Ventilation Heterogeneity and Its Association with Nodule Formation Among Participants in the National Lung Screening Trial-A Preliminary Investigation.

RATIONALE AND OBJECTIVES: We have developed a technique to measure ventilation heterogeneity (VH) on low dose chest CT scan that we hypothesize may be associated with the development of lung nodules, and perhaps cancer. If true, such an analysis may improve screening by identifying regional areas of higher risk. MATERIALS AND METHODS: Using the National Lung Screening Trial database, we identified a small subset of those participants who were labeled as having a positive screening test at 1 year (T1) but not at baseline (T0). We isolated the region in which the nodule would form on the T0 scan ("target region") and measured VH as the standard deviation of the linear dimension of a virtual cubic airspace based on measurement of lung attenuation within the region. RESULTS: We analyzed 24 cases, 9 with lung cancer and 15 with a benign nodule. We found that the VH of the target region was nearly statistically greater than that of the corresponding contralateral control region (0.168 [0.110-0.226] vs. 0.112 [0.083-0.203], p = 0.051). The % emphysema within the target region was greater than that of the corresponding contralateral control region (1.339 [0.264-4.367] vs. 1.092 [0.375-4.748], p = 0.037). There was a significant correlation between the % emphysema and the VH of the target region (rho = +0.437, p = 0.026). CONCLUSION: Our study provides the first data in support of increased local VH being associated with subsequent lung nodule formation. Further work is necessary to determine whether this technique can enhance screening for lung cancer by low dose chest CT scan.

Ultrasound and Clinical Measures for Lymphedema.

BACKGROUND: Treatment for breast cancer has increased patient survivorship exponentially over the past few decades. With increased survivorship, more women are living with the longstanding effects of breast cancer treatment, such as lymphedema. Patients, health care providers, and payers depend on practical and efficient clinical measures to accurately diagnose and monitor disease progression or regression. However, current clinical measures do not include objective measures that assess lymphedetamous tissue accurately. This study compared current measures to a novel use of ultrasound (US) imaging to quantify tissue texture. METHODS AND RESULTS: Seventeen women diagnosed with lymphedema completed self-report questionnaires and then were tested twice by two lymphedema physical therapists who measured edema, fibrosis, and limb volume differences. One therapist measured subjects' limbs using US imaging and derived measures of entropy and average pixel intensity. Volume measures were consistent between therapists (p < 0.01) but palpation was not (0.01 < p < 0.72). Therapists' measures correlated better to subjects' self-report of edema (0.01 < p > 0.32) as compared to fibrosis (0.23 < p > 0.90). US measures were reliable (Cronbachs's α = 0.7 and 0.91 for entropy and API, respectively). Entropy measures demonstrated significant differences between subjects' involved versus uninvolved forearms (p = 0.03). CONCLUSIONS: Therapists were not consistent with each other when rating edema or fibrosis; however, they were consistent when measuring limb volume differences. US measures (entropy) demonstrated a significant difference between involved and uninvolved. US imaging, as a tool to quantify subcutaneous tissues, holds promise to be a safe, mobile, and effective method to measure lymphedema tissue texture.

The effect of age and emphysematous and fibrotic injury on the re-cellularization of de-cellularized lungs.

Use of de-cellularized cadaveric lungs as 3-dimensional scaffolds for ex vivo lung tissue generation offers a new potential therapeutic approach for clinical lung transplantation. However, it is likely that some of the available cadaveric human lungs may be from older donors or from donors with previously existing structural lung diseases such as emphysema or pulmonary fibrosis. It is not known whether these lungs will be suitable for either de-cellularization or re-cellularization. To investigate this, we assessed the effects of advanced age, representative emphysematous and fibrotic injuries, and the combination of advanced age and emphysematous injury and found significant differences both in histologic appearance and in the retention of extracellular matrix (ECM) and other proteins, as assessed by immunohistochemistry and mass spectrometry, between the different conditions. However, despite these differences, binding, retention and growth of bone marrow-derived mesenchymal stromal cells (MSCs) over a 1-month period following intratracheal inoculation were similar between the different experimental conditions. In contrast, significant differences occurred in the growth of C10 mouse lung epithelial cells between the different conditions. Therefore, age, lung injury, and the cell type used for re-cellularization may significantly impact the usefulness of de-cellularized whole lungs for ex vivo lung tissue regeneration.

The effects of storage and sterilization on de-cellularized and re-cellularized whole lung.

Despite growing interest on the potential use of de-cellularized whole lungs as 3-dimensional scaffolds for ex vivo lung tissue generation, optimal processing including sterilization and storage conditions, are not well defined. Further, it is unclear whether lungs need to be obtained immediately or may be usable even if harvested several days post-mortem, a situation mimicking potential procurement of human lungs from autopsy. We therefore assessed effects of delayed necropsy, prolonged storage (3 and 6 months), and of two commonly utilized sterilization approaches: irradiation or final rinse with peracetic acid, on architecture and extracellular matrix (ECM) protein characteristics of de-cellularized mouse lungs. These different approaches resulted in significant differences in both histologic appearance and in retention of ECM and intracellular proteins as assessed by immunohistochemistry and mass spectrometry. Despite these differences, binding and proliferation of bone marrow-derived mesenchymal stromal cells (MSCs) over a one month period following intratracheal inoculation was similar between experimental conditions. In contrast, significant differences occurred with C10 mouse lung epithelial cells between the different conditions. Therefore, delayed necropsy, duration of scaffold storage, sterilization approach, and cell type used for re-cellularization may significantly impact the usefulness of this biological scaffold-based model of ex vivo lung tissue regeneration.

Increased local cytokine production at culprit superficial femoral artery plaques.

Characterization of local inflammation at culprit superficial femoral artery (SFA) stenosis has not been studied. We hypothesized that arterial cytokine concentrations would be greater at sites of stenosis. Twenty patients with ≥50 % angiographic stenosis of the SFA had blood drawn just proximal to the lesion and from a contralateral site free of disease. A microplate immunoassay was used to determine the concentrations of 42 distinct cytokines and growth factors. Exact conditional logistic analysis was used to compare measures at the two sites with interaction terms describing clinical factors used to identify difference mediators. Interaction terms identified clinical factors that could predict cytokine levels. The concentrations of soluble CD40 ligand (sCD40L; mean 212 and 177 pg/ml, p = 0.01) and tumor necrosis factor beta (TNF-B; mean 16.6 and 15.9 pg/ml, p = 0.04) were increased immediately proximal to areas of stenosis. Factors associated with greater concentrations at sites of stenosis were bilateral ankle-brachial index ≤0.90 (p = 0.04), no statin use (p = 0.02), claudication (p = 0.03), low leukocyte count (p = 0.03), absence of limb ischemia (p = 0.04) and lack of aspirin or clopidogrel therapy (p ≤ 0.06). Greater concentrations of sCD40L and TNF-B at sites of stenosis suggest that these cytokines play a role in the pathogenesis of symptomatic SFA disease. Our results also suggest that statin, aspirin and clopidogrel therapy may attenuate localized inflammation in the SFA, though due to a small sample size and the use of multiple comparisons across groups, these findings can be viewed as hypothesis generating only. In conclusion, selected cytokines are heightened at culprit SFA lesions and inflammation may be modulated by statin and antiplatelet therapy.

Patterns of success: online self-monitoring in a web-based behavioral weight control program.

OBJECTIVES: Online weight control technologies could reduce barriers to treatment, including increased ease and convenience of self-monitoring. Self-monitoring consistently predicts outcomes in behavioral weight loss programs; however, little is known about patterns of self-monitoring associated with success. METHOD: The current study examines 161 participants (92% women; 31% African American; mean body mass index = 35.7 ± 5.7) randomized to a 6-month online behavioral weight control program that offered weekly group "chat" sessions and online self-monitoring. Self-monitoring log-ins were continuously monitored electronically during treatment and examined in association with weight change and demographics. Weekend and weekday log-ins were examined separately and length of periods of continuous self-monitoring were examined. RESULTS: We found that 91% of participants logged in to the self-monitoring webpage at least once. Over 6 months, these participants monitored on an average of 28% of weekdays and 17% of weekend days, with most log-ins earlier in the program. Women were less likely to log-in, and there were trends for greater self-monitoring by older participants. Race, education, and marital status were not significant predictors of self-monitoring. Both weekday and weekend log-ins were significant independent predictors of weight loss. Patterns of consistent self-monitoring emerged early for participants who went on to achieve greater than a 5% weight loss. CONCLUSIONS: Patterns of online self-monitoring were strongly associated with weight loss outcomes. These results suggest a specific focus on consistent self-monitoring early in a behavioral weight control program might be beneficial for achieving clinically significant weight losses.

Relationship of Neonatal Oral Motor Assessment Scale to Feeding Performance of Premature Infants.

OBJECTIVE: Some premature infants require prolonged tube-feeding, beyond term equivalent gestational age. Tools that could prospectively identify such infants from among otherwise healthy patients are needed. We examined how well the Neonatal Oral Motor Assessment Scale (NOMAS) predicts premature infants' transition from tube to oral feeding. DESIGN: Data from a prospective study of sucking behavior as a predictor of feeding skills were used to examine the relationship of NOMAS and other nominal predictors to pre-defined feeding milestones. SETTING: Neonatal intensive Care Unit PATIENTS: 51 tube-fed, premature infants METHODS: NOMAS was administered soon (<72 hours) after oral feeding was initiated, and weekly thereafter, until infants reached full oral feeding. A timed measure of feeding efficiency was also done as oral feeding was initiated. A standardized, permissive protocol for feeding advance was used. Nonparametric rank sum tests and ANOVA were used to relate NOMAS, feeding efficiency, and other baseline variables to feeding milestones. RESULTS: Gestational age at birth, birth weight, and initial feeding efficiency predicted shorter transition and earlier acquisition to full oral feeding; NOMAS scores did not predict feeding outcomes. CONCLUSIONS: NOMAS was a poor predictor, while feeding efficiency and other baseline traits were better predictors of feeding skills in premature infants.

The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis.

BACKGROUND: In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate. METHODS: We found 3,588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9,306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published. RESULTS: There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant. CONCLUSIONS: The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.

Pilot trial of spirometer games for airway clearance practice in cystic fibrosis.

BACKGROUND: Many children with cystic fibrosis (CF) adhere poorly to airway clearance techniques (ACTs), and would rather play video games that challenge their dexterity and visual tracking skills. We developed gaming technology that encourages forced expiratory maneuvers. OBJECTIVE: Following interviews regarding recreational activities and subjects' practice of ACTs, we conducted a pilot trial of spirometer games in 13 adolescents with CF, to test the hypothesis that games could increase subjects' engagement with forced expiratory breathing maneuvers and improve pulmonary function tests (PFTs). METHODS: After baseline PFTs, subjects were provided with digital spirometers and computers set up as "game only" or "control" devices. After the first of 2 periods (each > 2 weeks), the computer was set-up for the alternate condition for period 2. The t test and non-parametric correlation analyses examined use, number of expiratory high flow events (HFEs), and change in PFTs, identifying trends at P ≤ .1, significance at P < .05. RESULTS: Interviews disclosed minimal awareness of ACTs among our pediatric CF patients. Subjects used games and control software a similar percentage of days during the game (26%) and control periods (32%). There was a trend toward more minutes with the game versus control setup (P = .07), though HFE count did not differ between the 2 conditions (P = .71). Game play showed no overall effect on FEV(1), though correlation analysis showed a modest relation between minutes of play and change in FEV(1) from baseline (r = 0.50, P = .09). The game period showed a trend to increased vital capacity (P = .05). CONCLUSIONS: Spirometer games elicit forced expiratory breath maneuvers in pediatric CF patients. Improvement in PFTs may be due to improved test performance technique, though improved obstructive/restrictive lung function due to game play cannot be excluded. A formal clinical trial of this approach is planned.

A phase 1 study of nifurtimox in patients with relapsed/refractory neuroblastoma.

The primary aim of this phase 1 study was to determine the maximum tolerated dose (MTD) and evaluate the safety of nifurtimox alone and in combination with cyclophosphamide and topotecan in multiple relapsed/refractory neuroblastoma pediatric patients. The secondary aim was to evaluate the pharmacokinetics of nifurtimox and the treatment response. To these ends, we performed a phase 1 dose escalation trial of daily oral nifurtimox with toxicity monitoring to determine the MTD, followed by 3 cycles of nifurtimox in combination with cyclophosphamide and topotecan. Samples were collected to determine the pharmacokinetic parameters maximum concentration, time at which maximum concentration is reached, and area under the curve between 0 and 8 hours. Treatment response was evaluated by radiographic and radionuclide (I-metaiodobenzylguanidine) imaging, measurement of urinary catecholamines, and clearance of bone marrow disease. We determined the MTD of nifurtimox to be 30 mg/kg/d. The non-dose-limiting toxicities were mainly nausea and neuropathy. The dose-limiting toxicities of 2 patients at 40 mg/kg/d were a grade 3 pulmonary hemorrhage and a grade 3 neuropathy (reversible). Overall, nifurtimox was well tolerated by pediatric patients at a dose of 30 mg/kg/d, and tumor responses were seen both as a single agent and in combination with chemotherapy. A Phase 2 study to determine the antitumor efficacy of nifurtimox is currently underway.

Prospective study of non-nutritive sucking and feeding skills in premature infants.

OBJECTIVE: The aim of the present work was to assess the value of non-nutritive sucking (NNS) measures as predictors of oral feeding performance in comparison to other putative predictors of feeding skills: respiratory support, post-menstrual age (PMA) at birth and the neonatal oral motor assessment score (NOMAS). METHODS: This was a prospective, observational study. Cox proportional hazards and non-parametric rank sum tests were used to assess the relationship between NNS and feeding outcome measures. The setting was neonatal intensive care units (NICU) in rural/academic, urban/tertiary centres in the USA. In all, 51 premature infants born between 25 and 34 weeks' PMA, birth weight 1512.3+/-499.4 g, were included in this study. Interventions were measurement of NNS, standardised feeding advance schedule, performance of NOMAS, and standardised, permissive, oral feeding advance schedule. MAIN OUTCOME MEASURES: were transition time from first to full oral feeding (FOF) and gestational age at FOF. RESULTS: Higher NNS organisation scores predicted shorter transition to FOF (p<0.05): infants with a more organised suck pattern reached independent oral feeding 3 days earlier (16 vs 13 day transition) than infants with more chaotic patterns of suck bursts. Consistency of the suck waves also corresponded with feeding milestones: infants with more regular suck wave pressure deflections became competent oral feeders approximately 3 days earlier than those with irregular suck pressure waves. PMA at birth was inversely associated with PMA at FOF. NOMAS measures were not associated with outcome measures. CONCLUSIONS: Measures of NNS organisation and suck consistency constitute useful candidate predictors of feeding performance by premature infants. The results accord with previous findings linking PMA at birth with age at independent feeding.

Nifurtimox induces apoptosis of neuroblastoma cells in vitro and in vivo.

Neuroblastoma is the most common extracranial solid tumor in children and, when disseminated, carries a poor prognosis. Even with aggressive combinations of chemotherapy, surgery, autologous bone marrow transplant, and radiation, long-term survival remains at 30% and new therapies are needed. Recently, a patient with neuroblastoma who acquired Chagas disease was treated with nifurtimox with subsequent reduction in tumor size. The effect of nifurtimox on the neuroblastoma cell lines CHLA-90, LA1-55n, LA-N2, SMS-KCNR, and SY5Y was examined. Nifurtimox decreased cell viability in a concentration-dependent manner. Cell morphology, terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling assay, and caspase-3 activation indicate that cell death was primarily due to apoptosis. Nifurtimox also suppressed basal and TrkB-mediated Akt phosphorylation, and the cytotoxicity of nifurtimox was attenuated by a tyrosine hydroxylase inhibitor (alpha-methyl-tyrosine). Nifurtimox killed catecholaminergic, but not cholinergic, autonomic neurons in culture. In vivo xenograft models showed inhibition of tumor growth with a histologic decrease in proliferation and increase in apoptosis. These results suggest that nifurtimox induces cell death in neuroblastoma. Therefore, further studies are warranted to develop nifurtimox as a promising new treatment for neuroblastoma.

Breast milk odor via olfactometer for tube-fed, premature infants.

Human newborns use odor cues to orient to their source of nutrition. However, tube-fed, premature infants have restricted chemosensory experience. New methods of introducing breast milk odor to tube-fed premature infants will permit empiric tests of the effect of controlled exposure to nutrient odor. We therefore developed an infant olfactometer and piloted its use in 7 tube-fed, premature infants in the neonatal intensive care unit. Since nonnutritive sucking shortens the amount of time required to wean from tube-feeding, we tested the effect of breast milk odor on nonnutritive sucking. Six out of 7 subjects responded to breast milk odor with an increase in number of sucks. Statistical analysis supported the hypothesis that breast milk odor reinforces nonnutritive sucking. These results indicate the feasibility and potential of this experimental approach, and warrant further study of the effect of controlled nutrient odor exposure on feeding behavior of premature infants.

Results of an intervention for individuals and families with BRCA mutations: a model for providing medical updates and psychosocial support following genetic testing.

: Providing medical management updates and long-term support to families with hereditary cancer syndromes in rural areas is a challenge. To address this, we designed a one-day retreat for BRCA1/2 carriers in our region. The retreat included educational updates about medical management, genetic privacy and discrimination, and addressed psychological and family issues. Evaluations completed at the conclusion of the retreat were overwhelmingly positive with requests for a similar event in the future. The impact of this retreat on a variety of health behaviors was assessed. Eligible participants completed questionnaires before and 6 months after the retreat. Questionnaires focused on lifestyle, cancer screening and prevention practices, psychological history and distress, decision-making regarding genetic testing, and family communication issues. For individuals who completed both the pre and post retreat questionnaires, one-half made lifestyle changes and nearly two-thirds increased cancer screening, initiated chemoprevention, completed or planned to complete preventative surgery in the future. We conclude that this type of forum provides a valuable opportunity for BRCA carriers and their families to receive updated medical information, share personal experiences, provide and receive support, as well as change health behaviors.

Selection of tumor-binding ligands in cancer patients with phage display libraries.

Phage display has been used extensively in vitro and in animal models to generate ligands and to identify cancer-relevant targets. We report here the use of phage-display libraries in cancer patients to identify tumor-targeting ligands. Eight patients with stage IV cancer, including breast, melanoma, and pancreas, had phage-displayed random peptide or scFv library (1.6 x 10(8)-1 x 10(11) transducing units/kg) administered i.v.; tumors were excised after 30 minutes; and tumor-homing phage were recovered. In three patients, repeat panning was possible using phage recovered and amplified from that same patient's tumor. No serious side effects, including allergic reactions, were observed with up to three infusions. Patients developed antiphage antibodies that reached a submaximal level within the 10-day protocol window for serial phage administration. Tumor phage were recoverable from all the patients. Using a filter-based ELISA, several clones from a subset of the patients were identified that bound to a tumor from the same patient in which clones were recovered. The clone-binding to tumor was confirmed by immunostaining, bioassay, and real-time PCR-based methods. Binding studies with noncancer and cancer cell lines of the same histology showed specificity of the tumor-binding clones. Analysis of insert sequences of tumor-homing peptide clones showed several motifs, indicating nonrandom accumulation of clones in human tumors. This is the first reported series of cancer patients to receive phage library for serial panning of tumor targeting ligands. The lack of toxicity and the ability to recover clones with favorable characteristics are a first step for further research with this technology in cancer patients.

NSABP-32: Phase III, randomized trial comparing axillary resection with sentinal lymph node dissection: a description of the trial.

The NSABP-32 trial is a randomized, phase III clinical trial to compare sentinel node (SN) resection to conventional axillary dissection in clinically node-negative breast cancer patients. The primary aims of the trial are to determine if removal of only SNs provides survival and regional control equivalent to those of axillary dissection, while diminishing the magnitude of surgically related side effects. In order to ensure consistency of the outcomes for this trial, a standardized method of SN surgery has been utilized for all cases. A secondary aim of the B32 trial is to evaluate whether patients with "occult" metastases in the SNs have worse survival. Accrual is taking place at 73 institutions in North America, and 217 surgeons are enrolling patients.

Comparison of pathologist-detected and automated computer-assisted image analysis detected sentinel lymph node micrometastases in breast cancer.

Sentinel lymph node biopsy has stimulated interest in identification of micrometastatic disease in lymph nodes, but identifying small clusters of tumor cells or single tumor cells in lymph nodes can be tedious and inaccurate. The optimal method of detecting micrometastases in sentinel nodes has not been established. Detection is dependent on node sectioning strategy and the ability to locate and confirm tumor cells on histologic sections. Immunohistochemical techniques have greatly enhanced detection in histologic sections; however, comparison of detection methodology has not been undertaken. Automated computer-assisted detection of candidate tumor cells may have the potential to significantly assist the pathologist. This study compares computer-assisted micrometastasis detection with routine detection by a pathologist. Cytokeratin-stained sentinel lymph node sections from 100 patients at the University of Vermont were evaluated by automated computer-assisted cell detection. Based on original routine light microscopy screening, 20 cases that were positive and 80 cases that were negative for micrometastases were selected. One-level (43 cases) or two-level (54 cases) cytokeratin-stained sections were examined per lymph node block. All 100 patients had previously been classified as node negative by using routine hematoxylin and eosin stained sections. Technical staining problems precluded computer-assisted cell detection scanning in three cases. Computer-assisted cell detection detected 19 of 20 (95.0%; 95% confidence interval, 75-100%) cases positive by routine light microscopy. Micrometastases missed by computer-assisted cell detection were caused by cells outside the instrument's scanning region. Computer-assisted cell detection detected additional micrometastases, undetected by light microscopy, in 8 of 77 (10.4%; 95% confidence interval, 5-20%) cases. The computer-assisted cell detection-positive, light microscopy-missed detection rate was similar for cases with one (3 of 30; 10.0%) or two (5 of 47; 10.6%) cytokeratin sections. Metastases detected by routine light microscopy tended to be larger (0.01-0.50 mm) than did metastases detected only by computer-assisted cell detection (0.01-0.03 mm). In a selected series of patients, automated computer-assisted cell detection identified more micrometastases than were identified by routine light microscopy screening of cytokeratin-stained sections. Computer-assisted detection of events that are limited in number or size may be more reliable than detection by a pathologist using routine light microscopy. Factors such as human fatigue, incomplete section screening, and variable staining contribute to missing metastases by routine light microscopy screening. Metastases identified exclusively by computer-assisted cell detection tend to be extremely small, and the clinical significance of their identification is currently unknown.

Use of complimentary and alternative medicine by breast cancer patients: prevalence, patterns and communication with physicians.

This study examined the use of complementary and alternative medicine (CAM) therapies by breast cancer patients and the communication of their CAM use to their physicians relative to lymphedema symptoms and other factors. Breast cancer patients ( N = 148) in the State of Vermont were interviewed 2-3 years after their primary surgery using computer-aided telephone interviewing methods. Questionnaire items included demographic information, treatment, CAM use, lymphedema symptoms, and other measures. A large proportion (72.3%) reported using at least one CAM treatment after surgery. The most frequently used treatments were vitamins and nonfood supplements (72.3%), with herbal treatments, meditation, and traditional massage each being reported by about one-fifth of the women. Age, education, adjuvant chemotherapy, and extremity swelling were associated with use of more CAM treatments in a regression model. A large proportion (73.8%) of CAM users reported their CAM use to their physicians. Correlations between patients' income, adjuvant radiation therapy, and adjuvant tamoxifen use with communication of CAM use to their physicians were sought in a logistic regression model. CAM use is high among breast cancer patients in Vermont, and the number of CAM therapies used is related to demographic factors, adjuvant treatment, and lymphedema symptoms. Communication of CAM use to physicians appears to be multifaceted.