The importance of aspirin, catheterization accuracy, and catheter design in external ventricular drainage-related hemorrhage: a multicenter study of 1002 procedures.

BACKGROUND: External ventricular drainage (EVD) is the commonest neurosurgical procedure performed in daily neurosurgical practice, but relatively few studies have investigated the incidence and risk factors of its related hemorrhagic complications. METHODS: This was a multicenter retrospective review of consecutive EVD procedures. Patients 18 years or older who underwent EVD and had a routine postoperative computed tomography (CT) scan performed within 24 hours were included. EVD-related hemorrhage was defined as new intracranial hemorrhage immediately adjacent or within the ventricular catheter trajectory. The volume of hemorrhage and the position of the catheter tip were assessed. A review of patient-, disease-, and surgery-related factors including the ventricular catheter design utilized was conducted. The Bonferroni correction was applied to the alpha level of significance (0.05) for multivariable analysis. RESULTS: Nine hundred sixty-two patients underwent 1002 EVD performed by neurosurgeons in the operating theater. Sixteen percent (154) of patients were on aspirin before the procedure. Thirty-four percent (333) of patients had intracerebral hemorrhage, 25% (251) had aneurysmal subarachnoid hemorrhage and 16% (158) had traumatic brain injury. The mean duration from EVD to the first postoperative CT scan was 20 ± 4 h. EVD-related hematomas were detected after 81 procedures with a per-catheter risk of 8.1%. Mean hematoma volume was 1.2 ± 3.3 ml. Most were less than 1 ml (grade I, 79%, 64), 1 to 15 ml (grade II) in 20% (16) and a single clot larger than 15 ml (grade III, 1%) were detected. Clinically significant hemorrhage that resulted in catheter occlusion occurred in 1.7% (17) of procedures. Most catheters (62%, 625) were optimally placed, i.e., its tip being within the ipsilateral frontal horn or third ventricle. Three non-antibiotic-impregnated ventricular catheter designs were used with 55% (550) being the 2.2-mm Integra™ catheter, 14% (137) being the 2.8-mm Medtronic™ catheter, and 31% (315) being the 3.1-mm Codman™ catheter. Independent significant predictors for EVD-related hemorrhage were the preoperative prescription of aspirin (adjusted OR 1.94; 95% CI 1.10-3.44), catheter malposition (aOR 1.99; 95% CI 1.22-3.23), and use of the 2.8-mm Medtronic™ catheter (aOR 4.22; 95% CI 2.39-7.41). CONCLUSIONS: The per-catheter risk of hemorrhage was 8.1%, but the incidence of symptomatic hemorrhage was low. The only patient risk factor was aspirin intake. This is the first study to evaluate and establish an association between catheter malposition and catheter design with EVD-related hemorrhage.

Experimental autoimmune prostatitis induces microglial activation in the spinal cord.

BACKGROUND: The pathogenesis of chronic prostatitis/chronic pelvic pain syndrome is unknown and factors including the host's immune response and the nervous system have been attributed to the development of CP/CPPS. We previously demonstrated that mast cells and chemokines such as CCL2 and CCL3 play an important role in mediating prostatitis. Here, we examined the role of neuroinflammation and microglia in the CNS in the development of chronic pelvic pain. METHODS: Experimental autoimmune prostatitis (EAP) was induced using a subcutaneous injection of rat prostate antigen. Sacral spinal cord tissue (segments S14-S5) was isolated and utilized for immunofluorescence or QRT-PCR analysis. Tactile allodynia was measured at baseline and at various points during EAP using Von Frey fibers as a function for pelvic pain. EAP mice were treated with minocycline after 30 days of prostatitis to test the efficacy of microglial inhibition on pelvic pain. RESULTS: Prostatitis induced the expansion and activation of microglia and the development of inflammation in the spinal cord as determined by increased expression levels of CCL3, IL-1ß, Iba1, and ERK1/2 phosphorylation. Microglial activation in mice with prostatitis resulted in increased expression of P2X4R and elevated levels of BDNF, two molecular markers associated with chronic pain. Pharmacological inhibition of microglia alleviated pain in mice with prostatitis and resulted in decreased expression of IL-1ß, P2X4R, and BDNF. CONCLUSION: Our data show that prostatitis leads to inflammation in the spinal cord and the activation and expansion of microglia, mechanisms that may contribute to the development and maintenance of chronic pelvic pain.

Ikaros sets the potential for Th17 lineage gene expression through effects on chromatin state in early T cell development.

Th17 cells are important effectors of immunity to extracellular pathogens, particularly at mucosal surfaces, but they can also contribute to pathologic tissue inflammation and autoimmunity. Defining the multitude of factors that influence their development is therefore of paramount importance. Our previous studies using Ikaros(-/-) CD4+ T cells implicated Ikaros in Th1 versus Th2 lineage decisions. Here we demonstrate that Ikaros also regulates Th17 differentiation through its ability to promote expression of multiple Th17 lineage-determining genes, including Ahr, Runx1, Rorc, Il17a, and Il22. Ikaros exerts its influence on the chromatin remodeling of these loci at two distinct stages in CD4+ T helper cell development. In naive cells, Ikaros is required to limit repressive chromatin modifications at these gene loci, thus maintaining the potential for expression of the Th17 gene program. Subsequently, Ikaros is essential for the acquisition of permissive histone marks in response to Th17 polarizing signals. Additionally, Ikaros represses the expression of genes that limit Th17 development, including Foxp3 and Tbx21. These data define new targets of the action of Ikaros and indicate that Ikaros plays a critical role in CD4+ T cell differentiation by integrating specific cytokine cues and directing epigenetic modifications that facilitate activation or repression of relevant genes that drive T cell lineage choice.

Nitrous oxide as a tracer gas in the ASHRAE 110-1995 Standard.

ANSI/ASHRAE Standard 110 provides a quantitative method for testing the performance of laboratory fume hoods. Through release of a known quantity (4.0 Lpm) of a tracer gas, and subsequent monitoring of the tracer gas concentration in the "breathing zone" of a mannequin positioned in front of the hood, this method allows for evaluation of laboratory hood performance. Standard 110 specifies sulfur hexafluoride (SF6) as the tracer gas; however, suitable alternatives are allowed. Through three series of performance tests, this analysis serves to investigate the use of nitrous oxide (N2O) as an alternate tracer gas for hood performance testing. Single gas tests were performed according to ASHRAE Standard 110-1995 with each tracer gas individually. These tests showed identical results using an acceptance criterion of AU 0.1 with the sash half open, nominal 18 inches (0.46m) high, and the face velocity at a nominal 60 fpm (0.3 m/s). Most data collected in these single gas tests, for both tracer gases, were below the minimum detection limit, thus two dual gas tests were developed for simultaneous sampling of both tracer gases. Dual gas dual ejector tests were performed with both tracer gases released simultaneously through two ejectors, and the concentration measured with two detectors using a common sampling probe. Dual gas single ejector tests were performed with both tracer gases released though a single ejector, and the concentration measured in the same manner as the dual gas dual ejector tests. The dual gas dual ejector tests showed excellent correlation, with R typically greater than 0.9. Variance was observed in the resulting regression line for each hood, likely due to non-symmetry between the two challenges caused by variables beyond the control of the investigators. Dual gas single ejector tests resulted in exceptional correlation, with R>0.99 typically for the consolidated data, with a slope of 1.0. These data indicate equivalent results for ASHRAE 110 performance testing using either SF6 or N2O, indicating N2O as an applicable alternate tracer gas.

Bioaccessibility of uranium in soil samples from Port Hope, Ontario, Canada.

Adequate assessment of human health risk of uranium contamination at hazardous waste sites, which is an important step in determining the cleanup strategy, is based on bioavailability data. Bioavailability of uranium from contaminated soil has not been properly determined yet. Bioaccessibility is an in vitro conservative estimate of bioavailability and is thus frequently used for site-specific risk assessment. Bioaccessibility of uranium was measured in 33 soil samples from the Port Hope area in Ontario, Canada, by the physiologically based extraction test (PBET). Higher bioaccessibility values in the gastric plus intestinal phase, 48.4% ± 16.8%, than in the gastric phase, 20.8% ± 11.7%, are very probably the result of more efficient extraction of uranium from soil by intestinal fluid rich in carbonate ions. The observed variability of measured bioaccessibility values is discussed in light of the results of scanning electron microscope examination of the soil samples. Uranium bioaccessibility values in both gastric (acidic) and gastric plus intestinal (neutral) phases are higher in soil samples with smaller uranium-bearing particles and lower in samples where the uranium-bearing particles are larger. We postulate that the most important reason for variability of measured bioaccessibility values in Port Hope soil samples may be the difference in particle size of uranium-bearing particles.

Neuronal/astrocytic expression of chemokine (C-C motif) ligand 2 is associated with monocyte/macrophage recruitment in male chronic pelvic pain.

Chronic pelvic pain syndrome is a multisymptom syndrome with unknown etiology. The experimental autoimmune prostatitis (EAP) mouse model of chronic pelvic pain syndrome is associated with immune cell infiltration into the prostate, expression of C-C chemokine ligand 2 (CCL2), and neuroinflammation in the spinal cord. Here, we studied CCL2 expression in tissues along the nociceptive pathway and its association with neuroimmune cells during pain development. Examination of prostate tissues at days 14 and 28 after EAP induction revealed CCL2 expression was increased in epithelial cells and was associated with increased numbers of macrophages lying in close apposition to PGP9.5-positive afferent neuronal fibers. C-C Chemokine ligand 2 immunoreactivity was elevated to a similar degree in the dorsal root ganglia at day 14 and day 28. D14 of EAP was associated with elevated IBA1 cells in the dorsal root ganglia that were not evident at D28. Adoptive transfer of green fluorescent protein+ leukocytes into EAP mice demonstrated monocytes are capable of infiltrating the spinal cord from peripheral blood with what seemed to be a proinflammatory phenotype. In the lower dorsal spinal cord, CCL2 expression localized to NeuN expressing neurons and GFAP-expressing astrocytes. Myeloid derived cell infiltration into the spinal cord in EAP was observed in the L6-S2 dorsal horn. Myeloid-derived CD45 IBA1+ cells were localized with IBA1+ TMEM199+ microglia in the dorsal horn of the spinal cord in EAP, with intimate association of the 2 cell types suggesting cell-cell interactions. Finally, intrathecal administration of liposomal clodronate ameliorated pelvic pain symptoms, suggesting a mechanistic role for macrophages and microglia in chronic pelvic pain.

Relationship between manual air valve positioning, water quality and energy usage in activated sludge processes.

Diffused aeration is the most implemented method for oxygen transfer in municipal activated sludge systems and governs the economics of the entire treatment process. Empirical observations are typically used to regulate airflow distribution through the adjustment of manual valves. However, due to the associated degrees of freedom, the identification of a combination of manual valves that optimizes all performance criteria is a complex task. For the first time a multi-criteria optimization algorithm was used to minimize effluent constituents and energy use by parametrizing manual valves positions. Data from a full-scale facility in conjunction with specific model assumptions were used to develop a base-case facility consisting of a detailed air supply model, a bio-kinetic model and a clarification model. Compared to the base-case condition, trade-offs analysis showed potential energy savings of up to 13.6% and improvement of effluent quality for NH4+ (up to 68.5%) and NOx (up to 81.6%). Based on two different tariff structures of a local power utility, maximum costs savings of 12800 USD mo-1 to 19000 USD mo-1 were estimated compared to baseline condition.

The TCL1 oncoprotein binds the RNase PH domains of the PNPase exoribonuclease without affecting its RNA degrading activity.

TCL1 is an AKT kinase coactivator that, when dysregulated, initiates mature lymphocyte malignancies in humans and transgenic mice. While TCL1 augments AKT pathway signaling, additional TCL1 interacting proteins that may contribute to cellular homeostasis or transformation are lacking. Here, an exoribonuclease, PNPase, was identified in a complex with TCL1. The AKT interaction domain on TCL1 bound either RNase PH repeat domain of PNPase without influencing its RNA degrading activity, which was compatible with predicted docking models for a TCL1-PNPase complex. Our data provide a novel protein interaction for mammalian PNPase that may impact TCL1 mediated transformation.

Moving the goalposts: A comparison of different definitions for primary external ventricular drain infection and its risk factors: A multi-center study of 2575 patients.

External ventricular drainage is the most common procedure performed in daily neurosurgical practice. One devastating complication is ventriculostomy-associated infection, but the establishment of evidence-based management guidelines has been hindered by the lack of an universal definition. There is also limited data with regard to the utility of comorbidity health indices and surgery-related factors in predicting infection. This study aims to compare the incidence of infection according to five commonly used definitions and to identify risk factors for this complication. 2575 patients from seven neurosurgical centers in Hong Kong underwent primary external ventricular drainage. The frequency of infection according to Gozal was 2.2% (n=57), 4.7% (Chi), 0.6% (Lozier), 0.8% (Lyke) and 2.8% (Scheithauer). The commonest pathogen was coagulase negative staphylococcus (39%) and 49% of all microbial isolates were multiple-drug resistant. The mean Charlson comorbidity index was 0.5±1.1. Using Gozal's definition as the primary endpoint, the index was not predictive of infection and no surgical risk factors were identified. The only significant risk factor was the performance of two or more additional neurosurgical procedures within 30days of catheterization (OR: 2.1, 95% CI 1.1-4.5). The rate of infection is relatively low, but considerable disparity exists depending on the definition used. Our data implies that patient factors, in particular the Charlson comorbidity index, and variations in surgical practice are less influential than the strict observance of infection control measures. The high incidence of antibiotic-resistant bacteria is concerning and the routine of exchange of catheters within 30days should be discouraged.

IL17 Mediates Pelvic Pain in Experimental Autoimmune Prostatitis (EAP).

Chronic pelvic pain syndrome (CPPS) is the most common form of prostatitis, accounting for 90-95% of all diagnoses. It is a complex multi-symptom syndrome with unknown etiology and limited effective treatments. Previous investigations highlight roles for inflammatory mediators in disease progression by correlating levels of cytokines and chemokines with patient reported symptom scores. It is hypothesized that alteration of adaptive immune mechanisms results in autoimmunity and subsequent development of pain. Mouse models of CPPS have been developed to delineate these immune mechanisms driving pain in humans. Using the experimental autoimmune prostatitis (EAP) in C57BL/6 mice model of CPPS we examined the role of CD4+T-cell subsets in the development and maintenance of prostate pain, by tactile allodynia behavioral testing and flow cytometry. In tandem with increased CD4+IL17A+ T-cells upon EAP induction, prophylactic treatment with an anti-IL17 antibody one-day prior to EAP induction prevented the onset of pelvic pain. Therapeutic blockade of IL17 did not reverse pain symptoms indicating that IL17 is essential for development but not maintenance of chronic pain in EAP. Furthermore we identified a cytokine, IL7, to be associated with increased symptom severity in CPPS patients and is increased in patient prostatic secretions and the prostates of EAP mice. IL7 is fundamental to development of IL17 producing cells and plays a role in maturation of auto-reactive T-cells, it is also associated with autoimmune disorders including multiple sclerosis and type-1 diabetes. More recently a growing body of research has pointed to IL17's role in development of neuropathic and chronic pain. This report presents novel data on the role of CD4+IL17+ T-cells in development and maintenance of pain in EAP and CPPS.

Th1-Th17 cells contribute to the development of uropathogenic Escherichia coli-induced chronic pelvic pain.

The etiology of chronic prostatitis/chronic pelvic pain syndrome in men is unknown but may involve microbes and autoimmune mechanisms. We developed an infection model of chronic pelvic pain in NOD/ShiLtJ (NOD) mice with a clinical Escherichia coli isolate (CP-1) from a patient with chronic pelvic pain. We investigated pain mechanisms in NOD mice and compared it to C57BL/6 (B6) mice, a strain resistant to CP-1-induced pain. Adoptive transfer of CD4+ T cells, but not serum, from CP-1-infected NOD mice was sufficient to induce chronic pelvic pain. CD4+ T cells in CP-1-infected NOD mice expressed IFN-γ and IL-17A but not IL-4, consistent with a Th1/Th17 immune signature. Adoptive transfer of ex-vivo expanded IFN-γ or IL-17A-expressing cells was sufficient to induce pelvic pain in naïve NOD recipients. Pelvic pain was not abolished in NOD-IFN-γ-KO mice but was associated with an enhanced IL-17A immune response to CP1 infection. These findings demonstrate a novel role for Th1 and Th17-mediated adaptive immune mechanisms in chronic pelvic pain.

The toll-like receptor pathway: a novel mechanism of infection-induced carcinogenesis of prostate epithelial cells.

BACKGROUND: Inflammation and infection have been linked to the pathogenesis of many cancers including prostate cancer. Components of bacteria and viruses have been identified within pathological specimens of men with prostate cancer. METHODS: We characterized the in vitro response of benign prostate epithelial cells to components of infectious agents as they relate to toll-like receptors. RESULTS: Primary and immortalized prostate epithelial cells (RWPE) exhibited increased proliferation in response to exposure to lipopolysaccharide (LPS) and CpG DNA. These molecules are well-characterized surrogates for gram negative bacteria (e.g., E. coli) and DNA viruses (e.g., HPV and HSV), which are common in the genitourinary system. Our experiments show that RWPE cells express both TLR 4 (LPS-specific) and TLR 9 (CpG-specific). Targeted knock down of individual TLR expression using siRNA abrogated the proliferative response of RWPE cells to LPS and CpG, respectively. In addition, compared to non-stimulated cells, LPS and CpG up-regulate active NF-kB expression. Increased NF-kB activation was confirmed using RWPE cells that were stably transfected with a NF-kB reporter construct. Interestingly, NF-kB activation was both concentration- and time-dependent when stimulated with LPS. RWPE cells were less susceptible to TNF-alpha induced apoptosis as measured by TUNEL staining when stimulated with CpG or LPS. High concentrations of LPS also prevented cell death as measured by LDH release. CONCLUSIONS: Our study has identified a unique mechanism that describes how components of pathogens common in the urinary system may contribute to the malignant transformation of benign prostate epithelia.

Treatment of transforming growth factor-beta-insensitive mouse Renca tumor by transforming growth factor-beta elimination.

OBJECTIVES: The mouse renal cell carcinoma line, Renca, is insensitive to transforming growth factor-beta (TGF-beta) in vitro. The present study was conducted to determine whether removal of TGF-beta from these tumor cells would inhibit tumor progression in vivo. METHODS: TGF-beta elimination was accomplished either by administration of neutralizing TGF-beta antibody into mice receiving intravenous injection of Renca tumor cells or infection of TGF-beta antisense expression vector into these tumor cells before subcutaneous injection into recipient mice. RESULTS: Although a low dose of TGF-beta antibody (5 mg/kg every 3 days) was without any effect, a high dose of TGF-beta antibody (50 mg/kg every 3 days), administered to recipient mice, resulted in a significant reduction in lung metastasis and was accompanied by increased apoptosis in the tumor cells. When the tumor cells were transfected with a TGF-beta1 antisense expressing vector, a significant reduction occurred in the tumor incidence, as well as the tumor burden. However, in nude mice, cells with reduced TGF-beta1 production grew almost as well as did the unmodified Renca cells, suggesting that the host's immune system might play an antitumor role. CONCLUSIONS: These results indicate that progression of Renca tumor can be inhibited by eliminating TGF-beta from the tumor cells. Our results also suggest that, although insensitive to TGF-beta under in vitro conditions, Renca tumors could be inhibited by TGF-beta removal through the systemic host environment.

Improved rejection of multiply scattered photons in confocal microscopy using dual-axes architecture.

We perform Monte Carlo simulations to show that the dual-axes (DA) confocal architecture has superior rejection of multiply scattered photons in tissue to that of single axis. As a result, the DA configuration provides improved signal-to-noise ratio and dynamic range, and thus is sensitive to ballistic photons from deeper within tissue, features that are particularly useful for performing vertical cross-sectional reflectance images in tissue.

Tumor evasion of the immune system by converting CD4+CD25- T cells into CD4+CD25+ T regulatory cells: role of tumor-derived TGF-beta.

CD4+CD25+ T regulatory (T(reg)) cells were initially described for their ability to suppress autoimmune diseases in animal models. An emerging interest is the potential role of T(reg) cells in cancer development and progression because they have been shown to suppress antitumor immunity. In this study, CD4+CD25- T cells cultured in conditioned medium (CM) derived from tumor cells, RENCA or TRAMP-C2, possess similar characteristics as those of naturally occurring T(reg) cells, including expression of Foxp3, a crucial transcription factor of T(reg) cells, production of low levels of IL-2, high levels of IL-10 and TGF-beta, and the ability to suppress CD4+CD25- T cell proliferation. Further investigation revealed a critical role of tumor-derived TGF-beta in converting CD4+CD25- T cells into T(reg) cells because a neutralizing Ab against TGF-beta, 1D11, completely abrogated the induction of T(reg) cells. CM from a nontumorigenic cell line, NRP-152, or irradiated tumor cells did not convert CD4+CD25- T cells to T(reg) cells because they produce low levels of TGF-beta in CM. Finally, we observed a reduced tumor burden in animals receiving 1D11. The reduction in tumor burden correlated with a decrease in tumor-derived TGF-beta. Treatment of 1D11 also reduced the conversion of CD4+ T cells into T(reg) cells and subsequent T(reg) cell-mediated suppression of antitumor immunity. In summary, we have demonstrated that tumor cells directly convert CD4+CD25- T cells to T(reg) cells through production of high levels of TGF-beta, suggesting a possible mechanism through which tumor cells evade the immune system.

Miniature near-infrared dual-axes confocal microscope utilizing a two-dimensional microelectromechanical systems scanner.

The first, to our knowledge, miniature dual-axes confocal microscope has been developed, with an outer diameter of 10 mm, for subsurface imaging of biological tissues with 5-7 microm resolution. Depth-resolved en face images are obtained at 30 frames per second, with a field of view of 800 x 100 microm, by employing a two-dimensional scanning microelectromechanical systems mirror. Reflectance and fluorescence images are obtained with a laser source at 785 nm, demonstrating the ability to perform real-time optical biopsy.

Infiltration of tumor-reactive transforming growth factor-beta insensitive CD8+ T cells into the tumor parenchyma is associated with apoptosis and rejection of tumor cells.

BACKGROUND: TGF-beta is a potent immunosuppressant. High levels of TGF-beta produced by cancer cells have a negative inhibition effect on surrounding host immune cells and leads to evasion of the host immune surveillance and tumor progression. In the present study, we report a distinct ability of tumor reactive, TGF-beta-insensitive CD8+ T cells to infiltrate into established tumors, secrete relevant cytokines, and induce apoptosis of tumor cells. METHODS: CD8+ T cells were isolated from the spleens of C57BL/6 mice, which were primed with irradiated mouse prostate cancer cells, the TRAMP-C2 cells. After ex vivo expansion, these tumor reactive CD8+ cells were rendered TGF-beta-insensitive by infection with a retroviral (MSCV)-mediated dominant negative TGF-beta type II receptor (TbetaRIIDN). Control CD8+ cells consist of those transfected with the GFP-only empty vector and naïve CD8+ T cells. Recipient mice were challenged with a single injection of TRAMP-C2 cells 21 days before adoptive transfer of CD8+ T cells was performed. Forty days after the adoptive transfer, all animals were sacrificed. The presence of pulmonary metastases was evaluated pathologically. Serial slides of malignant tissues were used for immunofluorescent staining for different kinds of immune cell infiltration, cytokines, and apoptosis analysis. RESULTS: Pulmonary metastases were either eliminated or significantly reduced in the group receiving adoptive transfer of tumor-reactive TGF-beta-insensitive CD8+ T cells (3 out of 12) when compared to GFP controls (9 out of 12), and naïve CD8+ T cells (12 out of 12). Results of immunofluorescent studies demonstrated that only tumor-reactive TGF-beta-insensitive CD8+ T cells were able to infiltrate into the tumor and mediate apoptosis when compared to CD4+ T cells, NK cells, and B cells. A large amount of cytokines such as perforin, nitric oxide, IFN-gamma, IL-2, TNF-alpha were secreted in tumor tissue treated with tumor-reactive TGF-beta-insensitive CD8+ T cells. No immune cells infiltration and cytokine secretion were detected in tumor tissues treated with naïve T cells and GFP controls. CONCLUSIONS: Our results demonstrate the mechanism of anti-tumor effect of tumor-reactive TGF-beta-insensitive CD8+ T cells that adoptive transfer of these CD8+ T cells resulted in infiltration of these immune cells into the tumor parenchyma, secretion of relevant cytokines, and induction of apoptosis in tumor cells. These results support the concept that tumor-reactive TGF-beta-insensitive CD8+ T cells may prove beneficial in the treatment of advanced cancer patients.