal for determining the presence of a disparate effect on CNI concentrations. We retrospectively investigated the interaction of CNIs with fluconazole, evaluating CNI blood troughs corrected for daily CNI dose, the factors influencing the interaction, and the effect on clinical outcomes in renal and simultaneous pancreas kidney transplant recipients.

METHODS

Twenty-eight patients received a CNI and fluconazole during the calendar year 1999, but only 19 patients had documented CNI blood troughs and outpatient follow-up. There were 25 episodes of use in the 19 included patients. CNI blood troughs were evaluated for changes induced by fluconazole, given by both routes, and clinical outcomes were tracked.

RESULTS

Data demonstrated both intravenous and oral fluconazole alter CNI blood concentrations. Two metabolic patterns were observed, and we termed these convergent and divergent. Divergent metabolizers did not have significant interaction (n=5), and convergent metabolizers did have a significant interaction (n=15). One patient had a divergent episode after a previous convergent episode. The main contributors to the lack of interaction appeared to be female sex and African American ethnicity. Additionally, tacrolimus levels were significantly more affected than cyclosporine, during and after fluconazole administration. No patient experienced nephrotoxicity or cellular rejection related to antifungal therapy.

CONCLUSIONS

Oral and intravenous fluconazole appear to increase oral CNI trough concentrations to a similar extent even after adjusting for daily calcineurin dose. These interactions appear to be chiefly influenced by sex and ethnicity. Further prospective study is necessary to clarify this issue.

Immunohistochemical detection of steroid receptors in breast cancer: a working protocol. UK Receptor Group, UK NEQAS, The Scottish Breast Cancer Pathology Group, and The Receptor and Biomarker Study Group of the EORTC

The biochemical assay for the oestrogen receptor has shown the clinical value of knowing the concentration of the receptor within tissue. The immunohistochemical assay is rapidly taking over from the biochemical assay. Therefore, it is vital to have an equivalent scoring system that will have the same predictive value. This paper reports both a practical protocol and a scoring system that should achieve this aim. This approach should be applicable to many more biomarkers detected by immunohistochemistry.

Loss of matrix metalloproteinase 9 activity in Theileria annulata-attenuated cells is at the transcriptional level and is associated with differentially expressed AP-1 species

The schizont stage of the protozoan parasite Theileria annulata reversibly transforms bovine monocytes into an immortalised and metastatic state. We have been studying T. annulata induction of host matrix metalloproteinases (MMP) which are involved in parasite dissemination and pathogenesis. We have observed that prolonged in vitro culture of T. annulata-infected cell lines results in their attenuation and this process is associated with alterations in both host and parasite gene expression. In particular, a loss in bovine MMP expression in later passage cultures suggests that these parasite-induced MMPs are virulence factors. As a means to further our understanding of the attenuation process we examine in detail the parasite-induced differential expression of one particular bovine proteinase, MMP9, in non-attenuated (p58) and attenuated (p158) passage levels of the Ode vaccine line. We show here that MMP9 expression is regulated at the transcriptional level and we suggest that a particular parasite-induced AP-1 recognition transcription factor present in the Ode non-attenuated line may have a role to play in the expression of this host gene.

Comparison of functional capacity in patients with end-stage heart failure following implantation of a left ventricular assist device versus heart transplantation: results of the experience with left ventricular assist device with exercise trial

BACKGROUND

Use of a permanent left ventricular assist device (LVAD) has been proposed as an alternate treatment of patients with end-stage heart failure. The purpose of this study was to compare the functional capacity of patients following implantation of a LVAD vs heart transplant (HTx).

METHODS

Eighteen patients from 6 centers who received an intracorporeal LVAD as a bridge to HTx underwent treadmill testing 1 to 3 months post-LVAD and again post-HTx. Baseline and peak measurements, including oxygen consumption, blood pressures, and respiratory rate were made during each treadmill test.

RESULTS

Peak oxygen consumption was 14.5+/-3.9 ml/kg/minute post-LVAD and 17.5+/-5.0 ml/kg/minute post-HTx (p < .005). The percentage of the predicted peak oxygen consumption based on gender, weight, and age was 39.5%+/-5.5% post-LVAD and 47.7%+/-10.9% post-HTx (p < .005). Exercise duration was lower post-LVAD than post-HTx (10.3+/-4.2 minute vs 12.5+/-5.4 minute, p < .05). After LVAD implantation, peak total oxygen consumption correlated with peak LVAD rate and output. Eight patients reached an LVAD rate of 120 beats per minute (bpm) before the conclusion of exercise, the maximum rate for the outpatient electric device. The peak respiratory exchange ratio post-LVAD was 1.15+/-0.22 and post-HTx was 1.15+/-0.18, consistent with a good effort in both groups.

CONCLUSIONS

Patients demonstrated a lower functional capacity post-LVAD than post-HTx. For some patients functional capacity post-LVAD may be improved by a higher maximum LVAD rate and output.

Mechanism(s) of attenuation of Theileria annulata vaccine cell lines

Attenuated vaccines are an important means of controlling Theileria annulata infection of cattle. Production is by prolonged cultivation of macroschizont-infected cells. The mechanism of attenuation remains unclear. There are three general nonmutually exclusive possibilities: Selection of avirulent subpopulations, genome rearrangements and alterations in gene expression. Several groups, including ours, have provided evidence that the population structure usually tends to simplify during attenuation. Our data on the T. annulata (Ta) Ankara cell line show that attenuation is not necessarily accompanied by the population becoming clonal. We have been unable to detect large DNA rearrangements. Evidence for alterations in host and parasite gene expression during attenuation is available. With respect to the host we have shown that attenuation is accompanied by loss of expression of parasite induced matrix metalloproteinases (MMPs). However, in different lines different protease activities are involved. In the T. annulata Ode line we have shown that 8 activities (including MMP9) are downregulated and that this correlates with a loss of metastatic behaviour. This has previously been shown in vitro using reconstituted basement membrane (Matrigel) and is demonstrated in vivo using scid mice in this study. Thus part of the pathology, namely the ability to disseminate, mediated by host MMPs, is lost upon attenuation. Re-isolation experiments have shown that the reduction/loss of MMP is a stable transferable trait. A logical extension is that loss of MMP activity (and virulence in general) must be at the most fundamental level a genetic trait of the parasite. Evidence for loss of parasite gene expression is implied by the loss of the ability to differentiate into merozoites on attenuation. Specific evidence for loss of parasite gene expression has been obtained using differential RNA display. We view virulence as a multifactorial phenomenon involving interacting subpopulations of cells and attenuation is a threshold effect whereby the number of virulence factors is reduced below a critical level. On this basis there will be many different ways to achieve attenuation.

Upregulation of Jun and Fos family members and permanent JNK activity lead to constitutive AP-1 activation in Theileria-transformed leukocytes

Theileria parasitises bovine leukocytes and transforms them into proliferating, metastatic tumours, where the infection resembles a leukaemia-like disease. We have studied the signal transduction pathways leading to activation of the transcription factor AP-1 in different transformed leukocytes. Parasite infection leads to an up-regulation of all members of the Jun/Fos family of proteins and surprisingly, this occurs in the absence of any detectable ERK, or p38 MAP kinase activity. In the parasitised B-sarcoma TBL3, AP-1 induction occurs in the absence of any JNK activity. In contrast, in infected macrophage and B-cell lines, AP-1 transcriptional activity is strictly associated with the parasite-induced constitutive activation of JNK and subsequent c-Jun N-terminal phosphorylation. Thus, constant AP-1 transcriptional activity involves both an upregulation in the levels of Jun and Fos proteins and constitutive JNK activation.

Effects of exercise during long-term support with a left ventricular assist device. Results of the experience with left ventricular assist device with exercise (EVADE) pilot trial

BACKGROUND

Long-term implantation of a left ventricular assist device (LVAD) may be a future alternative treatment for end-stage heart failure. The objective of the present study was to determine the hemodynamic effects of supine bicycle exercise and functional capacity during upright treadmill exercise in 10 patients after LVAD implantation placed for refractory heart failure as a bridge to cardiac transplantation.

METHODS AND RESULTS

With supine bicycle exercise, 46 +/- 25 days after device placement, heart and LVAD rates increased in parallel from 87 +/- 12 to 117 +/- 14 bpm and 82 +/- 18 to 107 +/- 21 bpm, respectively. Peak O2 consumption was 8.2 +/- 1.7 mL O2.kg-1.min-1. Fick Systemic blood flow rose from 5.0 +/- 1.2 to 7.8 +/- 2.5 L/min. Right atrial and pulmonary capillary wedge pressures increased from 6 +/- 4 and 5 +/- 3 mm Hg to 12 +/- 5 and 13 +/- 8 mm Hg, respectively. End-diastolic left ventricular dimension increased from 3.9 +/- 1.3 to 4.8 +/- 1.6 cm; however, right ventricular dimension decreased from 3.2 +/- 1.0 to 2.3 +/- 0.9 cm. With upright treadmill exercise, peak O2 consumption was 14.1 +/- 2.9 mL O2.kg-1.min-1.

CONCLUSIONS

This study indicates that exercise during long-term LVAD support is safe and is not limited by right heart decompensation. It also justifies a larger study to examine how exercise after LVAD implantation compares with that after cardiac transplantation.

Breast MRI: early experience with a 3-D fat-suppressed gradient echo sequence in the evaluation of breast lesions

The early clinical experience with a 3-Dimensional Fourier Transform Gradient Echo sequence with fat suppression in the evaluation of breast masses is reported. Ten female patients with breast malignancies were pre-operatively evaluated with this sequence and the results compared with the pathological specimens. The scanning protocol included a non-contrast sequence followed by an immediate post-contrast sequence (completed 4.5 min after intravenous contrast injection) and a delayed sequence. Images were assessed for maximum lesion and parenchymal enhancement, lesion size and additional enhancing abnormalities. In six patients, malignant masses enhanced maximally on the immediate post-contrast sequence with parenchyma enhancing maximally on delayed images. In three cases, there was preferential enhancement of malignant lesions over normal parenchyma but to a similar degree on both post-contrast sequences. In one case, both the lesion and parenchyma enhanced maximally on the delayed sequence. Magnetic resonance assessed lesion size accurately and also detected satellite malignancies in one case. However, lesion grade, associated in situ carcinoma and lymphovascular invasion did not impact on lesion enhancement. In this small series, a contrast-enhanced, fat-suppressed 3-D Gradient Echo Sequence detected breast carcinoma with high sensitivity. The technique holds promise but further evaluation is required.

Allelotype of squamous cell carcinoma of the head and neck: fractional allele loss correlates with survival

Allelic imbalance or loss of heterozygosity (LOH) studies have been used extensively to identify regions on chromosomes that may contain putative tumour-suppressor genes. We have undertaken an extensive allelotype of 80 specimens of squamous cell carcinoma of the head and neck (SCCHN) using 145 polymorphic microsatellite markers on 39 chromosome arms. Allelic imbalances were found most frequently on chromosome arms 3p, 9p, 17p and 18q with over 45% LOH and imbalances on 1p, 1q, 2p, 5q, 6p, 6q, 8p, 8q, 9q, 11q, 13q, 17q and 19q were found in more than 20% of SCCHN. These LOH data were analysed against a range of clinicopathological parameters which included previously untreated and previously treated tumours; correlations were found between LOH on 9q and nodes at pathology (P = 0.02) and between histopathological grade and LOH on 12q (P = 0.02) and 13q (P = 0.01). In the group of previously untreated tumours, a correlation was found between site of tumour and LOH on 3p (P = 0.019), and 8p (P = 0.029), while TNM staging correlated with LOH on 3p (P = 0.019) and 17p (P = 0.016). Fractional allele loss (FAL) was calculated for 52 tumours with LOH data on nine or more chromosomal arms and found to have a median value of 0.22 (range 0.0-0.80). Correlations were found between FAL > median value and nodes at pathology (P = 0.01) and tumour grade (P = 0.06), demonstrating that advanced tumours with lymph node metastasis often had LOH at multiple sites. FAL > median value was found to correlate with a poor survival (P < 0.03) and, furthermore, FAL > median value correlated with poor survival in the previously untreated patients (P < 0.019). These results indicate that assessment of the accumulation of genetic damage, as provided by allelotype data, provides a useful molecular indicator of the tumour behaviour and clinical outcome.

Carcinoma of the breast with sarcomatous metaplasia

Carcinoma of the breast with sarcomatous metaplasia (CSM) is a rare and interesting tumour with a poorer prognosis than the usual breast malignancies. The mammographic appearances of this lesion have only previously been described once in the literature. A case of CSM is presented with mammographic-pathological correlation and review of the literature.

Physiology of the native heart and Thermo Cardiosystems left ventricular assist device complex at rest and during exercise: implications for chronic support

Studies of patients supported with a left ventricular assist device have considered determinants of acute survival emphasizing the role of right heart function. In patients with refractory heart failure awaiting heart transplantation, chronic left ventricular assist device implantation may provide an opportunity for rehabilitation before surgery if hemodynamics are adequate at rest and during activities of daily life. For the assessment of the efficacy of the left ventricular assist device in this setting, four patients in whom the HeartMate pneumatic left ventricular assist device had been implanted were tested during graded supine bicycle exercise with Doppler echocardiography interrogation and central hemodynamic measurements. Patients with left ventricular assist device increased total left ventricular-left ventricular assist device complex output with exercise as Fick cardiac output increased from 5.7 +/- 1.5 to 8.6 +/- 3.1 L/min (mean +/- standard deviation). In two patients, peak left ventricular assist device rate and output were either present at the start of exercise or reached at mid-exercise and were associated with abrupt increases in left ventricular filling pressures (pulmonary capillary wedge pressure = 9 to 27 mm Hg and 12 to 24 mm Hg, respectively). During exercise, left ventricular end-diastolic size and pressure increased as right ventricular dimensions decreased or remained the same (patients 1, 3, and 4: 1.7 to 1.8 cm, 4.7 to 3.9 cm, and 2.6 to 1.8 cm, respectively) despite increased right atrial filling pressures, implying a decrease in functional right ventricular diastolic compliance. Although the left ventricular assist device functioned as a series pump at rest, Fick cardiac output exceeded left ventricular assist device output during exercise consistent with parallel ejection of the left ventricle through the native aortic valve. During exercise, residual left ventricular function may contribute to the hemodynamic response by (1) active filling of the left ventricular assist device to reduce filling time and to overcome left ventricular assist device inflow cannula impedance, (2) augmentation of total cardiac output with parallel ejection out of the native aortic valve, or (3) reduction of ventricular interaction-related changes in functional right ventricular diastolic compliance. When residual left ventricular function is sufficient, hemodynamics with exercise may be limited by peak left ventricular assist device rate. Although right ventricular function may affect acute postoperative survival, residual left ventricular function and peak left ventricular assist device rate may be important determinants of exercise performance during chronic implantation. A preliminary model of factors affecting the "left ventricular-left ventricular assist device complex" performance at rest and during exercise is presented.

Loss of heterozygosity studies on chromosome 17 in head and neck cancer using microsatellite markers

In this study we have analysed 38 squamous cell carcinomas (SCC) two basal cell carcinomas (BCC), a malignant salivary gland carcinoma, a neurosarcoma and a Warthins carcinoma, all isolated from patients with head and neck cancers. These tumour types have been examined by PCR for loss of heterozygosity (LOH) on both arms of chromosome 17 using nine polymorphic microsatellite markers. LOH on 17p in SCCHN was found to be 50% (19/38), and often involved TP53 (42%) but more frequently involved the CHRNB1 locus (56%). Twelve tumours showed loss of heterozygosity on 17q (34%) and ten of these also had loss on 17p. Four SCCHN tumours lost an entire copy of chromosome 17. It was of particular note that 77% (10/13) of the SCCHN at the hypopharyngeal site had LOH at CHRNB1. We propose from our data that the 17p12-p11 region contains a novel predisposing gene for hypopharyngeal SCCHN that may function as a tumour suppressor gene.

Cutaneous leishmaniasis in Tachira State, Venezuela

Cutaneous and mucocutaneous leishmaniases are widely spread in the mountainous Andean regions of South America. In Venezuela, these regions consist of the coffee-growing states of Trujillo, Merida and Tachira. Entomological and parasitological investigations in three geographically different climatic zones (Lomas Bajas, Delicias and La Grita) in Tachira state have shown a predominance of the sandfly species Lutzomyia spinicrassa (verrucarum group) and two Leishmania species, Leishmania mexicana and Leishmania braziliensis. Two transmission cycles appear to occur: a peridomestic cycle in Lomas Bajas and a sylvatic one in Delicias and La Grita.

Exercise hemodynamics during long-term implantation of a left ventricular assist device in patients awaiting heart transplantation

OBJECTIVES

The goal of this study was to assess patients with end-stage heart disease after implantation of a left ventricular assist device at rest and during exercise compatible with activities of daily life.

BACKGROUND

Mechanical circulatory assistance with a left ventricular assist device is an accepted therapy for bridging patients with end-stage heart disease to heart transplantation and has been proposed for long-term implantation.

METHODS

Three patients (aged 37, 42 and 57 years) with end-stage heart failure required implantation of a pneumatically driven, asynchronous Thermedics left ventricular assist device while awaiting heart transplantation. All were assessed 1 month later during graded supine bicycle exercise (maximal work load 100 to 150 W). Detailed central hemodynamics, including continuous pulmonary artery oxygen saturation and oxygen consumption measurements, were obtained. Two of the patients also underwent upright treadmill exercise with oxygen consumption measurements.

RESULTS

During supine bicycle exercise, the heart rate increased from 93 +/- 37 beats/min (95% confidence interval: mean +/- t0.025 x SE) at rest to 119 +/- 54 beats/min and left ventricular assist device rate increased from 82 +/- 47 to 109 +/- 55 beats/min. Oxygen consumption increased from 3.0 +/- 0.9 to 8.7 +/- 2.9 ml oxygen/min per kg body weight. Cardiac output increased from 6.0 +/- 4.4 to 9.6 +/- 7.1 liters/min, yielding an average exercise factor of 8.5 +/- 7.7 and an exercise index of 0.83 +/- 0.61. The patients assessed during treadmill exercise achieved a maximal oxygen consumption of 14.3 and 16.7 ml of oxygen/min per kg. No thromboembolic or other complications attributable to left ventricular assist device implantation occurred during the duration of support. All patients survived orthotopic heart transplantation and are doing well.

CONCLUSIONS

Significant work loads compatible with activities of daily life and adequate exercise hemodynamics were demonstrated by these patients while awaiting heart transplantation. Definitive conclusions regarding the use of this device must be viewed as preliminary because only three patients were involved in this study and the failure rate may be as high as 71% (95% confidence interval of left ventricular assist device success as a bridge to transplantation 29.3% to 100%). Final conclusions regarding the safety and efficacy of the left ventricular assist device as a possible long-term circulatory support device must await results of larger multicenter trials in progress.

Molecular approaches applied to the epidemiology of leishmaniasis in Venezuela

Leishmaniasis is on the increase in Venezuela (ca 30,000 new cases per year) due to deterioration in health management, increased risk groups among inmunosuppressed individuals and increased human penetration into the ecological habitats of sandfly vectors. An STD2-funded project (1989-1992) focused on the Andean state of Táchira, which showed the highest annual index of new cases (ca 200-250). The project aimed at contributing to vector/parasite identification through a combination of molecular and well established field techniques: Newly developed molecular methods distinguished among Lu. spinicrassa, Lu. youngi and Lu. townsendi. These three species of the Verrucarum group are sympatric in the Northeast of the state and could be successfully identified by CHA, DNA probes and RAPD. A Le. braziliensis specific KDNA probe used with squash blots indicated that Lu. spinicrassa is the main vector and that Le. braziliensis is the main parasite species in Táchira state, Venezuela. PCR and the Le. brasiliensis specific DNA probe, schizodemes, isoenzymes and polyclonal antibodies agreed as taxonomic criteria for classification of Leishmania isolated from parasitologically confirmed cases in Tachira. Considerable degree of antigen heterogeneity in Venezuelan Le. braziliensis complex and Le. mexicana complex isolates from Tachira suggests multiple candidate antigens for improving the specificity of immunological diagnosis. The methods developed and tested in Táchira state should be valuable in order to help solving other outstanding epidemiological problems such as following of the epidemiological impact of intervention and vector control measures in highly endemic areas. Future work (STD3 funded, 1993-1996) aims to apply these molecular techniques to a vector control pilot study in Lara state, an area showing the highest incidence of new cases in the country.

The manufacturing process of recombinant factor VIII, recombinate

In summary, this brief report documents the cell culture and rAHF purification systems used to produce rFVIII and has focused on the unique characteristics of the cell line, the production process, and purification system used. This review emphasizes the general philosophy used throughout the research and development of this innovative and complex therapeutic agent, in order to provide a safe and efficacious rAHF in the management of individuals with hemophilia A. This review provides a brief description of the in-process system and controls that have been incorporated to meet the high standards and safety objective.