What does "Advanced" mean in 2023? reflecting on 10 years of the ESTRO advanced Skills in modern radiotherapy course

The roles and responsibilities of radiation therapists (RTTs) are many and varied. Professional expectations are influenced by the technology available, as well as the level of autonomy RTTs have in their daily practice. This professional range requires RTTs to possess a unique set of ever evolving skills, posing challenges from an educational perspective. Teaching these "advanced skills" has been the ambition the ESTRO Advanced Skills in Modern Radiotherapy course. In the 10th year of this course, the Faculty look back and reflect on how our programme has evolved and what it has achieved.

Evaluation of Ultra-low-dose Paediatric Cone-beam Computed Tomography for Image-guided Radiotherapy

AIMS

In image-guided radiotherapy, daily cone-beam computed tomography (CBCT) is rarely applied to children due to concerns over imaging dose. Simulating low-dose CBCT can aid clinical protocol design by allowing visualisation of new scan protocols in patients without delivering additional dose. This work simulated ultra-low-dose CBCT and evaluated its use for paediatric image-guided radiotherapy by assessment of image registration accuracy and visual image quality.

MATERIALS AND METHODS

Ultra-low-dose CBCT was simulated by adding the appropriate amount of noise to projection images prior to reconstruction. This simulation was validated in phantoms before application to paediatric patient data. Scans from 20 patients acquired at our current clinical protocol (0.8 mGy) were simulated for a range of ultra-low doses (0.5, 0.4, 0.2 and 0.125 mGy) creating 100 scans in total. Automatic registration accuracy was assessed in all 100 scans. Inter-observer registration variation was next assessed for a subset of 40 scans (five scans at each simulated dose and 20 scans at the current clinical protocol). This subset was assessed for visual image quality by Likert scale grading of registration performance and visibility of target coverage, organs at risk, soft-tissue structures and bony anatomy.

RESULTS

Simulated and acquired phantom scans were in excellent agreement. For patient scans, bony atomy registration discrepancies for ultra-low-dose scans fell within 2 mm (translation) and 1° (rotation) compared with the current clinical protocol, with excellent inter-observer agreement. Soft-tissue registration showed large discrepancies. Bone visualisation and registration performance reached over 75% acceptability (rated 'well' or 'very well') down to the lowest doses. Soft-tissue visualisation did not reach this threshold for any dose.

CONCLUSION

Ultra-low-dose CBCT was accurately simulated and evaluated in patient data. Patient scans simulated down to 0.125 mGy were appropriate for bony anatomy set-up. The large dose reduction could allow for more frequent (e.g. daily) image guidance and, hence, more accurate set-up for paediatric radiotherapy.

Online adaptive radiotherapy compared to plan selection for rectal cancer: quantifying the benefit

Background

To compare online adaptive radiation therapy (ART) to a clinically implemented plan selection strategy (PS) with respect to dose to the organs at risk (OAR) for rectal cancer.

Methods

The first 20 patients treated with PS between May–September 2016 were included. This resulted in 10 short (SCRT) and 10 long (LCRT) course radiotherapy treatment schedules with a total of 300 Conebeam CT scans (CBCT). New dual arc VMAT plans were generated using auto-planning for both the online ART and PS strategy.

For each fraction bowel bag, bladder and mesorectum were delineated on daily Conebeam CTs. The dose distribution planned was used to calculate daily DVHs. Coverage of the CTV was calculated, as defined by the dose received by 99% of the CTV volume (D99%). The volume of normal tissue irradiated with 95% of the prescribed fraction dose was calculated by calculating the volume receiving 95% of the prescribed fraction or more dose minus the volume of the CTV. For each fraction the difference between the plan selection and online adaptive strategy of each DVH parameter was calculated, as well as the average difference per patient.

Results

Target coverage remained the same for online ART. The median volume of the normal tissue irradiated with 95% of the prescribed dose dropped from 642 cm3 (PS) to 237 cm3 (online-ART)(p < 0.001). Online ART reduced dose to the OARs for all tested dose levels for SCRT and LCRT (p < 0.001). For V15Gy of the bowel bag the median difference over all fractions of all patients was − 126 cm³ in LCRT, while the average difference per patient ranged from − 206 cm³ to − 40 cm³. For SCRT the median difference was − 62 cm³, while the range of the average difference per patient was − 105 cm3 to − 51 cm³.

For V15Gy of the bladder the median difference over all fractions of all patients was 26% in LCRT, while the average difference per patient ranged from − 34 to 12%. For SCRT the median difference of V95% was − 8%, while the range of the average difference per patient was − 29 to 0%.

Conclusions

Online ART for rectal cancer reduces dose the OARs significantly compared to a clinically implemented plan selection strategy, without compromising target coverage.

Trial registration

Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center (W19_357 # 19.420; Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands).

Dosimetric benefit of an adaptive treatment by means of plan selection for rectal cancer patients in both short and long course radiation therapy

BACKGROUND

To compare target coverage and dose to the organs at risk in two approaches to rectal cancer: a clinically implemented adaptive radiotherapy (ART) strategy using plan selection, and a non-adaptive (non-ART) strategy.

METHODS

The inclusion of the first 20 patients receiving adaptive radiotherapy produced 10 patients with a long treatment schedule (25x2Gy) and 10 patients with a short schedule (5X5Gy). We prepared a library of three plans with different anterior PTV margins to the upper mesorectum, and selected the most appropriate plan on daily Conebeam CT scans (CBCT). We also created a non-adaptive treatment plan with a 20 mm margin. Bowel bag, bladder and target volume were delineated on CBCT. Daily DHVs were calculated based on the dose distribution of the selected and non-adaptive plans. Coverage of the target volume was compared per fraction between the ART and non-ART plans, as was the dose to the bladder and small bowel, assessing the following dose levels: V15Gy, V30Gy, V40Gy, V15Gy and V95% for long treatment schedules, and V15Gy and V95% for short ones.

RESULTS

Target volume coverage was maintained from 98.3% (non-ART) to 99.0% (ART)(p = 0.878). In the small bowel, ART appeared to have produced significant reductions in the long treatment schedule at V15Gy, V40Gy, V45Gy and V95% (p <  0.05), but with small absolute differences. The DVH parameters tested for the short treatment schedule did not differ significantly. In the bladder, all DVH parameters in both schedules showed significant reductions (p <  0.05), also with small absolute differences.

CONCLUSIONS

The adaptive treatment maintained target coverage and reduced dose to the organs at risk.

TRIAL REGISTRATION

Medical Research Involving Human Subjects Act (WMO) does not apply to this study and was retrospectively approved by the Medical Ethics review Committee of the Academic Medical Center, W19_194 # 19.233.

Human respiratory syncytial virus infection in the pre-clinical calf model

Human respiratory syncytial virus (hRSV) is the most important respiratory pathogen in young children worldwide. Experimental modelling of hRSV disease by bovine RSV (bRSV) infection in calves provides an important tool for developing new strategies for prevention and treatment. Depending on the scientific hypothesis under investigation, this cognate host-virus model might have the disadvantage of using a highly related but not genetically identical virus. In this study, we aim to describe viral kinetics and (clinical) disease characteristics in calves inoculated with hRSV. Our results show that hRSV infects the upper and, to a lesser extent, the lower respiratory tract of calves. Infection causes upper airway clinical disease symptoms and neutrophilic infiltration of the lower airways. We conclude that a hRSV model in calves may aid future research involving distinct scientific questions related to hRSV disease in children.

Fluorescent metal organic frameworks for the visual enhancement of latent fingermarks

Lanthanide-based (Eu and Tb) metal organic frameworks (MOFs) synthesized in this work are highly fluorescent crystalline structures that form through a self-assembly process in an aqueous environment. Various bio-organic molecules, including proteins and amino acids, can act as inducing agents for this process. The fact that these components are present in fingermark secretions, in combination with the excellent luminescent properties of the MOFs, create a visualisation method for (latent) fingermarks. The aqueous MOF precursor solutions are not ideal for the visualisation of latent fingermarks on non-porous surfaces, such as aluminium foil and glass. However, they offer a simple, non-toxic, long-lasting and effective approach for the visibility enhancement of fingermarks treated with cyanoacrylate fuming on aluminium foil and glass and latent fingermarks on the adhesive side of a transparent tape. The luminescent properties of MOF-treated fingermarks persevered for at least 12 months, providing great alternative for commonly used organic dyes such as Basic Yellow 40 and Gentian Violet. In this communication we evaluate the applicability of the proposed method for the forensic fingermark workflow.

Design and methodology of the COACH-2 (Comparative study on guideline adherence and patient compliance in heart failure patients) study: HF clinics versus primary care in stable patients on optimal therapy

BACKGROUND

Since the number of heart failure (HF) patients is still growing and long-term treatment of HF patients is necessary, it is important to initiate effective ways for structural involvement of primary care services in HF management programs. However, evidence on whether and when patients can be referred back to be managed in primary care is lacking.

AIM

To determine whether long-term patient management in primary care, after initial optimisation of pharmacological and non-pharmacological treatment in a specialised HF clinic, is equally effective as long-term management in a specialised HF clinic in terms of guideline adherence and patient compliance.

METHOD

The study is designed as a randomised, controlled, non-inferiority trial. Two-hundred patients will be randomly assigned to be managed and followed in primary care or in a HFclinic. Patients are eligible to participate if they are (1) clinically stable, (2) optimally up-titrated on medication (according to ESC guidelines) and, (3) have received optimal education and counselling on pre-specified issues regarding HF and its treatment. Furthermore, close cooperation between secondary and primary care in terms of back referral to or consultation of the HF clinic will be provided.The primary outcome will be prescriber adherence and patient compliance with medication after 12 months. Secondary outcomes measures will be readmission rate, mortality, quality of life and patient compliance with other lifestyle changes.

EXPECTED RESULTS

The results of the study will add to the understanding of the role of primary care and HF clinics in the long-term follow-up of HF patients.

Recurrence risk due to germ line mosaicism: Duchenne and Becker muscular dystrophy

The presence of multiple affected offspring from apparently non-carrier parents is caused by germ line mosaicism. Although germ line mosaicism has been reported for many diseases, figures for recurrence risks are known for only a few of them. In X-linked Duchenne and Becker muscular dystrophies (DMD/BMD), the recurrence risk for non-carrier females due to germ line mosaicism has been estimated to be between 14% and 20% (95% confidence interval 3-30) if the risk haplotype is transmitted. In this study, we have analyzed 318 DMD/BMD cases in which the detected mutation was de novo with the aim of obtaining a better estimate of the 'true' number of germ line mosaics and a more precise recurrence risk. This knowledge is essential for genetic counseling. Our data indicate a recurrence risk of 8.6% (4.8-12.2) if the risk haplotype is transmitted, but there is a remarkable difference between proximal (15.6%) (4.1-27.0) and distal (6.4%) (2.1-10.6) deletions. Overall, most mutations originated in the female. Deletions occur more often on the X chromosome of the maternal grandmother, whereas point mutations occur on the X chromosome of the maternal grandfather. In unhaplotyped de novo DMD/BMD families, the risk of recurrence of the mutation is 4.3%.

Risk indicator for agricultural inputs of trace elements to Canadian soils

Trace elements (TEs) are universally present in environmental media, including soil, but agriculture uses some materials that have increased TE concentrations. Some TEs (e.g., Cu, Se, and Zn) are added to animal feeds to ensure animal health. Similarly, TEs are present in micronutrient fertilizers. In the case of phosphate fertilizers, some TEs (e.g., Cd) may be inadvertently elevated because of the source rock used in the manufacturing. The key question for agriculture is "After decades of use, could these TE additions result in the deterioration of soil quality?" An early warning would allow the development of best management practices to slow or reverse this trend. This paper discusses a model that estimates future TE concentrations for the 2780 land area polygons composing essentially all of the agricultural land in Canada. The development of the model is discussed, as are various metrics to express the risk related to TE accumulation. The elements As, Cd, Cu, Pb, Se, and Zn are considered, with inputs from the atmosphere, fertilizers, manures, and municipal biosolids. In many cases, steady-state concentrations could be toxic, but steady state is far in the future. In 100 yr, the soil concentrations (Century soil concentrations) are estimated to be up to threefold higher than present background, an impact even if not a problematic impact. The geographic distribution reflects agricultural intensity. Contributions from micronutrient fertilizers are perhaps the most uncertain due to the limited data available on their use.

Selection of biting sites by mosquitoes

Most blood-feeding arthropods feed at specific sites on their hosts. There can be many reasons for such non-random distributions and not all of them are related to active selection of feeding sites by the parasites. Observations of mosquito biting on humans revealed that most species have preferred biting sites and that not all species share the same preferences. The selection of these sites may be related to several factors, depending on the mosquito species, which include the visual and chemical properties of the host. Identification of these factors can provide us with information on cues that are important in the finding and selection of a host. The choice of biting sites can be influenced by host-related cues of varying specificity. Therefore, it can in some cases reflect the host range of the mosquito species.

Between prepartum luteolysis and onset of expulsion

In the cow the foetal endocrine signals that initiate the calving process result in prepartum luteolysis. Withdrawal of progesterone (P4) action is a prerequisite for a normal calving. The rather abrupt declining influence of P4 is followed by a cascade of physiological processes in the myometrium and cervix. This contribution will focus on some of these events. Like in many other species, the myometrium in cows is not completely inactivated during pregnancy. So-called contractures have been registered during the final weeks of gestation and their EMG-characteristics in cows show a low frequency (on average: 13.6 per day) and long duration (on average 12.1 min). They are not evenly spread over the day because they occur less frequently when the cows are disturbed for feeding or cleaning their stables. Contractures affect several foetal functions. In the cow these contractures disappear during a period of about 8-9h when maternal plasma P4 levels are rapidly declining before calving. There is experimental evidence that this temporary inhibition is associated with prepartal luteal regression. The cause of this inhibition is still unknown. Because nitrous oxide inhibits smooth muscle cells and evidence in laboratory animals indicates that expression of the inducible form of nitrous oxide (iNOS) is downregulated in myometrium, but upregulated in the cervix around the onset of parturition, we started to investigate the role of this enzyme in bovine tissues around calving. By means of a RT-PCR technique, we obtained a first indication that iNOS is hardly expressed in the myometrium during calving, while expression was clearly detected at day 4 after calving. Analysis of prepartum en periparturient biopsies from myometrium and cervix with quantitative PCR is still underway. In six pregnant cows, provided with uterine EMG-electrodes and with ultrasonic crystals implanted on the caudal cervical rim to measure cervical dilatation, calving was induced with an injection of prostaglandin (PG) F2alpha. While maternal plasma P4 levels had significantly declined within 8h after PG treatment, the myometrium escaped from temporary inhibition with the development of a parturient contractility pattern on average at 13.5h after injection. However, it was only at 28 h after PG treatment that the first sustained increase of the opening of the vaginal ostium of the cervix was measured.

Decision making performance in obsessive compulsive disorder

BACKGROUND

Neuro-imaging studies in OCD report the orbitofrontal cortex to be functionally abnormal. As these areas are presumed to be involved in decision making, studying this behavior in OCD may provide further insight into the cognitive deficits accompanying the disorder.

METHODS

Performance of 27 drug-free OCD patients and 26 healthy volunteers was compared on the decision making task of Bechara et al. [Cognition, 50 (1994) 7-15].

RESULTS

OCD patients and volunteers displayed comparable decision-making behavior. Within OCD patients, risk taking was independently related to both anxiety and OCD severity.

LIMITATIONS

Results must be regarded as preliminary, due to the limited number of OCD patients included and the lack of a clinical control group.

CONCLUSIONS

Although VMpfc function is not generally impaired, it seems to be involved in OCD; possibly in another way than could be measured with this task.

CLINICAL RELEVANCE

Clarification of cognitive distortions underlying OCD may guide development of new strategies for cognitive-behavioral therapy.

Inhibitory inefficiency and failures of intention activation: age-related decline in the control of saccadic eye movements

Young and older adults' control of saccadic eye movements was compared using an antisaccade task, which requires the inhibition of a reflexive saccade toward a peripheral onset cue followed by an intentional saccade in the opposite direction. In 2 experiments, an age-related decline was found in the suppression of reflexive eye movements, as indicated by an increased proportion of saccades toward the cue, and a longer time needed to initiate correct antisaccades. The results from Experiment 2 suggested that older adults' slower antisaccades may be explained partly in terms of increased failures to maintain the cue-action representation at a sufficient activation level. The results suggest that the notion of selective preservation with age of the ability to inhibit spatial responses does not apply to the active inhibition of prepotent spatial responses.

Crkl enhances leukemogenesis in BCR/ABL P190 transgenic mice

The adapter protein Crkl has been implicated in the abnormal signal transduction pathways activated by the Bcr/Abl oncoprotein, which causes Philadelphia-positive leukemias in humans. To investigate the role of Crkl in tumorigenesis, we have generated transgenic mice that express human Crkl from the CRKL promoter. Western blot analysis showed a 4-6-fold overexpression of transgenic Crkl above endogenous crkl in two lines and increased constitutive complex formation between Crkl and C3G, an exchange factor for the small GTPase Rap1. This was associated with a significant increase in integrin-based motility of transgenic macrophages. Overexpression of Crkl was associated with increased incidence of tumor formation, and Rap1 was activated in a metastatic mammary carcinoma. The coexpression of Crkl and Bcr/Abl in mice transgenic for P190 BCR/ABL and CRKL markedly increased the rapidity of development of leukemia/lymphoma, decreasing the average survival by 3.8 months. These results provide direct evidence that Crkl plays a role in tumor development and is important in the leukemogenesis caused by Bcr/Abl.

Intramolecular photochemical dioxenone-alkene [2 + 2] cycloadditions as an approach to the bicyclo[2.1.1]hexane moiety of solanoeclepin A

A synthesis of the bicyclo[2.1.1]hexane substructure of solanoeclepin A (1), the most active natural hatching agent of potato cyst nematodes, was approached via an intramolecular [2 + 2] photocycloaddition. Aldehyde 12 containing the dioxenone chromophore served as a useful starting material, allowing the synthesis of a variety of photocycloaddition substrates via Grignard addition or via a Nozaki-Hiyama-Kishi reaction. Photolysis of the unsubstituted alkene 14 led to the expected crossed cycloadduct bicyclo[2.1.1]hexane 15 according to the so-called rule of five. However, several functionalized alkenes 18, 20, and 31 exhibited a complete reversal of cycloaddition regioselectivity, providing straight cycloadducts bicyclo[2.2.0]hexanes 21-26 and 4, respectively. Their structures were proved by a combination of extensive NMR measurements, X-ray analyses, and subsequent retro-aldol reactions. The latter de Mayo process allowed the formation of spiro-[3.5]nonane 35 and spiro[3.4]octane 36 as well as the cyclobutanes 37 and 38. Finally, the cyclization of the more rigid lactone precursor 28 occurred in high yield in the desired fashion with complete regio- and stereoselectivity to give 3 containing the core bicyclo[2.1.1]hexane skeleton of the natural product.

Inhibitory inefficiency and failures of intention activation: age-related decline in the control of saccadic eye movements

Young and older adults' control of saccadic eye movements was compared using an antisaccade task, which requires the inhibition of a reflexive saccade toward a peripheral onset cue followed by an intentional saccade in the opposite direction. In 2 experiments, an age-related decline was found in the suppression of reflexive eye movements, as indicated by an increased proportion of saccades toward the cue, and a longer time needed to initiate correct antisaccades. The results from Experiment 2 suggested that older adults' slower antisaccades may be explained partly in terms of increased failures to maintain the cue-action representation at a sufficient activation level. The results suggest that the notion of selective preservation with age of the ability to inhibit spatial responses does not apply to the active inhibition of prepotent spatial responses.

Flexibility, inhibition, and planning: frontal dysfunctioning in schizophrenia

Neuropsychological tests known to reveal abnormalities in patients with frontal lobe damage were used to explore cognitive function in 20 chronic schizophrenic patients. Eleven control subjects, matched on age and NLV-IQ (NLV is the Dutch version of the NART) were also tested. No impairments of planning ability were found on either the Action Program test or the Zoomap test, both subtests from the BADS (Behavioural Assessment of the Dysexecutive Syndrome). No abnormalities were apparent on tests of reactive flexibility, measured by task-switching and by the Rule Shift Cards test, also a subtest of the BADS. Patients with schizophrenia, however, had significantly greater difficulty in inhibiting irrelevant information and in generating words in a verbal fluency task, a measure of spontaneous flexibility.

Somatostatin receptor in breast cancer and axillary nodes: study with scintigraphy, histopathology and receptor autoradiography

We conducted a prospective analysis of somatostatin receptor scintigraphy using (111)In radiolabeled pentetreotide, a somatostatin analog, in patients with breast cancer in the aim to visualize the primary tumor and axillary or parasternal metastatic extension because some malignant breast tumors express somatostatin receptors (SS-R) in 50%, approximately. An analysis of SS-R was performed by autoradiography.

PATIENTS AND METHODS

Thirteen patients with clinically suspected breast tumors (T1, T2), and at least one palpable axillary node (N1) were included. In vivo planar scintigrams were acquired 1, 4, and 24 h after subcutaneous, then after intravenous injections (24 h delay between injections). Improved (111)In-pentetreotide uptake in invaded nodes after subcutaneous injection was hypothesized. Ex vivo scintigrams of surgical specimens were also acquired immediately after tumor resection and axillary dissection. Pathological examination and receptor autoradiography were performed on all surgical specimens.

RESULTS

Among 11 pathologically proven malignant tumors (9 ductal and 2 lobular carcinomas), only four were scintigraphically visible although six expressed SS-R receptors in vitro. Among six pathologically proven malignant nodes, four expressed SS-R, including two visualized scintigraphically. Scintigrams acquired after subcutaneous injections were less sensitive than after intravenous injections. There were no false positive. False negatives occurred in cases with small tumors with low-density or heterogeneously distributed SS-R. There was no significant difference by histological type or prognostic factors.

CONCLUSION

Somatostatin receptor scintigraphy does not appear to be sensitive enough to evaluate axillary node extension of breast cancer or even to confirm the presence of tumoral tissue, and this whatever the administration route for (111)In-pentetreotide.

Fourteen residues of the U1 snRNP-specific U1A protein are required for homodimerization, cooperative RNA binding, and inhibition of polyadenylation

It was previously shown that the human U1A protein, one of three U1 small nuclear ribonucleoprotein-specific proteins, autoregulates its own production by binding to and inhibiting the polyadenylation of its own pre-mRNA. The U1A autoregulatory complex requires two molecules of U1A protein to cooperatively bind a 50-nucleotide polyadenylation-inhibitory element (PIE) RNA located in the U1A 3' untranslated region. Based on both biochemical and nuclear magnetic resonance structural data, it was predicted that protein-protein interactions between the N-terminal regions (amino acids [aa] 1 to 115) of the two U1A proteins would form the basis for cooperative binding to PIE RNA and for inhibition of polyadenylation. In this study, we not only experimentally confirmed these predictions but discovered some unexpected features of how the U1A autoregulatory complex functions. We found that the U1A protein homodimerizes in the yeast two-hybrid system even when its ability to bind RNA is incapacitated. U1A dimerization requires two separate regions, both located in the N-terminal 115 residues. Using both coselection and gel mobility shift assays, U1A dimerization was also observed in vitro and found to depend on the same two regions that were found in vivo. Mutation of the second homodimerization region (aa 103 to 115) also resulted in loss of inhibition of polyadenylation and loss of cooperative binding of two U1A protein molecules to PIE RNA. This same mutation had no effect on the binding of one U1A protein molecule to PIE RNA. A peptide containing two copies of aa 103 to 115 is a potent inhibitor of polyadenylation. Based on these data, a model of the U1A autoregulatory complex is presented.

Unfiltered coffee increases plasma homocysteine concentrations in healthy volunteers: a randomized trial

BACKGROUND

An elevated plasma homocysteine concentration is a putative risk factor for cardiovascular disease. Observational studies have reported an association between coffee consumption and plasma homocysteine concentrations.

OBJECTIVE

We studied the effect of coffee consumption on plasma homocysteine in a crossover trial. We used unfiltered coffee so as to include the possible effects of coffee diterpenes, which are removed by filtering.

DESIGN

Sixty-four healthy volunteers (31 men and 33 women) with a mean (+/-SD) age of 43 +/- 11 y were randomly assigned to 2 groups. One group (n = 30) drank 1 L unfiltered cafetière (French press) coffee daily for 2 wk. Such coffee is rich in the cholesterol-raising diterpenes kahweol and cafestol. The other group (n = 34) received water, milk, broth, tea, and chocolate drinks instead of coffee. After a washout period of 8 wk, both groups received the alternate intervention for another 2 wk.

RESULTS

Consumption of 1 L unfiltered coffee/d for 2 wk significantly raised fasting plasma homocysteine concentrations by 10%, from 12.8 to 14.0 micromol/L.

CONCLUSIONS

Unfiltered coffee increases plasma homocysteine concentrations in volunteers with normal initial concentrations. It is unclear whether the effect is caused by the cholesterol-raising diterpenes present exclusively in unfiltered coffee or by factors that are also present in filtered coffee.

Influence of psychological stress on immune-inflammatory variables in normal humans. Part II. Altered serum concentrations of natural anti-inflammatory agents and soluble membrane antigens of monocytes and T lymphocytes

The effects of academic examination stress on serum concentrations of interleukin (IL)-1 receptor (R) antagonist (A), soluble(s) IL-2R, sIL-6R, soluble glycoprotein 130 (sgp130), Clara cell protein (CC16), sCD8 and sCD14 were evaluated in 38 university students. The relationships among changes in the above immune-inflammatory variables, levels of serum cortisol, and scores on the Perceived Stress Scale (PSS) or the State-Trait Anxiety Inventory (STAI) were examined. Academic examination stress was associated with significant increases in PSS and STAI scores, and in serum sgp130 and sCD8 values. Academic examination stress was associated with significantly decreased serum sCD14 concentrations in students with high, but not low, stress perception. There were stress-induced differences in serum IL-1RA, sIL-6R and CC16 concentrations between students with high vs. low stress-induced anxiety. The stress-induced increase in serum sCD8 was significantly more pronounced in male students, whereas the increase in serum sgp130 was more pronounced in female students taking contraceptive drugs. These results suggest that: (1) psychological stress induces immune-inflammatory changes pointing toward complex regulatory responses in IL-6 signalling, a decreased anti-inflammatory capacity of the serum, and interactions with T cell and monocytic activation; and that (2) sex hormones may modify stress-induced immune-inflammatory responses.

C3G is tyrosine-phosphorylated after integrin-mediated cell adhesion in normal but not in Bcr/Abl expressing cells

The SH2-SH3 adaptor protein Crkl has been implicated in the signal transduction pathways of several membrane-bound receptors. Tyrosine phosphorylation of proteins associated with such signalling complexes can generate binding sites for the Crkl SH2-domain and can recruit proteins constitutively bound to Crkl via the Crkl SH3 domain into such complexes. In the current study we show that Crkl, but only a minor amount of the related Crk, form constitutive complexes in vivo with guanine nucleotide exchange factor C3G in 3T3 fibroblasts. Adhesion of both normal and transformed cells to fibronectin or other extracellular matrix proteins consistently induces the tyrosine-phosphorylation of C3G. Adhesion-induced tyrosine phosphorylation of C3G is dependent on an intact cytoskeleton and peaks at 5-10 min after attachment. In contrast, 3T3 cells stably transfected with Bcr/Abl P210 show a prominent reduction in the amount of C3G complexed to Crkl and do not exhibit tyrosine-phosphorylation of C3G upon spreading and attachment. These data establish that integrin-mediated cell adhesion results in Crkl-mediated tyrosine phosphorylation of C3G, a pathway which can be disrupted by Bcr/Abl.

Differential interaction of Crkl with Cbl or C3G, Hef-1, and gamma subunit immunoreceptor tyrosine-based activation motif in signaling of myeloid high affinity Fc receptor for IgG (Fc gamma RI)

Cbl-Crkl and Crkl-C3G interactions have been implicated in T cell and B cell receptor signaling and in the regulation of the small GTPase, Rap1. Recent evidence suggests that Rap1 plays a prominent role in the regulation of immunoreceptor tyrosine-based activation motif (ITAM) signaling. To gain insight into the role of Crkl in myeloid ITAM signaling, we investigated Cbl-Crkl and Crkl-C3G interactions following Fc gamma RI aggregation in U937IF cells. Fc gamma RI cross-linking of U937IF cells results in the tyrosine phosphorylation of Cbl, Crkl, and Hef-1, an increase in the association of Crkl with Cbl via direct SH2 domain interaction and increased Crkl-Hef-1 binding. Crkl constitutively binds to the guanine nucleotide-releasing protein, C3G, via direct SH3 domain binding. Our data show that distinct Cbl-Crkl and Crkl-C3G complexes exist in myeloid cells, suggesting that these complexes may modulate distinct signaling events. Anti-Crkl immunoprecipitations demonstrate that the ITAM-containing gamma subunit of Fc gamma RI is induced to form a complex with the Crkl protein, and Crkl binds to the cytoskeletal protein, Hef-1. The induced association of Crkl with Cbl, Hef-1, and Fc gamma RI gamma after Fc gamma RI activation and the constitutive association between C3G and Crkl provide the first evidence that a Fc gamma RI gamma-Crkl-C3G complex may link ITAM receptors to the activation of Rap1 in myeloid cells.

Use of albumin in intensive care unit patients--is continuous quality assessment necessary?

BACKGROUND

There are two main reasons for hypo-albuminaemia in severely ill patients: long-lasting malnutrition and metabolic response to stress. Hypo-albuminaemia is therefore a prognostic indicator of illness severity rather than a cause of disease. Supplementation with albumin has not yet been demonstrated to have measurable therapeutic effects. Hypovolaemia is often seen in intensive care unit (ICU) patients, either postoperatively or caused through shock. The main goal of any treatment is to maintain adequate intravascular filling. No clear benefit can be seen when using albumin instead of artificial colloids.

OBJECTIVE

Based on the literature, we performed an intervention study to evaluate and improve the use of albumin.

METHOD

After evaluation of the use of albumin over the last 4 years (by means of analysis of the pharmacy drug use statistics), all staff members of the ICU were invited to discuss information retrieved from recently published literature. This led to the introduction of the following new guidelines. Albumin may only be given to patients with very low serum albumin levels of less than 15 g/litre. Substitution of albumin between levels of 15-20 g/litre may take place if patients are in poor condition. The indication has to be documented in the patient's notes.

RESULTS

After the introduction of the guidelines, the use of albumin dropped by more than 50% from 3178 units in 1996 to 1565 units in 1997. This led to direct cost savings of approximately US$100000.

CONCLUSION

The available literature about the risks and benefits of using albumin in clinical practice is not conclusive. The use of albumin should therefore be restricted according to the guidelines.

Severe mycobacterial and Salmonella infections in interleukin-12 receptor-deficient patients

Interleukin-12 (IL-12) is a cytokine that promotes cell-mediated immunity to intracellular pathogens by inducing type 1 helper T cell (TH1) responses and interferon-gamma (IFN-gamma) production. IL-12 binds to high-affinity beta1/beta2 heterodimeric IL-12 receptor (IL-12R) complexes on T cell and natural killer cells. Three unrelated individuals with severe, idiopathic mycobacterial and Salmonella infections were found to lack IL-12Rbeta1 chain expression. Their cells were deficient in IL-12R signaling and IFN-gamma production, and their remaining T cell responses were independent of endogenous IL-12. IL-12Rbeta1 sequence analysis revealed genetic mutations that resulted in premature stop codons in the extracellular domain. The lack of IL-12Rbeta1 expression results in a human immunodeficiency and shows the essential role of IL-12 in resistance to infections due to intracellular bacteria.

Application of the ATC/DDD methodology to monitor antibiotic drug use

In order to monitor the use of antibiotics, it is essential to have comprehensive data on drug consumption. The findings of drug utilisation studies can serve to describe the pattern of drug use in a particular population, to detect areas of concern, and to evaluate the impact of interventions taken to influence the use of drugs. In the present study, the Anatomical Therapeutical Chemical Classification/Defined Daily Doses (ATC/DDD) system developed by the World Health Organisation was evaluated. The system measures the amount of drug used independent of package size and sales price, which allows comparisons not only within an institution but also within a region, a country, or even internationally. Obviously, there can be no modifications of this system. To illustrate the method, the pattern of quinolone use in the general population, in long-term care facilities, and within a single institution was analysed. These drugs were widely used in long-term care facilities in the Nijmegen region of the Netherlands, accounting for about 30% of the antibiotics used in these settings, whereas in the general population as well as in the University Hospital Nijmegen, these drugs constitute only about 6% of the total antibiotics used. These differences are large enough to warrant closer analysis of patterns of antibiotic usage in different settings to identify the reasons for the use of quinolones and to identify measures that might be taken to rationalise the prescription of these drugs.

BCR/ABL-induced leukemogenesis causes phosphorylation of Hef1 and its association with Crkl

BCR/ABL is considered responsible for the development of Philadelphia chromosome-positive leukemia. Experimental animal models, such as transgenic mice, have demonstrated unambiguously that Bcr/Abl is capable of inducing leukemogenesis. The adaptor molecule Crkl is a major in vivo substrate of the deregulated Bcr/Abl tyrosine kinase and functions as a molecular link with other signaling proteins. While associated in vivo with Bcr/Abl through its SH3 domain, Crkl can interact simultaneously via its SH2 domain with other tyrosine-phosphorylated proteins. Here we report the identification of prominently tyrosine-phosphorylated proteins with a molecular mass of approximately 110 kDa, which bind specifically to the Crkl SH2 domain in leukemic tissues of P190BCR/ABL transgenic mice. We demonstrate that these proteins are identical to Hef1/Cas-L, which is related to p130(Cas). The proto-oncoprotein p120(Cbl) and Hef1, but not p130(Cas), were detectably phosphorylated on tyrosine in P190Bcr/Abl-expressing leukemic cells and were found in complex with Crkl, showing the existence of protein complexes in P190Bcr/Abl leukemic cells, consisting of P190Bcr/Abl, Crkl, and Hef1 or p120(Cbl). This supports a model in which Crkl acts as mediator between Bcr/Abl and downstream effectors. Since Hef1 is involved in the beta1-integrin signaling pathway, our study demonstrates that Bcr/Abl could specifically interfere with normal beta1-integrin signaling.