Cone-beam computed tomography image-guided percutaneous microwave ablation for lung nodules in a hybrid operating room: an initial experience

OBJECTIVES

The experience of thermal ablation of lung lesions is limited, especially performing the procedure under localisation by cone-beam CT in the hybrid operation room (HOR). Here, we present the experience of microwave ablation (MWA) of lung nodules in the HOR.

METHODS

We reviewed patients who underwent image-guide percutaneous MWA for lung nodules in the HOR under general anaesthesia between July 2020 and July 2022. The workflow in the HOR including the pre-procedure preparation, anaesthesia consideration, operation methods, and postoperative care was clearly described.

RESULTS

Forty lesions in 33 patients who underwent MWA under general anaesthesia (GA) in the HOR were analysed. Twenty-seven patients had a single pulmonary nodule, and the remaining six patients had multiple nodules. The median procedure time was 41.0 min, and the median ablation time per lesion was 6.75 min. The median global operation room time was 115.0 min. The median total dose area product was 14881 μGym2. The median ablation volume was 111.6 cm3. All patients were discharged from the hospital with a median postoperative stay of 1 day. Four patients had pneumothorax, two patients had pleural effusion during the first month of outpatient follow-up, and one patient reported intercostal neuralgia during the 3-month follow-up.

CONCLUSIONS

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if we follow the workflow provided. The procedure provides an alternative to managing pulmonary nodules in patients.

CLINICAL RELEVANCE STATEMENT

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if the provided workflow is followed.

KEY POINTS

• We tested the feasibility of microwave ablation of lung lesions performed in a hybrid operating room. • To this end, we provide a description of microwave ablation of the lung under cone-beam CT localisation. • We describe a workflow by which ablation of the pulmonary nodule can be performed safely under general anaesthesia.

[Clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery]

Objective: To explore the clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery. Methods: A retrospective observational study was conducted. From January 2019 to June 2021, 12 patients with wounds after lower leg limb-sparing surgery who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital, including 6 males and 6 females, aged 17 to 74 years, with original wound area ranging from 17 cm×9 cm to 40 cm×15 cm. Five patients had infection in wounds. The wounds were all repaired by free anterolateral thigh perforator flap from contralateral thigh, with area of 18 cm×10 cm to 37 cm×9 cm. The artery of flap was anastomosed with the descending genicular artery, and the wounds in donor areas were sutured directly. Seven patients were transplanted with split-thickness skin grafts from the contralateral thigh to cover the remaining wounds that can not be covered by flap and the wounds in donor areas were covered with gauze. During the operation, the types of perforating branch carried by flap and the types of arteries and veins in recipient areas were recorded. The survival and occurrence of vascular crisis of flap, the survival of skin graft, the wound healing in donor and recipient areas, and the length of hospital stay after flap transplant surgery were recorded. During follow-up, the color and texture of flap, reinfection in lower leg, and fracture healing were recorded. At the last follow-up, the limb salvage function of patients was evaluated according to the functional evaluation criteria of Chen Zhongwei's amputated limb replantation. Results: The types of perforating branches carried by flaps were as follows: 6 cases of only carrying the descending branch of the lateral circumflex femoral artery, 3 cases of only carrying the oblique branch of the lateral circumflex femoral artery, and 3 cases of carrying the descending branch of the lateral circumflex femoral artery and oblique branch of the lateral circumflex femoral artery after internal pressurization anastomosis. The types of arteries in the recipient area of flap were as follows: one case of main trunk of the descending genicular artery, 8 cases of the saphenous branch of the descending genicular artery, and 3 cases of the articular branch of the descending genicular artery. The types of veins in the recipient area of flap were as follows: 8 cases of one accompanying vein of the descending genicular artery and one branch of the great saphenous vein, and 4 cases of two branches of the great saphenous vein. All the flaps survived without vascular crisis, and all the skin grafts also survived. The wounds in the donor and recipient areas were all healed. The length of hospital stay of patient after flap transplant surgery ranged from 13 to 79 days. During the follow-up of 6 to 23 months, the color and texture of flap were both good, with no infection in lower leg wound. Internal or external fixation were removed after fracture healing in 5 patients, and bone graft internal fixation was performed in 7 patients whose fractures were not healed after surgery and all the incisions healed without infection. At the last follow-up, the limb salvage effect of patients was evaluated as followings: excellent in 7 patients, good in 4 patients, and fair in one patient. Conclusions: Free anterolateral thigh flap pedicled with descending genicular artery can effectively repair the wounds after lower leg limb-sparing surgery and control infection with short length of hospital stay, while not increasing the risk of secondary injury of distal limb vessels. Thus, it can obtain satisfactory limb salvage effect which is worthy of clinical promotion.

Cone-Beam Computed-Tomography-Derived Augmented Fluoroscopy-Guided Biopsy for Peripheral Pulmonary Nodules in a Hybrid Operating Room: A Case Series

Lung cancer is the most lethal cancer type in Taiwan and worldwide. Early detection and treatment advancements have improved survival. However, small peripheral pulmonary nodules (PPN) biopsy is often challenging, relying solely on bronchoscopy with radial endobronchial ultrasound (EBUS). Augmented fluoroscopy overlays the intra-procedural cone-beam computed tomography (CBCT) images with fluoroscopy enabling real-time three-dimensional localization during bronchoscopic transbronchial biopsy. The hybrid operating room (HOR), equipped with various types of C-arm CBCT, is a perfect suite for PPN diagnosis and other interventional pulmonology. This study shares the single institute experience of EBUS transbronchial biopsy of PPN with the aid of augmented fluoroscopic bronchoscopy (AFB) and CBCT in an HOR. We retrospectively enrolled patients who underwent robotic CBCT, augmented fluoroscopy-guided, radial endobronchial ultrasound-confirmed transbronchial biopsy and cryobiopsy in a hybrid operating room. Patient demographic characteristics, computed tomography images, rapid on-site evaluation cytology, and final pathology reports were collected. Forty-one patients underwent transbronchial biopsy and 6 received additional percutaneous transthoracic core-needle biopsy during the same procedure. The overall diagnostic yield was 88%. The complications included three patients with pneumothorax after receiving subsequent CT-guided percutaneous transthoracic needle biopsy, and two patients with hemothorax who underwent transbronchial cryobiopsy. Overall, the bronchoscopic biopsy of PPN using AFB and CBCT as precise guidance in the hybrid operating room is feasible and can be performed safely with a high diagnostic yield.

Single-stage augmented fluoroscopic bronchoscopy localization and thoracoscopic resection of small pulmonary nodules in a hybrid operating room

OBJECTIVES

Hybrid operating rooms (HOR) have been increasingly used for image-guided lung surgery, and most surgical teams have used percutaneous localization for small pulmonary nodules. We evaluated the feasibility and safety of augmented fluoroscopic bronchoscopy localization under endotracheal tube intubation general anaesthesia followed by thoracoscopic surgery as a single-stage procedure in ab HOR.

METHODS

We retrospectively reviewed clinical records of patients who underwent single-stage augmented fluoroscopic bronchoscopy localization under general anaesthesia followed by thoracoscopic surgery in an HOR between August 2020 and March 2022.

RESULTS

Single-stage localization and resection were performed for 85 nodules in 74 patients. The median nodule size was 8 mm [interquartile range (IQR), 6-9 mm], and the median distance from the pleural space was 10.9 mm (IQR, 8-20 mm). All nodules were identifiable on cone-beam computed tomography images and marked transbronchially with indigo carmine dye (median markers per lesion: 3); microcoils were placed for deep margins in 16 patients. The median localization time was 30 min (IQR 23-42 min), and the median fluoroscopy duration was 3.3 min (IQR 2.2-5.3 min). The median radiation exposure (expressed as the dose area product) was 4303.6 μGym2 (IQR 2879.5-6268.7 μGym2). All nodules were successfully marked and resected, and the median global operating room time was 178.5 min (IQR 153.5-204 min). There were no localization-related complications, and the median length of postoperative stay was 1 day (IQR, 1-2 days).

CONCLUSIONS

Single-stage augmented fluoroscopic bronchoscopy localization under general anaesthesia followed by thoracoscopic surgery was feasible and safe.

Toll-like receptor and matrix metalloproteinase single-nucleotide polymorphisms, haplotypes, and polygenic risk score differentiated between tuberculosis disease and infection

OBJECTIVES

The association of toll-like receptors (TLRs) and matrix metalloproteinases (MMPs) single-nucleotide polymorphisms (SNPs) among latent tuberculosis (TB) infection and active TB remained less studied.

METHODS

We recruited participants with TB disease (active TB) (n = 400) and TB infection (latent TB infection) (n = 203) in this study. We genotyped SNPs in TLR1, TLR2, TLR4, MMP1, MMP8, MMP9, MMP12, and tissue inhibitor of MMP2. Single-variant analysis and haplotype analysis were performed, and a polygenic risk score (PRS) was created.

RESULTS

We found that SNPs in TLR1 (rs5743580, rs5743551), TLR2 (rs3804100), and MMP8 (rs2508383) were associated with different TB disease status risks. TLR1 rs5743580 was associated with a higher risk of TB disease status in genotypic, recessive, and additive models. TLR2 rs3804100 polymorphisms demonstrated significant association with TB disease status in genotypic, dominant, and additive models. In the haplotype analysis, the TLR1 haplotype was associated with a higher risk of TB disease, and the MMP12 haplotype was associated with a lower risk of TB disease. A PRS using 3 SNPs was associated with a higher risk of TB disease.

CONCLUSION

This study revealed that SNP variants in TLR1, TLR2, and MMP8 differed among TB infection and disease. Haplotypes and PRS could potentially help predict TB disease status.

[Study on mesentary margin in supply vessel-oriented radical resection of colorectal cancer]

The concept of radical surgery has experienced from vascular anatomy guidance, lymph node dissection guidance to en-bloc resection guidance. At present, the mesentery guided surgery has developed to a new level of understanding. There are many classical theories on the understanding of the mesentery, from "the mesentery is a wrapped composite structure" to "the mesentery is an organ" and then to "the generalized mesentery theory", but they do not clearly put forward the boundary mark of the mesentery. On the basis of various membrane anatomy theories at home and abroad, we summarized and defined three boundaries of mesenteric excision in radical resection of colorectal cancer. The lateral boundary of the mesentery is the intestinal resection boundary and its mesentery oriented by supplyvessel, the bottom boundary is the mesentery bed, and the central boundary is the degree of lymph node radical resection. Through the detailed description of the mesentery excision, it is helpful to accurately define the mesenteric margin in different stages of radical resection of tumors.

[Health-adjusted life expectancy in residents in Guangzhou, 2010-2019]

Objective: To analyze the spatiotemporal distribution of life expectancy (LE) and health-adjusted life expectancy (HALE) in Guangzhou from 2010 to 2019, and quantize the comprehensive impact of different causes and sequelae on health. Methods: The LE, HALE, and cause-excluded health adjusted life expectancy (CEHALE) were estimated using cause-of-death surveillance datasets from Guangzhou Municipal Center for Disease Control and Prevention from 2010 to 2019 and open data from the Global Burden of Disease Study. Joinpoint log-linear regression model was used to analyze the temporal trend and described spatial distribution. Results: In 2019, the LE in residents in Guangzhou was 82.9 years (80.1 years in men and 85.9 years in women), and the HALE was 75.6 years (74.0 years in men and 77.3 years in women). Compared with the urban fringe, the central urban area had higher LE and HALE, and the differences between LE and HALE were small. The LE and HALE in Guangzhou showed an increasing trend from 2010 to 2019. The LE increased by 2.8 years (AAPC=0.4, 95%CI: 0.3-0.4), with the increase of 2.8 years in men and 2.9 years in women. The HALE increased by 2.4 years (AAPC=0.3, 95%CI: 0.3-0.4), with the increase of 2.5 years in men and 2.2 years in women. The median healthy life lost due to communicable, maternal, neonatal, and nutritional diseases was 6.2 years (AAPC=-4.2, 95%CI: -5.3--3.1), while the median healthy life lost due to non-communicable diseases was 14.7 years (AAPC=1.6, 95%CI: 0.9-2.3), the median healthy life expectancy reduced by injury was 6.3 years (AAPC=-3.5, 95%CI: -4.5--2.6). Musculoskeletal disorders, skin and subcutaneous diseases, cardiovascular diseases, nutritional deficiencies, diabetes and kidney diseases were the top five diseases causing healthy life expectancy loss. Conclusion: The LE and HALE in residents in Guangzhou increased steadily from 2010 to 2019, but the quality of life in the urban fringe was lower than that of the central urban area. Non-communicable diseases were the leading causes of healthy life expectancy loss. Health policies and prevention measures should be developed according to area specific characteristics, and social medical resources should be rationally allocated to key diseases to reduce their disease burden.

[A multi-center retrospective study of perioperative chemotherapy for gastric cancer based on real-world data]

Objective: To explore the effect of perioperative chemotherapy on the prognosis of gastric cancer patients under real-world condition. Methods: A retrospective cohort study was carried out. Real world data of gastric cancer patients receiving perioperative chemotherapy and surgery + adjuvant chemotherapy in 33 domestic hospitals from January 1, 2014 to January 31, 2016 were collected. Inclusion criteria: (1) gastric adenocarcinoma was confirmed by histopathology, and clinical stage was cT2-4aN0-3M0 (AJCC 8th edition); (2) D2 radical gastric cancer surgery was performed; (3) at least one cycle of neoadjuvant chemotherapy (NAC) was completed; (4) at least 4 cycles of adjuvant chemotherapy (AC) [SOX (S-1+oxaliplatin) or CapeOX (capecitabine + oxaliplatin)] were completed. Exclusion criteria: (1) complicated with other malignant tumors; (2) radiotherapy received; (3) patients with incomplete data. The enrolled patients who received neoadjuvant chemotherapy and adjuvant chemotherapy were included in the perioperative chemotherapy group, and those who received only postoperative adjuvant chemotherapy were included in the surgery + adjuvant chemotherapy group. Propensity score matching (PSM) method was used to control selection bias. The primary outcome were overall survival (OS) and progression-free survival (PFS) after PSM. OS was defined as the time from the first neoadjuvant chemotherapy (operation + adjuvant chemotherapy group: from the date of operation) to the last effective follow-up or death. PFS was defined as the time from the first neoadjuvant chemotherapy (operation + adjuvant chemotherapy group: from the date of operation) to the first imaging diagnosis of tumor progression or death. The Kaplan-Meier method was used to estimate the survival rate, and the Cox proportional hazards model was used to evaluate the independent effect of perioperative chemo therapy on OS and PFS. Results: 2 045 cases were included, including 1 293 cases in the surgery+adjuvant chemotherapy group and 752 cases in the perioperative chemotherapy group. After PSM, 492 pairs were included in the analysis. There were no statistically significant differences in gender, age, body mass index, tumor stage before treatment, and tumor location between the two groups (all P>0.05). Compared with the surgery + adjuvant chemotherapy group, patients in the perioperative chemotherapy group had higher proportion of total gastrectomy (χ(2)=40.526, P<0.001), smaller maximum tumor diameter (t=3.969, P<0.001), less number of metastatic lymph nodes (t=1.343, P<0.001), lower ratio of vessel invasion (χ(2)=11.897, P=0.001) and nerve invasion (χ(2)=12.338, P<0.001). In the perioperative chemotherapy group and surgery + adjuvant chemotherapy group, 24 cases (4.9%) and 17 cases (3.4%) developed postoperative complications, respectively, and no significant difference was found between two groups (χ(2)=0.815, P=0.367). The median OS of the perioperative chemotherapy group was longer than that of the surgery + adjuvant chemotherapy group (65 months vs. 45 months, HR: 0.74, 95% CI: 0.62-0.89, P=0.001); the median PFS of the perioperative chemotherapy group was also longer than that of the surgery+adjuvant chemotherapy group (56 months vs. 36 months, HR=0.72, 95% CI:0.61-0.85, P<0.001). The forest plot results of subgroup analysis showed that both men and women could benefit from perioperative chemotherapy (all P<0.05); patients over 45 years of age (P<0.05) and with normal body mass (P<0.01) could benefit significantly; patients with cTNM stage II and III presented a trend of benefit or could benefit significantly (P<0.05); patients with signet ring cell carcinoma benefited little (P>0.05); tumors in the gastric body and gastric antrum benefited more significantly (P<0.05). Conclusion: Perioperative chemotherapy can improve the prognosis of gastric cancer patients.

[Safety and short-term efficacy of apatinib combined with oxaliplatin and S-1 in the conversion treatment for gastric cancer with peritoneal metastasis]

Objective: To investigate the safety and short-term efficacy of apatinib combined with oxaliplatin and S-1 in the conversion treatment for gastric cancer with different types of peritoneal metastasis. Methods: A prospective study "one arm exploratory clinical study of conversion therapy of apatinib with S-1 and oxaliplatin in the treatment of advanced gastric cancer" (clinical registration ChiCTR-ONC-17010430) from medical record database was retrospectively analyzed. Patients aged 18-70 years with gastric cancer peritoneal metastasis confirmed by histology and laparoscopic exploration, and had not receive radiotherapy, chemotherapy, targeted therapy or immunotherapy before were enrolled. Before operation, the patients received 6 cycles of S-1 (80-120 mg/d, d1-d14) and oxaliplatin (130 mg/m(2), d1), and 5 cycles of apatinib (500 mg/d, d1-d21) conversion regimen. Three weeks after chemotherapy, whether the operation was performed or not depending on re-evaluation and patient preference. The main outcome were adverse reactions, and the secondary outcome were objective remission rate (ORR), disease control rate (DCR), and overall survival (OS) rate. The follow-up period was up to May 2020. Results: A total of 27 patients with gastric cancer peritoneal metastasis were enrolled in this study. There were 13 males and 14 females, with a median age of 58 (30-68) years old. There were 9 cases of P1a, 5 cases of P1b, and 13 cases of P1c. There were 14 cases with 1-5 scores of PCI (peritoneal cancer index), and 13 cases with 6 scores or above. The incidence of adverse reactions was 100%. The most common adverse reactions were hematological events including leucopenia (70.4%, 19/27) and granulocytopenia (74.1%, 20/27). Non-hematological adverse events included fatigue (51.9%, 14/27) and oral mucositis (37.0%, 10/27). One patient was withdrawn due to grade 4 thrombocytopenia. Among 26 patients with feasible efficacy evaluation, 18 (69.2%) achieved partial remission, 3 (11.5%) achieved stable disease, and 5 (19.2%) disease progression. The objective remission rate was 69.2% (18/26) and the disease control rate was 80.8% (21/26). Fourteen patients underwent surgery, including 6 patients undergoing R0 resection with the R0 resection rate of 42.9% (6/14). The postoperative pathological response rate was 64.3% (9/14). The follow-up time was 12-40 months, and the follow-up rate was 100%. The 1-year OS rate was 65.2% and the survival time was (14.0±1.7) months. The 1-year OS rates of P1a/P1b group and P1c group were 81.8% and 42.0% respectively, whose difference was statistically significant (P=0.041). The 1-year OS rates of PCI 1-5 group and PCI ≥6 group were 67.3% and 38.5% respectively, whose difference was statistically significant (P=0.022). Conclusion: In the conversion treatment of gastric cancer peritoneal metastasis, the safety of apatinib combined with oxaliplatin and S-1 is acceptable, and this regimen shows a good short-term survival efficacy in patients with P1a/P1b and PCI of 1-5.

Deep Learning for Pediatric Posterior Fossa Tumor Detection and Classification: A Multi-Institutional Study

BACKGROUND AND PURPOSE

Posterior fossa tumors are the most common pediatric brain tumors. MR imaging is key to tumor detection, diagnosis, and therapy guidance. We sought to develop an MR imaging-based deep learning model for posterior fossa tumor detection and tumor pathology classification.

MATERIALS AND METHODS

The study cohort comprised 617 children (median age, 92 months; 56% males) from 5 pediatric institutions with posterior fossa tumors: diffuse midline glioma of the pons (n = 122), medulloblastoma (n = 272), pilocytic astrocytoma (n = 135), and ependymoma (n = 88). There were 199 controls. Tumor histology served as ground truth except for diffuse midline glioma of the pons, which was primarily diagnosed by MR imaging. A modified ResNeXt-50-32x4d architecture served as the backbone for a multitask classifier model, using T2-weighted MRIs as input to detect the presence of tumor and predict tumor class. Deep learning model performance was compared against that of 4 radiologists.

RESULTS

Model tumor detection accuracy exceeded an AUROC of 0.99 and was similar to that of 4 radiologists. Model tumor classification accuracy was 92% with an F₁ score of 0.80. The model was most accurate at predicting diffuse midline glioma of the pons, followed by pilocytic astrocytoma and medulloblastoma. Ependymoma prediction was the least accurate. Tumor type classification accuracy and F₁ score were higher than those of 2 of the 4 radiologists.

CONCLUSIONS

We present a multi-institutional deep learning model for pediatric posterior fossa tumor detection and classification with the potential to augment and improve the accuracy of radiologic diagnosis.

Clinical features and treatment outcomes of Mycobacterium chimaera lung disease and antimicrobial susceptibility of the mycobacterial isolates

BACKGROUND

Mycobacterium chimaera, one of the Mycobacterium avium complex (MAC) members, was recently identified using modern gene sequencing analysis. Unlike M. avium and M. intracellulare, little is known about the clinical features, antimicrobial susceptibilities, and treatment outcomes of M. chimaera lung disease.

METHODS

This study was conducted in a medical center from December 2012 to July 2015. Patients who fulfilled the 2007 ATS/IDSA diagnostic criteria for nontuberculous mycobacterial lung disease were enrolled. M. chimaera isolates were identified based on the findings of sequencing of rpoB gene, the internal transcribed spacer (ITS) region of the 16S-23S rRNA gene, and the heat-shock protein 65 gene (hsp65). Minimum inhibitory concentrations (MICs) of 13 antimicrobial agents were determined.

RESULTS

During the study period, 247 patients with MAC lung disease were identified, and 11.3% (28/247) of the patients had lung disease caused by M. chimaera. Among these patients, 17 (60.7%) were female, and their median age was 72.5 (40-100) years. All M. chimaera isolates were susceptible to clarithromycin and rifabutin. All the isolates were resistant to moxifloxacin and only 10 (35.7%) and 2 (7.1%) were susceptible to amikacin and linezolid, respectively. Of the nine patients who received macrolide-based regimens, more achieved radiographic resolution than those treated with non-macrolide-based regimens (66.7% vs. 15.8%, P = 0.013), and they tended to have better survival (P = 0.10).

CONCLUSIONS

A substantial portion (11.3%) of MAC lung disease cases were caused by M. chimaera, and treatment with macrolide-based regimens resulted in better clinical outcomes for patients with M. chimaera lung disease.

Sick leave and disability pension before and after breast cancer diagnosis: a Swedish cohort study

Background

Most working-aged women are, after diagnosed with breast cancer (BC), on some sickness absence and/or disability pension (SADP). We aimed to explore possible trajectories of their previous and subsequent SADP days and risk factors for consistently high levels of future SADP.

Methods

In a longitudinal cohort study of all 3536 women in Sweden aged 19-64 with a first BC diagnosis in 2010, we calculated their annual SADP net days from two years before to three years after BC diagnosis date. A group-based trajectory model was applied to depict SADP patterns. Logistic regressions were used to calculate odds ratios (OR) with 95% confidence intervals (CI) for having &gt;90 or &gt; 180 SADP days/year in the three postdiagnostic years.

Results

Three trajectories of SADP days/month over the five years were identified: “high” (30% of all)”, “increase only around diagnosis” (61%), and ’constant very high’ (9%). Across the study period, the risk factors associated with constantly high levels of SADP days (&gt;90 or &gt; 180 days/year) were similar. Particularly, factors significantly associated with having annual SADP &gt;90 days during all the three postdiagnostic years were: stage II cancer (OR = 4.59; 95% CI 2.98-7.07), stage III+IV (OR = 26.57; 13.52-52.22), prediagnosis SA 1-30 days (OR = 2.73; 1.30-5.70), prediagnosis SA &gt; 90 days (OR = 24.52; 12.25-49.08), and prediagnosis DP (OR = 659.97; 292.52-&gt;999.99).

Conclusions

When diagnosed with BC, SADP increased significantly postdiagnosis, however, decreased with time and the absolute majority had no SADP the third year after BC diagnosis. Advanced cancer stage and previous high SADP were the highest risk factors for later SADP.

Key messages

Most breast cancer survivors’ work capacity (sickness absence (SA) and disability pension (DP) is only affected shortly post-diagnosis. Prior SADP and high cancer stage were strongest risk factors. Register-based information on breast cancer patients and their sickness absence and disability pension before and after diagnosis are useful to identify different types of return-to-work patterns.

[Clinical timing and benefit of antiviral treatment for hepatitis C]

Current treatments for hepatitis C include pegylated interferon-α (Peg-IFNα) and ribavirin (RBV) combination therapy and direct antiviral agents (DAAs). Antiviral treatment can be initiated after 4 to 6 months of clinical observations for patients with acute infections, but should be started as early as possible for those with chronic infections. However, for patients who are ineligible for Peg-IFN and RBV combination therapy and have no unrestricted access to DAAs, it is advised that they wait for the approval of DAAs in China if their medical condition is under control. Though, antiviral therapy should be started immediately if the disease progresses. It has been reported that there are numerous clinical benefits of antiviral treatment for hepatitis C. However, the long-term impact of DAAs treatment including efficacy and safety is limited and remains to be explored.

Super-atmospheric pressure ionization mass spectrometry and its application to ultrafast online protein digestion analysis

Pressure is a key parameter for an ionization source. In this Special Feature article, Lee Chuin Chen and colleagues review super-atmospheric pressure ionization MS with electrospray, corona-discharge-based chemical ionization, and field desorption. They routinely run their mass spectrometer with ion source pressures ranging from several to several tens of atmospheres. A number of strategies have been used to preserve the high vacuum of the instrument while working with a high-pressure (HP) ion source. A recent prototype uses a booster pump with variable pumping speed added to the first pumping stage of the mass spectrometer to regulate a constant vacuum pressure. Further, a new HP-ESI source allowing rapid (a few seconds) online protein digestion MS is also reported. Dr. Lee Chuin Chen is Associate Professor in the Department of Interdisciplinary Research at the University of Yamanashi (Yamanashi, Japan). His main research interest is the development of novel mass spectrometric methods for in-situ medical diagnosis.

Atmospheric pressure chemical ionization of explosives using alternating current corona discharge ion source

The high-sensitive detection of explosives is of great importance for social security and safety. In this work, the ion source for atmospheric pressure chemical ionization/mass spectrometry using alternating current corona discharge was newly designed for the analysis of explosives. An electromolded fine capillary with 115 µm inner diameter and 12 mm long was used for the inlet of the mass spectrometer. The flow rate of air through this capillary was 41 ml/min. Stable corona discharge could be maintained with the position of the discharge needle tip as close as 1 mm to the inlet capillary without causing the arc discharge. Explosives dissolved in 0.5 µl methanol were injected to the ion source. The limits of detection for five explosives with 50 pg or lower were achieved. In the ion/molecule reactions of trinitrotoluene (TNT), the discharge products of NOx (-) (x = 2,3), O3 and HNO3 originating from plasma-excited air were suggested to contribute to the formation of [TNT - H](-) (m/z 226), [TNT - NO](-) (m/z 197) and [TNT - NO + HNO3 ](-) (m/z 260), respectively. Formation processes of these ions were traced by density functional theory calculations. Copyright © 2015 John Wiley & Sons, Ltd.

Excitons and biexcitons in InGaN quantum dot like localization centers

Indium segregation in a narrow InGaN single quantum well creates quantum dot (QD) like exciton localization centers. Cross-section transmission electron microscopy reveals varying shapes and lateral sizes in the range ∼1-5 nm of the QD-like features, while scanning near field optical microscopy demonstrates a highly inhomogeneous spatial distribution of optically active individual localization centers. Microphotoluminescence spectroscopy confirms the spectrally inhomogeneous distribution of localization centers, in which the exciton and the biexciton related emissions from single centers of varying geometry could be identified by means of excitation power dependencies. Interestingly, the biexciton binding energy (E(b)xx) was found to vary from center to center, between 3 to -22 meV, in correlation with the exciton emission energy. Negative binding energies are only justified by a three-dimensional quantum confinement, which confirms QD-like properties of the localization centers. The observed energy correlation is proposed to be understood as variations of the lateral extension of the confinement potential, which would yield smaller values of E(b)xx for reduced lateral extension and higher exciton emission energy. The proposed relation between lateral extension and E(b)xx is further supported by the exciton and the biexciton recombination lifetimes of a single QD, which suggest a lateral extension of merely ∼3 nm for a QD with strongly negative E(b)xx = -15.5 meV.

Changes in trends and pattern of strong opioid prescribing in primary care

Background

This study evaluated the prescribing trends of four commonly prescribed strong opioids in primary care and explored utilization in non-cancer and cancer users.

Methods

This cross-sectional study was conducted from 2000 to 2010 using the UK Clinical Practice Research Datalink. Prescriptions of buprenorphine, fentanyl, morphine and oxycodone issued to adult patients were included in this study. Opioid prescriptions issued after patients had cancer medical codes were defined as cancer-related use; otherwise, they were considered non-cancer use. Annual number of prescriptions and patients, defined daily dose (DDD/1000 inhabitants/day) and oral morphine equivalent (OMEQ) dose were measured in repeat cross-sectional estimates.

Results

In total, there were 2,672,022 prescriptions (87.8% for non-cancer) of strong opioids for 178,692 users (59.9% female, 83.9% non-cancer, mean age 67.1 ± 17.0 years) during the study period. The mean annual (DDD/1000 inhabitants/day) was higher in the non-cancer group than in the cancer group for all four opioids; morphine (0.73 ± 0.28 vs. 0.12 ± 0.04), fentanyl (0.46 ± 0.29 vs. 0.06 ± 0.24), oxycodone (0.24 ± 0.19 vs. 0.038 ± 0.028) and buprenorphine (0.23 ± 0.15 vs. 0.008 ± 0.006). The highest proportion of patients were prescribed low opioid doses (OMEQ ≤ 50 mg/day) in both non-cancer (50.3%) and cancer (39.9%) groups, followed by the dose ranks of 51–100 mg/day (26.2% vs. 28.7%), 101–200 mg/day (15.1% vs. 19.2%) and >200 mg/day (8.25% vs. 12.1%).

Conclusions

There has been a huge increase in strong opioid prescribing in the United Kingdom, with the majority of prescriptions for non-cancer pain. Morphine was the most frequently prescribed, but the utilization of oxycodone, buprenorphine and fentanyl increased markedly over time.

Treadmill training in moderate risk preterm infants promotes stepping quality--results of a small randomised controlled trial

Infants at risk for neuromotor delay (NMD) are associated with premature birth and low birth weight. These infants frequently exhibit tone, posture, and movement abnormalities. Therefore, it is important to identify potential interventions to facilitate early motor development within this population. The purpose of this study was to examine the potential benefits of treadmill (TM) training in infants at risk for NMD. Furthermore, relationships between TM stepping performance and onset of walking have been suggested, and therefore, were also explored. Twenty-eight infants at moderate risk for NMD were randomly assigned to one of two groups: (1) TM training (experimental) (N=15) or (2) control (N=13). Infants in the experimental group were trained for 8 min/day, five days/week from study entry until walking onset. Monthly, 5 min of TM stepping performance were videotaped and analysed for infants in both groups to obtain frequency and quality of TM stepping. Groups were different in terms of TM stepping performance with experimental group displaying better stepping. However, they did not differ in age of walking onset (experimental=15.1 months, control=14.6 months). In both groups, frequency of TM stepping was significantly related to onset of walking. Findings suggest that TM training as implemented impact the quality of TM stepping, but did not significantly improve walking onset. Given the significant relationship between stepping and walking onset, the moderate affection of the population, the relative low intensity and lack of individualisation of the training, we suggest future research should further explore the impact of TM training on gait-related variables and include individualised, more intense, and prolonged training.

Anomalous quantum efficiency for photoconduction and its power dependence in metal oxide semiconductor nanowires

The quantum efficiency and carrier lifetime that decide the photoconduction (PC) efficiencies in the metal oxide semiconductor nanowires (NWs) have been investigated. The experimental result surprisingly shows that the SnO2, TiO2, WO3, and ZnO NWs reveal extraordinary quantum efficiencies in common, which are over one to three orders of magnitude lower than the theoretical expectation. The surface depletion region (SDR)-controlled photoconductivity is proposed to explain the anomalous quantum efficiency and its power dependence. The inherent difference between the metal oxide nanostructures such as carrier lifetime, carrier concentration, and dielectric constant leading to the distinct PC performance and behavior are also discussed.

Long-term efficacy and safety of exemestane in the treatment of breast cancer

Exemestane, a steroidal aromatase inhibitor, is licensed for postmenopausal patients with estrogen receptor (ER)-positive breast cancer as second-line therapy in metastatic disease following antiestrogen failure and as part of sequential adjuvant therapy following initial tamoxifen. This study is a systematic literature review, evaluating exemestane in different clinical settings. The Ovid Medline (1948-2012), Embase (1980-2012), and Web of Science (1899-2012) databases were searched. Forty-two relevant articles covering randomized controlled trials were reviewed for efficacy and safety, and three for adherence. With regard to efficacy in metastatic disease, exemestane is superior to megestrol acetate after progression on tamoxifen. There is evidence for noninferiority to fulvestrant (following a prior aromatase inhibitor) and to nonsteroidal aromatase inhibitors in the first-line setting. Combined use with everolimus is shown to be more efficacious than exemestane alone following previous aromatase inhibitor use. In the adjuvant setting, a switch to exemestane after 2-3 years of tamoxifen is superior to 5 years of tamoxifen. Exemestane is noninferior to 5 years of tamoxifen as upfront therapy, and may have a role as an extended adjuvant therapy. Used as neoadjuvant therapy, increased breast conservation is achievable. As chemoprevention, exemestane significantly reduces the incidence of breast cancer in "at-risk" postmenopausal women. Exemestane is associated with myalgias and arthralgias, as well as reduced bone mineral density and increased risk of fracture, which do not appear to persist at follow-up, with subsequent return to pretreatment values. Compared with tamoxifen, there is a reduced incidence of endometrial changes, thromboembolic events, and hot flashes. Limited evidence shows nonadherence in 23%-32% of patients. Evidence is growing in support of exemestane in all clinical settings. It is generally more efficacious and has a better safety profile than tamoxifen. How it compares with the nonsteroidal aromatase inhibitors remains to be established. Further studies are required on adherence to ensure that maximum benefit is obtained.

Prospective study of birth interval dynamics in rural Bangladesh

Abstract A group of 209 married, fecund women in rural Bangladesh were studied prospectively for 24 months from 1969 to 1971 to define some of the biological and sociological factors relating to fertility performance. These women were selected from a larger study population of 112,000 that had been followed with a daily house-to-house vital registration programme since 1966. The selected women were interviewed bi-weekly and were asked questions about menstruation, pregnancy, lactation, husband's occupational absences, and monthly urine tests for pregnancy were taken. The results for 193 non-contracepting women revealed that the seasonal pattern of births previously observed in this population could be associated with a corresponding seasonal pattern of conceptions and that this was due to a seasonal trend in fecundability. The highest conception rates were in the coolest months of the year. Post-partum lactational amenorrhoea was very prolonged, averaging 17 months for women with a surviving child. The appearance of the first post-partum menstrual flow (onset of ovulation) also had a seasonal trend which could not be adequately explained. The median waiting time to conception, once menstruation had resumed was eight months. This interval was influenced by seasonal fluctuations, as well as by the age of women and by husbands' absences. The foetal wastage rate was 15·0 per 100 conceptions, with 62 per cent of the foetal losses occurring during the second month of gestation. Overall, the average birth interval was 33 months, with the prolonged lactational amenorrhoea accounting for almost 45 per cent of this interval. From the Department of Population Dynamics, Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland 21205.

Phase I safety, pharmacokinetic, and pharmacodynamic study of the oral phosphatidylinositol-3-kinase and mTOR inhibitor BGT226 in patients with advanced solid tumors

BACKGROUND

This phase I dose-escalation study investigated the maximum tolerated dose (MTD), safety, pharmacokinetics, pharmacodynamics (PDs), and preliminary antitumor activity of BGT226, a potent, oral dual phosphatidylinositol-3-kinase (PI3K)/mammalian target of rapamycin inhibitor.

PATIENTS AND METHODS

Fifty-seven patients with advanced solid tumors received BGT226 2.5-125 mg/day three times weekly (TIW). Dose escalation was guided by an adaptive Bayesian logistic regression model with overdose control. Assessments included response per RECIST, [18F]-fluorodeoxyglucose uptake, and phosphorylated-S6 in skin and paired tumor samples.

RESULTS

Three patients (125 mg cohort) had dose-limiting toxic effects (grade 3 nausea/vomiting, diarrhea). BGT226-related adverse events included nausea (68%), diarrhea (61%), vomiting (49%), and fatigue (19%). BGT226 demonstrated rapid absorption, variable systemic exposure, and a median half-life of 6-9 h. Seventeen patients (30%) had stable disease (SD) as best response. Nine patients had SD for ≥16 weeks. Thirty patients (53%) achieved stable metabolic disease as assessed by [18F]-fluorodeoxyglucose-positron emission tomography; however, no correlation between metabolic response and tumor shrinkage according to computed tomography was observed. PD changes suggested PI3K pathway inhibition but were inconsistent.

CONCLUSIONS

The MTD of BGT226 was 125 mg/day TIW, and the clinically recommended dose was 100 mg/day TIW. Limited preliminary antitumor activity and inconsistent target inhibition were observed, potentially due to low systemic exposure.

Probable Blastomyces dermatitidis infection in a young rat

A 21-week-old male untreated control SHR/NCrlNarl rat was found dead during an experiment. Grossly, pulmonary lesions were characterized by multifocal to coalescing firm gray-white nodules randomly scattered on the surface. Microscopically, bronchopneumonia was found with pyogranulomas containing neutrophils, macrophages, and numerous thick-walled yeast cells. Yeast cells, 5 to 25 μm in diameter, with no branching of hyphae were observed by staining with hematoxylin and eosin, Diff-Quik, and periodic acid-Schiff. Furthermore, polymerase chain reaction (PCR) using panfungal and nested PCR primers were used for detection of Blastomyces dermatitidis DNA in the lung tissue. After sequencing and matching with DNA sequences in the GenBank, the sample showed a similarity of 94.6% and 97% to Ajellomyces dermatitidis (B. dermatitidis), respectively. On the basis of these results, probable pulmonary blastomycosis was diagnosed. The origin of the infection in the colony rat is undetermined.

Photoconduction mechanism of oxygen sensitization in InN nanowires

The photoconduction (PC) mechanism in indium nitride (InN) nanowires (NWs) has been investigated via environment-, temperature-, and power-dependent measurements. The adsorbed oxygen-induced modulation of the surface state is proposed to be the leading factor in the long lifetime or high gain transport and in sensitizing photocurrent generation in the InN NWs. The electron trapping effect by adsorbed oxygen can be verified by the increased activation energy from 33 ± 4 (in vacuum) to 58 ± 2 meV (in oxygen). The observed supralinear power dependence of photocurrent also suggests the presence of acceptor states that influence the carrier recombination behavior and compensate the thermal carriers in the InN NWs. The potential influence of native oxide on the molecule-sensitive PC in this nitride nanomaterial is also inferred.

Pediatric lupus in Asia

Of all patients with systemic lupus erythematosus (SLE), 15-20% are diagnosed during childhood, with disease onset prior to the age of 16 years. Because disease expression in SLE is influenced by environment factors and differs between racial and ethnic groups. The aims of this review were to describe prevalence, clinical manifestations, common infectious complications, and outcome of pediatric-onset SLE in Asia. The prevalence of pediatric-onset SLE was 6.3-19.3 per 100,000 in Asia. The ratio of female to male was 4.7-6.2. The mean age at diagnosis of pediatric-onset SLE was 8.6-13.5 years. The most common clinical features of pediatric-onset SLE in Asia were cutaneous rashes, arthritis, hematological involvement and nephritis. The occurrence of nephritis varies from 29% to 81%. The most common histopathology of lupus nephritis was diffuse proliferative glomerulonephritis (WHO Class-IV) which occurred in 39.4-54% of case of lupus nephritis. Pediatric-onset SLE patients with infections have poor outcomes than uninfected patients. Gram-negative bacilli are the most common microorganisms responsible for bacteremia in Asian patients with SLE. Recurrent major infections predict poorer disease outcome and associated organ damage in pediatric-onset SLE. Improving the survival of SLE patients was reported in Asia in recent decades. The survival was 92% at the age of 5 years, 86% at 10 years and 79% at 15 years in children with SLE in Taiwan in 2008.

Analysis of protein profiles in human epithelial ovarian cancer tissues by proteomic technology

BACKGROUND

Screening in ovarian cancer is progressively finding out candidate genes and proteins which may work as screening biomarkers and play a role in tumor progression. We examined the protein expression patterns of ovarian cancer tissues using two-dimensional gel electrophoresis (2-DE) and matrix-assisted laser desorption/ionization-time of fight mass spectrometry (MALDI-TOF MS).

METHODS

Tissues from 36 ovarian cancers and 20 normal ovaries were examined by 2-DE. The images of silver stained gels were analyzed by ImageMaster 2D Elite. The peptide mixtures, after in-gel digestion, were determined by MALDI-TOF MS for fingerprinting. The de-isotope tryptic peptide profiles were matched by using the Mascot search engine based on the entire NCBI and Swiss-Prot protein databases. Western/dot blots were then applied to verify the findings.

RESULTS

In ovarian cancer, 12 proteins that showed differential expressions were identified unequivocally. Among these proteins, five proteins (galectin-1, cathepsin B, ubiquitin carboxy-terminal hydrolase L1, HLA class II antigen DRB1-11 and heat shock protein 27) were up-regulated and seven proteins (cellular retinol-binding protein, transthyretin, SH3 binding glutamic-rich-like protein, tubulin-specific chaperone A, DJ-1, gamma-actin and tropomyosin 4) were down-regulated.

CONCLUSION

The present study is the first to report the up-regulation of ubiquitin carboxy-terminal hydrolase L1 and the down-regulation of SH3 binding glutamic-rich-like protein, tubulin-specific chaperone A, and tropomyosin 4 in human ovarian cancer tissues. Further cloning and functional analysis of these salient proteins will provide more information on their pathophysiologic roles in ovarian cancer.

Allelochemicals and activities in a replanted Chinese fir (Cunninghamia lanceolata (Lamb.) Hook) tree ecosystem

Autotoxicity is a major reason for replant problems in managed tree ecosystems. Studies have related phenolics-based allelochemicals to autotoxicity. We selected a 20-year-old replanted Chinese fir [Cunninghamia lancealata (Lamb.) Hook] tree ecosystem to isolate, identify, determine the biological activity of, and quantify soil phytotoxins. Eight common phenolics (coumarin, vanillin, isovanillin, and p-hydroxybenzoic, vanillic, benzoic, cinnamic, and ferulic acids), friedelin, and a novel cyclic dipeptide (6-hydroxy-1,3-dimethyl-8-nonadecyl-[1,4]-diazocane-2,5-diketone) were obtained by using the bioassay-guided isolation technique from toxic soil of the replanted Chinese fir tree ecosystem. Chemical structures were determined by spectroscopic means, including 2D-NMR (COSY, HMQC, HMBC, and NOESY) experiments. High concentrations of soil phenolics and friedelin were observed in the natural evergreen broadleaf forest (CK) rather than in the Chinese fir tree ecosystem. The phenolics and friedelin were not phytotoxic to Chinese fir trees. However, the cyclic dipeptide inhibited Chinese fir growth at soil concentrations determined in the replanted Chinese fir tree ecosystem. There was a significantly higher soil concentration of cyclic dipeptide in the replanted Chinese fir tree ecosystem than in a fresh Chinese fir tree ecosystem. The results suggest that phenolics and friedelin are not key allelochemicals since they are weakly phytotoxic and are detected in low concentrations in the replanted Chinese fir tree ecosystem, while cyclic dipeptide is a highly active allelochemical with a phytotoxic effect that limits offspring growth in the replanted Chinese fir tree ecosystem. The discovery of cyclic dipeptide, as well as a further understanding of its potential action mechanism in the replanted Chinese fir tree ecosystem, may contribute to solving the replant problems in managed tree ecosystems.

Strong luminescence from strain relaxed InGaN/GaN nanotips for highly efficient light emitters

Semiconductor heterostructures represent the most important building block for current optoelectronic devices. One of the common features of semiconductor heterostructures is the existence of internal strain due to lattice mismatch. The internal strain can tilt the band alignment and significantly alter the physical properties of semiconductor heterostructures, such as reducing the internal quantum efficiency of a light emitter. Here, we provide a convenient route to release the internal strain by patterning semiconductor heterostructures into nanotip arrays. The fabrication of the nanotip arrays was achieved by self-masked dry etching technique, which is simple, low cost and compatible with current semiconductor technologies. By implementing our approach to InGaN/GaN multiple quantum wells, we demonstrate that the light emission can be enhanced by up to 10 times. Our approach renders an excellent opportunity to manipulate the internal strain, and is very useful to create highly efficient solid state emitters.

Epitaxial Growth of InN Films by Molecular-Beam Epitaxy Using Hydrazoic Acid (HN3) as an Efficient Nitrogen Source

Epitaxial InN films have been successfully grown on c-plane GaN template by gas-source molecular-beam epitaxy with hydrazoic acid (HN3) as an efficient nitrogen source. Results in residual-gas analyzer show that the HN3 is highly dissociated to produce nitrogen radicals and can be controlled in the amounts of active nitrogen species by tuning HN3 pressure. A flat and high-purity InN epifilm has been realized at the temperature near 550 degrees C, and a growth rate of 200 nm/hr is also achieved. Moreover, the epitaxial relationship of the InN(002) on the GaN(002) is reflected in the X-ray diffraction, and the full-width at half-maximum of the InN(002) peak as narrow as 0.05 degrees is related to a high-quality crystallinity. An infrared photoluminescence (PL) emission peak at 0.705 eV and the integrated intensity increasing linearly with excitation power suggest that the observed PL can be attributed to a free-to-bound recombination.

Visible-laser desorption/ionization on gold nanostructures

In this report, we describe the visible-laser desorption/ionization of biomolecules deposited on gold-coated porous silicon and gold nanorod arrays. The porous silicon made by electrochemical etching was coated with gold using argon ion sputtering. The gold nanorod arrays were fabricated by electrodepositing gold onto a porous alumina template, and the subsequent partial removal of the alumina template. A frequency-doubled/tripled Nd : YAG laser was used to irradiate the gold nanostructured substrate, and the desorbed molecular ions were mass-analyzed by a time-of-flight mass spectrometer. The desorption/ionization of biomolecules for both substrates was favored by the use of the 532-nm visible-laser, which is in the range of the localized surface plasmon resonance of the gold nanostructure. The present technique offers a potential analytical method for low-molecular-weight analytes that are rather difficult to handle in the conventional matrix-assisted laser desorption/ionization (MALDI) mass spectrometry.

Drug utilization pattern of Chinese herbal medicines in a general hospital in Taiwan

PURPOSE

Drug utilization studies are important for the optimization of drug therapy and have received a great attention in recent years. Most of the information on drug use patterns has been derived from studies in modern Western medicines; however, studies regarding the drug utilization of traditional Chinese medicine (CM) are few. The present study was the first clinical research to evaluate the drug utilization patterns of Chinese herbal medicines in a general hospital in Taiwan.

METHODS

Data were collected prospectively from the patients attending the Traditional Medicine Center of Taipei Veteran General Hospital under CM drug treatments. The study was carried out over a period of 1 year, from January 2002 to December 2002. Core drug use indicators, such as the average number of drugs per prescriptions, the dosing frequency of prescriptions, and the most common prescribed CM herbs and formulae were evaluated. The primary diagnosis and the CM drugs prescribed for were also revealed. All data were analyzed by descriptive statistics.

RESULTS

A total of 10 737 patients, representing 52 255 CM drugs, were screened during the study period. Regarding the prescriptions, the average number of drugs per prescription was 4.87 and 37.21% of prescriptions were composed by five drugs. Most of prescriptions (91.38%) were prescribed for three times a day. The most often prescribed Chinese herb was Hong-Hwa (5.76%) and the most common Chinese herbal formula was Jia-Wey-Shiau-Yau-San (3.80%). The most frequent main diagnosis was insomnia (15.58%), followed by menopause (5.22%) and constipation (5.09%).

CONCLUSION

The survey revealed the drug use pattern of CMs in a general hospital. The majority of CM prescriptions were composed by 3-6 drugs and often prescribed for three times a day. Generally, the rational drug uses of CM drugs were provided with respect to the various diagnoses.

Effects of airborne World Trade Center dust on cytokine release by primary human lung cells in vitro

There are continuing concerns regarding the respiratory health effects of airborne particulate matter (PM) after the destruction of the World Trade Centre (WTC). We examined cytokine (interleukin [IL]-8, IL-6, tumor necrosis factor-alpha) release by primary human lung alveolar macrophages (AM) and type II epithelial cells after exposure to WTC PM2.5 (indoor and outdoor), PM10-2.5 (indoor), and PM53-10 (outdoor), fractionated from settled dusts within 2 months of the incident. There was an increase in AM cytokine/chemokine release at 5 and/or 50 microg/well WTC PM, which fell at 500 microg/well. Type II cells did not release tumor necrosis factor-alpha, and the increase in IL-8 and IL-6, although significant, was lower than that of AM. Respirable PM generated by the WTC collapse stimulates inflammatory mediator release by lung cells, which may contribute to the increased incidence of respiratory illness since September 11th 2001.

Health and environmental consequences of the world trade center disaster

The attack on the World Trade Center (WTC) created an acute environmental disaster of enormous magnitude. This study characterizes the environmental exposures resulting from destruction of the WTC and assesses their effects on health. Methods include ambient air sampling; analyses of outdoor and indoor settled dust; high-altitude imaging and modeling of the atmospheric plume; inhalation studies of WTC dust in mice; and clinical examinations, community surveys, and prospective epidemiologic studies of exposed populations. WTC dust was found to consist predominantly (95%) of coarse particles and contained pulverized cement, glass fibers, asbestos, lead, polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), and polychlorinated furans and dioxins. Airborne particulate levels were highest immediately after the attack and declined thereafter. Particulate levels decreased sharply with distance from the WTC. Dust pH was highly alkaline (pH 9.0-11.0). Mice exposed to WTC dust showed only moderate pulmonary inflammation but marked bronchial hyperreactivity. Evaluation of 10,116 firefighters showed exposure-related increases in cough and bronchial hyperreactivity. Evaluation of 183 cleanup workers showed new-onset cough (33%), wheeze (18%), and phlegm production (24%). Increased frequency of new-onset cough, wheeze, and shortness of breath were also observed in community residents. Follow-up of 182 pregnant women who were either inside or near the WTC on 11 September showed a 2-fold increase in small-for-gestational-age (SGA) infants. In summary, environmental exposures after the WTC disaster were associated with significant adverse effects on health. The high alkalinity of WTC dust produced bronchial hyperreactivity, persistent cough, and increased risk of asthma. Plausible causes of the observed increase in SGA infants include maternal exposures to PAH and particulates. Future risk of mesothelioma may be increased, particularly among workers and volunteers exposed occupationally to asbestos. Continuing follow-up of all exposed populations is required to document the long-term consequences of the disaster.

Sequential changes to clinical parameters and adhesion molecules following intravenous pulse cyclophosphamide and methylprednisolone treatment of refractory juvenile idiopathic arthritis

It is believed that the systemic subtype and the positive rheumatoid factor, polyarticular subtype of juvenile idiopathic arthritis (JIA) show the least favorable outcomes for therapy; patients with systemic JIA are often resistant to recommended therapeutic modalities. We report the sequential changes to clinical and laboratory findings from pulse therapy with monthly intravenous cyclophosphamide (0.5 g/m2 body surface area) administration combined with methylprednisolone (30 mg/kg; 1 gm maximum) for 6 months, following which the medication interval was elongated to 3 months for a total of from 7 to 12 courses. Among 4 children suffering from refractory systemic JIA, 3 demonstrated clinical improvement, 2 of whom achieved clinical remission. Furthermore, we also adminstered this therapy to a girl suffering from refractory polyarticular JIA, following which she revealed clinical remission subsequent to 9 courses of such therapy. From our experience, we suggest that patients afflicted with JIA that is unresponsive to traditional medication may experience benefit from this type of pulse therapy.

Blue luminescence of Au nanoclusters embedded in silica matrix

Photoluminescence study using the 325 nm He-Cd excitation is reported for the Au nanoclusters embedded in SiO(2) matrix. Au clusters are grown by ion beam mixing with 100 KeV Ar(+) irradiation on Au [40 nm]/SiO(2) at various fluences and subsequent annealing at high temperature. The blue bands above approximately 3 eV match closely with reported values for colloidal Au nanoclusters and supported Au nanoislands. Radiative recombination of sp electrons above Fermi level to occupied d-band holes are assigned for observed luminescence peaks. Peaks at 3.1 and 3.4 eV are correlated to energy gaps at the X- and L-symmetry points, respectively, with possible involvement of relaxation mechanism. The blueshift of peak positions at 3.4 eV with decreasing cluster size is reported to be due to the compressive strain in small clusters. A first principle calculation based on density functional theory using the full potential linear augmented plane wave plus local orbitals formalism with generalized gradient approximation for the exchange correlation energy is used to estimate the band gaps at the X- and L-symmetry points by calculating the band structures and joint density of states for different strain values in order to explain the blueshift of approximately 0.1 eV with decreasing cluster size around L-symmetry point.

Use of a new fluorescence immunoassay to detect anti-dsDNA antibodies is more correlated with disease activity and complement than the ELISA method in SLE patients

To determine whether the serum levels of anti-double strand DNA (anti-dsDNA) autoantibodies detected using a newly developed fluorescence immunoassay (FIA) in patients with systemic lupus erythematosus (SLE) correlated more with clinical parameters, such as SLE disease activity index (SLEDAI), complement and the occurrence of nephritis when compared with traditional enzyme-linked immunosorbent assay (ELISA), we prospectively collected 124 serum samples from 31 patients who had juvenile-onset SLE and were regularly monitored every 2 months at our outpatient clinic. At every visit, clinical manifestations and laboratory parameters were assessed and the SLEDAI was determined. Correlation analyses between the two different measurements of anti-dsDNA antibodies and SLEDAI, serum complement levels and the occurrence of nephritis were performed. The results showed that anti-dsDNA autoantibodies detected using both ELISA and FIA significantly correlated with SLEDAI, and significantly and inversely correlated with the serum levels of C3 and C4. FIA had significantly higher correlation with SLEDAI and C4 than did ELISA. The mean values of anti-dsDNA antibodies detected using FIA in patients with nephritis were significantly higher than in those without nephritis. In contrast, the values of anti-dsDNA antibodies detected using ELISA did not show significant differences between these two groups. We conclude that FIA had better correlation with SLEDAI, C4 and the occurrence of nephritis, and comparable correlations with C3 that were similar to the results found using ELISA. Thus, it is worthwhile developing the FIA method for clinical evaluation of disease activity in SLE patients.

Persistent organic pollutants in the dusts that settled across lower Manhattan after September 11, 2001

The explosion and collapse of the World Trade Center (WTC) was a catastrophic event that produced an aerosol impacting many workers, residents, and commuters during the first few days after September 11, 2001. During the initial days that followed, 14 bulk samples of the settled dust were collected at locations surrounding the epicenter of the disaster, including one indoor location. Some samples were analyzed for many potential hazards, including inorganic and organic constituents as well as morphology. The results of the analyses for persistent organic pollutants are described herein, including polycyclic aromatic hydrocarbons, polychlorinated biphenyls, and select organochlorine pesticides on settled dust samples. The sigma86-PCBs comprising less than 0.001% by mass of the bulk in the three bulk samples analyzed indicated that PCBs were of limited significance in the total settled dust across lower Manhattan. Likewise, organochlorine pesticides, including chlordanes, hexachlorobenzene, heptachlor, 4,4'-DDE, 2,4'-DDT, 4,4'-DDT, and Mirex, were found at low concentrations in the bulk samples. Conversely, the sigma37-PAHs comprised up to nearly 0.04% (<0.005-0.039%) by mass of the bulk settled dust in the six bulk samples. Further size segregation of these three initial bulk samples and seven additional samples indicates that sigma37-PAHs were found in higher concentrations on relatively large particles (10-53 microm), representing up to 0.04% of the total dust mass. Significant concentrations were also found on fine particles (<2.5 microm), often accounting for approximately 0.005% by mass. We estimate that approximately 100-1000 tons of sigma37-PAHs were spread over a localized area immediately after the WTC disaster on September 11.

Observations of blanket characteristics in full-scale floc blanket clarifiers

We monitored the changes in concentrations, zeta potentials, sizes and capillary suction times of the solids flocs in the clarified water from eight floc blanket clarifiers of PingTsan Water Works of Taiwan Water Supply Company with low (< 10 NTU) and high (> 100 NTU) turbidity raw water. For the former, one-stage coagulation-sedimentation treatment was adopted which yielded a rather unstable blanket. Complete washout was noticeable when the PACl dosage was insufficient. On the treatment of high-turbidity raw water, on the other hand, the Works adopted the combined treatment process, that is, the raw water was first coagulated and settled in a pre-sedimentation tank, afterwards, its effluent was coagulated again and clarified in the clarifiers. The resulting flocs could form a networked blanket that was relatively stable to the shock load in raw water turbidity.

Network strength and dewaterability of flocculated activated sludge

Works in literature proposed the use of the rheological properties of wastewater sludges as an index for conditioner assessment and control. We demonstrated in this work, on the contrary, that one could not justify the consistency of the commonly used rheological characteristics of the sewage sludge samples taken from the same site but at different dates. A physically relevant index was proposed instead for describing the total network strength, which was hypothesized to correlate the dewatering efficiency of flocculated sludge. Based on this index, the network of a sludge was demonstrated to be largely destroyed after shearing, while the relaxation in an unbound environment or mild pouring over action could partially reinstall the structure. Moreover, a uniform shear rate field could produce network of greater strength when compared with that conditioned in a stirred tank.

Coronary artery calcium determined by electron beam computed tomography for predicting angiographic coronary artery disease in moderate- to high-risk Chinese patients

The aim of this study was to evaluate the prevalence of coronary calcification among moderate- to high-risk Chinese patients and to evaluate the ability of the coronary calcium score determined by electron beam computed tomography (EBCT) to predict angiographic coronary artery disease in this population. We enrolled 163 consecutive patients and analyzed their cardiovascular risk factors, coronary calcium scores and coronary angiogram results. One hundred and twenty-five patients (76.7%) had a positive EBCT scan result (coronary calcium score >0). The prevalence of calcification and the calcium scores showed a graded relation to the number of cardiovascular risk factors and age (p < 0.001 for trend). Coronary calcium scores showed statistically significant differences between patients with angiographic evidence of coronary artery disease and patients with normal coronary angiography (p < 0.05), but could not differentiate between patients with significant and insignificant coronary artery disease. Receiver operating characteristic curve analysis showed that a coronary calcium score >5 predicted angiographic coronary artery disease with 93% sensitivity and 86% specificity (area under the curve 0.95 +/- 0.019). Multivariate analysis showed a coronary calcium score >5 to be the strongest independent predictor of angiographic coronary artery disease (odds ratio 120.7, 95% confidence interval 21.7-671.4; p < 0.001). Coronary calcium score determined by EBCT appears to have a similar predictive value in Chinese patients as it does in other ethnic populations that have been reported to date.

Action of deferoxamine against Pneumocystis carinii

We found earlier that deferoxamine (DFO), a drug used for treatment of iron overload, is active against a rat model of Pneumocystis carinii pneumonia (PCP). We had assumed a mode of action by deprivation of nutritional iron; however, data here show that DFO penetrates P. carinii, causing irreversible damage, thus indicating a different mode of action. Penetration was demonstrated by showing DFO uptake by high-pressure liquid chromatography analysis. By using calcein-AM as an indicator, exposure to DFO was shown to cause a reduction in P. carinii cytoplasmic free iron. Exposure to >or=100 microM DFO for >or=8 h in vitro caused growth to cease and cell numbers to decline over several days. This direct and irreversible damage to P. carinii led to the prediction that infrequent delivery of DFO to the lungs via an aerosol would be an effective treatment in the animal model of PCP. This prediction was confirmed by demonstrating that a once-a-week aerosol treatment of rats was 100% effective both as a prophylactic and as a curative treatment in a rat model of PCP.

Genetic variability in the development of pulmonary tolerance to inhaled pollutants in inbred mice

After repeated exposures, many individuals develop tolerance to the adverse health effects of inhaled pollutants. Pulmonary tolerance can be characterized as the ability of the lung to withstand the adverse actions of a toxic compound after repeated exposures. To determine whether genetic background is important to the development of pulmonary tolerance to inhaled pollutants, 11 inbred strains of mice were exposed once (1x) or for 5 consecutive days (5x) to 1.0 mg/m(3) of zinc oxide (ZnO). Development of pulmonary tolerance was assessed by measuring polymorphonuclear leukocyte and protein levels in bronchoalveolar lavage fluid and comparing the responses of the 1x and 5x groups. Significant interstrain variation in polymorphonuclear leukocyte and protein responses was observed between the groups with 1x and 5x exposures, which indicates that genetic background has an important role in the development of pulmonary tolerance. The BALB/cByJ strain and the DBA/2J strain were the most tolerant and nontolerant, respectively. The CByD2F1/J offspring were uniformly nontolerant. The development of tolerance was also investigated in BALB/cByJ and DBA/2J mice after 1x and 5x exposure to ozone and aerosolized endotoxin. Discordance in the phenotypic pattern of pulmonary tolerance among strains after exposure to ZnO, ozone, and endotoxin suggested that different mechanisms may be responsible for the development of pulmonary tolerance to these agents.

Differential coronary calcification on electron-beam CT between syndrome X and coronary artery disease in patients with chronic stable angina pectoris

STUDY OBJECTIVES

The differential diagnosis of syndrome X and coronary artery disease (CAD) in patients with evidence of myocardial ischemia may be difficult. The possible difference in coronary calcium detected by electron-beam CT (EBCT) between syndrome X and CAD is rarely evaluated, especially in aged patients with chronic, stable angina.

DESIGN AND SETTINGS

Prospective, controlled study at a tertiary referral medical center.

PATIENTS AND MEASUREMENTS

Forty patients with syndrome X (85% male) and 53 patients with CAD (89% male) were enrolled. Ten control subjects (90% male) with negative exercise treadmill test results and normal coronary angiographic findings served as control subjects. EBCT determined the coronary calcium scores (CCSs), and standard cardiovascular risk factors of all study subjects were analyzed.

RESULTS

The 93 study patients had CCSs that ranged from 0 to 1,857. Coronary calcification was seen in 2 of the 10 control subjects (20%), 21 of the 40 syndrome X patients (52.5%), and 51 of the 53 CAD patients (96.2%) [p < 0.01]. The CCS (median [range]) was significantly lower in syndrome X patients than in CAD patients: 1 (0 to 117) vs 202 (0 to 1,857) [p < 0.001]. Receiver operating characteristic curve analyses also demonstrated that coronary calcification differentiated syndrome X from CAD (area under curve, 0.891; 95% confidence interval, 0.806 to 0.947). Of the CAD patients whose CCSs were < 117 and overlapped with CCSs of syndrome X, multivariate analyses determined CCS > 5 (odds ratio, 13.1; 95% confidence interval, 2.86 to 59.7), hypertension (odds ratio, 6.4; 95% confidence interval, 1.5 to 27.4), and hypercholesterolemia (odds ratio, 6.7; 95% confidence interval, 1.5 to 30.5) to be independent discriminators to differentiate CAD from syndrome X. Patients with CAD had more frequent hypertension than patients with syndrome X.

CONCLUSIONS

The coronary calcium detected noninvasively by EBCT was different, though with some overlapping, between patients with syndrome X and CAD. In addition to standard cardiovascular risk factors, CCS determined by EBCT (especially > 117 or = 0) could differentiate between syndrome X and CAD in patients with chronic, stable angina with evidence of myocardial ischemia. Larger trials would be useful to validate CCS on EBCT as a predictor of clinical outcome in these patients.

High-speed sludge freezing

The investigation examined the feasibility of applying a "high-speed freezing technique, using liquid nitrogen freezing, to condition activated sludges and alum sludges. Experimental results indicate that the freezing speed is much faster than that adopted in most previous works on sludge freezing. Although the filterability and settleability of the alum sludge is improved by 3-min liquid nitrogen freezing, no similar improvement is observed for activated sludge. Moreover, curing affects neither sludge after liquid nitrogen freezing, but affects the slow-freezing activated sludge.