3D visualization of perianal fistulas using parametric models.

BACKGROUND: Magnetic resonance imaging (MRI) is used as a standard for assessment of complex perianal fistulas. Apart from textual description of the case, 3D reconstructed models from MRI further aid in understanding the entire anatomy of the fistula tract and its relation to the pelvic floor. This information is crucial as it helps surgeons to understand the extent and complexity of the disease before surgical treatment. However, 3D model generation from MRI is a time-consuming step for a radiologist as it requires tedious manual delineations to be performed on every slice of the images. The aim of this study was to develop a method that could enable radiologists to present enhanced information to surgeons for treatment of complex perianal fistulas while simultaneously reducing the manual efforts and time required to generate the information. METHODS: A method was proposed to depict relevant anatomies of complex perianal fistula as parametric models in three-dimensional (3D) space. A plugin inside 3D Slicer software was developed for the generation of the parametric models from MRI. The levator ani muscle, internal sphincter, and external sphincter are represented as tubular structures, whereas fistula tracks and abscess are presented as splines. RESULTS: Parametric models were generated to depict three cases of complex perianal fistulas and similarity measures were computed for ten cases. Visual comparison of the parametric models was made with the 3D models generated by the standard approach. The parametric models took less time to create and were able to visually present enriched information as compared to the 3D models generated by the standard approach. CONCLUSIONS: The proposed method, using parametric models, shows potential for faster generation and better visualization of the 3D information required for the treatment of complex perianal fistula cases.

IL-5-stimulated eosinophils adherent to periostin undergo stereotypic morphological changes and ADAM8-dependent migration.

BACKGROUND: IL-5 causes suspended eosinophils to polarize with filamentous (F)-actin and granules at one pole and the nucleus in a specialized uropod, the "nucleopod," which is capped with P-selectin glycoprotein ligand-1 (PSGL-1). IL-5 enhances eosinophil adhesion and migration on periostin, an extracellular matrix protein upregulated in asthma by type 2 immunity mediators. OBJECTIVE: Determine how the polarized morphology evolves to foster migration of IL-5-stimulated eosinophils on a surface coated with periostin. METHODS: Blood eosinophils adhering to adsorbed periostin were imaged at different time points by fluorescent microscopy, and migration of eosinophils on periostin was assayed. RESULTS: After 10 minutes in the presence of IL-5, adherent eosinophils were polarized with PSGL-1 at the nucleopod tip and F-actin distributed diffusely at the opposite end. After 30-60 minutes, the nucleopod had dissipated such that PSGL-1 was localized in a crescent or ring away from the cell periphery, and F-actin was found in podosome-like structures. The periostin layer, detected with monoclonal antibody Stiny-1, shown here to recognize the FAS1 4 module, was cleared in wide areas around adherent eosinophils. Clearance was attenuated by metalloproteinase inhibitors or antibodies to disintegrin metalloproteinase 8 (ADAM8), a major eosinophil metalloproteinase previously implicated in asthma pathogenesis. ADAM8 was not found in podosome-like structures, which are associated with proteolytic activity in other cell types. Instead, immunoblotting demonstrated proteoforms of ADAM8 that lack the cytoplasmic tail in the supernatant. Anti-ADAM8 inhibited migration of IL-5-stimulated eosinophils on periostin. CONCLUSIONS AND CLINICAL RELEVANCE: Migrating IL-5-activated eosinophils on periostin exhibit loss of nucleopodal features and appearance of prominent podosomes along with clearance of the Stiny-1 periostin epitope. Migration and epitope clearance are both attenuated by inhibitors of ADAM8. We propose, therefore, that eosinophils remodel and migrate on periostin-rich extracellular matrix in the asthmatic airway in an ADAM8-dependent manner, making ADAM8 a possible therapeutic target.

Veterans with post-traumatic stress disorder exhibit altered emotional processing and attentional control during an emotional Stroop task.

BACKGROUND: Post-traumatic stress disorder (PTSD) is often associated with attention allocation and emotional regulation difficulties, but the brain dynamics underlying these deficits are unknown. The emotional Stroop task (EST) is an ideal means to monitor these difficulties, because participants are asked to attend to non-emotional aspects of the stimuli. In this study, we used magnetoencephalography (MEG) and the EST to monitor attention allocation and emotional regulation during the processing of emotionally charged stimuli in combat veterans with and without PTSD. METHOD: A total of 31 veterans with PTSD and 20 without PTSD performed the EST during MEG. Three categories of stimuli were used, including combat-related, generally threatening and neutral words. MEG data were imaged in the time-frequency domain and the network dynamics were probed for differences in processing threatening and non-threatening words. RESULTS: Behaviorally, veterans with PTSD were significantly slower in responding to combat-related relative to neutral and generally threatening words. Veterans without PTSD exhibited no significant differences in responding to the three different word types. Neurophysiologically, we found a significant three-way interaction between group, word type and time period across multiple brain regions. Follow-up testing indicated stronger theta-frequency (4-8 Hz) responses in the right ventral prefrontal (0.4-0.8 s) and superior temporal cortices (0.6-0.8 s) of veterans without PTSD compared with those with PTSD during the processing of combat-related words. CONCLUSIONS: Our data indicated that veterans with PTSD exhibited deficits in attention allocation and emotional regulation when processing trauma cues, while those without PTSD were able to regulate emotion by directing attention away from threat.

Physes around the shoulder girdle: normal development and injury patterns.

Traumatic injuries involving the scapula and clavicle in skeletally immature patients have unique characteristics that distinguish them from similar injuries in the mature skeleton. Fractures involving unossified cartilage and unfused epiphyses are difficult to appreciate on plain radiographs and computed tomography (CT) imaging. Knowledge of the developmental anatomy and normal radiological appearances during different stages of development of these bones is an essential prerequisite for the radiologist tasked with interpreting the imaging of such injuries in order to avoid potential diagnostic pitfalls. With increased availability and improved resolution of magnetic resonance imaging (MRI), we are now better able to distinguish between true joint dislocations and epiphyseal injuries. Making this distinction is important because it can have implications with regards to how the patient is managed and the prognosis.

Quality indicators for the primary care of osteoarthritis: a systematic review.

OBJECTIVE: To identify valid and feasible quality indicators for the primary care of osteoarthritis (OA). DESIGN: Systematic review and narrative synthesis. DATA SOURCES: Electronic reference databases (MEDLINE, EMBASE, CINAHL, HMIC, PsychINFO), quality indicator repositories, subject experts. ELIGIBILITY CRITERIA: Eligible articles referred to adults with OA, focused on development or implementation of quality indicators, and relevant to UK primary care. An English language restriction was used. The date range for the search was January 2000 to August 2013. The majority of OA management guidance has been published within this time frame. DATA EXTRACTION: Relevant studies were quality assessed using previous quality indicator methodology. Two reviewers independently extracted data. Articles were assessed through the Outcome Measures in Rheumatology filter; indicators were mapped to management guidance for OA in adults. A narrative synthesis was used to combine the indicators within themes. RESULTS: 10,853 articles were identified from the search; 32 were included in the review. Fifteen indicators were considered valid and feasible for implementation in primary care; these related to assessment non-pharmacological and pharmacological management. Another 10 indicators were considered less feasible, in various aspects of assessment and management. A small number of recommendations had no published corresponding quality indicator, such as use of topical non-steroidal anti-inflammatory drugs. No negative ('do not do') indicators were identified. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: There are well-developed, feasible indicators of quality of care for OA which could be implemented in primary care. Their use would assist the audit and quality improvement for this common and frequently disabling condition.

Efficacy of 0.01% low dose atropine and its correlation with various factors in myopia control in the Indian population.

We aimed to evaluate the efficacy and safety of low-dose atropine compared to placebo in the Indian population and also to study the impact of various modifiable and non-modifiable factors on myopia progression (MP) and drug efficacy (DE). It was a single-centre prospective placebo-controlled interventional study. 43 participants aged 6-16 years with progressive myopia received 0.01% atropine in the right eyes (treatment) and placebo in the left eyes (control) for 1-year. The main outcome measures were annual MP and axial length elongation (ALE) in treatment and control eyes and their percentage difference between two eyes (drug efficacy). Secondary outcome measures were the occurrence of any adverse events and the correlation of MP, ALE, and DE with various factors. 40 participants (80 eyes) completed the follow-up. After 1-year, MP was 0.25 D (IQR 0.13-0.44) and 0.69 D (IQR 0.50-1.0) (p < 0.001) in treatment and control respectively (63.89% reduction) with respective ALE of 0.14 mm (IQR 0.05-0.35) and 0.32 mm (IQR 0.19-0.46) (p < 0.001) (44.44% reduction). No adverse events were noted. Reduction in MP and ALE was statistically significant in all children irrespective of age-group, baseline MP, family history, screen-time, near and outdoor-time. The strongest determinants of annual MP were age (Treatment: r = - 0.418, p = 0.007; Control: r = - 0.452, p = 0.003) and baseline MP (Treatment: r = 0.64, p = 0.000; Control: r = 0.79, p = 0.000). Screen-time in control eyes was associated with greater ALE (r = 0.620, p = 0.042). DE was higher when outdoor time exceeded 2 h/day (p = 0.035) while the efficacy was lower with prolonged near activities (p = 0.03), baseline fast-progressors (p < 0.05) and history of parental myopia (p < 0.05). 0.01% atropine is effective and safe in retarding MP and ALE in Indian eyes.

Still Struggling: characteristics of youth with OCD who are partial responders to medication treatment.

The primary aim of this paper is to examine the characteristics of a large sample of youth with OCD who are partial responders (i.e., still have clinically significant symptoms) to serotonin reuptake inhibitor (SRI) medication. The sample will be described with regard to: demographics, treatment history, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 124 youth with OCD ranging in age from 7 to 17 with a primary diagnosis of OCD and a partial response to an SRI medication. The youth are a predominantly older (age 12 and over), Caucasian, middle to upper income group who had received significant past treatment. Key findings include moderate to severe OCD symptoms, high ratings of global impairment, and significant comorbidity, despite partial response to an adequate medication trial. Considerations regarding generalizability of the sample and limitations of the study are discussed.

Mucosal IL-4R antagonist HIV vaccination with SOSIP-gp140 booster can induce high-quality cytotoxic CD4+/CD8+ T cells and humoral responses in macaques.

Inducing humoral, cellular and mucosal immunity is likely to improve the effectiveness of HIV-1 vaccine strategies. Here, we tested a vaccine regimen in pigtail macaques using an intranasal (i.n.) recombinant Fowl Pox Virus (FPV)-gag pol env-IL-4R antagonist prime, intramuscular (i.m.) recombinant Modified Vaccinia Ankara Virus (MVA)-gag pol-IL-4R antagonist boost followed by an i.m SOSIP-gp140 boost. The viral vector-expressed IL-4R antagonist transiently inhibited IL-4/IL-13 signalling at the vaccination site. The SOSIP booster not only induced gp140-specific IgG, ADCC (antibody-dependent cellular cytotoxicity) and some neutralisation activity, but also bolstered the HIV-specific cellular and humoral responses. Specifically, superior sustained systemic and mucosal HIV Gag-specific poly-functional/cytotoxic CD4+ and CD8+ T cells were detected with the IL-4R antagonist adjuvanted strategy compared to the unadjuvanted control. In the systemic compartment elevated Granzyme K expression was linked to CD4+ T cells, whilst Granzyme B/TIA-1 to CD8+ T cells. In contrast, the cytotoxic marker expression by mucosal CD4+ and CD8+ T cells differed according to the mucosal compartment. This vector-based mucosal IL-4R antagonist/SOSIP booster strategy, which promotes cytotoxic mucosal CD4+ T cells at the first line of defence, and cytotoxic CD4+ and CD8+ T cells plus functional antibodies in the blood, may prove valuable in combating mucosal infection with HIV-1 and warrants further investigation.

Emerging influenza virus: a global threat.

Since 1918, in?uenza virus has been one of the major causes of morbidity and mortality, especially among young children. Though the commonly circulating strain of the virus is not virulent enough to cause mortality, the ability of the virus genome to mutate at a very high rate may lead to the emergence of a highly virulent strain that may become the cause of the next pandemic. Apart from the influenza virus strain circulating in humans (H1N1 and H3N2), the avian influenza H5N1 H7 and H9 virus strains have also been reported to have caused human infections, H5N1 H7 and H9 have shown their ability to cross the species barrier from birds to humans and further replicate in humans. This review addresses the biological and epidemiological aspects of influenza virus and efforts to have a control on the virus globally.

Electrophysiological patterns of diabetic polyneuropathy.

OBJECTIVE: This study evaluates the pattern of electrodiagnostic (EDX) abnormalities in diabetic sensorimotor polyneuropathies. METHODS: EDX data from 112 consecutive patients with type 2 diabetes mellitus with distal, predominantly sensory, polyneuropathies were reviewed. Motor conduction velocities (CV), distal motor latencies (DML), compound muscle action potential (CMAP) amplitudes, distal to proximal amplitude ratios (PID), and F-wave latencies (FWL) were analyzed. Data were normalized based on normative reference values, and the proportion of nerves with abnormal values in the lower and upper limbs were evaluated. These data were also analyzed in relation to whether there was possible demyelinating versus axonal injury. Statistical analyses included comparison of the proportions of abnormal nerves in upper versus lower limbs as well as using Generalized Estimating Equations (GEE) to account for correlated observations for each patient between lower and upper limbs and adjusting for patient age effect. RESULTS: CVs were significantly more abnormal in the legs than the arms (p < 0.0006) and decreased CMAP amplitudes meeting criteria for axonal injury were also more frequent in the legs (p < 0.0001). Using the GEE model, axonal injury was more common in the legs while demyelinating injury was more common in the arms based on FWLs, especially in younger persons (e.g., 40 years old vs. 50 years old). These differences are not readily explained by the duration of the diabetes. CONCLUSION: Since in diabetics "axonal" type injury may be more common in the legs while "demyelinating" injury more frequent in the arms, this study emphasizes the limitation of this type of classification, and supports the idea that the pattern of EDX abnormalities in different types of neuropathies may be more helpful.

Low prevalence of hepatitis B virus and hepatitis C virus co-infection in patients with human immunodeficiency virus in Northern India.

AIM: To study the prevalence of HBV and HCV co-infection in patients with HIV attending a referral hospital in Northern India. METHODS AND MATERIAL: The study cohort included six hundred and twenty consecutive HIV infected patients who were studied for co-infection with HBV/HCV or both. It included four hundred and seventy two male and one hundred and forty eight female patients between the age group 25-50 years. HBV and HCV infection was diagnosed by ELISA. Other routine investigations were also done. RESULTS: Out of a total of 620 consecutive HIV infected patients studied, HBV co-infection was detected in 14/ 620 (2.25%) patients and HCV co-infection in 10/620 (1.61%) patients and dual co-infection (HBV/HCV) in 1/620(0.16%). The mode of transmission of HBV was sexual contact in all (100%), while for HCV it was sexual contact in 5 patients (50%), blood transfusion in 4 patients (40%) and intravenous drug use (IDU) in 1 patient (10%). CONCLUSION: The prevalence of co-infection with HBV/HCV is much lower in our study population as compared to that reported in Western literature.

Polyphasic approach of bacterial classification - An overview of recent advances.

Classification of microorganisms on the basis of traditional microbiological methods (morphological, physiological and biochemical) creates a blurred image about their taxonomic status and thus needs further clarification. It should be based on a more pragmatic approach of deploying a number of methods for the complete characterization of microbes. Hence, the methods now employed for bacterial systematics include, the complete 16S rRNA gene sequencing and its comparative analysis by phylogenetic trees, DNA-DNA hybridization studies with related organisms, analyses of molecular markers and signature pattern(s), biochemical assays, physiological and morphological tests. Collectively these genotypic, chemotaxonomic and phenotypic methods for determining taxonomic position of microbes constitute what is known as the 'polyphasic approach' for bacterial systematics. This approach is currently the most popular choice for classifying bacteria and several microbes, which were previously placed under invalid taxa have now been resolved into new genera and species. This has been possible owing to rapid development in molecular biological techniques, automation of DNA sequencing coupled with advances in bioinformatic tools and access to sequence databases. Several DNA-based typing methods are known; these provide information for delineating bacteria into different genera and species and have the potential to resolve differences among the strains of a species. Therefore, newly isolated strains must be classified on the basis of the polyphasic approach. Also previously classified organisms, as and when required, can be reclassified on this ground in order to obtain information about their accurate position in the microbial world. Thus, current techniques enable microbiologists to decipher the natural phylogenetic relationships between microbes.

Prospective randomised comparison of ring versus rail fixator in infected gap nonunion of tibia treated with distraction osteogenesis.

AIMS: This is a prospective randomised study which compares the radiological and functional outcomes of ring and rail fixators in patients with an infected gap (> 3 cm) nonunion of the tibia. PATIENTS AND METHODS: Between May 2008 and February 2013, 70 patients were treated at our Institute for a posttraumatic osseocutaneous defect of the tibia measuring at least 3 cm. These were randomised into two groups of 35 patients using the lottery method. Group I patients were treated with a ring fixator and group II patients with a rail fixator. The mean age was 33.2 years (18 to 64) in group I and 29.3 years (18 to 65) in group II. The mean bone gap was 5.84 cm in group I and 5.78 cm in group II. The mean followup was 33.8 months in group I and 32.6 months in group II. Bone and functional results were assessed using the classification of the Association for the Study and Application of the Method of Ilizarov (ASAMI). Functional results were also assessed at six months using the short musculoskeletal functional assessment (SMFA) score. RESULTS: The bone result was excellent, good, fair and poor in 21, 12, 0 and 2 in group I; and 14, 15, 3, and 3 in group II, respectively. The functional results were excellent, good, fair, poor and failure in 16, 17, 1, 0 and 1 in group I; and 22, 10, 0, 3 and 0 in group II, respectively. Both fixator systems achieved comparable rates of union and functional outcomes. The rate of deep pintract infection was significantly higher in the rail fixator group but patients found it more comfortable. CONCLUSION: We recommend the use of a ring fixator in patients with a bone gap of more than 6 cm. Patients with a bone gap up to 6 cm can be managed with either a ring or rail fixator. Cite this article: Bone Joint J 2016;98B:1399-1405.

Multiplex PCR/LDR for detection of K-ras mutations in primary colon tumors.

Point mutations in codons 12, 13, and 61 of the K-ras gene occur early in the development of colorectal cancer and are preserved throughout the course of tumor progression. These mutations can serve as biomarkers for shed or circulating tumor cells and may be useful for diagnosis of early, curable tumors and for staging of advanced cancers. We have developed a multiplex polymerase chain reaction/ligase detection reaction (PCR/LDR) method which identifies all 19 possible single-base mutations in K-ras codons 12, 13, and 61, with a sensitivity of 1 in 500 wild-type sequences. In a blinded study, 144 paraffin-embedded archival colon carcinomas were microdissected and K-ras mutations determined by both dideoxy-sequencing and multiplex PCR/LDR. Results were concordant for 134 samples. The ten discordant samples were re-evaluated using higher sensitivity uniplex PCR/LDR, and the original multiplex PCR/LDR result was confirmed in nine of these ten cases. Multiplex PCR/LDR was able to identify mutations in solid tumors or paraffin-embedded tissues containing a majority of wild-type stromal cells, with or without microdissection. The technique is well suited for large scale studies and for analysis of clinical samples containing a minority population of mutated cells.

Structure of a gene coding for human dihydrodiol dehydrogenase/bile acid-binding protein.

The structure and sequence of the gene (DD/BABP) encoding a human dihydrodiol dehydrogenase/bile acid-binding protein (DD/BABP) were determined by analysis of genomic clones. Several overlapping clones containing parts of the gene were isolated from a lambda EMBL3 SP6/T7 library and characterized by restriction mapping and DNA sequencing. The gene spans approx. 16kb and consists of nine exons. The sizes of the exons range from 77 to 167 bp, whereas the intron sizes range from 375 to 3430 bp. The transcription start point (tsp) is located at -56 bp of the first ATG codon, as determined by primer extension. Neither a TATA box nor a CAT box was found upstream from the tsp. Southern blot analysis of the human genomic DNA, using the cDNA as the probe, revealed several additional hybridizing DNA bands, suggesting the existence of multiple related genes.

Distribution of 3 alpha-hydroxysteroid dehydrogenase in rat brain and molecular cloning of multiple cDNAs encoding structurally related proteins in humans.

3 alpha-Hydroxysteroid dehydrogenase in the brain is responsible for production of neuroactive tetrahydrosteroids that interact with the major inhibitory gamma-aminobutyric acid receptor complexes. Distribution of 3 alpha-hydroxysteroid dehydrogenase in different regions of the brain in rats was evaluated by activity assay and by Western immunoblotting using a monoclonal antibody against liver 3 alpha-hydroxysteroid dehydrogenase as the probe. The olfactory bulb was found to contain the highest level of 3 alpha-hydroxysteroid dehydrogenase activity, while moderate levels of the enzyme activity were found in other regions such as cerebellum, cerebral cortex, hypothalamus and pituitary. Some activity was found in the rest of the brain such as amygdala, brain stem, caudate putamen, cingulate cortex, hippocampus, midbrain, and thalamus. The protein levels of 3 alpha-hydroxysteroid dehydrogenase in different regions of the brain as detected by Western immunoblotting are comparable to those of the enzyme activity. We used the rat cDNA as the probe to screen a human liver lambda gt11 cDNA library. A total of four different cDNAs were identified and sequenced. One of the cDNAs is identical to that of the human chlordecone reductase cDNA except that our clone contains a much longer 5'-coding sequence than previously reported. The other three cDNAs display high degrees of sequence homology to those of both rat 3 alpha-hydroxysteroid dehydrogenase and human chlordecone reductase. We are currently investigating the functional relationship between the enzymes encoded by these human cDNAs and 3 alpha-hydroxysteroid dehydrogenase.

Distribution and ontogeny of 3 alpha-hydroxysteroid dehydrogenase in the rat brain.

3 alpha-Hydroxysteroid dehydrogenase in the brain is responsible for production of neuroactive tetrahydrosteroids that interact with the major inhibitory gamma-aminobutyric acid receptor complexes. Distribution of 3 alpha-hydroxysteroid dehydrogenase in different regions of the brain in rats was evaluated by activity assay and by Western immunoblotting using a monoclonal antibody against liver 3 alpha-hydroxysteroid dehydrogenase as the probe. The olfactory bulb was found to contain the highest level of 3 alpha-hydroxysteroid dehydrogenase activity, while moderate levels of the enzyme activity were found in other regions such as cerebellum, cerebral cortex, hypothalamus and pituitary. Some activities were found in the rest of the brain such as amygdala, brain stem, caudate putamen, cingulate cortex, hippocampus, midbrain, and thalamus. The protein levels of 3 alpha-hydroxysteroid dehydrogenase in different regions of the brain as detected by Western immunoblotting are comparable to those of the enzyme activity. No sexual dimorphism was found in either the concentration levels or the activities of the brain 3 alpha-hydroxysteroid dehydrogenase. At the time of birth, the rat brain already expresses a significant level of 3 alpha-hydroxysteroid dehydrogenase; the levels of brain 3 alpha-hydroxysteroid dehydrogenase activity in rats continue to rise during the first week after their birth, and reach a plateau thereafter.

Margin status and local recurrence after breast-conserving surgery.

OBJECTIVE: To examine the effect of microscopic tumor at the margins on local recurrence after breast-conserving surgery for invasive carcinoma. DESIGN: Retrospective review of patients treated with surgical resection followed by radiation therapy. SETTING: A university-based radiation department and a community-based cancer referral center. PATIENTS: A consecutive series of 272 women treated between 1982 and 1990. MAIN OUTCOME MEASURE: Local recurrence according to the histopathologic status of excised margins and the total dose of radiation. RESULTS: During a mean follow-up period of 48 months, the overall rate of local recurrence was 6.3%. Local recurrence was more frequent (P = .0001) in patients with histologically positive margins (18.2%) than in those with unknown margins (7.1%) or negative margins (3.7%). In the 44 patients with positive margins, the local recurrence rate was 8.3% after radiation doses of 66 Gy or more compared with 21.9% following lower doses. CONCLUSIONS: Microscopic involvement of resection margins increases the risk of local recurrence following breast-conserving surgery for invasive carcinoma. Therefore, every effort should be made to achieve negative margins intraoperatively.