Antibiotics or Tonsillectomy for Adult Recurrent Tonsillitis: Analyzing the Lesser of Two Evils

OBJECTIVE

To determine the best timing for surgical intervention for adults with recurrent tonsillitis (RT).

METHODS

A Markov model was constructed using variables and ranges based upon a literature review. A 1-way sensitivity analysis was performed to evaluate the number of yearly bouts at which each algorithm (antibiotics or tonsillectomy) would be favored. A Monte-Carlo probabilistic sensitivity analysis was calculated for gains and cost. Model outcomes were measured with quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER) for tonsillectomy versus repeat antibiotic treatment.

RESULTS

Patients expected to sustain a single annual tonsillitis event will have a negative QALY of 0.02 if treated with surgery and those with 2 annual events will have a QALY gain from undergoing tonsillectomy of 0.01, 3 events = 0.03, 4 events = 0.05, 5 events = 0.07, 6 events = 0.09, 7 events = 0.1, and 8 events = 0.11. These gains became meaningful only after 2 years of recurrent bouts. The average cost of tonsillectomy was 3,238 USD, and the overall average cost of RT was 7,069 USD (an incremental cost of 3,831 USD). The ICER of tonsillectomy over antibiotic treatment for 1 QALY gain was 44,741 USD.

CONCLUSION

Adult patients who sustain more than 3 annual bouts of tonsillitis over a period of at least 2 years will gain QALY after tonsillectomy. These gains increase proportionally to the number of yearly events and perennial episodes. The incremental costs of tonsillectomy fail to meet the NICE guidelines but are within other acceptable reference ranges.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2153-2161, 2024.

Asymptomatic Dysphagia and Aspiration in Patients with Idiopathic Bronchiectasis

PURPOSE

Although considered contributors to idiopathic bronchiectasis (IB), neither dysphagia nor silent aspiration have been systematically evaluated in IB patients. We aimed to explore the prevalence of asymptomatic dysphagia and silent aspiration in IB patients and to identify parameters predictive of their presence.

METHODS

This prospective cohort study included IB patients from our Pulmonary Institute without prior history of dysphagia and without prior dysphagia workup. Swallowing function was assessed by the Eating Assessment Tool (EAT-10) questionnaire and by the Fiberoptic Endoscopic Evaluation of Swallowing (FEES) test.

RESULTS

Forty-seven patients (31 females, mean age 67 ± 16 years) were recruited. An EAT-10 score ≥ 3 (risk for swallowing problems) was present in 21 patients (44.6%). Forty-two patients (89.3%) had at least one abnormal swallowing parameter in the FEES test. Six patients (12.7%) had a penetration aspiration score (PAS) in the FEES of at least 6, indicating aspiration. An EAT-10 score of 3 was found to be the ideal cutoff to predict aspiration in the FEES, with a good level of accuracy (area under the curve = 0.78, 95% CI 0.629-0.932, p = 0.03) and sensitivity of 83%. This cutoff also showed a trend towards a more severe disease using the FACED (forced expiratory volume, age, colonization with pseudomonas, extension of lung involvement, dyspnea) score (p = 0.05).

CONCLUSION

Dysphagia is prevalent in IB and may be undiagnosed if not specifically sought. We recommend screening all patients with IB for dysphagia by the EAT-10 questionnaire and referring all those with a score of ≥ 3 to formal swallowing assessment.

157 A Rare Case of Cutaneous-Urachovesicoenteric Fistula in a Patient with Crohn’s Disease

Background

Entero-Uracho Vesicle fistulae are a rare sequelae of aggressive Crohn’s disease with only a small number of case reports being available in the literature. Such cases are most often managed via “SSNAP” principles with many Crohn’s fistulas requiring complex surgical intervention to definitively deal with the offending fistulous tracts. We present a case with an even rarer consequence of uncontrolled Crohn’s disease despite immunomodulatory therapy in a 34-year-old male who presented with a Entero-Uracho Vesicle fistula. We discuss the presenting symptoms and management protocol involved in this case.

Case:

A 34-year-old male with known Crohn’s disease presented with an entero-uracho vesicle fistula, which further developed into a cutenaous-urachovesicoenteric fistula while awaiting surgery during his index admission. The fistula tract was confirmed via Computed Tomography with evidence of significant inflammation. Bowel rest, antibiotics, and nutritional support with Total Parenteral Nutrition preceded total excision of the fistulous tract with ileo-caecal resection of the diseased bowel with primary anastomosis, and resection of the urachus and closure of the cutaneous fistula site with desirable outcome. Patient completed a full-recovery with return of normal bowel function and nutritional status, with no delayed complications at 6-month follow-up.

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.

A balance and proprioception intervention programme to enhance combat performance in military personnel

BACKGROUND

Optimal functioning of the lower extremities under repeated movements on unstable surfaces is essential for military effectiveness. Intervention training to promote proprioceptive ability should be considered in order to limit the risk for musculoskeletal injuries. The aim of this study was to assess the effect of a proprioceptive intervention programme on static and dynamic postural balance among Israel Defense Forces combat soldiers.

METHODS

Twenty-seven male soldiers, aged 18-20 years, from a physical fitness instructor's course, were randomly divided into two groups matched by age and army unit. The intervention group (INT) underwent 4 weeks of proprioceptive exercises for 10 min daily; the control group underwent 4 weeks of upper body stretching exercises for 10 min daily. All participants were tested pre and postintervention for both static and dynamic postural balance.

RESULTS

Significant interaction (condition*pre-post-test*group) was found for static postural balance, indicating that for the INT group, in condition 3 (on an unstable surface-BOSU), the post-test result was significantly better compared with the pretest result (p<0.05). Following intervention, the INT group showed significant correlations between static postural stability in condition 2 (eyes closed) and the dynamic postural stability (length of time walked on the beam following fatigue) (r ranged from 0.647 to 0.822; p<0.05).

CONCLUSIONS

The proprioceptive intervention programme for combat soldiers improved static postural balance on unstable surfaces, and improved the correlation between static postural balance in the eyes closed condition and dynamic postural balance following fatigue. Further longitudinal studies are needed to verify the relationship between proprioception programmes, additional weight bearing and the reduction of subsequent injuries in combat soldiers.

Cyanophenyl vs. pyridine substituent: impact on the adlayer structure and formation on HOPG and Au(111)

A new cyano substituted bis(terpyridine) derivative CN-BTP was synthesized and its adsorption on highly oriented pyrolytic graphite (HOPG) and Au(111) was investigated. CN-BTP is closely related to the previously investigated 2,4'-BTP, where the cyanophenyl groups are replaced by pyridine moieties. The scanning tunneling microscopy (STM) investigation of CN-BTP at the liquid|HOPG interface shows a highly ordered herringbone structure that is stabilized by double weak intermolecular C-HN hydrogen bonds, partially through the -CN substituents, which is different from the most stable square structure of 2,4'-BTP. The adsorption processes were investigated using cyclic voltammetry (CV) on Au(111) in a neutral phosphate buffer. A fast and full adlayer formation could be observed with CN-BTP, whereas an extremely slow process with 2,4'-BTP under the same conditions was found. Our data show that the CN substituents on BTP not only change the structure of the monolayer at the liquid|HOPG interface, but also accelerate the phase transition process in the electrolyte dramatically. This could be explained by the adlayer-substrate interactions, which is supported by DFT calculations. Our findings might be extended more generally to further pyridine comprising self-assembling molecules to fine-tune the adlayer structure and phase transition/adsorption kinetics by replacing pyridine by cyanophenyl moieties.

The interface between HOPG and 1-butyl-3-methyl-imidazolium hexafluorophosphate

The interface between highly oriented pyrolytic graphite (HOPG) and 1-butyl-3-metyl-imidazolium hexafluorophosphate (BMIPF₆) has been studied using cyclic voltammetry, electrochemical impedance spectroscopy, immersion charge measurements and in situ scanning tunneling microscopy (in situ STM).

QM/MM description of periodic systems

A quantum mechanical molecular mechanics (QM/MM) implementation for periodic systems is reported. This is done for the case of molecules and for systems with two and three-dimensional periodicity, which is suitable to model electrolytes in contact with electrodes. Tests on different water-containing systems, ranging from the water dimer up to liquid water indicate the correctness of the scheme. Furthermore, molecular dynamics simulations are performed, as a possible direction to study realistic systems.

Acute superior mesenteric artery embolism: reperfusion with AngioJet hydrodynamic suction thrombectomy and pharmacologic thrombolysis with the EKOS catheter

Acute mesenteric ischemia is commonly treated by surgical exploration and open thrombectomy. Very few reports describe using newer, minimally invasive methods which utilize catheter-based mechanical and pharmacological thrombolysis. Herein, we report a case of acute superior mesenteric embolism successfully treated with AngioJet hydrodynamic mechanical thrombectomy and EKOS catheter pharmacological thrombolysis. A 76-year-old man with new onset atrial fibrillation presented with abdominal pain of 48 hours duration. Subsequent contrast computed tomography scan of the abdomen revealed a filling defect in the superior mesenteric artery (SMA), suggestive of an acute embolus, which was confirmed by SMA angiogram. The AngioJet aspiration device was used for hydrodynamic suction thrombectomy. The repeat angiogram demonstrated only a partial restoration of blood flow, and thus the EKOS tissue plasminogen activator catheter was left in the SMA for continuous thrombolysis. The patient underwent continuous thrombolysis for two days, with two subsequent sessions of angiography. Thereafter, the patient improved symptomatically and serum lactate was normalized. In conclusion, the AngioJet suction thrombectomy and pharmaco-mechanical thrombolysis using the EKOS catheter is associated with minimal morbidity and can be rapidly performed. It may be used as an alternative to open surgical thrombectomy in selected cases of acute SMA embolism.

An Integrative Approach for Studying the Etiology of Alcoholism and Other Addictions

Studies of alcoholism etiology often focus on genetic or psy-chosocial approaches, but not both. Greater understanding of the etiology of alcohol, tobacco and other addictions will come from integration of these research traditions. A research approach is outlined to test three models for the etiology of addictions — behavioral undercontrol, pharmacologic vulnerability, negative affect regulation — addressing key questions including (i) mediators of genetic effects, (ii) genotype-environment correlation effects, (iii) genotype x environment interaction effects, (iv) the developmental unfolding of genetic and environmental effects, (v) subtyping including identification of distinct trajectories of substance involvement, (vi) identification of individual genes that contribute to risk, and (vii) the consequences of excessive use. By using coordinated research designs, including prospective assessment of adolescent twins and their siblings and parents; of adult substance dependent and control twins and their MZ and DZ cotwins, the spouses of these pairs, and their adolescent offspring; and of regular families; by selecting for gene-mapping approaches sibships screened for extreme concordance or discordance on quantitative indices of substance use; and by using experimental (drug challenge) as well as survey approaches, a number of key questions concerning addiction etiology can be addressed. We discuss complementary strengths and weaknesses of different sampling strategies, as well as methods to implement such an integrated approach illustrated for the study of alcoholism etiology. A coordinated program of twin and family studies will allow a comprehensive dissection of the interplay of genetic and environmental risk-factors in the etiology of alcoholism and other addictions.

A nanotechnology-based delivery system: Nanobots. Novel vehicles for molecular medicine

AIM

We previously demonstrated that adenovirus-mediated p53 gene transfer following balloon angioplasty, decreased neointimal hyperplasia. However, safety concerns arise because viral promoters can cause unrestricted transgene expression. The paucity of safe and efficient vehicles for gene transfer thus limits the potential for clinical utilization of gene therapy. Our objective was to design and clone a virus-free p53 construct, targeted to express specifically in vascular smooth muscle cells (SMCs), via a nanoparticle-based delivery system for therapeutic modulation in vascular wall.

METHODS

Biodegradable poly(lactide-co-glycolide) (PLGA), an FDA approved polymer, was used to formulate the nanoparticles. Cloned constructs consisting of SMC promoter, SM22, and p53 cDNA sequences along with enhanced green fluorescent protein (EGFP) gene, were loaded into PLGA nanoparticles. The affect of these nanobots on cell growth was examined.

RESULTS

The gene sequences carried by the nanobot are expressed in target cells. The p53/EGFP construct under the constitutive promoter was found to express in 293T human embryonic kidney cells, whereas the p53/EGFP with SMC promoter expressed only in human aortic SMCs. SMCs internalize these nanobots without compromising cell viability or growth kinetics.

CONCLUSION

A novel genetic sequence that targets a specific cell population has been successfully designed, cloned and encapsulated in a nanoparticle. This experiment is a significant step towards the development of a nanoparticle-based delivery system for therapeutic delivery of targeted gene-therapy towards attenuation of restenosis. Further work is necessary to expand the repertoire of this delivery system and determine whether it could become a versatile vehicle in molecular medicine.

The effect of cotinine on telomerase activity in human vascular smooth muscle cells

AIM

Cotinine, the main stable metabolite of nicotine, has been shown to have a biological half-life approximately 10 times longer than nicotine. It has also been demonstrated to have a powerful effect on vascular smooth muscle cell (VSMC) proliferation. Telomerase activation is known to play an important role in cell viability and proliferation. The purpose of our experiment was to evaluate the effect of cotinine on proliferative potential of vascular smooth muscle cells via its effects on telomerase activity.

METHODS

Primary cultures of human VSMC obtained from greater saphenous veins were used in this experiment from 3(rd) to 5(th) passage. Cotinine was added in doses equivalent to plasma levels of cotinine in an active smoker by dissolving, 0.0, 2.88x10(-6), 5.76x10(-6), and 1.44x10(-5) mol/L of cotinine in the media. The number of viable cells was assessed by trypan blue exclusion. The Telomeric Repeat Amplification Protocol (TRAP) was used to detect telomerase activity. TRAP products were detected by ELISA.

RESULTS

The mitogenic effect of cotinine in VSMC was observed at 48 hours after treatment. The viable cell numbers were significantly increased (4.0x10(7)) at lower doses of cotinine exposure as compared to untreated cultures (2.5x10(5)). At the concentration of 1.44x10(-5) mol/L, cotinine was cytotoxic to VSMCs. Telomerase activity was detected in all sets of VSMC cultures treated with cotinine (P<0.01).

CONCLUSIONS

Cotinine causes abnormal cell proliferation as demonstrated by increased cell numbers and reactivation of telomerase in a dose dependent manner. This study demonstrated cotinine's stimulatory effect on human SMC proliferation in vitro at low doses while high doses of cotinine had a toxic effect. These data correlate with the results of other studies concerning the mitogenic effect of cotinine and telomerase activation during cellular proliferative response.

Optimized expression, solubilization and purification of nuclear inclusion protein b of cardamom mosaic virus

All RNA viruses encode an RNA-dependent RNA polymerase (RdRP) that is required for replication of the viral genome. Nuclear inclusion b (NIb) gene codes for the RdRp in Potyviridae viruses. In this study, expression, solubilization and purification of NIb protein of Cardamom mosaic virus (CdMV) is reported. The objective of the present study was to express and purify the NIb protein of CdMV on a large scale for structural characterization, as the structure of the RdRp from a plant virus is yet to be determined. However, the expression of NIb protein with hexa-histidine tag in Escherichia coli led to insoluble aggregates. Out of all the approaches [making truncated versions to reduce the size of protein; replacing an amino acid residue likely to be involved in hydrophobic intermolecular interactions with a hydrophilic one; expressing the protein along with chaperones; expression in Origami cells for proper disulphide bond formation, in E. coli as a fusion with maltose-binding protein (MBP) and in Nicotiana tabacum] to obtain the RdRp in a soluble form, only expression in E. coli as a fusion with MBP and its expression in N. tabacum were successful. The NIb expressed in plant or as a fusion with MBP in E. coli can be scaled up for further work.

Carotid Artery Stump Pressure (CASP) in 1135 consecutive endarterectomies under general anesthesia: an old method that survived the test of times

AIM

Intraoperative electroencephalography, somato-sensory evoked potentials and transcranial Doppler have been proposed to replace carotid artery stump pressure measurement (CASP) as the test of choice in the evaluation of cerebral tolerance during temporary carotid occlusion. CASP is a simple, inexpensive test that does not require an additional specialist in the operating room. Herein, we attempt to demonstrate that CASP is a reliable test that does not need to be replaced by more sophisticated and expensive techniques.

METHODS

Over the last 6 years, 1 135 consecutive carotid endarterectomies (CEA) were performed under general anesthesia at our institution. There were 592 males and 429 female patients with an age range of 39 to 95 years (mean 72 +/- 9 years). Hypertension, diabetes, smoking, coronary artery disease and chronic renal insufficiency were present in 71%, 39%, 36%, 32% and 26%, respectively. Internal carotid artery (ICA) stenosis ? 70% was confirmed by duplex scanning in 92% of the cases. The remaining 8% of cases had 50% to 69% ICA stenosis in neurologically symptomatic patients. Asymptomatic patients accounted for 75% of the cases. Contralateral ICA occlusion was observed in 57 cases (5%). Indwelling shunts were used when CASP was < 45 mmHg. Carotid patches were used in 233 cases. Completion duplex scanning was performed in all cases. CASP was measured by inserting a 23-gauge needle into the common carotid artery (CCA) after clamping the ICA to avert possible embolization during needle insertion. Once the tip of the needle was confirmed intraluminally by pressure measurement and triphasic waveform tracing, the CCA and the external carotid artery were clamped. After a flat line tracing was depicted on the monitor, ICA clamp was released and CASP was recorded.

RESULTS

CASP was < 45 mmHg in 233 cases (21%) (Group I) and > or = 45 mmHg in 902 cases (79%) (Group II). The mean CASP in presence of contralateral ICA occlusions was 40 +/- 15 mmHg while it was 65 +/- 27 mmHg for patent contralateral ICAs (P < 0.0001). The overall 30-day stroke rate was 1% (1 135 cases). It was 3% (7/233) for group I and 0.5% (4/902) for group II (P < 0.01). In patients with postoperative strokes CASP ranged from 23 to 44 mmHg (mean 33 +/- 8) in group I (shunted) and it varied from 59 to 116 mmHg (mean 99 +/- 28) in group II (non-shunted) with P < 0.001. The causes of stroke in group I were hyperperfusion (2), partial ICA thrombosis (2), embolization (2) and worsening of acute stroke (1). In group II there were 2 cases of embolization and 2 of ICA thrombosis. No patient had a stroke caused by decreased intraoperative global cerebral perfusion. The overall 30-day mortality rate was 0.5%. The overall combined stroke/death rate was 1.5%.

CONCLUSION

CASP > or = 45 mmHg was a reliable predictor of adequate cerebral perfusion during 1,135 consecutive CEAs performed under general anesthesia. The percentage of indwelling shunts utilized in this series was not significantly different from the ones using more expensive and sophisticated techniques.

Proteomic Analysis of the Genotoxicant Methylazoxymethanol (MAM)-Induced Changes in the Developing Cerebellum

The genotoxicant methylazoxymethanol (MAM) is a widely used developmental neurotoxin, and its glucoside is an etiological factor for western Pacific amyotrophic lateral sclerosis-parkinsonism-dementia complex (ALS/PDC). Identification of global protein expression changes that occur in response to MAM in the developing cerebellum could provide valuable insight into the potential mechanisms involved in the neurodegeneration process. We have utilized fluorescence 2-dimensional differential gel electrophoresis (2D-DIGE), to determine the protein expression changes that occur during normal cerebellar development and in response to MAM. Three day-old postnatal C57BL/6 mice (PND3) received a single injection of MAM, and the cerebella of postnatal day 4 (PND4) and day 22 (PND22) were analyzed. Approximately, 1400 unique spots were matched and quantified in all samples. Comparison of PND4 and PND22 developing cerebellum showed that a significant fraction of the proteome (approximately 68%) changes at this stage. The immediate response of the developing cerebellum to MAM was minimal (approximately 10%). However, significant differences (27%) were noted 14 days after MAM exposure. In contrast, the transcriptome changes were more pronounced at 24 h compared to 14 days. MAM targeted several proteins networks including transport (e.g., alpha-synuclein), cytoskeletal (e.g., beta-tubulin, vimentin), and mitochondrial (e.g., Atp5b) proteins. Immunochemistry confirmed several of the changes in protein expression (alpha-synuclein). Comparison with gene expression changes revealed that the temporal changes observed in the transcriptome and proteome are not correlative. These studies demonstrate for the first time the potential networks involved during neuronal development and neurodegenerative processes that are perturbed by MAM.

Pygmoid Australomelanesian Homo sapiens skeletal remains from Liang Bua, Flores: population affinities and pathological abnormalities

Liang Bua 1 (LB1) exhibits marked craniofacial and postcranial asymmetries and other indicators of abnormal growth and development. Anomalies aside, 140 cranial features place LB1 within modern human ranges of variation, resembling Australomelanesian populations. Mandibular and dental features of LB1 and LB6/1 either show no substantial deviation from modern Homo sapiens or share features (receding chins and rotated premolars) with Rampasasa pygmies now living near Liang Bua Cave. We propose that LB1 is drawn from an earlier pygmy H. sapiens population but individually shows signs of a developmental abnormality, including microcephaly. Additional mandibular and postcranial remains from the site share small body size but not microcephaly.

Intérêt de la TEP au 18FDG couplée à la TDM dans la surveillance post-thérapeutiquedes carcinomes épidermoïdesdes voies aérodigestives supérieures

OBJECTIVE

To evaluate the contribution of 18FDG positron emission tomography for the post treatment surveillance of head and neck carcinomas.

METHODS

: This prospective study included 61 patients with advanced squamous cell carcinoma of the upper airways and/or digestive tract and who underwent curative treatment. Patients underwent a standard workup (physical examination, CT scan and panendoscopy) and a PET/CT image fusion 3 months after the end of treatment. The follow-up was 6 months minimum in all patients after this workup. PET/CT was evaluated in terms of: primary tumor, cervical lymph nodes, metastases and overall patient assessment.

RESULTS

: For diagnosis of the primary tumor, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT were respectively 86.7%, 82.6%, 62%, 95% and 83.6%. Values for cervical lymph nodes were: 100%, 98.2%, 80%, 100% and 98.3%. Values for metastases were: 100%, 92.2%, 66.7%, 100% and 93.2%. Values for overall patient assessment were: 88.8%, 78.1%, 64%, 94.1% and 81.4%. Performances of PET/CT were better than standard workup in 22% of patients.

CONCLUSION

PET/CT contributes useful information in this indication, particularly an excellent negative predictive value.

[Contribution of 18-F-FDG PET for detection of head and neck carcinomas with an unknown primary tumor]

OBJECTIVES

To evaluate the usefulness of fusioning positron emission tomography with computed tomography (PET/CT) for the detection of head and neck carcinomas of unknown primary.

METHODS

This prospective study included 20 patients with cervical lymph node of squamous cell carcinoma of unknown primary after standard initial workup (nasofibroscopy and CT scan of the chest and head and neck). Patients underwent PET/CT and panendoscopy of the upper airways and upper digestive tract with PET/CT directed biopsies. The follow-up was 6 months minimum in all patients.

RESULTS

A potential primary tumor was found in 10 of the 20 cases and confirmed by histology in 7 cases (3 bases of tongue, 1 tonsillar pillar, 1 vallecula, 1 tonsillar fossa, 1 piriform sinus). Four of these seven patients presented a normal endoscopy (diagnosis was made with submucosal PET/CT directed biopsies). PET/CT was normal in 10 of 20 cases with 3 false negatives. The sensitivity of PET/CT was 70%, the specificity was 70% and the accuracy was 70%.

CONCLUSION

PET/CT seems to be of interest in the detection of head and neck carcinoma of unknown primary. PET/CT detected 15% of unknown primary tumors with treatment-related implications.

Activation of P38MAPK Signaling Cascade in a VSMC Injury Model: Role of P38MAPK Inhibitors in Limiting VSMC Proliferation

INTRODUCTION

P38 mitogen-activated protein kinase (MAPK) has a crucial role in regulating signaling pathways implicated in the cellular events leading to restenosis. We examine p38MAPK activation in response to vascular cell injury, its biological effects and determine whether selective p38MAPK inhibitors, SB220025/SB203580, decrease vascular smooth muscle cell (VSMC) proliferation.

METHODS

Human aortic VSMCs were cultured and wounds made on the monolayers to elicit mitogenic responses and induce p38MAPK activation. P38MAPK inhibitor pretreatment, at varying doses (1-100 microM) and treatment duration was used to block p38MAPK phosphorylation. Cytotoxicity, viability, proliferation and apoptosis were determined and expression of p38MAPK/phospho-p38MAPK was obtained by chemiluminiscent immunoblot analysis.

RESULTS

Phosphorylation of p38MAPK depended on injury severity and was inhibited by both p38MAPK inhibitors, but not by SB202474, a specific antagonist of p38MAPK inhibitors. VSMCs treated with p38MAPK inhibitors showed a dose-dependent decrease in viable cell number, apoptosis and proliferation, reversing the deleterious effects of p38MAPK activation comparable to controls (p < 0.05).

CONCLUSIONS

This wound injury model activates the p38MAPK-signaling cascade in VSMC and causes cell proliferation that can be abrogated by pre-incubation with p38MAPK selective synthetic inhibitors in a time and dose-dependent manner. SB220025 used here for the first time in VSMC reveals itself to be a stronger p38MAPK inhibitor than SB203580 and being a second generation inhibitor may be the preferred drug for novel therapeutic maneuvers.

Early brain growth in Homo erectus and implications for cognitive ability

Humans differ from other primates in their significantly lengthened growth period. The persistence of a fetal pattern of brain growth after birth is another important feature of human development. Here we present the results of an analysis of the 1.8-million-year-old Mojokerto child (Perning 1, Java), the only well preserved skull of a Homo erectus infant, by computed tomography. Comparison with a large series of extant humans and chimpanzees indicates that this individual was about 1 yr (0-1.5 yr) old at death and had an endocranial capacity at 72-84% of an average adult H. erectus. This pattern of relative brain growth resembles that of living apes, but differs from that seen in extant humans. It implies that major differences in the development of cognitive capabilities existed between H. erectus and anatomically modern humans.

Carotid endarterectomy in octogenarians and nonagenarians : is it worth the effort?

PURPOSE

The safety, effectiveness and cost issues of carotid endarterectomy (CEA) in the elderly patient have been debated due to the limited life expectancy and presumably increased rate of complications. This is despite multiple reports in the literature of excellent results in this population. To further examine this issue, we compared characteristics of three populations who underwent CEA at our institution: 53-79 year old patients (youngest group), 80-89 years old patients (middle group), and 90-98 year old patients (oldest group).

METHODS

Medical and financial data were obtained by retrospective review of hospital charts and billing records. We analyzed 266 random CEAs performed in 251 patients in the youngest group, 280 CEAs performed in 247 patients in the middle group and 19 CEA in 16 patients in the oldest group performed between 2/1/90 and 2/5/01.

RESULTS

Comparing each CEA group, there were no differences in gender (males: 56% vs. 51% vs. 53%), incidence of preoperative symptoms (43% vs. 43% vs. 42%), hypertension (68% vs. 60% vs. 42%), combined perioperative death and stroke rate (1.8% vs. 2.1% vs. 10%) or other complications (11% vs. 10% vs. 10%). Significant differences (p<0.05) were noted between the groups in incidence of diabetes (33% vs. 51% vs. 5% in each group), and heart disease (28% vs. 38% vs. 21%). Length of stay for admissions for CEA only were also similar in all three groups (2.37 days vs. 2.67 days vs. 2.36 days). A cost analysis of the earliest 230 patients in the entire series examining hospital cost per case revealed similar data for the < 80 years old and > 80 year old patients ($7,842 vs. $9,400).

CONCLUSIONS

Carotid endarterectomy can be performed in the elderly as safely and cost effectively as in the younger population.

High negative predictive value of slow lymphatic drainage on metastatic node spread detection in malignant limb and trunk cutaneous melanoma

AIM

Harvesting of the "sentinel lymph node" (SLN) as identified by lymphoscintigraphy (LSG) is becoming increasingly important in the staging of patients with malignant melanoma. The purpose of the current study was to determine whether the appearance time of the LSG had a prognostic value in predicting metastasis dissemination in thick cutaneous malignant melanoma.

METHODS

Between July 1999 and July 2003, 88 consecutive patients with histologically proven melanoma with a Breslow's thickness > 1 mm, without clinical or radiological evidence of lymph node involvement or metastasis, prospectively underwent lymphoscintigraphy with 32 Mbq Tc 99m sulfur colloid prior to sentinel lymphadenectomy with sentinel lymph node (SLN) histological examination.

RESULTS

LSG was performed in 88 patients with limb and trunk melanoma and identified a total of 149 sentinel nodes. Pathological examination revealed lymph node involvement in 21 patients (24%). All positive SLNs were imaged with a scintigraphic appearance time of less than 30 min. With a scintigraphic appearance time greater than 30 min, the negative predictive value (NPV) of spread in the SLN was 100% (27/27)(CI 87-100%).

CONCLUSION

The strong NPV of LSG in identifying "slow" sentinel lymph nodes in patients with no clinical evidence of lymph node involvement suggests that patients could be spared sentinel lymph node biopsy when LSG detects "slow" sentinel lymph nodes. Another prospective study will be required to confirm that the scintigraphic appearance time of sentinel lymph nodes is an important predictive parameter of metastatic disease in sentinel lymph nodes and consequently might reduce the number of sentinel lymph node biopsies.

Lack of efficacy of recombinant human thyrotropin versus thyroid hormone withdrawal for radioiodine therapy imaging in a patient with differentiated thyroid carcinoma lung metastases

The treatment of lung metastases of thyroid cancer is nearly exclusively limited to the administration of iodine-131. For patients presented with micronodular lesions, the therapeutic response is often excellent, increasing life expectancy. Because of the necessity of multiple iodine-131 treatments in the course of this therapy, and subsequently, the lack of tolerance of hormonal withdrawal, the use of recombinant human thyrotropin (rhTSH) as a method of stimulation could represent an interesting alternative. However, as in the present case, the stimulation by rhTSH can be less effective than hormonal withdrawal, as shown in the posttherapy scan to detect metastatic lesions and thus could be detrimental to the treatment efficiency.

[[18F]-FDG imaging in apparently isolated pleural lesions]

While a great deal of work has been performed concerning the impact of [18F]-FDG imaging in isolated lung lesion(s), there are still very few data about its role in case of isolated pleural lesions. The aim of this preliminary study was to shed some light on the utility of [18F]-FDG imaging, using PET or CDET detection, in this context.

PATIENTS AND METHOD

Sixteen patients referred for apparently isolated pleural lesions were included in this study, since their 22 [18F]-FDG examinations were evaluable on bases of histology (9 cases), rapid disease progression (4 cases) or a follow-up period of more than 6 months (9 cases). Twelve [18F]-FDG examinations were performed with a dedicated PET machine (C-PET, Adac) and ten with a coincidence detection gamma camera (Irix, Picker). The precise clinical settings were the following: characterization of pleural masses or search for the unknown primary tumor in case of adenocarcinoma (6 cases), staging of a mesothelioma (5 cases), suspicion of recurrence and/or residual lesions (11 cases).

RESULTS

The malignant pleural lesions took up [18F]-FDG in all cases. There was one false positive result due to an inflammatory lesion. False negative results for the detection of lymph node invasion occurred in three patients and were in relation with their infracentimetric size and the difficulty to distinguish on [18F]-FDG images mediastinal lymph nodes from widespread pleural and pulmonary extension of cancer. A change in patient management resulted from the [18F]-FDG examination in 4 patients (25%) and the course confirmed that the change was correct. Unknown lesions or active lesions wrongly considered residual that could have modified the management were discovered in 3 other patients.

CONCLUSIONS

This study highlights the fact that [18F]-FDG imaging has an impact on the management of patients with solitary pleural lesions and can detect recurrences, in some cases even more accurately than invasive procedures with histology. In our limited experience, the lack of anatomical details of the PET images is a major drawback in this setting and we are convinced that PET-CT will substantially enhance the impact of [18F]-FDG imaging.

High genetic diversity in the coat protein and 3′ untranslated regions among geographical isolates ofCardamom mosaic virus from south India

A survey was conducted to study the biological and genetic diversity of Cardamom mosaic virus (CdMV) that causes the most widespread disease in the cardamom growing area in the Western Ghats of south India. Six distinct subgroups were derived based on their symptomatology and host range from the sixty isolates collected. The serological variability between the virus isolates was analysed by ELISA and Western blotting. The 3 terminal region consisting of the coat protein (CP) coding sequence and 3 untranslated region (3 UTR) was cloned and sequenced from seven isolates. Sequence comparisons revealed considerable genetic diversity among the isolates in their CP and 3 UTR, making CdMV one of the highly variable members of Potyviridae. The possible occurrence of recombination between the isolates and the movement of the virus in the cardamom tract of south India are discussed.

Hemodynamics of infrapopliteal PTFE bypasses and adjunctive arteriovenous fistulas

PURPOSE

Blood flow, pressure and peripheral resistance in patients with established polytetrafluoroethylene (PTFE) grafts and adjunctive arteriovenous fistulas (AVF) have rarely been investigated. To better elucidate the effects of this AVF, we obtained noninvasive measurements of hemodynamic variables in patients with infrapopliteal PTFE grafts and an AVF.

METHODS

. Systolic, mean and diastolic arm and toe pressures were measured with an oscillometric technique employed in automatic blood pressure monitors. Peak-systolic velocity, end-diastolic velocity and flow rates at the graft and recipient distal artery were measured with duplex ultrasound. Resistance for the leg and foot in peripheral resistance units ( PRU ) was estimated as mean arm pressure divided by graft flow rate and as mean toe pressure divided by distal artery flow rate respectively. We analyzed data from 21 patients. Toe pressures were measurable in 13 patients. Bypass graft inflow was at the external iliac artery in 11 patients, common femoral in six, common iliac in two and superficial femoral in two. The distal anastomosis was at the anterior tibial artery in 10 patients, peroneal in seven and posterior tibial in four patients.

RESULTS

. Graft systolic and diastolic velocities were 91+/-46 (mean+/-sd) and 38+/-31 (mean+/-sd) cm/s respectively. Toe systolic pressure averaged 81+/-28 (mean+/-SD) mmHg with a corresponding toe/brachial index (TBI) of 0.53+/-0.18 (mean+/-SD). The ratio between arm mean pressure, 104+/-20 (mean+/-SD) mmHg, and graft flow rate, 413+/-290 (mean+/-sd) ml/min, yielded an estimated leg resistance of 0.32+/-0.20 peripheral resistance units (PRU) (mean+/-sd). The ratio between mean toe pressure, 51+/-21 (mean+/-SD) mmHg, and distal artery flow rate, 37+/-26 (mean+/-SD) ml/min, produced an estimated foot resistance averaging 1.66+/-1.18 PRU (mean+/-sd).

CONCLUSIONS

Average graft flow rate was five times greater than flow reported for standard tibial bypasses. Although distal artery flow rate and graft peak systolic velocity were within reported normal ranges, mean toe pressure and toe-brachial index were below normal. Leg and foot resistances were decreased. These data suggest that bypasses with arteriovenous fistulas have increased flow, desirable for graft patency, but may affect distal perfusion pressure.

Instability of short-sequence DNA repeats of pear pathogenic Erwinia strains from Japan and Erwinia amylovora fruit tree and raspberry strains

An array of short-sequence DNA repeats (SSRs) occurs in the plasmid pEA29 of the fire blight pathogen Erwinia amylovora. A large number of "fruit tree" strains, mainly from Central and Western Europe, were screened for their SSR numbers, and the analyses were extended to five raspberry strains from North America and six pear pathogenic Erwinia strains from Japan. The repeat ATTACAGA present in all E. amylovorastrains was found to be reiterated 3 to 15 times. The Japanese strains contained the major repeat sequence GGATTCTG, which was reiterated 16 to 24 times. ATTACAGG, which resembles the SSR of E. amylovora, was reiterated two or three times. In a novel approach, sequencing gels were used to visualize the rare occurrence of shorter arrays (down to three repeats) in E. amylovoraand the Japanese Erwinia strains. Changes in the repeat numbers in E. amylovora were observed repeatedly when the bacteria had been exposed to stress conditions. The repeat structures of homo- and heteroduplices of PCR-amplified repeats were also analyzed by cleavage of annealed molecules with the single-strand-specific endonuclease from bacteriophage T4. Not only heteroduplexes, but also homoduplexes showed non-matching regions in the SSRs, which could arise from transient formation of loops due to strand slippage during the assays.