A scoring system for grading corkscrew claws in dairy cattle

Corkscrew claw (CC) in dairy cattle is increasingly reported in dairy herds. CC is a progressive deformity of the claw capsule with uncertain aetiology and pathogenesis. Genetics and specific environmental factors are suspected of contributing to the development of this irreversible condition. CC has been found in lame cows; however, the cause and effect has not been established. To perform analysis of risk factors, treatment and pathogenesis, a definition of severity scores is called for. The aim of this study was to measure and analyse CC characteristics from photos of cows' feet to describe and evaluate a scoring system for CC. Width of the visible part of the axial wall, degree of contact between the toe and the floor and angle of the distal part of the abaxial wall as a proxy for the deviation of the abaxial wall was measured from 393 pictures of CC. Based on the measurements on the claws, the parameter "width of the axial wall" was chosen to define the scores. The parameter was divided into three intervals to define either mild CC 0.3-2.0 cm, moderate CC 2.1-3.5 cm or severe CC>3.5 cm and correlation between the parameters; level of contact between the toe and the floor and the angle of the distal abaxial wall was evaluated. There was a significant positive linear correlation between width of the axial wall and angle of the distal part of the abaxial wall (r=0.91), the wider the axial wall, the more the abaxial wall deviated in the distal part. As the width of the axial wall increased the toe increasingly lost contact with the floor, this association was significant for mild CC and moderate CC but not for severe CC. The Interobserver agreement of the CC Scoring system was tested by 30 claw trimmers each scoring 32 cadaver feet and by 2 trained observers on 28 photos of feet using Cohen´s weighted kappa and showed substantial to almost perfect agreement between untrained and trained observers, respectively.

Clinical predictors of donor antibody titre and correlation with recipient antibody response in a COVID-19 convalescent plasma clinical trial

BACKGROUND

Convalescent plasma therapy for COVID-19 relies on transfer of anti-viral antibody from donors to recipients via plasma transfusion. The relationship between clinical characteristics and antibody response to COVID-19 is not well defined. We investigated predictors of convalescent antibody production and quantified recipient antibody response in a convalescent plasma therapy clinical trial.

METHODS

Multivariable analysis of clinical and serological parameters in 103 confirmed COVID-19 convalescent plasma donors 28 days or more following symptom resolution was performed. Mixed-effects regression models with piecewise linear trends were used to characterize serial antibody responses in 10 convalescent plasma recipients with severe COVID-19.

RESULTS

Donor antibody titres ranged from 0 to 1 : 3892 (anti-receptor binding domain (RBD)) and 0 to 1 : 3289 (anti-spike). Higher anti-RBD and anti-spike titres were associated with increased age, hospitalization for COVID-19, fever and absence of myalgia (all P < 0.05). Fatigue was significantly associated with anti-RBD (P = 0.03). In pairwise comparison amongst ABO blood types, AB donors had higher anti-RBD and anti-spike than O donors (P < 0.05). No toxicity was associated with plasma transfusion. Non-ECMO recipient anti-RBD antibody titre increased on average 31% per day during the first three days post-transfusion (P = 0.01) and anti-spike antibody titre by 40.3% (P = 0.02).

CONCLUSION

Advanced age, fever, absence of myalgia, fatigue, blood type and hospitalization were associated with higher convalescent antibody titre to COVID-19. Despite variability in donor titre, 80% of convalescent plasma recipients showed significant increase in antibody levels post-transfusion. A more complete understanding of the dose-response effect of plasma transfusion amongst COVID-19-infected patients is needed.

Forecasting Survival in the Medical Intensive Care Unit: A Comparison of Clinical Prognoses With Formal Estimates

Physicians often need to make prognostic judgments. In the present study, the accuracy was explored of survival estimates for patients in the Medical Intensive Care Unit (MICU). Estimates were made by physicians and nurses several times during each patient’s stay in the MICU and were compared to those of the APACHE II scale, a widely used quantitative index for critically ill patients. ROC curve and calibration curve analyses were performed to assess the accuracy of these estimates. Results revealed that MICU personnel were fairly accurate discriminators of patients who survived vs. who died, although there was a consistent tendency to underestimate survival. In addition, there was some relationship between the level of physician training and forecasting accuracy, but only within the patient’s first 24 hours in the MICU. Finally, the estimates of physicians did not differ significantly from those of the APACHE II scale. Physicians tended to be better calibrated in their predictions, while the APACHE II scale was slightly superior in terms of discrimination.

A Scalable Cyberinfrastructure for Interactive Visualization of Terascale Microscopy Data

The goal of the recently emerged field of connectomics is to generate a wiring diagram of the brain at different scales. To identify brain circuitry, neuroscientists use specialized microscopes to perform multichannel imaging of labeled neurons at a very high resolution. CLARITY tissue clearing allows imaging labeled circuits through entire tissue blocks, without the need for tissue sectioning and section-to-section alignment. Imaging the large and complex non-human primate brain with sufficient resolution to identify and disambiguate between axons, in particular, produces massive data, creating great computational challenges to the study of neural circuits. Researchers require novel software capabilities for compiling, stitching, and visualizing large imagery. In this work, we detail the image acquisition process and a hierarchical streaming platform, ViSUS, that enables interactive visualization of these massive multi-volume datasets using a standard desktop computer. The ViSUS visualization framework has previously been shown to be suitable for 3D combustion simulation, climate simulation and visualization of large scale panoramic images. The platform is organized around a hierarchical cache oblivious data layout, called the IDX file format, which enables interactive visualization and exploration in ViSUS, scaling to the largest 3D images. In this paper we showcase the VISUS framework used in an interactive setting with the microscopy data.

Abstract P5-01-04: uPAR PET imaging in breast cancer: First-in-humans studies using 64Cu-DOTA-AE105 and 68Ga-NOTA-AE105

Objective

The urokinase-type plasminogen activator receptor (uPAR) is a well-established prognostic biomarker in many cancer types including breast cancer (BC). Numerous studies using immunohistochemically evaluation of uPAR expression in tissue samples from BC patients have shown that not only is uPAR consistently overexpressed, but also carries strong prognostic value and is associates with overall survival. Accordingly, uPAR is an obvious target for identifying BC and for phenotyping aggressiveness in BC. Using whole body Positron Emission Tomography (PET) imaging rather than tissue specimens circumvents possible sampling error and allows for staging. Our objective was therefore to perform first-in-humans studies of uPAR-specific PET imaging in BC using either 64Cu-DOTA-AE105 or 68Ga-NOTA-AE105

Methods

Six patients with BC and scheduled for surgery were included. Prior to operation, patients were either PET/CT scanned 1, 3 and 24 h after injection of the uPAR PET ligand 64Cu-DOTA-AE105 (n=3; half life of 64Cu: 13 h) or PET/CT scanned 10 min, 1 h or 2 h after injection of 68Ga-NOTA-AE105 (n=3; half life of 68Ga: 1 h). PET Images were visually analyzed for visible tumor uptake of 64Cu-DOTA-AE105 or 68Ga-NOTA-AE105 and Standardized Uptake Values (SUV) were obtained by manually drawing volumes of interest (VOIs) around the primary tumor as well as identified metastases. Results are given as SUVmax. Tumor-to-background ratios relative to liver, kidney, blood and muscle were also calculated. Surgical tumor specimens were obtained from all patients during subsequent surgery. In addition to routine pathological examination, tissue was analyzed for ex vivo uPAR expression as target validation.

Results

Both primary tumors and metastases were visually detectable. For 64Cu-DOTA-AE105 SUVmax values were 2.9–4.0., and 2.9-4.0 after 1 and 3 h, respectively. Tumor-to-background ratios after 1 h were 0.91 (tumor-liver), 1.65 (tumor-kidney), 0.96 (tumor-blood) and 8.9 (tumor-muscle), respectively. Tumor-to-background ratios after 3 h were 0.50 (tumor-liver), 0.96 (tumor-kidney), 4.2 (tumor-blood) and 11.4 (tumor-muscle), respectively. Ex vivo analysis by immunohistochemistry confirmed uPAR expression in all primary cancer lesions. For 68Ga-NOTA-AE105, SUVmax was 5.0, 3.8 and 4.2 after 10 min, 1 h and 3 h, respectively (first patient analyzed). Tumor-to-background ratios after 10 min were 2.8 (tumor-liver), 0.4 (tumor-kidney), 1.6 (tumor-blood) and 8.4 (tumor-muscle), respectively. Tumor-to-background ratios after 1 h were 3.2 (tumor-liver), 0.6 (tumor-kidney), 1.7 (tumor-blood) and 7.1 (tumor-muscle), respectively.

Conclusion

This is the first study in humans using PET imaging of uPAR in BC. Both primary tumors and metastases were clearly visible with robust PET tracer uptake and a high and sufficient contrast between tumors and background. Our data supports continuation into phase II clinical studies using uPAR PET for staging and risk stratification, which potentially may be used for selection of treatment strategy in BC.

Citation Format: Kjaer A, Persson M, Skovgaard D, Brandt-Larsen M, Christensen C, Madsen J, Nielsen CH, Loft A, Berthelsen AK, Kroman N, Højgaard L. uPAR PET imaging in breast cancer: First-in-humans studies using 64Cu-DOTA-AE105 and 68Ga-NOTA-AE105. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-01-04.

Exome sequencing-driven discovery of coding polymorphisms associated with common metabolic phenotypes

AIMS/HYPOTHESIS

Human complex metabolic traits are in part regulated by genetic determinants. Here we applied exome sequencing to identify novel associations of coding polymorphisms at minor allele frequencies (MAFs) >1% with common metabolic phenotypes.

METHODS

The study comprised three stages. We performed medium-depth (8×) whole exome sequencing in 1,000 cases with type 2 diabetes, BMI >27.5 kg/m(2) and hypertension and in 1,000 controls (stage 1). We selected 16,192 polymorphisms nominally associated (p < 0.05) with case-control status, from four selected annotation categories or from loci reported to associate with metabolic traits. These variants were genotyped in 15,989 Danes to search for association with 12 metabolic phenotypes (stage 2). In stage 3, polymorphisms showing potential associations were genotyped in a further 63,896 Europeans.

RESULTS

Exome sequencing identified 70,182 polymorphisms with MAF >1%. In stage 2 we identified 51 potential associations with one or more of eight metabolic phenotypes covered by 45 unique polymorphisms. In meta-analyses of stage 2 and stage 3 results, we demonstrated robust associations for coding polymorphisms in CD300LG (fasting HDL-cholesterol: MAF 3.5%, p = 8.5 × 10(-14)), COBLL1 (type 2 diabetes: MAF 12.5%, OR 0.88, p = 1.2 × 10(-11)) and MACF1 (type 2 diabetes: MAF 23.4%, OR 1.10, p = 8.2 × 10(-10)).

CONCLUSIONS/INTERPRETATION

We applied exome sequencing as a basis for finding genetic determinants of metabolic traits and show the existence of low-frequency and common coding polymorphisms with impact on common metabolic traits. Based on our study, coding polymorphisms with MAF above 1% do not seem to have particularly high effect sizes on the measured metabolic traits.

PageRank and rank-reversal dependence on the damping factor

PageRank (PR) is an algorithm originally developed by Google to evaluate the importance of web pages. Considering how deeply rooted Google's PR algorithm is to gathering relevant information or to the success of modern businesses, the question of rank stability and choice of the damping factor (a parameter in the algorithm) is clearly important. We investigate PR as a function of the damping factor d on a network obtained from a domain of the World Wide Web, finding that rank reversal happens frequently over a broad range of PR (and of d). We use three different correlation measures, Pearson, Spearman, and Kendall, to study rank reversal as d changes, and we show that the correlation of PR vectors drops rapidly as d changes from its frequently cited value, d_{0}=0.85. Rank reversal is also observed by measuring the Spearman and Kendall rank correlation, which evaluate relative ranks rather than absolute PR. Rank reversal happens not only in directed networks containing rank sinks but also in a single strongly connected component, which by definition does not contain any sinks. We relate rank reversals to rank pockets and bottlenecks in the directed network structure. For the network studied, the relative rank is more stable by our measures around d=0.65 than at d=d_{0}.

Sampling properties of directed networks

For many real-world networks only a small "sampled" version of the original network may be investigated; those results are then used to draw conclusions about the actual system. Variants of breadth-first search (BFS) sampling, which are based on epidemic processes, are widely used. Although it is well established that BFS sampling fails, in most cases, to capture the IN component(s) of directed networks, a description of the effects of BFS sampling on other topological properties is all but absent from the literature. To systematically study the effects of sampling biases on directed networks, we compare BFS sampling to random sampling on complete large-scale directed networks. We present new results and a thorough analysis of the topological properties of seven complete directed networks (prior to sampling), including three versions of Wikipedia, three different sources of sampled World Wide Web data, and an Internet-based social network. We detail the differences that sampling method and coverage can make to the structural properties of sampled versions of these seven networks. Most notably, we find that sampling method and coverage affect both the bow-tie structure and the number and structure of strongly connected components in sampled networks. In addition, at a low sampling coverage (i.e., less than 40%), the values of average degree, variance of out-degree, degree autocorrelation, and link reciprocity are overestimated by 30% or more in BFS-sampled networks and only attain values within 10% of the corresponding values in the complete networks when sampling coverage is in excess of 65%. These results may cause us to rethink what we know about the structure, function, and evolution of real-world directed networks.

Unusual manifestation of Langerhans' cell histiocytosis

An unusual manifestation of the disease Langerhans' cell histiocytosis (LHC) is presented. An 18-year-old man was admitted to the Department of Dermatology after he had been suffering for some time from affections of the skin in the scalp and perianal region which were resistant to treatment. Shortly after LHC was diagnosed, he developed spontaneous bilateral pneumothorax. In his past life he had been without cardiopulmonary complaints. In addition to this, he developed a diabetes insipidus, originating in connexion with the present disease. The combination of skin affection in the perianal region, spontaneous bilateral pneumothorax and diabetes insipidus in relation to LHC has not been described previously.

Clinical significance of elevated alpha-fetoprotein in Alaskan Native patients with chronic hepatitis C

The clinical significance of elevated serum alpha-fetoprotein (AFP) in patients with chronic hepatitis C virus (HCV) infection is not well defined. We analysed data from a population-based cohort of patients with HCV infection to assess the prevalence of elevated serum AFP, to determine its association with clinical and virologic parameters and with clinical outcomes. We defined a slightly elevated serum AFP level as 8 to <15 and a high-AFP level as > or =15 microg/L. Among 541 HCV-RNA-positive persons, 61 (11%) had a slightly elevated or high AFP at the time of consent. AFP > or =8 microg/L was associated with the older age, aspartate aminotransferase/alanine aminotransferase ratio >1, and higher alkaline phosphatase levels, but not with heavy alcohol use, IV drug use, genotype, viral load or duration of HCV infection. Among 192 persons with an AFP at liver biopsy, 17% had an AFP > or =8 microg/L. The sensitivity/specificity of an AFP level > or =8 in detecting Ishak 3-6 fibrosis was 39%/95%. Among 372 persons with a minimum of four AFP measurements over 6 years, 5% had persistently elevated AFP >8 microg/L, 19% had both elevated and normal AFP measurements, and 76% had persistently normal AFP. Elevated AFP at consent was associated with hepatocellular carcinoma (HCC) and end-stage liver disease. Over 6 years of follow-up, persistently elevated AFP was associated with the development of HCC; no person with AFP persistently <8 microg/mL developed HCC. Serial AFP measurements appear to be useful in identifying persons with advanced fibrosis and help to determine who needs periodic screening with liver ultrasound to detect HCC.

Systems-level insights into cellular regulation: inferring, analysing, and modelling intracellular networks

Genes and gene products interact on several levels, forming transcriptional regulatory-, protein interaction-, metabolic- and signal transduction networks. Genetic, biochemical and molecular biology techniques have been used for decades to identify biological interactions; newly developed high-throughput methods now allow for the construction of genome-level interaction maps. In parallel, high-throughput expression data paired with computational algorithms can be used to infer networks of interactions and causal relationships capable of producing the observed experimental data. Graph-theoretical measures and network models are more and more frequently used to discern functional and evolutionary constraints in the organisation of biological networks. Perhaps most importantly, the combination of interaction and expression information allows the formulation of quantitative and predictive dynamic models. Some of the dominant experimental and computational methods used for the reconstruction or inference of cellular networks are reviewed, also the biological insights that have been obtained from graph-theoretical analysis of these networks, and the extension of static networks into various dynamic models capable of providing a new layer of insight into the functioning of cellular systems is discussed.

Phototoxic reaction and porphyrin fluorescence in skin after topical application of methyl aminolaevulinate

BACKGROUND

Photodynamic therapy using topical methyl aminolaevulinate (MAL) is a new treatment modality for skin disorders. MAL is metabolized into endogenous porphyrins, which act as photosensitizers when illuminated.

OBJECTIVES

To evaluate the severity and duration of skin photosensitivity after MAL application, and to investigate its relation to the presence of endogenous porphyrins.

METHODS

Placebo and 160 mg g(-1) MAL creams were randomly assigned to contralateral sites located at the forearms and fingertips of 16 healthy volunteers and were applied for 3 h. The porphyrin content in the skin was monitored by in situ fluorescence measurements following cream removal. Phototoxic reaction was evaluated after exposure to a high dose of red light.

RESULTS

The porphyrin fluorescence in forearm skin peaked about 1 h after the cream removal, was halved after 8 h, and was reduced by > 90% within 24 h. Most forearm sites were photosensitive at 1 and 8 h following cream removal. Six subjects were still sensitive at 24 h, and at this time point the phototoxicity was coincidental with residual porphyrin fluorescence. In general, all reactions were mild or moderate, and included pain, erythema, oedema and transient hyperpigmentation. No photosensitivity or porphyrin fluorescence was detected at 48 h. At the fingertips photosensitivity was absent except for sporadic cases of mild pain.

CONCLUSIONS

Topical MAL application and exposure to red light induced mild and moderate phototoxicity. The photosensitivity ceased within 24-48 h after cream removal, and its duration was associated with the degradation of porphyrins.

Diagnostic accuracy of a fibrosis serum panel (FIBROSpect II) compared with Knodell and Ishak liver biopsy scores in chronic hepatitis C patients

Liver biopsy is the primary method of assessing liver injury in hepatitis C patients. FIBROSpect II (FS), a diagnostic panel of three extracellular matrix remodelling markers, may be useful as a noninvasive alternative to this procedure. The purpose of this study was to correlate FS results with liver fibrosis scores to determine if this test is sufficiently accurate to be a viable alternative to liver biopsy. A total of 142 serum specimens were evaluated for fibrosis with FS and were compared with Knodell and Ishak fibrosis scores. FS reports an index score ranging from 0.1 to 1.0, which corresponds to the probability of progressive liver fibrosis. Using a FS index cut-off of 0.42, 50 of 54 patients with Ishak 3-6 were classified as having advanced fibrosis (METAVIR F2-F4) and 58 of 88 patients with Ishak 0-2 as having no/mild fibrosis (METAVIR F0-F1), resulting in a sensitivity of 93%, specificity of 66%, and an overall test accuracy of 76%. With a 38% prevalence of advanced fibrosis, the negative predictive value was 94% and positive predictive value was 63%. A biopsy length of > or = 2 cm was associated with higher concordance between FS results and liver fibrosis scores (P = 0.01). FS was clinically useful in ruling out advanced fibrosis in hepatitis C by identifying patients with mild disease in whom treatment could be deferred. The limitation of this test is its decreased sensitivity and specificity in the middle of the test's reporting range between scores of 0.42 and 0.80.

Uncertainty in predictions of the climate response to rising levels of greenhouse gases

The range of possibilities for future climate evolution needs to be taken into account when planning climate change mitigation and adaptation strategies. This requires ensembles of multi-decadal simulations to assess both chaotic climate variability and model response uncertainty. Statistical estimates of model response uncertainty, based on observations of recent climate change, admit climate sensitivities--defined as the equilibrium response of global mean temperature to doubling levels of atmospheric carbon dioxide--substantially greater than 5 K. But such strong responses are not used in ranges for future climate change because they have not been seen in general circulation models. Here we present results from the 'climateprediction.net' experiment, the first multi-thousand-member grand ensemble of simulations using a general circulation model and thereby explicitly resolving regional details. We find model versions as realistic as other state-of-the-art climate models but with climate sensitivities ranging from less than 2 K to more than 11 K. Models with such extreme sensitivities are critical for the study of the full range of possible responses of the climate system to rising greenhouse gas levels, and for assessing the risks associated with specific targets for stabilizing these levels.

Catalyhtic asymmetric Henry reactions--a simple approach to optically active beta-nitro alpha-hydroxy esters

The development and potential of a catalytic enantioselective Henry reaction of nitromethane with various alpha-keto esters catalyzed by chiral bisoxazoline-copper(II) complexes are presented.

The metastasis-associated Mts1(S100A4) protein could act as an angiogenic factor

The involvement of Mts1(S100A4), a small Ca(2+)-binding protein in tumor progression and metastasis had been demonstrated. However, the mechanism by which mts1(S100A4) promoted metastasis had not been identified. Here we demonstrated that Mts1(S100A4) had significant stimulatory effect on the angiogenesis. We detected high incidence of hemangiomas--benign tumors of vascular origin in aged transgenic mice ubiquitously expressing the mts1(S100A4) gene. Furthermore, the serum level of the Mts1(S100A4) protein increased with ageing. Tumors developed in Mts1-transgenic mice revealed an enhanced vascular density. We showed that an oligomeric, but not a dimeric form of the Mts1(S100A4) protein was capable of enhancing the endothelial cell motility in vitro and stimulate the corneal neovascularization in vivo. An oligomeric fraction of the protein was detected in the conditioned media as well as in human serum. The data obtained allowed us to conclude that mts1(S100A4) might induce tumor progression via stimulation of angiogenesis.

Weight training injury trends: a 20-year survey

Weight training is a popular activity, but injuries can be a consequence. Research has documented the types and venues of weight training injuries.

OBJECTIVE

The objective of this study was to identify weight lifting injury trends.

DESIGN

A retrospective review of data from US emergency departments (EDs) that reported injuries from weight training and weight training equipment. The data include people who were treated for injuries from weight training or weight equipment from October 1, 1978, through December 31, 1998, and were identified by the National Electronic Injury Surveillance System (NEISS).

RESULTS

NEISS identified 20,489 weight training-related injuries. An estimated 980,173 persons were treated in EDs for injuries related to weight training activity or equipment during the study period. The number of ED-treated injuries has increased 35% since 1978. About one of four injuries occurred from the misuse or abuse of weight training equipment.

CONCLUSION

Cautionary messages should be aimed at young children, older adults, and users of home gyms. Those who train with weights should be instructed in the proper use of weight equipment.

Hepatitis A vaccine administration: comparison between jet-injector and needle injection

INTRODUCTION

Type A hepatitis virus (HAV) is a serious health problem throughout the world and can be spread via fecal-oral contact. Both immune globulin and an HAV vaccine provide protection, but the vaccine gives complete protection. Efficacy of methods of vaccination in relation to the formation of anti-HAV antibodies is unclear; thus, this study seeks to determine if significant differences exist between the syringe as compared to the jet injection technique. The purpose of this study was to compare in a randomized trial Biojet jet-injection system to a needle-syringe method. To determine if a significant difference between these two methods in seroconversion rates or geometric mean titers of anti HAV antibody occurs at day 15, 30, and 210 days after vaccination.

METHOD

Anti-HAV IgG(-) adult hospital employees were randomized to receive 1440 EL.U of hepatitis a vaccine (HAVRIX(R)) in 2 doses by either needle or jet-injector (Biojector(R)) system at month 0 and 6. HAV seroconversion titer results were measured by the Boehringer-Mannheim method.

RESULTS/DISCUSSION

A higher proportion of persons who received HAV vaccine via the Biojector(R) seroconverted with anti-HAV level >/=20 mIU at day 15, 30, and month 7 when compared with a needle injection.Side-effect profiles reported by participants in both methods were below those identified in current published and insert information, but the Biojector(R) had greater local reactivity in all categories when compared to the needle method.

Decision making of clinical teams: communication patterns and diagnostic error

This study examined the discussion of information among mixed-status clinical teams while constructing differential diagnoses. Twenty-four ad hoc teams, each consisting of a resident, an intern, and a third-year medical student, were given two hypothetical patient cases to discuss and diagnose. Prior to discussion, team members individually viewed different versions of a videotaped interview with a "patient" (trained actor). Each videotape contained some information that was present in all three versions (shared information) and some that was present in only that version (unique information). In addition, half of the time, the cases were constructed so that the unique information that appeared in only one tape was crucial for a correct diagnosis (a "hidden profile" condition). After viewing the videotapes, team members met to discuss the case and develop a differential diagnosis. Discussions were videotaped and analyzed. Overall, shared information was mentioned more often than unique information (p < 0.0001). Furthermore, teams offered incorrect diagnoses significantly more often for hidden-profile cases than for control cases (p < 0.01). The teams' overreliance on previously shared information (inability to appropriately utilize unique information) was detrimental when a correct diagnosis demanded the inclusion of such information. Clinical discussions that require the consideration of uniquely held information may be susceptible to error.

Effects of prognosis, perceived benefit, and decision style on decision making and critical care on decision making in critical care

OBJECTIVE

To assess the effects of prognostic estimates, perceived benefit of treatment, and practice style on decision-making in critical care.

DESIGN

Randomized assignment of subjects to either of two versions of a questionnaire designed to elicit treatment decisions for six intensive care unit cases based on actual patients. One version offered optimistic survival forecasts; the other, pessimistic forecasts.

SUBJECTS

A random sample of 120 clinicians obtained from the Canadian Critical Care Society was contacted by mail. One version of the questionnaire was randomly assigned and mailed to each. Thirty-four replies, 17 for each version (response rate, 28%), were received and analyzed.

MEASUREMENTS AND MAIN RESULTS

A list of treatment/management options was developed for each case, in three categories: recommended, questionable, and unacceptable. Subjects were also able to list new options that they would order that were not on the list. The dependent variables were the number of actions ordered in each category and the total for each case. Perceived benefit was measured by comparing subjective estimates of the probability of survival with the optimistic/pessimistic forecast given in the case. Practice style was assessed by correlating the total number of actions ordered across all possible pairs of cases. There were no significant differences between the two questionnaires on actions ordered either by category or by amount per category. Perceived benefit did not appear to be an important factor in decision-making. However, statistically significant correlations provide evidence for practice style in intensive care unit decision-making on an interventionist/noninterventionist dimension.

CONCLUSIONS

There is no evidence that erroneous or biased prognostic estimates affect intensive care unit treatment choices. Neither the principle of maximizing expected utility nor the Rule of Rescue appear to affect these decisions systematically, but practice style does.

Diagnosing groups: the pooling, management, and impact of shared and unshared case information in team-based medical decision making

The impact of group discussion on the decision-making effectiveness of medical teams was examined. Three-person teams of physicians diagnosed 2 hypothetical medical cases. Some of the information about each case was given to all team members prior to discussion (shared information), whereas the rest was divided among them (unshared information). Compared with unshared information, shared information was more likely to be pooled during discussion and was pooled earlier. In addition, team leaders were consistently more likely than other members to ask questions and to repeat shared information and, over time, also became more likely than others to repeat unshared information. Finally, pooling unshared (but not shared) information improved the overall accuracy of the team diagnoses, whereas repeating both shared and unshared information affected bias (but not accuracy) in the diagnoses.

Diagnosing groups: the pooling, management, and impact of shared and unshared case information in team-based medical decision making

The impact of group discussion on the decision-making effectiveness of medical teams was examined. Three-person teams of physicians diagnosed 2 hypothetical medical cases. Some of the information about each case was given to all team members prior to discussion (shared information), whereas the rest was divided among them (unshared information). Compared with unshared information, shared information was more likely to be pooled during discussion and was pooled earlier. In addition, team leaders were consistently more likely than other members to ask questions and to repeat shared information and, over time, also became more likely than others to repeat unshared information. Finally, pooling unshared (but not shared) information improved the overall accuracy of the team diagnoses, whereas repeating both shared and unshared information affected bias (but not accuracy) in the diagnoses.

Radiation therapy for endometrial cancer in patients treated for postoperative recurrence

PURPOSE

To retrospectively evaluate the outcome and risk factors in patients treated with radiation for endometrial cancer at time of recurrence.

MATERIALS AND METHODS

Three hundred ninety-nine women were treated with radiation therapy for endometrial cancer at KCI/WSU from January 1980 to December 1994. Of these, 26 patients treated primarily with surgery received radiation therapy at the time of recurrence. Median time to recurrence after surgery was 8 months, with all recurrences occurring within 24 months. Twenty-four patients had recurrences in the vaginal cuff, vagina, or pelvis. These patients received external-beam radiation to the pelvis (45.00-50.40 Gy) and periaortic lymph nodes (45.00-50.00 Gy), along with a boost given by external-beam radiation or brachytherapy (16.00-30.00 Gy). Mean follow-up was 15 months (range 1-85 months).

RESULTS

The 2-year survival was 50% and median survival was 16 months (survival range 1-85 months). Of 26 patients, 54% (14) failed locally following radiation therapy. Factors indicative of poor survival included histology (sarcoma, poorly differentiated adenocarcinoma), grade, and lymph node positivity. Histological differentiation influenced local control; lymphovascular space invasion was of borderline significance with regard to local control.

CONCLUSION

Local control and survival for surgically treated endometrial cancer patients who receive radiation at the time of recurrence are poor, with the exception of those patients with recurrent disease limited to the vagina. Early detection of recurrence may improve outcome. Pathologic risk factors may identify those patients at risk for extrapelvic recurrence. Alternative treatment modalities need to be developed for this high-risk group of patients.

Postoperative radiation for cervical cancer with pathologic risk factors

PURPOSE

To examine the efficacy of postoperative radiation therapy for early-stage cervical cancer with pathologic risk factors.

METHODS AND MATERIALS

We reviewed the charts of 83 patients who received postoperative radiation therapy at our facility from March 1980 to November 1993 for early stage cervix cancer with positive surgical margins, positive pelvic or periaortic lymph nodes, lymphovascular space invasion, deep invasion, or for disease discovered incidently at simple hysterectomy. Twenty-eight patients received low dose rate (LDR) intracavitary radiation with or without external beam pelvic irradiation and 55 patients received external beam pelvic irradiation with high dose rate (HDR) intracavitary implants. Of these 83 patients, 66 were evaluable--20 LDR and 46 HDR patients. All patients received 45-50 Gy external beam irradiation and 20 Gy LDR equivalent intracavitary irradiation prescribed to 0.5 cm below the mucosa. Ninety percent of the LDR group and 92% of the HDR group completed treatment within < 56 days. Treatment-related toxicities were scored according to the GOG toxicity scale. Mean and median follow-up times were 101 months and 111 months (3-172 months) for the LDR group and 42 and 40 months (3-98 months) for the HDR group.

RESULTS

The 5-year disease-free survival was 89% for the LDR group and 72% for the HDR group. Local control was observed in 90% (18 out of 20) of the LDR patients and 89% (41 out of 46) of the HDR patients for an overall local control rate of 89.5%. Two of 20 LDR patients (10%) experienced recurrence (two pelvic with distant metastasis). Nine of 46 HDR patients (22%) had recurrence of disease (three pelvic, four distant metastasis, and two pelvic with distant metastasis). In the HDR group, 6 out of 16 (38%) with positive lymph nodes died of disease whereas, 27 out of 30 (90%) of the patients with negative lymph nodes remain free of disease. Three of 20 (15%) LDR patients and 4 out of 46 (9%) HDR patients experienced Grade 2 or 3 late treatment- related complications. No patient in either group had Grade 4 or 5 complications. Pathologic risk factors were analyzed. Lymph node positivity and lymphovascular space invasion were found to be significant (p = 0.01 and p = 0.02). Positive margins, deep invasion, and age were not significant.

CONCLUSION

Our results demonstrate the efficacy of postoperative irradiation for cervical cancer with pathologic risk factors. Overall, the local control rate was 89.5% The HDR results demonstrate that this method can be delivered safely and effectively.

Paclitaxel-induced apoptosis in MCF-7 breast-cancer cells

A study of MCF-7 human breast cancer cells was undertaken to ascertain the degree of apoptosis induction by paclitaxel and if the induction of apoptosis could be enhanced by caffeine. Paclitaxel (0-20 ng/ml) caused concentration-dependent increases in morphologically identifiable apoptotic cells (up to 43% of cell population) and cells with DNA strand breaks (up to 38%), a commonly cited marker of apoptosis. Maximal DNA strand breakage occurred after 16 hr of exposure to paclitaxel and maximal apoptotic-appearing cells occurred after 24 hr. The remaining non-apoptotic paclitaxel-exposed cells were growth arrested in G2. A 4-hr exposure to caffeine concentration-dependently (0-20 mM) increased apoptosis to 88% of the cell population. Our results show induction of apoptosis in breast cancer cells by paclitaxel, and enhancement of this process by caffeine.

Diagnosing groups: charting the flow of information in medical decision-making teams

Several hypotheses derived from an information sampling model of group discussion were tested with 3-person teams of physicians given 2 hypothetical medical cases to diagnose. Some of the information about each case was given to all 3 team members before discussion (shared information), whereas the rest was divided among them (unshared information). As predicted, shared information was, overall, more likely to be discussed than unshared information, and it was brought into discussion earlier. In addition, it was found that team leaders repeated substantially more case information than did other members and that, over time, they repeated unshared information at a steadily increasing rate. The latter findings are interpreted as evidence of leaders' information management role in problem-solving discussions.

Multifractionated high-dose-rate brachytherapy with concomitant daily teletherapy for cervical cancer

BACKGROUND

High-dose-rate (HDR) brachytherapy has been the preferred treatment for cervical cancer at Wayne State University since 1987. The outcome of the first 105 patients treated is analyzed.

PURPOSE

To determine clinical efficacy of the HDR modality.

METHODS

We reviewed 105 patients and evaluated the 88 patients treated for cervical carcinoma with HDR and external beam radiotherapy (EBRT) from August 1987 to December 1992. Patients received initial external radiation to the pelvis (total dose of 19.8 to 39.6 Gy in 11 to 22 fractions), followed by outpatient HDR brachytherapy (3 fractions/week, 386 cGy/fraction to Point A, total of 8 to 12 fractions) and concurrent daily EBRT (1.8 to 2.0 Gy) to lateral parametria. During the HDR period of treatment, step wedge transmission blocks were used to shield central pelvic tissue while treating peripheral pelvic tissues with EBRT. Patient distributions were as follows: 25, IB/IIA; 35, IIB/IIIA; and 28, IIIB/IVA. There were 56 African American and 32 Caucasian patients with mean age of 55 (range 19-89). The median follow-up was 33 months (range 20 to 76 months). Kaplan-Meier analysis was performed.

RESULTS

Three-year survival rates were 88%, IB/IIA; 69%, IIB/IIIA; 56%, IIIB/IVA; and 72% overall. Local control was achieved in 71/88 (80%) of patients. Failure site was cervix or within the pelvis in 12 patients, distant metastasis only 17 patients, and combined local and distant in 5 patients. Of the failures, 82% (28/34) died within 2 years. There were 3 grade III/complications (3.4%).

CONCLUSION

Results compare favorably with previous LDR experience.

Diagnosing groups: charting the flow of information in medical decision-making teams

Several hypotheses derived from an information sampling model of group discussion were tested with 3-person teams of physicians given 2 hypothetical medical cases to diagnose. Some of the information about each case was given to all 3 team members before discussion (shared information), whereas the rest was divided among them (unshared information). As predicted, shared information was, overall, more likely to be discussed than unshared information, and it was brought into discussion earlier. In addition, it was found that team leaders repeated substantially more case information than did other members and that, over time, they repeated unshared information at a steadily increasing rate. The latter findings are interpreted as evidence of leaders' information management role in problem-solving discussions.

Aphthous vaginal ulceration in two women with acquired immunodeficiency syndrome

Two women with advanced human immunodeficiency virus infection are described who were seen with painful aphthous vaginal ulceration and CD4+ lymphocyte counts < 50 cells/mm3. A chronic rectovaginal fistula developed in one patient. In spite of extensive investigation no underlying cause of the ulceration was discovered. Clinical therapeutic response suggests that corticosteroid therapy may be of value in healing or stabilizing the destructive process. Clinicians should be aware of this complication in human immunodeficiency virus-infected women with severe vaginal pain and unexplained discharge.

Influence of parboiling and physico-chemical characteristics of rice on the glycaemic index in non-insulin-dependent diabetic subjects

OBJECTIVE

To study the influence of parboiling, amylose content and gelatinisation temperature of rice on the postprandial blood glucose and insulin responses in non-insulin-dependent diabetic (NIDDM) subjects.

DESIGN AND SUBJECTS

Twelve NIDDM subjects ingested high (27%) and low amylose content five test meals of 50 g available carbohydrates as white bread, cooked polished rice with high (27%) and low amylose content (12%) with different gelatinisation temperature and as nonparboiled and parboiled. The meals were taken in random order after a 12h fast with approximately 7 days interval.

RESULTS

The glycaemic indices (GI) of all rice varieties were lower than that of white bread (P <0.001). Furthermore, GI of parboiled rice with a high amylose content was lower than that of parboiled rice with a low amylose content (50 +/- 7 vs 73 +/- 7, P <0.01). No differences were 47 +/- 4, n.s.), nor between non-parboiled and parboiled rice (50 +/- 7 vs 53 +/- 7, n.s.). Insulin responses to the five test meals were not significantly different in the NIDDM subjects.

CONCLUSIONS

In NIDDM subjects the investigated rices were all low glycaemic as compared to white bread,independent of parboiling and physico-chemical characteristics. The mildparboiling process used did not influence GI. The study showed that the amylose content, but not the gelatinisation temperature, may be an useful criterion in selection of low GI rices also after parboiling.

Inhibition of breast and ovarian carcinoma cell growth by 1,25-dihydroxyvitamin D3 combined with retinoic acid or dexamethasone

This study examined the growth inhibitory effects of combining 1,25-dihydroxyvitamin D3 (calcitriol) with retinoic acid or dexamethasone against cultured breast and ovarian carcinoma cells. Retinoic acid (12.5-50 nM) increased the effectiveness of calcitriol (12.5-50 nM) against MCF-7 and NIH:OVCAR3 cells, with synergistic interactions at two of the three ratios tested. Dexamethasone augmented calcitriol effects, with synergism at 0.05 and 0.1 nM dexamethasone in MCF-7 cells and 5 nM in Caov-4 ovarian cells. This study showed favorable interactions for calcitriol-retinoic acid and calcitriol-dexamethasone combinations in breast and ovarian cancer cell lines.

Cloning and characterization of a protective outer membrane lipoprotein of Actinobacillus pleuropneumoniae serotype 5

The gene encoding an outer membrane lipoprotein (omlA) of Actinobacillus pleuropneumoniae serotype 5 was cloned, and the protein was expressed in Escherichia coli. One open reading frame of 1,104 bp was detected that encoded a protein (OmlA) with a predicted molecular mass of 40 kDa. A comparison with the omlA gene and the corresponding protein of A. pleuropneumoniae serotype 1 (G.-F. Gerlach, C. Anderson, S. Klashinsky, A. Rossi-Kampos, A.A. Potter, and P.J. Wilson, Infect. Immun. 61:565-572, 1993) revealed that the nucleic acid sequences had an overall sequence identity of 62.9% and the deduced amino acid sequences showed a sequence agreement of 57.3%. Both proteins were antigenically distinct. In a Western blot (immunoblot) analysis using a specific antiserum against A. pleuropneumoniae serotype 5 OmlA, a homologous protein was detected in the reference strains of A. pleuropneumoniae serotypes 5A, 5B, and 10. Pigs immunized with this recombinant protein were protected from death in an aerosol challenge experiment with an A. pleuropneumoniae serotype 5 isolate.