Longitudinal comparison of the self-administered ALSFRS-RSE and ALSFRS-R as functional outcome measures in ALS

Objective: Test the feasibility, adherence rates and optimal frequency of digital, remote assessments using the ALSFRS-RSE via a customized smartphone-based app. Methods: This fully remote, longitudinal study was conducted over a 24-week period, with virtual visits every 3 months and weekly digital assessments. 19 ALS participants completed digital assessments via smartphone, including a digital version of the ALSFRS-RSE and mood survey. Interclass correlation coefficients (ICC) and Bland-Altman plots were used to assess agreement between staff-administered and self-reported ALSFRS-R pairs. Longitudinal change was evaluated using ANCOVA models and linear mixed models, including impact of mood and time of day. Impact of frequency of administration of the ALSFRS-RSE on precision of the estimate slope was tested using a mixed effects model. Results: In our ALS cohort, digital assessments were well-accepted and adherence was robust, with completion rates of 86%. There was excellent agreement between the digital self-entry and staff-administered scores computing multiple ICCs (ICC range = 0.925-0.961), with scores on the ALSFRS-RSE slightly higher (1.304 points). Digital assessments were associated with increased precision of the slope, resulting in higher standardized response mean estimates for higher frequencies, though benefit appeared to diminish at biweekly and weekly frequency. Effects of participant mood and time of day on total ALSFRS-RSE score were evaluated but were minimal and not statistically significant. Conclusion: Remote collection of digital patient-reported outcomes of functional status such as the ALSFRS-RSE yield more accurate estimates of change over time and provide a broader understanding of the lived experience of people with ALS.

Upper limb movements as digital biomarkers in people with ALS

BACKGROUND

Objective evaluation of people with amyotrophic lateral sclerosis (PALS) in free-living settings is challenging. The introduction of portable digital devices, such as wearables and smartphones, may improve quantifying disease progression and hasten therapeutic development. However, there is a need for tools to characterize upper limb movements in neurologic disease and disability.

METHODS

Twenty PALS wore a wearable accelerometer, ActiGraph Insight Watch, on their wrist for six months. They also used Beiwe, a smartphone application that collected self-entry ALS Functional Rating Scale-Revised (ALSFRS-RSE) survey responses every 1-4 weeks. We developed several measures that quantify count and duration of upper limb movements: flexion, extension, supination, and pronation. New measures were compared against ALSFRS-RSE total score (Q1-12), and individual responses to specific questions related to handwriting (Q4), cutting food (Q5), dressing and performing hygiene (Q6), and turning in bed and adjusting bed clothes (Q7). Additional analysis considered adjusting for total activity counts (TAC).

FINDINGS

At baseline, PALS with higher Q1-12 performed more upper limb movements, and these movements were faster compared to individuals with more advanced disease. Most upper limb movement metrics had statistically significant change over time, indicating declining function either by decreasing count metrics or by increasing duration metric. All count and duration metrics were significantly associated with Q1-12, flexion and extension counts were significantly associated with Q6 and Q7, supination and pronation counts were also associated with Q4. All duration metrics were associated with Q6 and Q7. All duration metrics retained their statistical significance after adjusting for TAC.

INTERPRETATION

Wearable accelerometer data can be used to generate digital biomarkers on upper limb movements and facilitate patient monitoring in free-living environments. The presented method offers interpretable monitoring of patients' functioning and versatile tracking of disease progression in the limb of interest.

FUNDING

Mitsubishi-Tanabe Pharma Holdings America, Inc.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Ramsey Spectroscopy of the 2S_{1/2} Hyperfine Interval in Atomic Hydrogen

The 2S_{1/2} hyperfine interval in atomic hydrogen was measured using Ramsey spectroscopy with a thermal beam cooled to cryogenic temperatures. The measured value is 177 556 838.87(85) Hz, which represents the most precise determination of this interval to date. The 1S_{1/2} hyperfine interval f(1S_{1/2}) and the 2S_{1/2} hyperfine interval f(2S_{1/2}) can be combined to give the quantity D_{21}=8f(2S_{1/2})-f(1S_{1/2}), which mostly eliminates uncertainty due to nuclear structure effects and is well described by bound-state quantum electrodynamics. Using the value of f(2S_{1/2}) from this work gives a value of D_{21}^{expt}=48 959.2(6.8)  Hz, which is in agreement with the theoretical value of D_{21}^{Theory}=48 954.1(2.3)  Hz.

Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training

OBJECTIVE

Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity.

METHODS

Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey.

RESULTS

A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models.

CONCLUSIONS

The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.

Ultrasound-guided glenohumeral joint injections for shoulder pain in ALS: A case series

Introduction

Shoulder pain is a common secondary impairment for people living with ALS (PALS). Decreased range of motion (ROM) from weakness can lead to shoulder pathology, which can result in debilitating pain. Shoulder pain may limit PALS from participating in activities of daily living and may have a negative impact on their quality of life. This case series explores the efficacy of glenohumeral joint injections for the management of shoulder pain due to adhesive capsulitis in PALS.

Methods

People living with ALS and shoulder pain were referred to sports medicine-certified physiatrists for diagnostic evaluation and management. They completed the Revised ALS Functional Rating Scale and a questionnaire asking about their pain levels and how it impacts sleep, function, and quality of life at baseline pre-injection, 1-week post-injection, 1 month post-injection, and 3 months post-injection.

Results

We present five cases of PALS who were diagnosed with adhesive capsulitis and underwent glenohumeral joint injections. Though only one PALS reported complete symptom resolution, all had at least partial symptomatic improvement during the observation period. No complications were observed.

Conclusions

People living with ALS require a comprehensive plan to manage shoulder pain. Glenohumeral joint injections are safe and effective for adhesive capsulitis in PALS, but alone may not completely resolve shoulder pain. Additional therapies to improve ROM and reduce pain should be considered.

Longitudinal comparison of the self-entry Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-RSE) and Rasch-Built Overall Amyotrophic Lateral Sclerosis Disability Scale (ROADS) as outcome measures in people with amyotrophic lateral sclerosis

INTRODUCTION/AIMS

Improved functional outcome measures in amyotrophic lateral sclerosis (ALS) would aid ALS trial design and help hasten drug discovery. We evaluate the longitudinal performance of the Rasch-Built Overall Amyotrophic Lateral Sclerosis Disability Scale (ROADS) compared to the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised for Self-Entry (ALSFRS-RSE) as patient reported outcomes of functional status in people with ALS.

METHODS

Participants completed the ROADS and the ALSFRS-RSE questionnaires at baseline, 3-, 6-, and 12- mo using Research Electronic Data Capture as part of a prospective, longitudinal, remote, online survey study of fatigue in ALS from 9/2020 to 12/2021. The scales were compared cross-sectionally (at baseline) and longitudinally. Correlation coefficients, coefficients of variation, and descriptive statistics were assessed.

RESULTS

A total of 182 adults with ALS consented to the study. This volunteer sample was comprised of predominantly White, non-Hispanic, non-smoking participants. Consented participant survey completion was approximately 90% at baseline and greater than 40% at 12 mo. The ALSFRS-RSE and the ROADS had high, significant agreement at 3 and 6 mo by Cohen's kappa ≥71% (p < 0.001); the number of functional increases or plateaus on the two scales were not significantly different; and the coefficient of variation of functional decline was similar at the 6-month mark, though higher for the ROADS at 3 mo and lower at 12 mo.

DISCUSSION

Although the ROADS performed similarly to the ALSFRS-RSE in an observational cohort, it has psychometric advantages, such as Rasch-modeling and unidimensionality. It merits further investigation as a patient reported outcome of overall disability and efficacy outcome measure in ALS trials.

Pharmacotherapy for Amyotrophic Lateral Sclerosis: A Review of Approved and Upcoming Agents

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disorder involving loss of upper and lower motor neurons, with most cases ending in death within 3-5 years of onset. Several molecular and cellular pathways have been identified to cause ALS; however, treatments to stop or reverse disease progression are yet to be found. Riluzole, a neuroprotective agent offering only a modest survival benefit, has long been the sole disease-modifying therapy for ALS. Edaravone, which demonstrated statistically significant slowing of ALS disease progression, is gaining approval in an increasing number of countries since its first approval in 2015. Sodium phenylbutyrate and taurursodiol (PB-TURSO) was conditionally approved in Canada in 2022, having shown significant slowing of disease progression and prolonged survival. Most clinical trials have focused on testing small molecules affecting common cellular pathways in ALS: targeting glutamatergic, apoptotic, inflammatory, and oxidative stress mechanisms among others. More recently, clinical trials utilizing stem cell transplantation and other biologics have emerged. This rich and ever-growing pipeline of investigational products, along with innovative clinical trial designs, collaborative trial networks, and an engaged ALS community', provide renewed hope to finding a cure for ALS. This article reviews existing ALS therapies and the current clinical drug development pipeline.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Secondary trigeminal neuralgia diagnosed in orofacial pain setting as epidermoid tumor

This case report describes the rare occurrence of an epidermoid tumor compressing the ipsilateral trigeminal nerve resulting in secondary trigeminal neuralgia. MRI is the imaging modality of choice for the diagnosis of secondary trigeminal neuralgia. The epidermoid tumor was discovered by an orofacial pain specialist after reassessing the MRI study, previously reported as normal. Clinicians encounter a diagnostic dilemma when the clinical picture is not consistent with the MRI reports, clinical presentation, and expected results of treatment. The reassessment of the MRI and discovery of the epidermoid tumor resulted in a prompt referral to a neurosurgeon with a successful treatment outcome.

Acute ischaemic stroke associated with SARS-CoV-2 infection in North America

BACKGROUND

To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome.

METHODS

Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications.

RESULTS

A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome.

CONCLUSION

There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.

Small Fiber Neuropathy Incidence, Prevalence, Longitudinal Impairments, and Disability

BACKGROUND AND OBJECTIVES

There are limited population-based data on small fiber neuropathy (SFN). We wished to determine SFN incidence, prevalence, comorbid conditions, longitudinal impairments, and disabilities.

METHODS

Test-confirmed patients with SFN in Olmsted, Minnesota, and adjacent counties were compared 3:1 to matched controls (January 1, 1998-December 31, 2017).

RESULTS

Ninety-four patients with SFN were identified, with an incidence of 1.3/100,000/y that increased over the study period and a prevalence of 13.3 per 100,000. Average follow-up was 6.1 years (0.7-43 years), and mean onset age was 54 years (range 14-83 years). Female sex (67%), obesity (body mass index mean 30.4 vs 28.5 kg/m²), insomnia (86% vs 54%), analgesic-opioid prescriptions (72% vs 46%), hypertriglyceridemia (180 mg/dL mean vs 147 mg/dL), and diabetes (51% vs 22%, p < 0.001) were more common (odds ratio 3.8-9.0, all p < 0.03). Patients with SFN did not self-identify as disabled with a median modified Rankin Scale score of 1.0 (range 0-6) vs 0.0 (0-6) for controls (p = 0.04). Higher Charlson comorbid conditions (median 6, range 3-9) occurred vs controls (median 3, range 1-9, p < 0.001). Myocardial infarctions occurred in 46% vs 27% of controls (p < 0.0001). Classifications included idiopathic (70%); diabetes (15%); Sjögren disease (2%); AL-amyloid (1%); transthyretin-amyloid (1%); Fabry disease (1%); lupus (1%); postviral (1%); Lewy body (1%), and multifactorial (5%). Foot ulcers occurred in 17, with 71% having diabetes. Large fiber neuropathy developed in 36%, on average 5.3 years (range 0.2-14.3 years) from SFN onset. Median onset Composite Autonomic Severity Score (CASS) was 3 (change per year 0.08, range 0-2.0). Median Neuropathy Impairment Scale (NIS) score was 2 at onset (range 0-8, change per year 1.0, range -7.9 to +23.3). NIS score and CASS change >1 point per year occurred in only AL-amyloid, hereditary transthyretin-amyloid, Fabry, uncontrolled diabetes, and Lewy body. Death after symptom onset was higher in patients with SFN (19%) vs controls (12%, p < 0.001), 50% secondary to diabetes complications.

DISCUSSION

Isolated SFN is uncommon but increasing in incidence. Most patients do not develop major neurologic impairments and disability but have multiple comorbid conditions, including cardiovascular ischemic events, and increased mortality from SFN onsets. Development of large fiber involvements and diabetes are common over time. Targeted testing facilitates interventional therapies for diabetes but also rheumatologic and rare genetic forms.

Outcomes and Spectrum of Major Neurovascular Events Among COVID-19 Patients: A 3-Center Experience

BACKGROUND

Preliminary data suggest that Coronavirus Disease-2019 (COVID-19) is associated with hypercoagulability and neurovascular events, but data on outcomes is limited.

OBJECTIVE

To report the clinical course and outcomes of a case series of COVID-19 patients with a variety of cerebrovascular events.

METHODS

We performed a multicentric, retrospective chart review at our three academic tertiary care hospitals, and identified all COVID-19 patients with cerebrovascular events requiring neuro-intensive care and/or neurosurgical consultation.

RESULTS

We identified 26 patients between March 1 and May 24, 2020, of whom 12 (46%) died. The most common event was a large-vessel occlusion (LVO) in 15 patients (58%), among whom 8 died (8/15, 53%). A total of 9 LVO patients underwent mechanical thrombectomy, of whom 5 died (5/9, 56%). A total of 7 patients (27%) presented with intracranial hemorrhage. Of the remaining patients, 2 had small-vessel occlusions, 1 had cerebral venous sinus thrombosis, and another had a vertebral artery dissection. Acute Respiratory Distress Syndrome occurred in 8 patients, of whom 7 died. Mortalities had a higher D-dimer on admission (mean 20 963 ng/mL) than survivors (mean 3172 ng/mL). Admission Glasgow Coma Scale (GCS) score was poor among mortalities (median 7), whereas survivors had a favorable GCS at presentation (median 14) and at discharge (median 14).

CONCLUSION

COVID-19 may be associated with hemorrhage as well as ischemia, and prognosis appears poorer than expected-particularly among LVO cases, where outcome remained poor despite mechanical thrombectomy. However, a favorable neurological condition on admission and lower D-dimer may indicate a better outcome.

Bacillus subtilis DE111 intake may improve blood lipids and endothelial function in healthy adults

Cardiovascular disease (CVD) is the leading cause of death in the US and worldwide. By 2030 it is anticipated that CVD will claim the lives of more than 24 million people. Throughout the last decade, researchers have investigated the role of the gut microbiota in the development of CVD. Evidence exists for a positive correlation between Bifidobacterium and vascular function, glucose tolerance, and reduced systemic inflammation. Another probiotic species, Bacillus subtilis, has also been found to reduce cholesterol levels in human and animal models. In light of these data, we examined various measures of cardiovascular health after consumption of Bifidobacterium animalis subsp. lactis strain BL04, with and without a cocktail of Escherichia coli-targeting bacteriophages (marketed as PreforPro), Bacillus subtilis strain DE111 or a maltodextrin-based placebo in a healthy human population. In a randomised, double-blind, placebo-controlled 4-week intervention conducted in individuals 18 to 65 years of age with a body mass index of 20 to 34.9, we saw no significant changes in measured CVD parameters among individuals consuming B. lactis with or without bacteriophages. However, B. subtilis supplementation resulted in a significant reduction in total cholesterol relative to baseline measures (−8 mg/dl; P=0.04, confidence interval (CI): −13.40, −0.19), as well as non-high-density lipoprotein-cholesterol (−11 mg/dl; P=0.01, CI: −12.43, −2.07). In addition we observed trending improvements in endothelial function (P=0.05, CI: −0.003, 0.370) and in low-density lipoprotein-cholesterol (P=0.06, CI: −12.29, 0.2864). Strikingly, these effects were seen in a largely healthy population. These data suggest that B. subtilis supplementation may be beneficial for improving risk factors associated with CVD. Further studies in populations of older adults or those with dyslipidaemia and endothelial dysfunction is warranted.

Visual Evoked Potentials and Intraoperative Awakening in Ophthalmic Artery Sacrifice During Aneurysm Clipping: 2 Cases and Literature Review

BACKGROUND

Complete aneurysm obliteration is the goal of aneurysm treatment. In selected cases, a neck remnant may be left to preserve a critical branch. Literature on ophthalmic artery sacrifice in the treatment of cerebral aneurysms and subsequent risk of vision loss is limited.

CASE DESCRIPTION

Herein, we describe 2 cases where the ophthalmic artery originated from the aneurysm dome, resulting in a situation where we either incompletely obliterate the aneurysm or sacrifice the ophthalmic artery in order to completely clip the lesion, risking visual function.

CONCLUSIONS

We report for the first time the use of visual evoked potential monitoring and intraoperative awakening to test visual function following intentional ophthalmic artery sacrifice to demonstrate gross vision preservation.

The perirhinal cortex supports spatial intertemporal choice stability

In order to optimize outcomes in the face of uncertainty, one must recall past experiences and extrapolate to the future by assigning values to different choice outcomes. This behavior requires an interplay between memory and reward valuation, necessitating communication across many brain regions. At the anatomical nexus of this interplay is the perirhinal cortex (PRC). The PRC is densely connected to the amygdala and orbital frontal cortex, regions that have been implicated in reward-based decision making, as well as the hippocampus. Thus, the PRC could serve as a hub for integrating memory, reward, and prediction. The PRC's role in value-based decision making, however, has not been empirically examined. Therefore, we tested the role of the PRC in a spatial delay discounting task, which allows rats to choose between a 1-s delay for a small food reward and a variable delay for a large food reward, with the delay to the large reward increasing after choice of each large reward and decreasing after each small reward. The rat can therefore adjust the delay by consecutively choosing the same reward or stabilize the delay by alternating between sides. The latter has been shown to occur once the 'temporal cost' of the large reward is established and is a decision-making process termed 'exploitation'. When the PRC was bilaterally inactivated with the GABA(A) agonist muscimol, rats spent fewer trials successfully exploiting to maintain a fixed delay compared to the vehicle control condition. Moreover, PRC inactivation resulted in an increased number of vicarious trial and error (VTE) events at the choice point, where rats had to decide between the two rewards. These behavioral patterns suggest that the PRC is critical for maintaining stability in linking a choice to a reward outcome in the face of a variable cost.

Nighttime administration of high-dose, sustained-release melatonin does not decrease nocturnal blood pressure in African-American patients: Results from a preliminary randomized, crossover trial

OBJECTIVES

This preliminary study tested whether a high-dose, sustained-release form of melatonin reduced 24-hour blood pressure in African-Americans.

DESIGN

Randomized, placebo-controlled, crossover pilot study of 40 self-defined African-American patients with essential hypertension.

SETTINGS/LOCATION

Urban, academic medical center and associated outpatient clinics.

INTERVENTIONS

Patients ingested either melatonin (high dose [24 mg], sustained-release formulation] or placebo in randomized order over a 4-week period.

OUTCOME MEASURES

Mean nighttime and daytime systolic and diastolic blood pressures, as measured with 24-hour ambulatory blood pressure monitors. The primary outcome was mean nighttime systolic blood pressure.

RESULTS

There were no statistically differences between melatonin and placebo conditions in mean nighttime or daytime systolic or diastolic blood pressures.

CONCLUSIONS

In contrast with studies in other populations, this preliminary study showed that nighttime dosing of continuous-release melatonin had no significant effect on nocturnal blood pressure in African Americans with essential hypertension when compared to placebo.

Isoflurane exposure for three hours triggers apoptotic cell death in neonatal macaque brain

Background

Retrospective clinical studies suggest there is a risk for neurodevelopmental impairment following early childhood exposure to anaesthesia. In the developing animal brain, including those of non-human primates (NHPs), anaesthetics induce apoptotic cell death. We previously reported that a 5 h isoflurane (ISO) exposure in infant NHPs increases apoptosis 13-fold compared with control animals. However, the majority of paediatric surgeries requiring anaesthesia are of shorter durations. We examined whether 3 h ISO exposure similarly increases neuroapoptosis in the NHP developing brain.

Methods

Six-day-old NHP infants ( Macaca mulatta ) were exposed to 3 h of a surgical plane of ISO ( n =6) or to room air ( n =5). Following exposure, NHP brains were screened for neuronal and oligodendrocyte apoptosis using activated caspase-3 immunolabelling and unbiased stereology.

Results

ISO treatment increased apoptosis (neurones + oligodendrocyte) to greater than four times that in the control group [mean density of apoptotic profiles: 57 (SD 22) mm -3 vs 14 (SD 5.2) mm -3 , respectively]. Oligodendrocyte apoptosis was evenly distributed throughout the white matter whereas neuroapoptosis occurred primarily in the cortex (all regions), caudate, putamen and thalamus.

Conclusions

A 3 h exposure to ISO is sufficient to induce widespread neurotoxicity in the developing primate brain. These results are relevant for clinical medicine, as many surgical and diagnostic procedures in children require anaesthesia durations similar to those modelled here. Further research is necessary to identify long-term neurobehavioural consequences of 3 h ISO exposure.

Cranial nerve outcomes after primary stereotactic radiosurgery for symptomatic skull base meningiomas

OBJECTIVE

To evaluate cranial nerve (CN) outcomes after primary stereotactic radiosurgery (SRS) for petroclival, cavernous sinus, and cerebellopontine angle meningiomas.

METHODS

From our prospectively maintained database of 2022 meningioma patients who underwent Leksell stereotactic radiosurgery (SRS) during a 30-year interval, we found 98 patients with petroclival, 242 with cavernous sinus, and 55 patients with cerebellopontine angle meningiomas. Primary radiosurgery was performed in 245 patients. Patients included in this report had at least one CN deficit at the time of initial presentation and a minimum of 12 month follow up. Median age at the time of SRS was 58 years. Median follow up was 58 months (range 12-300 months), Median tumor volume treated with SRS was 5.9 cm³ (range 0.5-37.5 cm³), and median margin dose was 13 Gy (range 9-20Gy).

RESULTS

Tumor control was achieved in 229 patients (93.5%) at a median follow up of 58 months. Progression free survival rate (PFS) after SRS was 98.7% at 1 year, 96.4% at 3 years, 93.7% at 5 years, and 86.4% at 10 years Overall, 114 of the 245 patients (46.5%) reported improvement of CN function. Patients with CP angle meningiomas demonstrated lower rates of CN improvement compared to petroclival and cavernous sinus meningioma patients. Deterioration of CN function after SRS developed in 24 patients (10%). The rate of deterioration was 2.8% at 1 year, 5.2% at 3 years, and 8% at 10 years.

CONCLUSION

Primary SRS provides effective tumor control and favorable rate of improvement of preexisting CN deficit.

Caffeine Augments Anesthesia Neurotoxicity in the Fetal Macaque Brain

Caffeine is the most frequently used medication in premature infants. It is the respiratory stimulant of choice for apnea associated with prematurity and has been called the silver bullet in neonatology because of many proven benefits and few known risks. Research has revealed that sedative/anesthetic drugs trigger apoptotic death of neurons and oligodendrocytes in developing mammalian brains. Here we evaluated the influence of caffeine on the neurotoxicity of anesthesia in developing nonhuman primate brains. Fetal macaques (n = 7–8/group), at a neurodevelopmental age comparable to premature human infants, were exposed in utero for 5 hours to no drug (control), isoflurane, or isoflurane + caffeine and examined for evidence of apoptosis. Isoflurane exposure increased apoptosis 3.3 fold for neurons and 3.4 fold for oligodendrocytes compared to control brains. Isoflurane + caffeine caused neuronal apoptosis to increase 8.0 fold compared to control levels but did not augment oligoapoptosis. Neuronal death was particularly pronounced in the basal ganglia and cerebellum. Higher blood levels of caffeine within the range considered therapeutic and safe for human infants correlated with increased neuroapoptosis. Caffeine markedly augments neurotoxicity of isoflurane in the fetal macaque brain and challenges the assumption that caffeine is safe for premature infants.

Validation of healthcare-associated infection surveillance in smaller Australian hospitals

A validation study was conducted in smaller (<100 acute beds) Victorian hospitals to evaluate case detection for Staphylococcus aureus bloodstream (SAB), meticillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections. Overall, 142 infections were identified in 20 hospitals. For routine surveillance of SAB events, sensitivity was 74.4% and specificity was 100.0%. For MRSA infections, sensitivity was 47.5% and specificity was 90.9%. All confirmed VRE infections were reported correctly. Of unreported SAB and MRSA infections, 80% (N = 16) and 83.9% (N = 26) were community-associated infections, respectively. Future programme refinements include targeted education to ensure appropriate application of case definitions, particularly those including community onset.

Lessons learned from a multidisciplinary renal genetics clinic

BACKGROUND

Inherited renal disorders comprise a significant proportion of cases in both paediatric and adult nephrology services. Genetic advances have advanced rapidly while clinical models of care delivery have remained static.

AIM

To describe a cohort of patients attending a multidisciplinary renal genetics clinic and the insights gained from this experience.

DESIGN AND METHODS

A retrospective review of clinic cases and their molecular genetic diagnosis over a 5-year period.

RESULTS

We report details of 244 individuals including 80 probands who attended the clinic. The commonest reasons for referral was familial haematuria which accounted for 37.5% of cases and cystic kidney disease, accounting for 31% of cases. Eighteen probands had a known molecular genetic diagnosis and were referred for genetic counselling and screening of at risk relatives and management plans. About 62 probands and their families were referred for a precise molecular diagnosis and this was achieved in 26 cases (42%). The most frequent new genetic diagnoses were COL4A5 mutations underlying familial haematuria and familial end stage renal disease. The clinic also allowed for patients with rare renal syndromes to be reviewed, such as ciliopathy syndromes, allowing detailed phenotyping and often a precise molecular genetic diagnosis to be provided.

CONCLUSIONS

The integration of modern day genetics and genomics into multidisciplinary clinics often allows a precise diagnosis which benefits patients, their relatives and the clinicians providing care and future management.

Mechanical strength vs. degradation of a biologically-derived surgical mesh over time in a rodent full thickness abdominal wall defect

The use of synthetic surgical mesh materials has been shown to decrease the incidence of hernia recurrence, but can be associated with undesirable effects such as infection, chronic discomfort, and adhesion to viscera. Surgical meshes composed of extracellular matrix (i.e., biologically-derived mesh) are an alternative to synthetic meshes and can reduce some of these undesirable effects but are less frequently used due to greater cost and perceived inadequate strength as the mesh material degrades and is replaced by host tissue. The present study assessed the temporal association between mechanical properties and degradation of biologic mesh composed of urinary bladder matrix (UBM) in a rodent model of full thickness abdominal wall defect. Mesh degradation was evaluated for non-chemically crosslinked scaffolds with the use of (14)C-radiolabeled UBM. UBM biologic mesh was 50% degraded by 26 days and was completely degraded by 90 days. The mechanical properties of the UBM biologic mesh showed a rapid initial decrease in strength and modulus that was not proportionately associated with its degradation as measured by (14)C. The loss of strength and modulus was followed by a gradual increase in these values that was associated with the deposition of new, host derived connective tissue. The strength and modulus values were comparable to or greater than those of the native abdominal wall at all time points.

The effect of two doses of dried plum on bone density and bone biomarkers in osteopenic postmenopausal women: a randomized, controlled trial

Daily consumption of 50 g of dried plum (equivalent to 5-6 dried plums) for 6 months may be as effective as 100 g of dried plum in preventing bone loss in older, osteopenic postmenopausal women. To some extent, these results may be attributed to the inhibition of bone resorption with the concurrent maintenance of bone formation.

INTRODUCTION

The objective of our current study was to examine the possible dose-dependent effects of dried plum in preventing bone loss in older osteopenic postmenopausal women.

METHODS

Forty-eight osteopenic women (65-79 years old) were randomly assigned into one of three treatment groups for 6 months: (1) 50 g of dried plum; (2) 100 g of dried plum; and (3) control. Total body, hip, and lumbar bone mineral density (BMD) were evaluated at baseline and 6 months using dual-energy X-ray absorptiometry. Blood biomarkers including bone-specific alkaline phosphatase (BAP), tartrate-resistant acid phosphatase (TRAP-5b), high-sensitivity C-reactive protein (hs-CRP), insulin-like growth factor-1 (IGF-1), and sclerostin were measured at baseline, 3 months, and 6 months. Osteoprotegerin (OPG), receptor activator of nuclear factor kappa-B ligand (RANKL), calcium, phosphorous, and vitamin D were measured at baseline and 6 months.

RESULTS

Both doses of dried plum were able to prevent the loss of total body BMD compared with that of the control group (P < 0.05). TRAP-5b, a marker of bone resorption, decreased at 3 months and this was sustained at 6 months in both 50 and 100 g dried plum groups (P < 0.01 and P < 0.04, respectively). Although there were no significant changes in BAP for either of the dried plum groups, the BAP/TRAP-5b ratio was significantly (P < 0.05) greater at 6 months in both dried plum groups whereas there were no changes in the control group.

CONCLUSIONS

These results confirm the ability of dried plum to prevent the loss of total body BMD in older osteopenic postmenopausal women and suggest that a lower dose of dried plum (i.e., 50 g) may be as effective as 100 g of dried plum in preventing bone loss in older, osteopenic postmenopausal women. This may be due, in part, to the ability of dried plums to inhibit bone resorption. This clinical trial was registered at ClinicalTrials.gov: NCT02325895 .

An assessment of the accuracy and utility of the primary care electronic medical record as used by the British Army

INTRODUCTION

For the purposes of patient safety, audit and research, the electronic patient record (EPR) must be accurate and searchable. No evaluation of the accuracy of EPRs compared with paper records has been made. Furthermore, the use of Read codes is known to be heterogeneous. This study was designed to evaluate the EPR used by the UK Armed Forces.

METHODS

A cross-sectional study reviewing the paper records and EPRs of 50 consecutive soldiers posted to a British Army Training Regiment.

RESULTS

There was a pre-enlistment summary in only 38% of the paper notes, although 24% had some primary care records from prior to enlistment. There were 357 entries that should have been transferred to the EPR. Of these, only 190 (53.2%) were transferred with appropriate Read codes, while only 24% of patients reviewed had all their entries appropriately Read coded. There were 168 secondary care letters discovered with 122 (72.6%) generically Read coded and 46 (27.4%) using an appropriate Read code. Of those letters with more than one potential Read code, 34 (73.9%) were coded using all appropriate Read codes. Several incidental errors in the medical records were also discovered with significant patient safety implications.

CONCLUSIONS

The historical paper-based medical record was found to have many data missing. The transfer of these paper records to the EPR has been inaccurate with many records not transferred or transferred ineffectively. These findings have an impact on patient safety, audit and data security and should trigger a review of how the Armed Forces manage their primary care records.

Nickel complexes for catalytic C-H bond functionalization

The direct catalytic functionalization of traditionally unreactive C-H bonds is an atom-economic transformation that has become increasingly important and commonplace in synthetic applications. In general, 2(nd) and 3(rd) row transition metal complexes are used as catalysts in these reactions, whereas the less costly and more abundant 1(st) row metal complexes have limited utility. This Perspective article summarizes progress from our laboratory towards understanding the fundamental issues that complicate the use of Ni complexes for catalytic C-H bond functionalization, as well as approaches to overcoming these limitations. In practice it is found that Ni complexes can functionalize C-H bonds by processes that, to date, have not been observed with the heavier metals. An example is provided by the catalytic stannylation of C-H bonds with tributylvinyltin, Bu3SnCH=CH2, which produces ethylene as a by-product.

Indoor nature exposure (INE): a health-promotion framework

Engaging in outdoor nature-based spaces has significant positive physiological and psychological health benefits. Although the integration of nature into indoor spaces is rarely considered a health-promoting tool, it may be an effective method for increasing nature engagement in a largely urbanized world. This paper presents an overview of indoor nature exposure (INE) by summarizing the current evidence of INE through the use of a scoping methodology. Results show that INE can be a health-promoting tool through the interaction of nature-based stimuli and individual characteristics (e.g. gender, age). Moreover, the results of the current literature need to be interpreted with consideration to methodological issues, such as the lack of participant characteristics, the issue of exposure realism and little qualitative data to highlight individual experiences. The scoping review process allowed for the summation of results and for a framework to be created in order to better understand how INE is facilitated.

The potential of irradiation as a postharvest disinfestation treatment against Phlyctinus callosus (Coleoptera: Curculionidae)

Phlyctinus callosus (Boheman) (Coleoptera: Curculionidae) is a pest of major phytosanitary concern for some of South Africa's biggest export markets such as the United States and Europe because this pest does not occur there. At present, fumigation with methyl bromide is the only postharvest disinfestation treatment against this pest; therefore, sustainable alternatives are needed. One such alternative is irradiation treatment of whole pallets of packed fruit to sterilize insects that may be present within the cartons. Wild adult P. callosus weevils were treated with 5, 10, 20, 40, and 80 Gy of gamma-irradiation and then cross mated to breed with either treated or nontreated adults of the opposite sex. Fecundity and fertility were monitored and recorded. Trials were conducted during the 2009-2010 and 2010-2011 fruit harvesting seasons. The results from both seasons indicated that irradiation did not affect fecundity but fertility was significantly affected, decreasing as irradiation doses increased. Egg hatch was zero for mating crosses that involved females weevils treated with a dose of 80 Gy gamma-irradiation. Probit analysis indicated that in the first season, the estimated LD95 for crosses involving treated males and treated females was 30 Gy, while in the second season it was 49.5 Gy. Respective estimated LD99S were 47.9 and 169.4 Gy. Ultimately, a dose lower than the current generic dose of 400 Gy, approved for irradiation disinfestation treatments, would control P. callosus should they occur in packed export fruit.

Advances in the treatment of Waldenström’s macroglobulinemia

Waldenström's macroglobulinemia is a distinct disorder characterized by a monoclonal immunoglobulin M paraprotein and morphological evidence of lymphoplasmacytic lymphoma. It is relatively rare, accounting for approximately 2% of all hematological malignancies. The aim of treatment for patients with Waldenström's macroglobulinemia should be to improve the quality and duration of life with minimal side effects in the most cost-effective manner. It is not yet clear if achievement of a complete remission confers clinical benefit and it is possible that prolonging therapy to maximal response may increase toxicity without extra benefit. Plasma exchange is indicated for the acute management of patients with severe problems due to a circulating paraprotein. There are no comparative data but alkylating agent-based treatments, combination therapy or purine analogs are all suitable choices for the initial therapy of patients requiring treatment. In younger patients, in whom high-dose treatment is contemplated, there is a role for the use of rituximab; however, it should be administered with caution in patients with high levels of immunoglobulin M paraprotein or signs of hyperviscosity because of the risk of 'flare' in the paraprotein level and consequent adverse clinical events.

Parasellar arachnoid cyst presenting with a nonpupil sparing third nerve palsy mimicking a posterior communicating artery aneurysm in an adult

Background:

Arachnoid cysts are congenital lesions that contain fluid identical to cerebrospinal fluid (CSF). They usually do not communicate with CSF spaces. The vast majority of arachnoid cysts are congenital asymptomatic lesions that are discovered incidentally. Those lesions that do become symptomatic typically present in childhood with signs and symptoms of intracranial hypertension, seizures, and focal neurologic deficits specific to cyst location.

Case Description:

A rare case of a parasellar arachnoid cyst presenting with oculomotor palsy is presented. The patient is a 45-year-old male who presented with acute onset diplopia and frontal headache. Neurologic examination revealed right ptosis, pupillary dilation, and opthalmoparesis consistent with an oculomotor palsy. Computed tomography (CT) scan and lumbar puncture failed to reveal evidence of a subarachnoid hemorrhage. Magnetic resonance imaging (MRI) of the brain demonstrated a 1 cm right parasellar nonenhancing mass that was hyperintense on T2 flair and with a fluid-fluid level concerning for a thrombosed posterior communicating artery (PCommA) aneurysm. There was an additional finding of a left occipital pole intraparenchymal hemorrhage in the setting of multiple hereditary cavernomas. Formal cerebral angiography revealed normal intracranial and extracranial vasculature. The patient was taken to the operating room for a right frontotemporal craniotomy, which revealed compression of the right oculomotor nerve by an arachnoid cyst. The cyst was fenestrated and resected with decompression of the oculomotor nerve. Postoperatively, the third nerve palsy had completely resolved.

Conclusions:

The above case demonstrates that arachnoid cysts should be considered in the differential for patients presenting with nonpupil sparing third nerve palsy and require timely surgical intervention. As is the case for an expanding PCommA aneurysm, prompt decompression results in the best chance for recovery of oculomotor nerve function.

Alcohol-induced apoptosis of oligodendrocytes in the fetal macaque brain

Background

In utero exposure of the fetal non-human primate (NHP) brain to alcohol on a single occasion during early or late third-trimester gestation triggers widespread acute apoptotic death of cells in both gray and white matter (WM) regions of the fetal brain. In a prior publication, we documented that the dying gray matter cells are neurons, and described the regional distribution and magnitude of this cell death response. Here, we present new findings regarding the magnitude, identity and maturational status of the dying WM cells in these alcohol-exposed fetal NHP brains.

Results

Our findings document that the dying WM cells belong to the oligodendrocyte (OL) lineage. OLs become vulnerable when they are just beginning to generate myelin basic protein in preparation for myelinating axons, and they remain vulnerable throughout later stages of myelination. We found no evidence linking astrocytes, microglia or OL progenitors to this WM cell death response. The mean density (profiles per mm³) of dying WM cells in alcohol-exposed brains was 12.7 times higher than the mean density of WM cells dying by natural apoptosis in drug-naive control brains.

Conclusions

In utero exposure of the fetal NHP brain to alcohol on a single occasion triggers widespread acute apoptotic death of neurons (previous study) and of OLs (present study) throughout WM regions of the developing brain. The rate of OL apoptosis in alcohol-exposed brains was 12.7 times higher than the natural OL apoptosis rate. OLs become sensitive to the apoptogenic action of alcohol when they are just beginning to generate constituents of myelin in their cytoplasm, and they remain vulnerable throughout later stages of myelination. There is growing evidence for a similar apoptotic response of both neurons and OLs following exposure of the developing brain to anesthetic and anticonvulsant drugs. Collectively, this body of evidence raises important questions regarding the role that neuro and oligo apoptosis may play in the human condition known as fetal alcohol spectrum disorder (FASD), and also poses a question whether other apoptogenic drugs, although long considered safe for pediatric/obstetric use, may have the potential to cause iatrogenic FASD-like developmental disability syndromes.

Multistate outbreak of Escherichia coli O145 infections associated with romaine lettuce consumption, 2010

Non-O157 Shiga toxin-producing Escherichia coli (STEC) can cause severe illness, including hemolytic uremic syndrome (HUS). STEC O145 is the sixth most commonly reported non-O157 STEC in the United States, although outbreaks have been infrequent. In April and May 2010, we investigated a multistate outbreak of STEC O145 infection. Confirmed cases were STEC O145 infections with isolate pulsed-field gel electrophoresis patterns indistinguishable from those of the outbreak strain. Probable cases were STEC O145 infections or HUS in persons who were epidemiologically linked. Case-control studies were conducted in Michigan and Ohio; food exposures were analyzed at the restaurant, menu, and ingredient level. Environmental inspections were conducted in implicated food establishments, and food samples were collected and tested. To characterize clinical findings associated with infections, we conducted a chart review for case patients who sought medical care. We identified 27 confirmed and 4 probable cases from five states. Of these, 14 (45%) were hospitalized, 3 (10%) developed HUS, and none died. Among two case-control studies conducted, illness was significantly associated with consumption of shredded romaine lettuce in Michigan (odds ratio [OR] = undefined; 95% confidence interval [CI] = 1.6 to undefined) and Ohio (OR = 10.9; 95% CI = 3.1 to 40.5). Samples from an unopened bag of shredded romaine lettuce yielded the predominant outbreak strain. Of 15 case patients included in the chart review, 14 (93%) had diarrhea and abdominal cramps and 11 (73%) developed bloody diarrhea. This report documents the first foodborne outbreak of STEC O145 infections in the United States. Current surveillance efforts focus primarily on E. coli O157 infections; however, non-O157 STEC can cause similar disease and outbreaks, and efforts should be made to identify both O157 and non-O157 STEC infections. Providers should test all patients with bloody diarrhea for both non-O157 and O157 STEC.

Do enhanced sexual health services meet the needs of men who have sex with men?

Enhanced Sexual Health Services (ESHS) have the potential to widen access to sexual health services for populations in England. This study aimed to identify what provision was commissioned in ESHS for men who have sex with men (MSM). We undertook a web-based survey of Primary Care Trust (PCT) commissioners in the south-east of England, exploring what sexual health services were commissioned for MSM and comparing them with published standards. Fourteen of 17 PCTs (82%) responded. All PCTs identified at least one genitourinary (GU) medicine clinic and 13 identified at least one ESHS commissioned for their population. However no single ESHS provided the full range of essential services for MSM. Testing for Chlamydia (84.6% PCTs) and for HIV (69.2% PCTs) were most commonly provided in ESHS, while only 46% and 62% of PCTs had an ESHS commissioned to provide gonorrhoea testing and hepatitis B/syphilis serology testing respectively. Under two-thirds reported training of staff in the sexual health needs of MSM. ESHS are not commissioned to provide the full range of essential sexual health services for MSM. This needs to be addressed by improving staff training in these services and strengthening care pathways between ESHS and GU medicine clinics.

Non-linear inverse scattering: high resolution quantitative breast tissue tomography

Recent published results in inverse scattering generally show the difficulty in dealing with moderate to high contrast inhomogeneities when employing linearized or iteratively linearized algorithms (e.g., distorted Born iterative method). This paper presents a fully nonlinear algorithm utilizing full wave field data, that results in ultrasound computed tomographic images from a laboratory breast scanner, and shows several such unique images from volunteer subjects. The forward problem, data collection process and inverse scattering algorithm used are discussed. A functional that represents the "best fit" between predicted and measured data is minimized, and therefore requires a very fast forward problem solver, Jacobian calculation, and gradient estimation, all of which are described. The data collection device is described. The algorithm and device yield quantitative estimates of human breast tissue in vivo. Several high resolution images, measuring ∼150 by 150 wavelengths, obtained from the 2D inverse scattering algorithms, using data collected from a first prototype, are shown and discussed. The quantitative values are compared with previous published work.

Damage associated molecular patterns within xenogeneic biologic scaffolds and their effects on host remodeling

The immune response is an important determinant of the downstream remodeling of xenogeneic biologic scaffolds in vivo. Pro-inflammatory responses have been correlated with encapsulation and a foreign body reaction, while anti-inflammatory reactions are associated with constructive remodeling. However, the bioactive and bioinductive molecules within the extracellular matrix (ECM) that induce this polarization are unclear, although it is likely that cellular remnants such as damage associated molecular patterns (DAMPs) retained within the scaffold may play a role. The present study investigated the immunomodulatory effects of common ECM scaffolds. Results showed that tissue source, decellularization method and chemical crosslinking modifications affect the presence of the well characterized DAMP - HMGB1. In addition, these factors were correlated with differences in cell proliferation, death, secretion of the chemokines CCL2 and CCL4, and up regulation of the pro-inflammatory signaling receptor toll-like receptor 4 (TLR4). Inhibition of HMGB1 with glycyrrhizin increased the pro-inflammatory response, increasing cell death and up regulating chemokine and TLR4 mRNA expression. The present study suggests the importance of HMGB1 and other DAMPS as bioinductive molecules within the ECM scaffold. Identification and evaluation of other ECM bioactive molecules will be an area of future interest for new biomaterial development.

Single-arc volumetric-modulated arc therapy can provide dose distributions equivalent to fixed-beam intensity-modulated radiation therapy for prostatic irradiation with seminal vesicle and/or lymph node involvement

OBJECTIVES

Volumetric-modulated arc therapy (VMAT) is becoming an increasingly utilised modality for treating a variety of anatomical sites. However, the efficacy of single-arc VMAT to treat prostate cancer suspicious for extraprostatic extension was heretofore unknown. In this work, we report our institutional experience with single-arc VMAT and fixed-beam intensity-modulated radiation therapy (IMRT) for prostate cancer patients treated for seminal vesicle and/or lymph node involvement.

METHODS

Single-arc VMAT and 7- or 9-field IMRT treatment plans were compared for 10 prostate cancer patients treated for seminal vesicle involvement and/or lymph node involvement. All treatment plans were constructed using the Philips Pinnacle treatment planning system (v.9.0, Fitchburg, WI) and delivered on an Elekta Infinity radiotherapy accelerator (Crawley, UK). Resulting plans were compared using metrics that characterised dosimetry and delivery efficiency.

RESULTS

No statistically significant differences in target coverage, target homogeneity or normal tissue doses were noted between the plans (p>0.05). For prostate patients treated for seminal vesicle involvement, VMAT plans were delivered in 1.4±0.1 min (vs 9.5±2.4 min for fixed-beam IMRT) (p<0.01) and required approximately 20% fewer monitor units (p=0.01). For prostate patients treated for lymph node involvement, VMAT plans were delivered in 1.4±0.1 min (vs 11.7±1.3 min for fixed-beam IMRT) (p<0.01) and required approximately 45% fewer monitor units (p<0.01).

CONCLUSION

Single-arc VMAT plans were dosimetrically equivalent to fixed-beam IMRT plans with significantly improved delivery efficiency.

Salivary gland gene expression atlas identifies a new regulator of branching morphogenesis

During organ development, local changes in gene expression govern morphogenesis and cell fate. We have generated a microanatomical atlas of epithelial gene expression of embryonic salivary glands. The mouse submandibular salivary gland first appears as a single mass of epithelial cells surrounded by mesenchyme, and it undergoes rapid branching morphogenesis to form a complex secretory organ with acini connected to an extensive ductal system. Using laser capture microdissection, we collected samples from 14 distinct epithelial locations at embryonic days 12.5, 13.5, 14, and 15, and characterized their gene expression by microarray analysis. These microarray results were evaluated by qPCR of biological replicates and by comparisons of the gene expression dataset with published expression data. Using this gene expression atlas to search for novel regulators of branching morphogenesis, we found a substantial reduction in mRNA levels of GSK3β at the base of forming clefts. This unexpected finding was confirmed by immunostaining, and inhibition of GSK3β activity enhanced salivary gland branching. This first microanatomical expression atlas of a developing gland characterizes changes in local gene expression during salivary gland development and differentiation, which should facilitate the identification of key genes involved in tissue morphogenesis.

Heated-controlled atmosphere postharvest treatments for Macchiademus diplopterus (Hemiptera: Lygaeidae) and Phlyctinus callosus (Coleoptera: Curculionidae)

Nonchemical, environmentally friendly quarantine treatments are preferred for use in postharvest control of insect pests. Combined high temperature and controlled atmosphere quarantine treatments for phytosanitary fruit pests Macchiademus diplopterus (Distant) (Hemiptera: Lygaeidae) and Phlyctinus callosus (Schoenherr) (Coleoptera: Curculionidae) were investigated to determine the potential of such treatments for quarantine security. Field-collected, aestivating M. diplopterus adults and P. callosus adults were treated using a controlled atmosphere waterbath system. This system simulates the controlled atmosphere temperature treatment system (CATTS) used to control a number of phytosanitary pests in the United States and allows for a rapid assessment of pest response to treatment. Insects were treated under regular air conditions and a controlled atmosphere of 1% oxygen, 15% carbon dioxide in nitrogen, at two ramping heat rates, 12 and 24 degrees C/h. Treatment of both species was more effective under both heating rates when the controlled atmosphere condition was applied. Under these conditions of controlled atmospheres, mortality of P. callosus was greater when the faster heating rate was used, but the opposite was true for M. diplopterus. This could be due to the physiological condition of aestivation contributing to metabolic arrest in response to the stresses being applied during treatment. Results indicate that the potential for the development of CATTS treatments for these phytosanitary pests, particularly P. callosus, is promising.

A rapid and reliable PCR method for detecting clonal T cell populations

Aims-To establish a reverse transcription polymerase chain reaction (RT-PCR) for the detection of clonal T cell populations, and to evaluate the sensitivity and reliability of the technique.Methods-After reverse transcription of the target RNA with a consensus T cell receptor (TCR) beta constant (C) region primer, consensus C, variable (V), diversity (D) and joining (J) region primers were used to amplify across various portions of the TCRbeta V-D-J-C junction.Results-In normal T cells the polyclonal rearrangements produce a ladder of PCR bands representing the different sized junction fragments. The presence of a T cell clone leads to over-representation of one junction fragment, hence a disproportionately brighter band in the PCR ladder. In a series of 16 patients the RT-PCR detected nine of nine shown to have a clonal TCRbeta rearrangement by Southern blotting and for six of seven patients, it confirmed the presence of a clone indicated by histology or immunophenotyping with FACS analysis, but which was undetectable (five patients) or not investigated (two patients) by Southern blotting. Investigations mixing RNA from normal lymphocytes and the Jurkat TCR-Vbeta8 T cell line suggested that the method was more sensitive than Southern blotting.Conclusions-All PCR methods are faster and easier than Southern blotting, but RT-PCR also improves detection of clonal T cell populations, is reliable and produces results that are easy to interpret.

Potential of heated controlled atmosphere postharvest treatments for the control of Thaumatotibia leucotreta (Lepidoptera: Tortricidae)

Controlled atmosphere/temperature treatment system (CATTS) is an environmentally friendly postharvest mitigation treatment that uses high temperature forced-air combined with a low oxygen and high carbon dioxide atmosphere to control quarantine pests. The development of CATTS treatments is expensive and time-consuming. For a more rapid assessment of different species and life stages' tolerances to heated controlled atmospheres, the controlled atmosphere water bath (CAWB) system can be used to help advance the development of CATTS treatments for pests. The CAWB system was used to test the response of eggs and larval stages of Thaumatotibia leucotreta (Meyrick) (Lepidoptera: Tortricidae). Eggs and larvae at different developmental stages were treated under regular air and a modified controlled atmosphere of 1% O2 and 15% CO2, at two ramping heat rates: 12 and 24 degrees C/h. Typically the faster heat rate and modified atmosphere reduced treatment times required to control the different life stages. T. leucotreta larvae were more tolerant of the treatments than eggs. The most tolerant life stage was the fourth instar. Effective treatments against the most tolerant life stage determined by the CAWB system can now be used to develop CATTS technology against T. leucotreta. Further research will focus on developing CATS treatments using infested fruit to determine effective treatments that maintain fruit quality.

Temperature-dependent phase behavior and protein partitioning in giant plasma membrane vesicles

Liquid-ordered (Lo) and liquid-disordered (Ld) phase coexistence has been suggested to partition the plasma membrane of biological cells into lateral compartments, allowing for enrichment or depletion of functionally relevant molecules. This dynamic partitioning might be involved in fine-tuning cellular signaling fidelity through coupling to the plasma membrane protein and lipid composition. In earlier work, giant plasma membrane vesicles, obtained by chemically induced blebbing from cultured cells, were observed to reversibly phase segregate at temperatures significantly below 37 degrees C. In this contribution, we compare the temperature dependence of fluid phase segregation in HeLa and rat basophilic leukemia (RBL) cells. We find an essentially monotonic temperature dependence of the number of phase-separated vesicles in both cell types. We also observe a strikingly broad distribution of phase transition temperatures in both cell types. The binding of peripheral proteins, such as cholera toxin subunit B (CTB), as well as Annexin V, is observed to modulate phase transition temperatures, indicating that peripheral protein binding may be a regulator for lateral heterogeneity in vivo. The partitioning of numerous signal protein anchors and full length proteins is investigated. We find Lo phase partitioning for several proteins assumed in the literature to be membrane raft associated, but observe deviations from this expectation for other proteins, including caveolin-1.

Are primary care-based sexually transmitted infection services in the UK delivering public health benefit?

Sexual health services in primary care, known in the UK as local enhanced services in sexual health (LESSH), aim to increase access to sexually transmitted infection (STI) screening and treatment. Little is known about the characteristics, quality or public health impact of these services. We identified national standards for service provision, and evaluated LESSH against them using a structure, process and outcome approach. Clinical structure and process standards were generally well met, with the exception of partner notification provision. However, public health and outcome measures were largely unascertainable and often undefined in the standards. If the primary care STI services are to deliver public health benefit, improved outcome measures and data collection are required.