Reversing immunosuppression in the tumor microenvironment of fibrolamellar carcinoma via PD-1 and IL-10 blockade

Fibrolamellar carcinoma (FLC) is a rare liver tumor driven by the DNAJ-PKAc fusion protein that affects healthy young patients. Little is known about the immune response to FLC, limiting rational design of immunotherapy. Multiplex immunohistochemistry and gene expression profiling were performed to characterize the FLC tumor immune microenvironment and adjacent non-tumor liver (NTL). Flow cytometry and T cell receptor (TCR) sequencing were performed to determine the phenotype of tumor-infiltrating immune cells and the extent of T cell clonal expansion. Fresh human FLC tumor slice cultures (TSCs) were treated with antibodies blocking programmed cell death protein-1 (PD-1) and interleukin-10 (IL-10), with results measured by cleaved caspase-3 immunohistochemistry. Immune cells were concentrated in fibrous stromal bands, rather than in the carcinoma cell compartment. In FLC, T cells demonstrated decreased activation and regulatory T cells in FLC had more frequent expression of PD-1 and CTLA-4 than in NTL. Furthermore, T cells had relatively low levels of clonal expansion despite high TCR conservation across individuals. Combination PD-1 and IL-10 blockade signficantly increased cell death in human FLC TSCs. Immunosuppresion in the FLC tumor microenvironment is characterized by T cell exclusion and exhaustion, which may be reversible with combination immunotherapy.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims

INTRODUCTION

As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees.

METHODS

The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age.

RESULTS

We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05).

CONCLUSION

Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes.

Ribosomal protein S3 associates with the TFIIH complex and positively regulates nucleotide excision repair

In mammalian cells, the bulky DNA adducts caused by ultraviolet radiation are mainly repaired via the nucleotide excision repair (NER) pathway; some defects in this pathway lead to a genetic disorder known as xeroderma pigmentosum (XP). Ribosomal protein S3 (rpS3), a constituent of the 40S ribosomal subunit, is a multi-functional protein with various extra-ribosomal functions, including a role in the cellular stress response and DNA repair-related activities. We report that rpS3 associates with transcription factor IIH (TFIIH) via an interaction with the xeroderma pigmentosum complementation group D (XPD) protein and complements its function in the NER pathway. For optimal repair of UV-induced duplex DNA lesions, the strong helicase activity of the TFIIH complex is required for unwinding damaged DNA around the lesion. Here, we show that XP-D cells overexpressing rpS3 showed markedly increased resistance to UV radiation through XPD and rpS3 interaction. Additionally, the knockdown of rpS3 caused reduced NER efficiency in HeLa cells and the overexpression of rpS3 partially restored helicase activity of the TFIIH complex of XP-D cells in vitro. We also present data suggesting that rpS3 is involved in post-excision processing in NER, assisting TFIIH in expediting the repair process by increasing its turnover rate when DNA is damaged. We propose that rpS3 is an accessory protein of the NER pathway and its recruitment to the repair machinery augments repair efficiency upon UV damage by enhancing XPD helicase function and increasing its turnover rate.

Global Volunteerism for Orthopaedic Surgeons-A Primer

The burden of unmet surgical need is heavily weighted toward low-income and middle-income countries. North American orthopaedic surgeons are increasingly interested in volunteer activities in resource-limited areas around the globe. There are multiple avenues through which an orthopaedic surgeon can positively contribute to improving musculoskeletal care around the world. Unfortunately, short-term missions are at risk of undermining local long-term development efforts if they do not mitigate harm and optimize benefit for host communities. Work in this area should be grounded in beneficence and sustainability with an emphasis on mutual respect, exchange, and a commitment to capacity building. All of the necessary information for adequate preparation for these activities is beyond the scope of this chapter, but the goal is to introduce a range of volunteer options, ethical considerations, cultural competence and volunteer preparedness principles, considerations when including trainees in global health work, and some nuts-and-bolts details on trip planning.

Targeting NLRP3 Inflammasome Reduces Age-Related Experimental Alveolar Bone Loss

The cause of chronic inflammatory periodontitis, which leads to the destruction of periodontal ligament and alveolar bone, is multifactorial. An increasing number of studies have shown the clinical significance of NLRP3-mediated low-grade inflammation in degenerative disorders, but its causal linkage to age-related periodontitis has not yet been elucidated. In this study, we investigated the involvement of the NLRP3 inflammasome and the therapeutic potential of NLRP3 inhibition in age-related alveolar bone loss by using in vivo and in vitro models. The poor quality of alveolar bones in aged mice was correlated with caspase-1 activation by macrophages and elevated levels of IL-1β, which are mainly regulated by the NLRP3 inflammasome, in periodontal ligament and serum, respectively. Aged mice lacking Nlrp3 showed better bone mass than age-matched wild-type mice via a way that affects bone resorption rather than bone formation. In line with this finding, treatment with MCC950, a potent inhibitor of the NLRP3 inflammasome, significantly suppressed alveolar bone loss with reduced caspase-1 activation in aged mice but not in young mice. In addition, our in vitro studies showed that the addition of IL-1β encourages RANKL-induced osteoclastogenesis from bone marrow-derived macrophages and that treatment with MCC950 significantly suppresses osteoclastic differentiation directly, irrelevant to the inhibition of IL-1β production. Our results suggest that the NLRP3 inflammasome is a critical mediator in age-related alveolar bone loss and that targeting the NLRP3 inflammasome could be a novel option for controlling periodontal degenerative changes with age.

Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial

OBJECTIVES

Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia.

METHODS

This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture.

RESULTS

The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr).

DISCUSSION

ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Standardisation of defined approaches for skin sensitisation testing to support regulatory use and international adoption: position of the International Cooperation on Alternative Test Methods

Skin sensitisation is the regulatory endpoint that has been at the centre of concerted efforts to replace animal testing in recent years, as demonstrated by the Organisation for Economic Co-operation and Development (OECD) adoption of five non-animal methods addressing mechanisms under the first three key events of the skin sensitisation adverse outcome pathway. Nevertheless, the currently adopted methods, when used in isolation, are not sufficient to fulfil regulatory requirements on the skin sensitisation potential and potency of chemicals comparable to that provided by the regulatory animal tests. For this reason, a number of defined approaches integrating data from these methods with other relevant information have been proposed and documented by the OECD. With the aim to further enhance regulatory consideration and adoption of defined approaches, the European Union Reference Laboratory for Alternatives to Animal testing in collaboration with the International Cooperation on Alternative Test Methods hosted, on 4-5 October 2016, a workshop on the international regulatory applicability and acceptance of alternative non-animal approaches, i.e., defined approaches, to skin sensitisation assessment of chemicals used in a variety of sectors. The workshop convened representatives from more than 20 regulatory authorities from the European Union, United States, Canada, Japan, South Korea, Brazil and China. There was a general consensus among the workshop participants that to maximise global regulatory acceptance of data generated with defined approaches, international harmonisation and standardisation are needed. Potential assessment criteria were defined for a systematic evaluation of existing defined approaches that would facilitate their translation into international standards, e.g., into a performance-based Test Guideline. Informed by the discussions at the workshop, the ICATM members propose practical ways to further promote the regulatory use and facilitate adoption of defined approaches for skin sensitisation assessments.

Patient-Reported Outcomes Demonstrate The Value Of Non-Operative And Operative Orthopedic Treatments And Predict The Odds Of Improvement With Surgery

Category:

Outcomes Measurement

Introduction/Purpose:

The importance of patient reported outcomes (PROs) has become increasingly recognized as an important tool to measure our clinical value. The National Institute of Health (NIH) created the Patient-Reported Outcomes Measurement Information System (PROMIS), a series of validated item banks, to help clinicians and researches measure key clinical domains. The PROMIS computer adaptive tests (CAT) may be administered with minimal resources or administrative burden. This study describes the results of administering computer adaptive tests (CAT) to every patient in a high volume Orthopedic Surgery practice. We test the hypotheses that both non-operative treatment and operative treatments improve PRO scores. Furthermore, we test the hypothesis that preoperative scores in these domains may be used to predict chances of improvement after surgery.

Methods:

The PROMIS CAT was administered prospectively for all patients as part of standard clinic intake and recorded in the patient’s electronic medical record (EMR) at each clinic visit. The PROMIS item banks are normalized to mean 50±10 for the US population. De-identified data was retrospectively extracted from the EMR including PROMIS scores, demographic information, as well as surgery specific information. As of this submission, 1688 PROMIS CATs from March 2015 to September 2016 have been analyzed. Data for initial and final clinic visits, as well as for the final preoperative visit for patients who had surgery, are compared using Wilcoxon Matched Pairs Test for paired samples and Mann-Whitney U Test for unpaired samples. Linear regression is used to assess the association of initial values to change in value after treatment. The effect of stratified initial clinic domain value on odds of improving with surgery is assessed using Analysis of Variance.

Results:

Non-surgical and surgical patients present with similar pain intensity (49.6±7.9 vs. 49.4±7.8). Surgical patients do not improve prior to surgery, but both improve by their final visit (45.7±7.5, 43.7±8.8, p<0.05). Non-surgical and surgical patients present with similar pain interference (60.0±8.4 vs. 60.3±8.9). Surgical patients do not improve prior to surgery, but both improve by their final visit (56.9±8.8, 54.3±9.4, p<0.05). For surgical patients, change in pain intensity and pain interference correlate with initial values (R2 0.32 and 0.27, p<0.05). The percentage whose pain intensity improves after surgery when initial value is over one SD worse than mean is 96%, within one SD worse than mean is 81%, within one SD better than mean is 56%, and over one SD better than mean is 40% (p<0.05).

Conclusion:

Both non-operative and operative orthopedic treatments improve patient reported pain intensity and pain interference. For patients that have surgery, patients that present with more severe symptoms tend to improve more with surgery. Furthermore, the odds of improving after surgery can be calculated based on preoperative PRO scores. This may allow surgeons to counsel patients about the potential benefits of surgery with personalized precision that is currently unavailable. Measuring PROs using PROMIS CATs demonstrates the value of both non-operative and operative Orthopedic Surgery care for our patients. Preoperative PRO scores may predict the odds of successful surgical intervention.

Distal Tibial Bone Grafting for Talar Dome Osteochondral Lesions

Category:

Arthroscopy

Introduction/Purpose:

Osteochondral lesions (OCLs) of the talar dome are very common and often cause disabling pain. Smaller lesions are treated successfully with bone marrow stimulation techniques such as arthroscopic microfracture. Controversy exists, however, about the optimal treatment for larger, cystic lesions. Osteochondral grafting, either allograft or autograft, is the most common technique but is not optimal, as it requires allograft tissue or donor autograft from another joint. This procedure often requires a malleolar osteotomy for access to the talus, which carries inherent morbidity. We describe a technique of treating large, cystic OCLs by transferring structurally intact autograft from the distal tibia to the talus, which can be performed without osteotomy, does not require allograft tissue, and can be obtained from a local donor site.

Methods:

Twenty-three ankles in 22 patients underwent distal tibial bone grafting procedure for treatment of large, cystic OCLs of the talus. A cancellous autograft bone plug was harvested from the ipsilateral distal tibial metaphysis and implanted into the drilled out talar lesion through a small anterior arthrotomy. The graft may be placed oblique to the talar surface and contoured to match the level of the surrounding subchondral bone. Allograft bone chips were used to backfill the distal tibia donor site. Pre-operative and final post-operative data was available for 11 patients with a minimum of 6 months follow-up. Validated patient reported outcomes scores and other data collected included Foot Function Index (FFI), AOFAS hindfoot score, SF-12, and Visual Analog Scale (VAS) pain. Final postoperative data also included VAS patient satisfaction and PROMIS validated and normalized lower extremity function and pain scores. Comparisons were made by paired t-Test and data reported mean±SD.

Results:

Mean patient age was 47 (range 15-70). Seven of 11 patients were female. Lesions were all medial and measured 122 mm2 (range 80-160) by 8 mm depth (range 6-9). Average follow-up was 23 months (range 7-33). There were no complications or reoperations. Significant improvement (p < 0.05) occurred in AOFAS Hindfoot score (67±16 to 88±12), FFI (55±20 to 22±17), VAS pain score (6.3±2.4 to 1.4±1.5), and SF-12 (31±9 to 50±10). Final VAS patient satisfaction was 8.5±1.8/10, and 10 of 11 patients reported they would have the procedure again. PROMIS scores (normalized to population mean 50±10) at final follow-up were physical function: 53±6; pain intensity: 40±10; and pain interference: 45±6. Eight of 9 patients who were employed were able to return to full duty without limitation.

Conclusion:

Distal tibial bone grafting is a safe and effective treatment for large talar OCLs. This technique avoids the need for allograft tissue, distant donor site morbidity, and malleolar osteotomy. Early to mid-term clinical outcomes, including validated outcomes scores, are encouraging. Our results are comparable if not better than the results reported with other described techniques for large talar OCLs. Further follow-up is necessary to define longer-term results, to assess cartilage healing with advanced imaging or second look arthroscopy, and to help define the exact role for this technique in treatment of talar osteochondral lesions.

Evaluation of Xpert(®) MTB/RIF assay: diagnosis and treatment outcomes in rifampicin-resistant tuberculosis

SETTING

The Xpert(®) MTB/RIF assay is endorsed by the World Health Organization for the detection of rifampicin (RMP) resistant tuberculosis (TB).

OBJECTIVE

To evaluate Xpert for its diagnostic accuracy in detecting RMP-resistant TB and its impact on treatment outcomes.

DESIGN

Patients with available phenotypic drug susceptibility testing (DST) results and those in whom RMP-resistant pulmonary TB was diagnosed using Xpert were evaluated. The accuracy and turnaround time (TAT) of Xpert for determining RMP-resistant TB was calculated. The TATs for treatment between patients diagnosed with RMP-resistant TB using Xpert and those diagnosed without the assay (phenotypic DST group) were compared.

RESULTS

In 321 patients, when phenotypic DST was used as the gold standard, Xpert sensitivity and specificity for RMP resistance diagnosis was respectively 100% and 98.7%; the positive and negative predictive values were respectively 86.2% and 100%. The Xpert group had a much shorter interval from initial evaluation to commencing second-line anti-tuberculosis treatment (64 vs. 2 days, P < 0.001), and negative conversion of mycobacterial cultures (197 vs. 62.5 days, P < 0.001) than the phenotypic DST group.

CONCLUSION

Xpert was accurate at diagnosing RMP resistance in this setting with an intermediate TB burden and a low level of RMP resistance. Xpert might reduce disease transmission by reducing the sputum culture conversion times for patients with RMP-resistant TB.

Applicability of the Sparse Temporal Acquisition Technique in Resting-State Brain Network Analysis

BACKGROUND AND PURPOSE

The ability of sparse temporal acquisition to minimize the effect of scanner background noise is of utmost importance in auditory fMRI; however, it has considerably lower temporal efficiency and resolution than the conventional continuous acquisition method. The purpose of this study was to determine whether sparse sampling could be applied to resting-state research by comparing its results with those obtained by using continuous acquisition.

MATERIALS AND METHODS

We identified resting-state networks by using independent component analysis and measured their functional connectivity strength in 14 healthy subjects who underwent two 6-minute sparse (60 volumes) and continuous (360 volumes) imaging sessions. To account for the sample size difference, an additional continuous dataset was generated by temporally matching the continuous dataset to 60 volumes of the sparse dataset.

RESULTS

Consistent resting-state network maps were produced through all 3 datasets. Scanner background noise did not appear to affect the spatial constitution of the networks, whereas a larger sample size influenced it substantially. The strength of the intranetwork connectivity was similar through the 3 datasets.

CONCLUSIONS

Our results indicated that continuous acquisition is a recommended technique that should be applied in most of the resting-state studies due to its superior temporal efficiency and increased statistical power. The use of sparse temporal acquisition should be restricted to very particular conditions when continuous scanner noise is unacceptable.

Modification to the accelerator of the NBI-1B ion source for improving the injection efficiency

Minimizing power loss of a neutral beam imposes modification of the accelerator of the ion source for further improvement of the beam optics. The beam optics can be improved by focusing beamlets. The injection efficiencies by the steering of ion beamlets are investigated numerically to find the optimum modification of the accelerator design of the NBI-1B ion source. The beam power loss was reduced by aperture displacement of three edge beamlets arrays considering power loadings on the beamline components. Successful testing and operation of the ion source at 60 keV/84% of injection efficiency led to the possibility of enhancing the system capability to a 2.4 MW power level at 100 keV/1.9 μP.

Predisposition to and effects of methamphetamine use on the adolescent brain

Adolescence is a period of heightened vulnerability both to addictive behaviors and drug-induced brain damage. Yet, only limited information exists on the brain mechanisms underlying these adolescent-specific characteristics. Moreover, distinctions in brain correlates between predisposition to drug use and effects of drugs in adolescents are unclear. Using cortical thickness and diffusion tensor image analyses, we found greater and more widespread gray and white matter alterations, particularly affecting the frontostriatal system, in adolescent methamphetamine (MA) users compared with adult users. Among adolescent-specific gray matter alterations related to MA use, smaller cortical thickness in the orbitofrontal cortex was associated with family history of drug use. Our findings highlight that the adolescent brain, which undergoes active myelination and maturation, is more vulnerable to MA-related alterations than the adult brain. Furthermore, MA-use-related executive dysfunction was greater in adolescent MA users than in adult users. These findings may provide explanation for the severe behavioral complications and relapses that are common in adolescent-onset drug addiction. Additionally, these results may provide insights into distinguishing the neural mechanisms that underlie the predisposition to drug addiction from effects of drugs in adolescents.

Histologic Analysis of Retrieved Clots in Acute Ischemic Stroke: Correlation with Stroke Etiology and Gradient-Echo MRI

BACKGROUND AND PURPOSE

It is unclear whether clot composition analysis is helpful to predict a stroke mechanism in acute large vessel occlusion. In addition, the relationship between early vessel signs on imaging studies and clot compositions has been poorly understood. The purpose of this study was to elucidate the relationship between clot composition and stroke etiology following mechanical thrombectomy and to investigate the effect of varied clot compositions on gradient-echo MR imaging of clots.

MATERIALS AND METHODS

Histopathologic analysis of retrieved clots from 37 patients with acute MCA occlusion was performed. Patients underwent gradient-echo imaging before endovascular therapy. Retrieved clots underwent semiquantitative proportion analysis to quantify red blood cells, fibrin, platelets, and white blood cells by area. Correlations between clot compositions and stroke subtypes and susceptibility vessel signs on gradient-echo imaging were assessed.

RESULTS

Stroke etiology was classified as cardioembolism in 22 patients (59.4%), large-artery atherosclerosis in 8 (21.6%), and undetermined in 7 (18.9%). The clots from cardioembolism had a significantly higher proportion of red blood cells (37.8% versus 16.9%, P = .031) and a lower proportion of fibrin (32.3% versus 48.5%, P = .044) compared with those from large-artery atherosclerosis. The proportion of red blood cells was significantly higher in clots with a susceptibility vessel sign than in those without it (48.0% versus 1.9%, P < .001), whereas the proportions of fibrin (26.4% versus 57.0%, P < .001) and platelets (22.6% versus 36.9%, P = .011) were significantly higher in clots without a susceptibility vessel sign than those with it.

CONCLUSIONS

The histologic composition of clots retrieved from cerebral arteries in patients with acute stroke differs between those with cardioembolism and large-artery atherosclerosis. In addition, a susceptibility vessel sign on gradient-echo imaging is strongly associated with a high proportion of red blood cells and a low proportion of fibrin and platelets in retrieved clots.

Evaluation of the bonding strength of dental zirconia with veneering porcelains

The effect of thermo-cycling treatment on the bond strength and flexural strength of porcelain veneered zirconia was evaluated. After thermo-cycling treatment between 5 degrees C to 55 degrees C, porcelain-zirconia bond strength and zirconia flexural strength was not significantly affected. In the phase analyses using XRD after thermo-cycling treatment, both the experimental group and the control group showed only tetragonal phases. That is, the porcelain-zirconia bond strength and zirconia flexural strength were not affected by low temperature degradation. So low temperature aging treatment did not reduce the flexural strength and the effect of temperature applied to the aging treatment could beignorable.

Comparison and correlation analysis of different Swine breeds meat quality

This study was performed to determine the influence of pig breed and gender on the ultimate pH and physicochemical properties of pork. The correlations between pH and pork quality traits directly related to carcass grade, and consumer’s preference were also evaluated. The pH and meat grading scores for cold carcasses of 215 purebred pigs (Duroc, Landrace, and Yorkshire) from four different farms were obtained. Meat quality parameters of the pork loin were analyzed. Duroc and female animals were more affected compared to other breeds and male pigs. Duroc animals had the highest ultimate pH, carcass back fat thickness, marbling scores, yellowness, and fat content (p<0.05). Landrace pigs had the highest color lightness and cooking loss values (p<0.05). Among all trait parameters, marbling scores showed the highest significant differences when evaluating the impact of breed and gender on meat quality characteristics (p<0.001). Ultimate pH was positively correlated with carcass weight (0.20), back fat thickness (0.19), marbling score (0.17), and color score (0.16) while negatively correlated with cooking loss (−0.24) and shear force (−0.20). Therefore, pork samples with lower ultimate pH had lower cooking loss, higher lightness, and higher shear force values irrespective of breed.

Pulmonary tuberculosis among patients hospitalised with community-acquired pneumonia in a tuberculosis-prevalent area

SETTING

A suburban teaching hospital in a tuberculosis (TB) prevalent area.

OBJECTIVES

To evaluate the proportion of pulmonary TB among patients hospitalised with suspected community-acquired pneumonia (CAP), and to develop a diagnostic index for identifying TB among these patients.

DESIGN

TB cases confirmed using 1) sputum culture, or 2) both sputum acid-fast bacilli smear and polymerase chain reaction for Mycobacterium tuberculosis, were compared with non-tuberculous CAP by demographic, clinical, laboratory and radiographic information. Using multiple logistic regression analysis, risk factors for TB were identified. A diagnostic index was developed by summing up their simplified regression coefficients. Its performance was checked using c-statistic.

RESULTS

TB was the second leading cause of CAP (37/528, 7.0%). Risk factors were initial symptoms >7 days, serum albumin <3.5 g/dl, cavitary/nodular infiltrates and upper lobe involvement (1 point for each). The c-statistic of the index was 0.856 (95%CI 0.789-0.923), and for bootstrapping samples of 1000 repetitions it was 0.856 (95%CI 0.791-0.921). For scores ≥2, sensitivity and specificity were respectively 81.1% and 75.8%.

CONCLUSION

TB is one of the leading causes of CAP in TB-prevalent areas. Our diagnostic index may help clinicians identify TB immediately from CAP and initiate appropriate isolation and optimal treatment.

A review of MR spectroscopy studies of pediatric bipolar disorder

Pediatric bipolar disorder is a severe mental illness whose pathophysiology is poorly understood and for which there is an urgent need for improved diagnosis and treatment. MR spectroscopy is a neuroimaging method capable of in vivo measurement of neurochemicals relevant to bipolar disorder neurobiology. MR spectroscopy studies of adult bipolar disorder provide consistent evidence for alterations in the glutamate system and mitochondrial function. In bipolar disorder, these 2 phenomena may be linked because 85% of glucose in the brain is consumed by glutamatergic neurotransmission and the conversion of glutamate to glutamine. The purpose of this article is to review the MR spectroscopic imaging literature in pediatric bipolar disorder, at-risk samples, and severe mood dysregulation, with a focus on the published findings that are relevant to glutamatergic and mitochondrial functioning. Potential directions for future MR spectroscopy studies of the glutamate system and mitochondrial dysfunction in pediatric bipolar disorder are discussed.

Outbreak among healthy newborns due to a new variant of USA300-related meticillin-resistant Staphylococcus aureus

BACKGROUND

The prevalence of community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) is increasing throughout the world and is an important cause of skin and soft tissue infection (SSTI) in children and neonates.

AIM

To describe the successful control of an outbreak caused by a new strain of CA-MRSA in a newborn nursery.

METHODS

The investigation of the outbreak in July 2012 is reported with the control measures taken. Molecular typing of the MRSA isolates was performed.

FINDINGS

An outbreak of SSTI caused by CA-MRSA occurred in a newborn nursery. Six neonates were infected in a one-month period [infection rate: 8.5% (6/71)]. A new variant of CA-MRSA was responsible, which was characterized as USA300-related, Panton-Valentine Leucocidin (PVL) positive, arginine catabolic mobile element (ACME) negative, sequence type 8 (ST8), staphylococcal cassette chromosome mec (SCCmec) type IVa, agr type I and spa type t008. The outbreak among term neonates followed a rapid transmission pattern and was successfully controlled by implementing various outbreak control measures, including universal chlorhexidine bathing.

CONCLUSION

This is the first report of a hospital outbreak caused by a USA300-related CA-MRSA clone in Korea. Early recognition and reinforcement of infection control measures are important in decreasing transmission of CA-MRSA in a hospital setting.

Development progresses of radio frequency ion source for neutral beam injector in fusion devices

A large-area RF (radio frequency)-driven ion source is being developed in Germany for the heating and current drive of an ITER device. Negative hydrogen ion sources are the major components of neutral beam injection systems in future large-scale fusion experiments such as ITER and DEMO. RF ion sources for the production of positive hydrogen (deuterium) ions have been successfully developed for the neutral beam heating systems at IPP (Max-Planck-Institute for Plasma Physics) in Germany. The first long-pulse ion source has been developed successfully with a magnetic bucket plasma generator including a filament heating structure for the first NBI system of the KSTAR tokamak. There is a development plan for an RF ion source at KAERI to extract the positive ions, which can be applied for the KSTAR NBI system and to extract the negative ions for future fusion devices such as the Fusion Neutron Source and Korea-DEMO. The characteristics of RF-driven plasmas and the uniformity of the plasma parameters in the test-RF ion source were investigated initially using an electrostatic probe.

Improvement of a plasma uniformity of the 2nd ion source of KSTAR neutral beam injector

The 2nd ion source of KSTAR (Korea Superconducting Tokamak Advanced Research) NBI (Neutral Beam Injector) had been developed and operated since last year. A calorimetric analysis revealed that the heat load of the back plate of the ion source is relatively higher than that of the 1st ion source of KSTAR NBI. The spatial plasma uniformity of the ion source is not good. Therefore, we intended to identify factors affecting the uniformity of a plasma density and improve it. We estimated the effects of a direction of filament current and a magnetic field configuration of the plasma generator on the plasma uniformity. We also verified that the operation conditions of an ion source could change a uniformity of the plasma density of an ion source.

Low-emittance electron bunches from a laser-plasma accelerator measured using single-shot x-ray spectroscopy

X-ray spectroscopy is used to obtain single-shot information on electron beam emittance in a low-energy-spread 0.5 GeV-class laser-plasma accelerator. Measurements of betatron radiation from 2 to 20 keV used a CCD and single-photon counting techniques. By matching x-ray spectra to betatron radiation models, the electron bunch radius inside the plasma is estimated to be ~0.1 μm. Combining this with simultaneous electron spectra, normalized transverse emittance is estimated to be as low as 0.1 mm mrad, consistent with three-dimensional particle-in-cell simulations. Correlations of the bunch radius with electron beam parameters are presented.

Histologically benign but clinically malignant neoplasms in the thorax: CT-pathological overview

The purpose of this article is to review the computed tomography (CT) and histopathological features of uncommon primary neoplasms of the thorax that can manifest clinically malignant features (multiplicity of pulmonary nodules, an invasive nature, and metastases or recurrence after surgery) with little evidence of histological malignancy.

First neutral beam injection experiments on KSTAR tokamak

The first neutral beam (NB) injection system of the Korea Superconducting Tokamak Advanced Research (KSTAR) tokamak was partially completed in 2010 with only 1∕3 of its full design capability, and NB heating experiments were carried out during the 2010 KSTAR operation campaign. The ion source is composed of a JAEA bucket plasma generator and a KAERI large multi-aperture accelerator assembly, which is designed to deliver a 1.5 MW, NB power of deuterium at 95 keV. Before the beam injection experiments, discharge, and beam extraction characteristics of the ion source were investigated. The ion source has good beam optics in a broad range of beam perveance. The optimum perveance is 1.1-1.3 μP, and the minimum beam divergence angle measured by the Doppler shift spectroscopy is 0.8°. The ion species ratio is D(+):D(2)(+):D(3)(+) = 75:20:5 at beam current density of 85 mA/cm(2). The arc efficiency is more than 1.0 A∕kW. In the 2010 KSTAR campaign, a deuterium NB power of 0.7-1.5 MW was successfully injected into the KSTAR plasma with a beam energy of 70-90 keV. L-H transitions were observed within a wide range of beam powers relative to a threshold value. The edge pedestal formation in the T(i) and T(e) profiles was verified through CES and electron cyclotron emission diagnostics. In every deuterium NB injection, a burst of D-D neutrons was recorded, and increases in the ion temperature and plasma stored energy were found.

Development of a plasma generator for a long pulse ion source for neutral beam injectors

A plasma generator for a long pulse H(+)/D(+) ion source has been developed. The plasma generator was designed to produce 65 A H(+)/D(+) beams at an energy of 120 keV from an ion extraction area of 12 cm in width and 45 cm in length. Configuration of the plasma generator is a multi-cusp bucket type with SmCo permanent magnets. Dimension of a plasma chamber is 25 cm in width, 59 cm in length, and 32.5 cm in depth. The plasma generator was designed and fabricated at Japan Atomic Energy Agency. Source plasma generation and beam extraction tests for hydrogen coupling with an accelerator of the KSTAR ion source have been performed at the KSTAR neutral beam test stand under the agreement of Japan-Korea collaborative experiment. Spatial uniformity of the source plasma at the extraction region was measured using Langmuir probes and ±7% of the deviation from an averaged ion saturation current density was obtained. A long pulse test of the plasma generation up to 200 s with an arc discharge power of 70 kW has been successfully demonstrated. The arc discharge power satisfies the requirement of the beam production for the KSTAR NBI. A 70 keV, 41 A, 5 s hydrogen ion beam has been extracted with a high arc efficiency of 0.9 -1.1 A/kW at a beam extraction experiment. A deuteron yield of 77% was measured even at a low beam current density of 73 mA/cm(2).

Efficacy and tolerability of mirtazapine in treating major depressive disorder with anxiety symptoms: an 8-week open-label randomised paroxetine-controlled trial

AIMS

Prominent anxiety symptoms are related to poor clinical course and outcome in major depressive disorder (MDD). The aim of this randomised, open-label, controlled study is to compare the efficacy and tolerability of mirtazapine in the form of orally disintegrating tablets against paroxetine in treating MDD patients with anxiety symptoms.

METHODS

A total of 60 MDD patients with a score above 18 on the Hamilton Anxiety Rating Scale (HARS) were randomly assigned to 8 weeks of fixed dosing treatment with mirtazapine (15-30 mg/day) and paroxetine (10-20 mg/day). Efficacy was primarily assessed with the HARS and with the 17-item Hamilton Depression Rating Scale (HDRS) at weeks 1, 2, 4 and 8 after treatment. Tolerability was assessed from adverse events.

RESULTS

The generalised estimating equations (GEE) models showed that the rates of improvement in HDRS scores from baseline to week 8 were similar between mirtazapine and paroxetine groups. However, patients with mirtazapine exhibited earlier improvement in HARS scores at weeks 1 and 2. Week-by-week GEE models showed that these significant differences in improvement of HARS scores between the two treatment groups were detectable from the first evaluation after the treatment (week 1) and maintained through week 2. There was no difference in the overall frequency of adverse events experienced between the two treatment groups. The most common adverse event in the mirtazapine group was somnolence (n = 8), whereas that in the paroxetine group was gastrointestinal discomfort (n = 9).

CONCLUSIONS

Mirtazapine and paroxetine were equally effective and well tolerated for the depressive symptoms in MDD patients with the high level of anxiety symptoms. Mirtazapine was, however, more effective in reducing the anxiety symptoms than paroxetine in the early weeks of treatment, suggesting that mirtazapine may have an earlier-onset action for the anxiety symptoms in MDD patients.

Herpes simplex virus pneumonia: high-resolution CT findings

The purpose of this study was to evaluate the high-resolution computed tomographic (HRCT) findings of five adult patients (either immunocompromised or immunocompetent) with herpes simplex virus (HSV) pneumonia. We retrospectively assessed HRCT images of 5 patients (all male patients, age range 39-70 years; mean 62 years) with HSV pneumonia. The specific pathological findings that allowed for a definite diagnosis of HSV pneumonia included the presence of intranuclear inclusion bodies on haematoxylin and eosin staining, or positive immunohistochemical staining. High-resolution CT scans (HiSpeed Advantage or LightSpeed QX/i, GE Healthcare) using 1- or 1.25-mm collimation at 10-mm intervals without intravenous contrast medium injection were assessed, in particular for the presence and distribution of parenchymal abnormalities including ground-glass attenuation, airspace consolidation, nodules and interlobular septal thickening. In two patients, pathological specimens were obtained from open lung biopsy or bronchoscopic biopsy, and were correlated with HRCT findings. Three HRCT patterns of pulmonary abnormalities were identified in our series of HSV pneumonia: predominant areas of diffuse or multifocal ground-glass attenuation, predominant areas of multifocal peribronchial consolidations, and a mixed pattern of both. Histopathologically, areas of ground-glass attenuation seen on HRCT corresponded to diffuse alveolar damage in one patient who underwent open lung biopsy. No specific differences in HRCT findings were seen between the immunocompromised and the immunocompetent patients. In patients suspected of having an acute lower respiratory infection, whether immunocompromised or immunocompetent, a possibility of HSV pneumonia can be included in differential diagnoses when diffuse or multifocal areas of ground-glass attenuation and/or consolidations are seen on HRCT.

Electrical properties and surface morphology of SiO(x)-Pt nano-composite thin films

Recently, ceramic metals (cermets) have been widely investigated for use as embedded resistor materials. In this study, SiO-Pt nano-composite cermets were developed to control the resitivity and temperature coefficients of resistance (TCR) of embedded thin film resistors. The SiO-Pt nano-composite was prepared by the co-sputtering of a SiO(x) target and Pt chips onto glass. The experiments were conducted Pt concentrations in order to find the optimum conditions to achieve a high resistivity and low TCR. The electrical properties of the sputtered SiO-Pt thin films were investigated by probe station and their crystal structures were observed by X-Ray Diffraction (XRD) and X-ray Photoelectron Spectroscopy (XPS). The surface morphology was observed by field emission scanning electron microscopy (FE-SEM) and high resolution transmission electron microscopy (HR-TEM). It was found that the Pt particles with a size of 3 approximately 5 nm were uniformly dispersed in the SiO matrix. A stable resistivity value of 26000 approximately 57000 microomega x cm and TCR value of -197 approximately -322 ppm/K were obtained at 3.5 approximately 3.7 at.% Pt.

Accelerometer signal-based human activity recognition using augmented autoregressive model coefficients and artificial neural nets

Automatic recognition of human activities is one of the important and challenging research areas in proactive and ubiquitous computing. In this work, we present some preliminary results of recognizing human activities using augmented features extracted from the activity signals measured using a single triaxial accelerometer sensor and artificial neural nets. The features include autoregressive (AR) modeling coefficients of activity signals, signal magnitude areas (SMA), and title angles (TA). We have recognized four human activities using AR coefficients (ARC) only, ARC with SMA, and ARC with SMA and TA. With the last augmented features, we have achieved the recognition rate above 99% for all four activities including lying, standing, walking, and running. With our proposed technique, real time recognition of some human activities is possible.

3-D diffusion tensor MRI anisotropy content-adaptive finite element head model generation for bioelectromagnetic imaging

Realistic finite element (FE) head models have been successfully applied to bioelectromagnetic problems due to a realistic representation of arbitrary head geometry with inclusion of anisotropic material properties. In this paper, we propose a new automatic FE mesh generation scheme to generate a diffusion tensor MRI (DT-MRI) white matter anisotropy content-adaptive FE head model. We term this kind of mesh as wMesh. With this meshing technique, the anisotropic electrical conductivities derived from DT-MRIs can be best incorporated into the model. The influence of the white matter anisotropy on the EEG forward solutions has been studied via our wMesh head models. The scalp potentials computed from the anisotropic wMesh models against those of the isotropic models have been compared. The results describe that there are substantial changes in the scalp electrical potentials between the isotropic and anisotropic models, indicating that the inclusion of the white matter anisotropy is critical for accurate computation of E/MEG forward and inverse solutions. This fully automatic anisotropy-adaptive wMesh meshing scheme could be useful for modeling of individual-specific FE head models with better incorporation of the white matter anisotropic property towards bioelectromagnetic imaging.

Spatiotemporal human facial expression recognition using fisher independent component analysis and Hidden Markov Model

Facial expression recognition is an essential research area in the field of Human Computer Interface. In this work, we present a spatiotemporal approach of facial expression recognition using image sequences. The system proposed in this paper describes fisher independent component analysis as a feature extractor where the higher order moment classification method (i.e., independent component analysis) is augmented with fisher linear discriminant. This procedure is simply abbreviated as FICA and produces the shape based spatial facial expression features. For recognition, we have utilized Hidden Markov Model (HMM) to learn the obtained spatial features with the temporal dynamics in six different expressions. Our proposed approach for the first time deals with sequential images of emotion-specific facial expression data analyzed with FICA and recognized with HMM. Performance of our proposed system has been compared with four conventional approaches where principal component analysis, generic independent component analysis, enhanced independent component analysis, and augmented principal component analysis with linear discriminant analysis are utilized for feature extraction. Our preliminary results show that our proposed system yields much improved recognition rates reaching the mean recognition rate of 92.85%.

Independent component feature-based human activity recognition via Linear Discriminant Analysis and Hidden Markov Model

In proactive computing, human activity recognition from image sequences is an active research area. This paper presents a novel approach of human activity recognition based on Linear Discriminant Analysis (LDA) of Independent Component (IC) features from shape information. With extracted features, Hidden Markov Model (HMM) is applied for training and recognition. The recognition performance using LDA of IC features has been compared to other approaches including Principle Component Analysis (PCA), LDA of PC, and ICA. The preliminary results show much improved performance in the recognition rate with our proposed method.

Differences in subgingival microflora of Korean and German periodontal patients

PURPOSE

The goal of this study was to characterize the microbiological profile in samples of subgingival plaque taken from periodontal patients with different ethnic origin.

METHODS

178 patients (n=90 from South Korea and n=88 from Germany; age: 45.4 +/- 10.4 years) were diagnosed with severe generalized periodontitis. In all patients the deepest pocket of each quadrant was sampled for subgingival plaque. The four samples per patient were pooled and subsequently analysed with a 16s-RNA-gene probe test.

RESULTS

Prevalence of Aggregatibacter actinomycetemcomitans was significantly higher in German patients (47.7%) compared to Korean patients (26.7%) (p < 0.01, chi(2)-test). For Tannerella forsythia and porphyromonas gingivalis, differences between Germans and Koreans were not as pronounced. A statistically significant difference could also be found for Treponema denticola (Germans: 95.5%, Koreans: 81.1%, p < 0.01, chi(2)-test). After logarithmic transformation, bacterial counts differed for all microorganisms under investigation between Germans and Koreans, even after using a General Linear Model/Analysis of Covariance (GLM/ANCOVA) to adjust for gender, age, smoking status, pocket probing depths (PPD) of sampled teeth, and gingival bleeding index (GBI).

CONCLUSION

Depending on their ethnic origin, the microbiological profile of pooled subgingival plaque sample seems to differ significantly between patients of Caucasian and Asian ethnic origin.

Differential enhancement of leukaemia cell differentiation without elevation of intracellular calcium by plant-derived sesquiterpene lactone compounds

BACKGROUND AND PURPOSE

All-trans retinoic acid (ATRA) induces complete remission in a majority of acute promyelocytic leukaemia patients, but resistance of leukaemic cells to ATRA and its toxicity, such as hypercalcaemia, lead to a limitation of treatment. Therefore, combination therapies with differentiation-enhancing agents at non-toxic concentrations of ATRA may overcome its side effects. Here, we investigated the effect of plant-derived sesquiterpene lactone compounds and their underlying mechanisms in ATRA-induced differentiation of human leukaemia HL-60 cells.

EXPERIMENTAL APPROACH

HL-60 cells were treated with four sesquiterpene lactones (helenalin, costunolide, parthenolide and sclareolide) and cell differentiation was determined by NBT reduction, Giemsa and cytofluorometric analyses. Signalling pathways were assessed by western blotting, gel-shift assay and kinase activity determinations and intracellular calcium levels were determined using a calcium-specific fluorescent probe.

KEY RESULTS

Helenalin, costunolide and parthenolide, but not sclareolide, increased ATRA-induced HL-60 cell differentiation into a granulocytic lineage. Signalling kinases PKC and ERK were involved in the ATRA-induced differentiation enhanced by all of the effective sesquiterpene lactones, but JNK and PI3-K were involved in the ATRA-induced differentiation enhanced by costunolide and parthenolide. Enhancement of cell differentiation closely correlated with inhibition of NF-kappaB DNA-binding activity by all three effective compounds. Importantly, enhancement of differentiation induced by 50 nM ATRA by the sesquiterpene lactones was not accompanied by elevation of basal intracellular calcium concentrations.

CONCLUSIONS AND IMPLICATIONS

These results indicate that plant-derived sesquiterpene lactones may enhance ATRA-mediated cell differentiation through distinct pathways.

Arc plasma simulation of the KAERI large ion source

The KAERI large ion source, developed for the KSTAR NBI system, recently produced ion beams of 100 keV, 50 A levels in the first half campaign of 2007. These results seem to be the best performance of the present ion source at a maximum available input power of 145 kW. A slight improvement in the ion source is certainly necessary to attain the final goal of an 8 MW ion beam. Firstly, the experimental results were analyzed to differentiate the cause and effect for the insufficient beam currents. Secondly, a zero dimensional simulation was carried out on the ion source plasma to identify which factors control the arc plasma and to find out what improvements can be expected.

An ion optics study for KSTAR neutral beam injector development

Ion optics of three accelerator geometries was studied in terms of an analytic linear optics analysis, a numerical simulation using the IGUN program, an optical multichannel measurement of Doppler-shifted H(alpha) lines, and a water-flow calorimetry on the beam absorbing target. In general, there was a reasonable agreement observed between the four analysis methods and thus the theoretical analyses can be utilized with confidence for design iteration.

Methotrexate, vinblastine, doxorubicin and cisplatin combination regimen as salvage chemotherapy for patients with advanced or metastatic transitional cell carcinoma after failure of gemcitabine and cisplatin chemotherapy

We investigated the safety and efficacy of a methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) combination regimen as second-line chemotherapy for patients with advanced or metastatic transitional cell carcinoma who failed first-line gemcitabine and cisplatin (GC) chemotherapy. Thirty patients who had progressed or relapsed after GC chemotherapy as first-line treatment were enrolled in this study. The major toxicities were neutropaenia and thrombocytopaenia. A grade 3 or 4 neutropaenia occurred in 19 (63.3%) and a grade 3 or 4 thrombocytopaenia developed in nine patients (30.0%). There were no life-threatening complications during the study. The overall response was 30%. A complete response was achieved in two patients (6.7%) and a partial response in seven (23.3%). The overall disease control rate was 50%. Seven out of 16 patients who had responded previously to GC responded to M-VAC, while 2 out of 14 who had not responded to GC responded to M-VAC. The median response duration was 3.9 months and the median progression-free survival was 5.3 months. The median overall survival was 10.9 months. M-VAC showed encouraging efficacy and reversible toxicities in patients who had progressed after GC chemotherapy and, especially, M-VAC appears to be a reasonable option as a sequential treatment regimen in patients who responded previously to GC chemotherapy.