Neuroimaging of complications arising after CD19 chimeric antigen receptor T-cell therapy: A review

Chimeric antigen receptor (CAR) T cells targeting the CD19 (cluster of differentiation 19) cell surface glycoprotein have emerged as a highly effective immunologic therapy in patients with relapsed or refractory B-cell malignancies. The engagement of CAR T cells with CD19 on the surface of neoplastic B cells causes a systemic cytokine release, which can compromise the blood-brain barrier and cause an immune effector cell-associated neurotoxicity syndrome (ICANS). In a small proportion of ICANS patients who demonstrate neuroimaging abnormalities, certain distinct patterns have been recognized, including signal changes in the thalami, external capsule, and brainstem, the subcortical and/or periventricular white matter, the splenium of the corpus callosum, and the cerebellum. On careful review of the underlying pathophysiology of ICANS, we noticed that these changes closely mirror the underlying blood-brain barrier disruption and neuroinflammatory and excitotoxic effects of the offending cytokines released during ICANS. Furthermore, other uncommon complications of CD19 CAR T-cell therapy such as posterior reversible encephalopathy syndrome, ocular complications, and opportunistic fungal infections can be catastrophic if not diagnosed in a timely manner, with neuroimaging playing a significant role in management. In this narrative review, we will summarize the current literature on the spectrum of neuroimaging findings in ICANS, list appropriate differential diagnoses, and explore the imaging features of other uncommon central nervous system complications of CD19 CAR T-cell therapy using illustrative cases from two tertiary care institutions.

Nicotinamide Adenine Dinucleotide Augmentation in Overweight or Obese Middle-Aged and Older Adults: A Physiologic Study

CONTEXT

Nicotinamide adenine dinucleotide (NAD) levels decline with aging and age-related decline in NAD has been postulated to contribute to age-related diseases.

OBJECTIVE

We evaluated the safety and physiologic effects of NAD augmentation by administering its precursor, β-nicotinamide mononucleotide (MIB-626, Metro International Biotech, Worcester, MA), in adults at risk for age-related conditions.

METHODS

Thirty overweight or obese adults, ≥ 45 years, were randomized in a 2:1 ratio to 2 MIB-626 tablets each containing 500 mg of microcrystalline β-nicotinamide mononucleotide or placebo twice daily for 28 days. Study outcomes included safety; NAD and its metabolome; body weight; liver, muscle, and intra-abdominal fat; insulin sensitivity; blood pressure; lipids; physical performance, and muscle bioenergetics.

RESULTS

Adverse events were similar between groups. MIB-626 treatment substantially increased circulating concentrations of NAD and its metabolites. Body weight (difference -1.9 [-3.3, -0.5] kg, P = .008); diastolic blood pressure (difference -7.01 [-13.44, -0.59] mmHg, P = .034); total cholesterol (difference -26.89 [-44.34, -9.44] mg/dL, P = .004), low-density lipoprotein (LDL) cholesterol (-18.73 [-31.85, -5.60] mg/dL, P = .007), and nonhigh-density lipoprotein cholesterol decreased significantly more in the MIB-626 group than placebo. Changes in muscle strength, muscle fatigability, aerobic capacity, and stair-climbing power did not differ significantly between groups. Insulin sensitivity and hepatic and intra-abdominal fat did not change in either group.

CONCLUSIONS

MIB-626 administration in overweight or obese, middle-aged and older adults safely increased circulating NAD levels, and significantly reduced total LDL and non-HDL cholesterol, body weight, and diastolic blood pressure. These data provide the rationale for larger trials to assess the efficacy of NAD augmentation in improving cardiometabolic outcomes in older adults.

Pediatric diencephalic tumors: a constellation of entities and management modalities

The diencephalon is a complex midline structure consisting of the hypothalamus, neurohypophysis, subthalamus, thalamus, epithalamus, and pineal body. Tumors arising from each of these diencephalic components differ significantly in terms of biology and prognosis. The aim of this comprehensive review is to describe the epidemiology, clinical symptoms, imaging, histology, and molecular markers in the context of the 2021 WHO classification of central nervous system neoplasms. We will also discuss the current management of each of these tumors.

Electric scooter sharing systems: An analysis of injury patterns associated with their introduction

BACKGROUND

With the increasing popularity of electric scooters (ES) and the introduction of ES sharing systems in 2017, hospitals are seeing more ES-related injuries. The effects of sharing systems on traumatic injuries are lacking in the literature. We, therefore, sought to describe trends in ES injuries.

METHODS

The Nationwide Inpatient Sample was queried for patients hospitalized with ES-related injuries in the United States from 2015 to 2019. Admissions due to ES were divided into two cohorts: before (≤2017) and after (>2018) the introduction of sharing systems. Patients were stratified by injuries sustained, age, gender, and race. Inpatient hospital charges and length of stay were compared. Exclusion criteria included patients older than 65 and patients with neurological disorders. Traumatic injuries were compared after adjusting for age, gender, and race in a multivariate logistic regression analysis.

RESULTS

During the study period, there were 686 admissions, of which 220 remained due to exclusion criteria. There was a consistent increase in ES-related injuries over the years (r = 0.91, p = 0.017). Patients who were injured after the introduction of sharing systems were more likely to sustain facial fractures (OR, 2.63; 95%CI, 1.30-5.32; p = 0.007) after controlling for age, gender, and race. The incidence of lumbar and pelvic fractures was higher following the introduction of such systems (7.1% vs. 0%; p<0.05).

CONCLUSIONS

The introduction of ES sharing systems resulted in increased incidence of facial, pelvic, and lumbar fractures. Federal and state regulations need to be implemented to mitigate the detrimental effects of ES sharing systems.

Infrared thermography of in situ natural freezing and mechanism of winter-thermonasty in Rhododendron maximum

Evergreen leaves of Rhododendron species inhabiting temperate/montane climates are typically exposed to both high radiation and freezing temperatures during winter when photosynthetic biochemistry is severely inhibited. Cold-induced "thermonasty," that is, lamina rolling and petiole curling, can reduce the amount of leaf area exposed to solar radiation and has been associated with photoprotection in overwintering rhododendrons. The present study was conducted on natural, mature plantings of a cold-hardy and large-leaved thermonastic North American species (Rhododendron maximum) during winter freezes. Infrared thermography was used to determine initial sites of ice formation, patterns of ice propagation, and dynamics of the freezing process in leaves to understand the temporal and mechanistic relationship between freezing and thermonasty. Results indicated that ice formation in whole plants is initiated in the stem, predominantly in the upper portions, and propagates in both directions from the original site. Ice formation in leaves initially occurred in the vascular tissue of the midrib and then propagated into other portions of the vascular system/venation. Ice was never observed to initiate or propagate into palisade, spongy mesophyll, or epidermal tissues. These observations, together with the leaf- and petiole-histology, and a simulation of the rolling effect of dehydrated leaves using a cellulose-based, paper-bilayer system, suggest that thermonasty occurs due to anisotropic contraction of cell wall cellulose fibers of adaxial versus abaxial surface as the cells lose water to ice present in vascular tissues.

MIB-626, an Oral Formulation of a Microcrystalline Unique Polymorph of β-Nicotinamide Mononucleotide, Increases Circulating Nicotinamide Adenine Dinucleotide and its Metabolome in Middle-Aged and Older Adults

BACKGROUND

Nicotinamide adenine dinucleotide (NAD) precursors, nicotinamide mononucleotide (NMN), or nicotinamide riboside (NR) extend healthspan and ameliorate some age-related conditions in model organisms. However, early-phase trials of NAD precursors have yielded varying results and their pharmacokinetics remain incompletely understood. Here, we report the pharmacokinetics and pharmacodynamics of MIB-626, a microcrystalline unique polymorph βNMN formulation.

METHODS

In this double-blind, placebo-controlled study, 32 overweight or obese adults, 55-80 years, were block-randomized, stratified by sex, to 1 000-mg MIB-626 once daily, twice daily, or placebo for 14 days. NMN, NAD, and NAD metabolome were measured using liquid chromatography-tandem mass spectrometry.

RESULTS

Participant characteristics were similar across groups. MIB-626 was well tolerated and frequency of adverse events was similar across groups. Blood NMN concentrations on Day 14 in MIB-626-treated groups were significantly higher compared to placebo (1.7-times and 3.7-times increase above baseline in 1 000 mg once-daily and twice-daily groups in mean AUClast, respectively). MIB-626 treatment was associated with substantial dose-related increases in blood NAD levels. Blood levels of NAD metabolites were higher in NMN-treated participants on Days 8 and 14 than at baseline. Changes in NMN or NAD levels were not related to sex, body mass index, or age. Very little unmodified NMN was excreted in the urine.

CONCLUSION

MIB-626 1 000 mg once-daily or twice-daily regimens were safe and associated with substantial dose-related increases in blood NAD levels and its metabolome. These foundational data that were obtained using a pharmaceutical-grade βNMN, standardized sample collection, and validated liquid chromatography-tandem mass spectrometry assays, should facilitate design of efficacy trials in disease conditions.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Visualizing the effect of freezing on the vascular system of wheat in 3 dimensions by in-block imaging of dye-infiltrated plants

Infrared thermography has shown after roots of grasses freeze, ice spreads into the crown and then acropetally into leaves initially through vascular bundles. Leaves freeze singly with the oldest leaves freezing first and the youngest freezing later. Visualising the vascular system in its native 3‐dimensional state will help in the understanding of this freezing process. A 2 cm section of the crown that had been infiltrated with aniline blue was embedded in paraffin and sectioned with a microtome. A photograph of the surface of the tissue in the paraffin block was taken after the microtome blade removed each 20 μm section. Two hundred to 300 images were imported into Adobe After Effects and a 3D volume of the region infiltrated by aniline blue dye was constructed. The reconstruction revealed that roots fed into what is functionally a region inside the crown that could act as a reservoir from which all the leaves are able to draw water. When a single root was fed dye solution, the entire region filled with dye and the vascular bundles of every leaf took up the dye; this indicated that the vascular system of roots was not paired with individual leaves. Fluorescence microscopy suggested the edge of the reservoir might be composed of phenolic compounds. When plants were frozen, the edges of the reservoir became leaky and dye solution spread into the mesophyll outside the reservoir. The significance of this change with regard to freezing tolerance is not known at this time.

Thermal cameras that allow visualisation of water freezing in plants have shown that in crops like wheat, oats and barley, ice forms first at the bottom of the plant and then moves upwards into leaves through water conducting channels. Leaves freeze one at a time with the oldest leaves freezing first and then younger ones further up the stem freeze later. To better understand why plants freeze like this, we reconstructed a 3‐dimensional view of the water conducting channels. After placing the roots of a wheat plant in a blue dye and allowing it to pull the dye upwards into leaves, we took a part of the stem just above the roots and embedded it in paraffin. We used a microtome to slice a thin layer of the paraffin containing the plant and then photographed the surface after each layer was removed. After taking about 300 images, we used Adobe After Effects software to re‐construct the plant with the water conducting system in three dimensions. The 3D reconstruction showed that roots fed into a roughly spherical area at the bottom of the stem that could act as a kind of tank or reservoir from which the leaves pull up water. When we put just one root in dye, the entire reservoir filled up and the water conducting channels in every leaf took up the dye. This indicates that the water channels in roots were not directly connected to specific leaves as we had thought. When plants were frozen, the dye leaked out of the reservoir and spread into cells outside. Research is continuing to understand the significance of this change during freezing. It is possible that information about this effect can be used to help breeders develop more winter‐hardy crop plants.

Microsphere stem blockage as a screen for nitrogen-fixation drought tolerance in soybean

Symbiotic nitrogen-fixation of soybean (Glycine max [Merr.] L) commonly decreases in response to soil drying in advance of other plant processes. While a few soybean lines express nitrogen-fixation drought tolerance, breeding for genetic variation is hampered by laborious phenotyping procedures. The objective of this research was to explore the potential of an initial screen for nitrogen-fixation drought-tolerant genotypes based on a possible relationship with xylem-vessel diameter. The hypothesis was that nitrogen-fixation drought tolerance might result from fewer, large-diameter xylem vessels in the stem that are vulnerable to disrupted flow as water deficit develops. The disrupted flow could cause nitrogen products to accumulate in nodules resulting in negative feedback on nitrogen-fixation rate. The proposed screen involved exposing de-rooted shoots to a suspension containing microspheres (45-53 μm diameter) and recording the decrease in transpiration rate as a result of microsphere xylem-blockage. Two soybean populations were tested. One population was progeny derived from mating of two parents with high and low nitrogen-fixation drought sensitivity. A high correlation (R2  = 0.68; P < 0.001) was found in this population between decreasing transpiration rate resulting from the microsphere treatment and increasing sensitivity of nitrogen-fixation to soil drying. The second tested population consisted of 16 genotypes, most of which had been previously identified in germplasm screens as expressing nitrogen-fixation drought tolerance. Nearly half of the lines in this second population were identified in the screen as showing minimum blockage of transpiration when exposed to the microspheres. Overall, these results showed the potential of using the microsphere screen to identify candidate genotypes expressing nitrogen-fixation drought tolerance.

Sequential Protocol Biopsies Post-Liver Transplant From Donors With Moderate Macrosteatosis: What Happens to the Fat?

The number of steatotic deceased donor livers encountered has continued to rise as a result of the obesity epidemic. Little is known about the histological characteristics of moderately macrosteatotic livers over time in the recipient following liver transplantation (LT). All recipients undergoing LT at Mayo Clinic Florida with donor livers with moderate macrosteatosis (30%-60%) from 2000-2017 were identified (n = 96). Routine protocol liver biopsies were performed 1-week and 6-months following LT. All liver donor and protocol biopsies were read by an experienced liver pathologist. Of the 96 moderate macrosteatosis LTs, 70 recipients had post-LT protocol liver biopsies available and comprised the study cohort. Median donor allograft macrosteatosis at the time of transplant was 33% (IQR, 30%-40%) compared with 0% (IQR, 0%-2%) at 1-week (P < 0.001) and 0% (IQR, 0%-0%) at 6-months (P < 0.001) following LT. Biopsies at 1-week post-LT displayed pericentral necrosis in 57.1% of recipients and lipopeliosis in 34.3% of recipients. In the 6-month post-LT biopsies, cholestasis was seen in 3 (4.3%) of the recipients, whereas grade 2 fibrosis was seen in 6 recipients (8.6%). Graft survival at 5 years in the present cohort was 74.0%. Moderate macrosteatosis (30%-60%) in the donor allograft demonstrates complete reversal on liver biopsies performed as early as 7 days following LT and remains absent at 6-months following LT. Both pericentral necrosis and lipopeliosis are common features on day 7 biopsies. Despite these encouraging findings, the perioperative risks of using these livers (postreperfusion cardiac arrest and primary nonfunction) should not be understated. Long-term graft survival is acceptable in patients who are able to overcome the immediate perioperative risk of using moderately steatotic donor livers.

Identifying participants for inclusion in hospital-based violence intervention: An analysis of 18 years of urban firearm recidivism

BACKGROUND

Identifying individuals at highest risk maximizes efficacy of prevention programs in decreasing recidivist gunshot wound (GSW) injury. Characteristics of GSW recidivists may identify this population. Hospital-based violence intervention programs (HVIPs) are one effective strategy; however, programs are expensive, therefore, when possible, epidemiologic data should guide inclusion criteria.

METHODS

Seventeen years of all GSW patients presenting to an urban Level I trauma center were reviewed. Countywide murders were reviewed from the same timeframe. Recidivists were any patient presenting twice, either to the hospital or once to the hospital and subsequently dying by firearm. Demographics and characteristics of future recidivists were compared with nonfuture recidivists.

RESULTS

There were 9,699 unique intentional, GSW cases reviewed and 1,426 died, leaving 8,273 at risk of recidivism. Five hundred fourteen (6.2%) became recidivists. Most recidivists were African-American men and were younger at first GSW. Median time between incidents was 2.5 years, with a range of 0 days to 16 years. Nearly half were treated and released from the emergency department at their first episode of GSW. For recidivists who died, 128 died at the second incident, 29 at later incidents. Mortality from a second incident of firearm injury is 10% higher than first injuries, second hospitalizations are US $5,000 more expensive, and loss of life has a societal cost of US $167 billion in this community alone.

CONCLUSION

The most appropriate population for inclusion in HVIPs at our hospital are young black men. The HVIP services are needed in the emergency department to address those treated and released at first GSW. Recidivists have higher mortality, and hospitalizations are significantly more expensive at the second injury. The investment in prevention is justified and may lead to a decrease in recidivism.

LEVEL OF EVIDENCE

Therapeutic/Care Management level III.

Glass table injuries: A silent public health problem

BACKGROUND

Glass tables can break and cause traumatic injury. This public health issue is avoidable by adequate regulatory measures. We describe the burden and characteristics of these injuries using the National Electronic Injury Surveillance System (NEISS) database and data from a level 1 trauma center.

METHODS

NEISS data was extracted from 2009 to 2015. Injuries were classified by type, severity, and involvement of faulty glass using predetermined criteria. A retrospective chart review of a level 1 trauma center data was performed. Epidemiologic and outcomes data are reported.

RESULTS

3241 cases were reviewed from NEISS. 56% of injuries were attributable to faulty tables. 15% were severe. A bimodal age distribution of age under 7 and early 20s was observed. Commonly injured areas were the upper extremity and forehead. 24 trauma center cases were reviewed. 21% presented with hemodynamic instability, 34% had major organ, body cavity or joint space injuries, and 58% required surgical intervention. 30-day mortality rate was 8%. More than 54% required inpatient care.

CONCLUSION

Glass table injuries are common, estimated at over 2.5 million per year. Regulation of glass quality may prevent injury.

SUMMARY

Glass table injuries are more common than may be recognized and represent a public health problem that can be mitigated through proper regulatory measures.

Endovascular Treatment of Aortohepatic Conduit Stenosis Following Liver Transplant

BACKGROUND

Aortohepatic conduits (AHCs) are valuable alternatives when conventional hepatic artery anastomoses are not possible. However, AHCs have earlier and higher occlusion rates and reduced graft and patient survival. While endovascular therapy is safe and effective for conventional anastomotic stenoses, data on AHC stenoses are limited. This study reviewed outcomes for endovascular management of AHC stenosis at a single liver transplant center.

METHODS

A retrospective review of a prospectively maintained database was performed on the endovascular management of AHC stenosis between January 1, 2000, and December 31, 2016. Medical records, laboratory data, and imaging were analyzed for technical and hemodynamic success, primary and assisted primary patency, and patient and graft survival.

RESULTS

Seven patients underwent angioplasty a median of 142 days after transplant, and 2 required reintervention. The primary patency rate was 67% at 6 months and 22% at 1 year. The assisted primary patency rate was 83% at 6 months and 42% at 1, 3, and 5 years. Patient and graft survival were 86% at 6 months and 71%, 57%, and 38% at 1, 3, and 5 years, respectively. Four conduits were patent at last follow-up. There were no major adverse events after angioplasty. One reintervention was complicated by acute AHC thrombosis after stenting, causing biliary necrosis, sepsis, and death. There was no 30-day mortality, retransplant, or surgical revascularization because of endovascular intervention.

CONCLUSIONS

Endovascular treatment of AHC stenosis appears to be safe with a high technical success rate but lower long-term patency than standard hepatic arterial anastomoses.

Systemic Artery-to-Pulmonary Artery Fistula Mimics Pulmonary Embolus

Systemic artery-to-pulmonary artery fistula (SA-PAF) is a rare phenomenon that can resemble a filling defect on computed tomography angiography (CTA). SA-PAF can be due to congenital or acquired etiologies and can alter the hemodynamics of the pulmonary circulation, with the most serious reported complication being hemoptysis, requiring embolization. We describe a case of an unusual SA-PAF between the right inferior phrenic artery and the right lower lobe pulmonary artery that mimicked an unprovoked pulmonary embolus (PE) on standard CTA in a patient with cardiomyopathy. This SA-PAF was interpreted on CTA as PE due to the presence of a filling defect, revealing that not all filling defects are PE. SA-PAF should always be considered when the clinical context or the imaging findings are atypical, specifically with an isolated filling defect visualized in the inferior lower lobe pulmonary artery. The false-positive PE was the result of mixing of systemic non-opacified blood with opacified pulmonary arterial blood.

Does Donor Allograft Microsteatosis Matter? Comparison of Outcomes in Liver Transplantation With a Propensity-Matched Cohort

It has been suggested that microsteatosis does not negatively impact graft survival following liver transplantation (LT). The present study represents the largest series on donor livers with significant microsteatosis and investigates the impact of microsteatosis on perioperative factors such as postreperfusion syndrome (PRS), early allograft dysfunction (EAD), and postoperative renal dysfunction. Clinical outcomes of all patients undergoing LT with donor livers with isolated microsteatosis (≥30%; n = 239) between 2000 and 2017 were compared with a propensity score-matched cohort of patients undergoing LT with donor livers with no steatosis (n = 239). Patients in the microsteatosis group had a higher rate of PRS (33.1% versus 24.2%; P = 0.03), EAD (38.2% versus 23.0%; P < 0.001), and continuous renal replacement therapy (CRRT) requirement following LT (10.9% versus 3.6%; P = 0.002) than the no steatosis group. No difference in patient (P = 0.33) or graft survival (P = 0.18) was observed between the 2 groups. On multivariate regression, livers with microsteatosis had an increased risk of graft loss with retransplant recipients (hazard ratio [HR], 1.59; P < 0.001), increasing Model for End-Stage Liver Disease (MELD) score (HR, 1.13; P = 0.01), and organs from donation after circulatory death donors (HR, 1.46; P = 0.003). In conclusion, recipients of donor livers with significant microsteatosis are at an increased risk of PRS, EAD, and postoperative renal dysfunction requiring CRRT. Livers with significant microsteatosis should be avoided in retransplant recipients and in recipients with high biological MELD scores. Once appropriately selected recipients of these livers are able to overcome the initial perioperative implications of using these donor livers, longterm patient and graft survival is similar to recipients receiving grafts with no steatosis.

The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis

The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long-term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.

"Tram-line" Calcifications in Granulomatosis with Polyangiitis

Nephrocalcinosis consists of deposition of calcium in the renal parenchyma. Renal cortical calcification is a rare entity in comparison to calcium deposits in the medulla and is seen only in a handful of pathologies with corresponding characteristic patterns on imaging. Thin linear calcifications may get deposited in the peripheral renal cortex suggestive of cortical necrosis due to a vascular insult (vasculitis), and rarely due to glomerulonephritis. This pattern of calcification has also been referred to as the “tramline” or “railroad track” sign.

Three-dimensional reconstruction of soybean nodules provides an update on vascular structure

PREMISE OF THE STUDY

In many cases, the functioning of a biological system cannot be correctly understood if its physical anatomy is incorrectly described. Accurate knowledge of the anatomy of soybean [Glycine max (L.) Merril] nodules and its connection with the root vasculature is important for understanding its function in supplying the plant with nitrogenous compounds. Previous two-dimensional anatomical observations of soybean nodules led to the assumption that vascular bundles terminate within the cortex of the nodule and that a single vascular bundle connects the nodule to the root. We wanted to see whether these anatomical assumptions would be verified by digitally reconstructing soybean nodules in three dimensions.

METHODS

Nodules were dehydrated, embedded in paraffin, and cut into 15 μm thick sections. Over 200 serial sections were stained with safranin and fast green, and then photographed using light microscopy. Images were digitally cleared, aligned, and assembled into a three-dimensional (3D) volume using the Adobe program After Effects.

KEY RESULTS

In many cases, vascular bundles had a continuous connection around the nodules. The 3D reconstruction also revealed a dual vascular connection originating in the nodule and leading to the root in 22 of the 24 nodules. Of the 22 dual connections, 11 maintained two separate vascular bundles into the root with independent connections to the root vasculature.

CONCLUSIONS

A more robust and complex anatomical pathway for vascular transport between nodules and root xylem in soybean plants is indicated by these observations and will contribute to a better understanding of the symbiotic relationship between soybean plants and nitrogen-fixing bacteria within the nodules.

Excellent translational research in oncology: A journey towards novel and more effective anti-cancer therapies

Comprehensive Cancer Centres (CCCs) serve as critical drivers for improving cancer survival. In Europe, we have developed an Excellence Designation System (EDS) consisting of criteria to assess "excellence" of CCCs in translational research (bench to bedside and back), with the expectation that many European CCCs will aspire to this status.

Energy Return on Investment (EROI) for Forty Global Oilfields Using a Detailed Engineering-Based Model of Oil Production

Studies of the energy return on investment (EROI) for oil production generally rely on aggregated statistics for large regions or countries. In order to better understand the drivers of the energy productivity of oil production, we use a novel approach that applies a detailed field-level engineering model of oil and gas production to estimate energy requirements of drilling, producing, processing, and transporting crude oil. We examine 40 global oilfields, utilizing detailed data for each field from hundreds of technical and scientific data sources. Resulting net energy return (NER) ratios for studied oil fields range from ≈2 to ≈100 MJ crude oil produced per MJ of total fuels consumed. External energy return (EER) ratios, which compare energy produced to energy consumed from external sources, exceed 1000:1 for fields that are largely self-sufficient. The lowest energy returns are found to come from thermally-enhanced oil recovery technologies. Results are generally insensitive to reasonable ranges of assumptions explored in sensitivity analysis. Fields with very large associated gas production are sensitive to assumptions about surface fluids processing due to the shifts in energy consumed under different gas treatment configurations. This model does not currently include energy invested in building oilfield capital equipment (e.g., drilling rigs), nor does it include other indirect energy uses such as labor or services.

Twenty-fifth annual Pezcoller Symposium: Metabolism and tumorigenesis

Choking cancer via inhibition of metabolic enzymes essential for tumor but dispensable in normal tissues was discussed as was the altered metabolism in cancer cells related to: tumor suppressor protein (pVHL) function, the histone acetylation dependence upon glucose, the epigenomic reprogramming of acetyl CoA synthesis, the plasticity of aging mechanisms, and the metabolism orchestration in macrophage polarization. The p53 and p73 pathways role in metabolic adaptation, the effects on growth of AMP-dependent kinase, the growth regulation by the mTOR pathways, and the bioenergetics requirements of cancer cells were also discussed. A novel computational model of personalized metabolic changes in cancer was outlined with applications in patients with breast cancer. Imaging metabolic characteristics of tumors by MRI and (13)C-nuclear magnetic resonance was described. The cancer metabolism regulation related to O-linked β-N-acetylglucosame was described. DNA hypermethylation and impaired hematopoietic differentiation in AML after isocitrate dehydrogenase 1/2 mutation and 2-hydroxyglutarate increases were outlined.

Twenty-fourth annual Pezcoller symposium: Molecular basis for resistance to targeted agents

The mechanisms of genetically determined mechanisms of resistance to several target drugs were discussed in breast cancer, melanoma, colorectal and prostate cancers, chronic myelogenous leukemia, small cell lung cancer, and medulloblastoma. In each case, heterogeneity of mechanisms was emphasized. In melanoma, therapeutic interference with the effects of BRAF mutations was repeatedly discussed. It was also reported that anti-CTLA4 antibodies provided the first treatment improving survival of patients with stage IV melanoma. Epithelial-mesenchymal transition (EMT) was introduced as a mechanism of resistance, particularly in lung and pancreatic cancer, where the role of microenvironment factors was also indicated. In colorectal and prostate cancers, the use of liquid biopsies, namely, measurements of tumor nucleic acid in blood, were indicated as a way to obtain whole-tumor assessment instead of the partial assessment obtainable with traditional biopsies. Knowledge of the mechanisms of drug action and resistance was stressed to be essential for the design of new agents and combination of agents aimed at increasing antitumor effectiveness and overcoming resistance.

Twenty-third annual Pezcoller Symposium: engineering influences in cancer research

The cross-disciplinary focus of the meeting highlighted recent progress in physical and genetic analysis and engineering of cancer disease models. As the central theme, mechanical forces affecting cell signaling, growth, differentiation, and metastasis were discussed with emphasis on the tumor microenvironment and cellular immunity, taking into account novel nanotechnology, biosensing, and intravital microscopy tools to monitor animal cancer models and human cancer. Emerging themes were the role of extracellular matrix imposing mechanical mechanisms on tumor cell function, including microenvironmental cues controlling the movement of tumor and immune cells, advanced genetic animal models for cancer that better recapitulate human disease, and preclinical and clinical molecular imaging of tumor architecture and stiffness, as well as novel nanotechnologies for anticancer drug delivery.

A Prospective Evaluation of the Value of Repeat Cranial Computed Tomography in Patients With Minimal Head Injury and an Intracranial Bleed

BACKGROUND

Patients with minimal head injury (MHI) and intracranial bleed (ICB) detected on cranial computed tomography (CT) scan routinely undergo a repeat cranial CT within 24 hours after injury to assess for progression of intracranial injuries. While this is clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination. The goal of this study was to prospectively assess the value of a repeat cranial CT in patients with a MHI and an ICB who have a normal neurologic examination.

METHODS

A prospective analysis of all adult patients admitted to a Level I trauma center after blunt trauma causing a MHI (defined as the loss of consciousness or posttraumatic amnesia with a Glasgow Coma Scale (GCS) score of greater or equal to 13) and an ICB on the initial cranial CT during a 12-month period (July 2002 through July 2003) was performed. All patients with MHI were prospectively evaluated and followed until discharge. Data collected included demographics, neurologic examination and findings on the initial and repeat cranial CT scan. Outcome data included neurologic deterioration, neurosurgical intervention, and Glasgow Outcome Scale (GOS) on discharge.

RESULTS

In all, 161 consecutive patients with MHI and a positive cranial CT scan were identified. The initial cranial CT lead to a neurosurgical intervention (1 craniotomy, 4 intracranial pressure monitors) in 4% of cases. The remaining 130 patients who met inclusion criteria, underwent a repeat cranial CT scan within 24 hours postadmission. Ninety nine (76%) patients had a normal neurologic examination at the time of their repeat cranial CT. After the repeat cranial CT none required immediate neurosurgical intervention or had delayed neurologic deterioration related to their head injury. Fifteen patients underwent additional neuroradiologic studies but none showed further progression of their ICB or lead to a change in management. One patient died from non-traumatic brain injury related causes and of the remaining 26 patients, 98% had an overall favorable GOS score (> 3) on discharge. In this group of patients with MHI and ICB, the negative predictive value of a normal neurologic examination was 100%.

CONCLUSIONS

Repeat cranial CT, in patients with a MHI and a normal neurologic examination, resulted in no change in management or neurosurgical intervention and is therefore not indicated. A multicenter prospective study would further validate these conclusions, reduce unnecessary CT scans, and likely improve our current standard of care in these patients.

Carbohydrate concentrations in crown fractions from winter oat during hardening at sub-zero temperatures

BACKGROUND AND AIMS

Contradictory results in correlation studies of plant carbohydrates with freezing tolerance may be because whole crown tissue is analysed for carbohydrates while differences exist in the survival of specific tissue within the crown. The aim of this study was to see if carbohydrate changes in tissue within oat crowns during second phase hardening (sub-zero hardening) are tissue specific.

METHODS

The lower portion of oat (Avena sativa) crowns was exposed to mild grinding in a blender and the remaining crown meristem complex, consisting of tough root-like vessels, was ground in a device developed specifically for grinding cereal crown tissue. Carbohydrates were extracted by water and measured by HPLC. Carbohydrate concentrations were compared in the two regions of the crown before and after hardening at sub-zero temperatures.

KEY RESULTS

Fructan of all size classes except DP>6 decreased during sub-zero hardening in both stems (base of leaf sheath) and crown meristem complex. Total simple sugar increase, including sucrose, was significantly higher in the crown meristem complex than in the stem.

CONCLUSIONS

Results support the hypothesis that carbohydrate change in mildly frozen plants is tissue specific within crowns and underscore the need to evaluate specific tissue within the crown when correlating the biochemistry of plants with freezing tolerance.

SV40 T antigen interacts with Nbs1 to disrupt DNA replication control

Nijmegen breakage syndrome (NBS) is characterized by radiation hypersensitivity, chromosomal instability, and predisposition to cancer. Nbs1, the NBS protein, forms a tight complex with Mre11 and Rad50, and these interactions contribute to proper double-strand break repair. The simian virus 40 (SV40) oncoprotein, large T antigen (T), also interacts with Nbs1, and T-containing cells experience chromosomal hyperreplication in a manner dependent on T/Nbs1 complex formation. A substantial fraction of NBS-deficient fibroblasts reinitiate DNA replication in discrete regions, and wild-type Nbs1 corrects this defect. Similarly, synthesis of an N-terminal Nbs1 fragment induced DNA rereplication and tetraploidy, in NBS-deficient but not NBS-proficient cells. Moreover, SV40 origin-containing DNA hyperreplicated in T-containing NBS-deficient cells by comparison with T-containing, Nbs1-reconstituted derivatives. Thus, Nbs1 suppresses rereplication of cellular DNA and SV40 origin-containing replicons, and T targets Nbs1, thereby enhancing the yield of new SV40 genomes during viral DNA replication.

Trauma from tire and rim explosions: a retrospective analysis

PURPOSE

The purpose of this study is to review injuries occurring as a result of tire and rim explosions treated at a level I trauma center.

MATERIALS AND METHODS

The retrospective audit evaluated the university hospital trauma database based on ICD-9 code to isolate patients sustaining tire and rim explosion injuries. A total of 12 complete patient records were derived from this search to allow determination of injuries and outcome assessments.

RESULTS

Injury patterns from tire and rim explosions were categorized in terms of anatomic region, treatment and hospitalization, disposition, and outcome assessment. Maxillofacial injuries were further subdivided into specific injuries involving a total of 7 patients from this case series.

CONCLUSIONS

Significant blast injuries can result from tire and rim explosions, which can often involve the maxillofacial region due to proximity to the source. Reductions in injuries have been seen since the implementation of physical safety measures by the Occupational Safety and Health Administration and the National Highway Transportation Safety Board.

Functional interactions between BRCA1 and the checkpoint kinase ATR during genotoxic stress

The BRCA1 gene encodes a tumor suppressor that is mutated in 50% of familial breast cancers. The BRCA1 protein has been implicated in the DNA damage response, as DNA damage induces the phosphorylation of BRCA1 and causes its recruitment into nuclear foci that contain DNA repair proteins. The ataxia-telangiectasia-mutated (ATM) gene product controls overall BRCA1 phosphorylation in response to gamma-irradiation (IR). In this study, we show that BRCA1 phosphorylation is only partially ATM dependent in response to IR and ATM independent in response to treatment with UV light, or the DNA replication inhibitors hydroxyurea (HU) and aphidicolin (APH). We provide evidence that the kinase responsible for this phosphorylation is the ATM-related kinase, ATR. ATR phosphorylates BRCA1 on six Ser/Thr residues, including Ser 1423, in vitro. Increased expression of ATR enhanced the phosphorylation of BRCA1 on Ser 1423 following cellular exposure to HU or UV light, whereas doxycycline-induced expression of a kinase-inactive ATR mutant protein inhibited HU- or UV light-induced Ser 1423 phosphorylation in GM847 fibroblasts, and partially suppressed the phosphorylation of this site in response to IR. Thus, ATR, like ATM, controls BRCA1 phosphorylation in vivo. Although ATR isolated from DNA-damaged cells does not show enhanced kinase activity in vitro, we found that ATR responds to DNA damage and replication blocks by forming distinct nuclear foci at the sites of stalled replication forks. Furthermore, ATR nuclear foci overlap with the nuclear foci formed by BRCA1. The dramatic relocalization of ATR in response to DNA damage points to a possible mechanism for its ability to enhance the phosphorylation of substrates in response to DNA damage. Together, these results demonstrate that ATR and BRCA1 are components of the same genotoxic stress-responsive pathway, and that ATR directly phosphorylates BRCA1 in response to damaged DNA or stalled DNA replication.

Precise measurement of the J = 1 to J = 2 fine structure interval in the 2( 3)P state of helium

We measure the J = 1 to J = 2 fine structure interval in the ( 3)2P state of helium to be 2 291 175.9(1.0) kHz. We use laser excitation of an atomic beam along with an integrated electro-optic modulator technique to obtain this result. The result is consistent (2.9+/-3.2 kHz) with what could be considered an earlier version of this experiment but is not in good agreement ( 20+/-5 kHz and 22+/-8 kHz) with the two other precision determinations of this interval. The current theoretical prediction lies between and overlaps the experiments.

Localization of human BRCA1 and its loss in high-grade, non-inherited breast carcinomas

Although the link between the BRCA1 tumour-suppressor gene and hereditary breast and ovarian cancer is established, the role, if any, of BRCA1 in non-familial cancers is unclear. BRCA1 mutations are rare in sporadic cancers, but loss of BRCA1 resulting from reduced expression or incorrect subcellular localization is postulated to be important in non-familial breast and ovarian cancers. Epigenetic loss, however, has not received general acceptance due to controversy regarding the subcellular localization of BRCA1 proteins, reports of which have ranged from exclusively nuclear, to conditionally nuclear, to the ER/golgi, to cytoplasmic invaginations into the nucleus. In an attempt to resolve this issue, we have comprehensively characterized 19 anti-BRCA1 antibodies. These reagents detect a 220-kD protein localized in discrete nuclear foci in all epithelial cell lines, including those derived from breast malignancies. Immunohistochemical staining of human breast specimens also revealed BRCA1 nuclear foci in benign breast, invasive lobular cancers and low-grade ductal carcinomas. Conversely, BRCA1 expression was reduced or undetectable in the majority of high-grade, ductal carcinomas, suggesting that absence of BRCA1 may contribute to the pathogenesis of a significant percentage of sporadic breast cancers.

Microsurgical selective peripheral neurotomy in the treatment of spasticity in cerebral-palsy children

Spasticity represents the most handicapping sequelae of cerebral palsy in children. In this study, 28 children with spastic cerebral palsy were treated over the last 4 years by microsurgical selective peripheral neurotomy: 28 times the posterior tibial nerve for spastic foot deformity, 3 times the ulnar and median nerves for spastic flexion of wrist and fingers, 2 times the sciatic nerve for spastic knee flexion associated with spastic foot deformity and 3 times obturator nerves for spastic adductors. Results on spasticity with follow-up ranging from 3 to 48 months were as follows: spastic foot deformity was corrected in all patients with pure spasticity, 2 out of the 3 children with ulnar and median neurotomy improved, knee flexion and hip adduction were improved in the other 5 patients. Selective peripheral neurotomy is an effective procedure in the treatment of segmental harmful spasticity after failure of a well-conducted conservative treatment associating physiotherapy and antispasmodic medications. It must be performed before the fixed deformities and other orthopedic complications arise.

Cytokine activation through sublethal hemorrhage is protective against early lethal endotoxic challenge

OBJECTIVES

To determine the immunologic consequences of nonlethal hemorrhage on subsequent exposure to lipopolysaccharide (LPS) and to determine the role of interleukin 1 beta (IL-1) specifically in mediating the response to LPS with and without prior hemorrhage.

DESIGN

Prospective, randomized, controlled experimental trial.

PARTICIPANTS

Male BALB/c mice and transgenic mice deficient in IL-1 converting enzyme.

INTERVENTIONS

Animals were subjected to hemorrhage (by cardiac puncture), LPS challenge by intraperitoneal injection, or hemorrhage followed 24 hours later by LPS challenge. Mortality was assessed every 4 hours for 96 hours following hemorrhage or LPS exposure. Serum IL-1 levels were determined 24 hours after exposure to hemorrhage and LPS.

SETTING

University of South Florida Core General Surgery Research Facility, Tampa.

MAIN OUTCOME MEASURES

Mortality and serum IL-1 levels.

RESULTS

Hemorrhage alone resulted in complete survival, whereas LPS alone resulted in near-complete (95%) mortality. Hemorrhage, when given 24 hours before LPS challenge, afforded significant protection compared with LPS alone (67% survival vs 5% survival; P < .001). Serum IL-1 levels 24 hours after exposure to LPS were significantly lower in prehemorrhaged mice than in those receiving LPS alone. Transgenic mice incapable of producing biologically active IL-1 were further protected, demonstrating near-complete (95%) survival following hemorrhage and LPS challenge.

CONCLUSIONS

Cytokine activation through nonlethal hemorrhage attenuates subsequent IL-1 response to early immunologic challenge. Such immune suppression appears to be protective early on and is supported by the near-complete immunity to LPS in animals incapable of producing biologically active IL-1.

Severity and mortality of experimental pancreatitis are dependent on interleukin-1 converting enzyme (ICE)

Interleukin-1 beta (IL-1 beta) is produced in large amounts during acute pancreatitis and is believed to play a role in disease progression. Because secretion of IL-1 beta is dependent on intracellular processing of pro-IL-1 beta by IL-1 converting enzyme (ICE), we aimed to determine the efficacy of a novel ICE inactivator (VE-13045) in inhibiting secretion of active IL-1 beta in vivo and if the loss of ICE activity would affect the severity and mortality of experimental pancreatitis. Severe hemorrhagic pancreatitis was induced in adult rats by infusion of bile acid into the pancreatic duct. Animals were randomized to receive VE-13045 or vehicle before induction of pancreatitis. To confirm our findings and to ensure that the results were not model dependent, a second series of experiments was conducted using mice possessing a homozygous knockout of the ICE gene in which lethal pancreatitis was induced by feeding a choline-deficient, ethionine-supplemented diet. The severity of pancreatitis was assessed for both experiments by standard surrogate markers, blind histologic grading, and serum IL-1 beta and tumor necrosis factor-alpha (TNF-alpha) levels. Pancreatic IL-1 beta mRNA induction was assessed by differential RT-PCR. Acute pancreatitis was associated with a 120-fold increase in IL-1 beta mRNA, which was not affected by ICE inhibition or gene deletion. Cytokine processing and secretion were affected, as evidenced by decreased serum levels of IL-1 beta and TNF-alpha (p < 0.001) in all animals with an inactive ICE enzyme. This lack of cytokine production increased survival from 32% to 78% following bile salt pancreatitis (p < 0.01) and from 24% to 80% following diet-induced pancreatitis (p < 0.005). Both ICE-defective groups demonstrated decreased pancreatic necrosis, edema, inflammation, wet weight (all p < 0.05), and amylase and lipase (p < 0.01). In vivo blockade or genetic deletion of ICE inhibits pancreatitis-induced secretion of proinflammatory cytokines without altering IL-1 mRNA production and is associated with decreased pancreatitis severity and dramatic survival benefits.

A framework for integrated quality improvement

The importance of maintaining and improving quality is well understood in most health care organizations. This work becomes more challenging as internal and external conditions rapidly change. A quality improvement framework was developed to help clinicians and administrators organize intergrated, multifaceted quality programs that have the flexibility necessary for success in today's fast-paced health care environment.