Immune-Related Endocrine Dysfunctions in Combined Modalities of Treatment: Real-World Data.

The number of immune-related endocrine dysfunctions (irEDs) has concurrently increased with the widespread use of immunotherapy in clinical practice and further expansion of the approved indications for immune checkpoint inhibitor (ICI) in cancer management. A retrospective analysis was conducted on consecutive patients ≥18 years of age with advanced solid malignancies who had received at least one dose of anti-programmed cell death protein 1 (anti-PD-1) and/or anti-CTLA4 antibodies between January 2014 and December 2019 at a university hospital in Hong Kong. Patients were reviewed up to two months after the last administration of an ICI. The types, onset times and grades of irEDs, including hypothyroidism, hyperthyroidism, adrenal insufficiency and immune-related diabetes mellitus, were recorded. Factors associated with irEDs were identified using multivariate analysis. A total of 953 patients (male: 603, 64.0%; median age: 62.0 years) were included. Of these, 580 patients (60.9%) used ICI-alone, 132 (13.9%) used dual-ICI, 187 (19.6%) used an ICI combined with chemotherapy (chemo + ICI), and 54 (5.70%) used immunotherapy with a targeted agent (targeted + ICI). A significantly higher proportion of patients using targeted + ICI had irEDs and hypothyroidism; in contrast, a higher proportion of patients using dual-ICI had adrenal insufficiency. There was no significant difference in the incidence of irED between the younger (<65 years) and older (≥65 years) patients. Using logistic regression, only treatment type was significantly associated with irEDs. Notably, older patients had a higher risk of having immune-related diabetes mellitus. This large, real-world cohort demonstrates that targeted + ICI has a higher risk of overall irED and hypothyroidism. Immunotherapy is safe and well-tolerated regardless of age, but close monitoring of fasting glucose is essential in older populations.

Oncolytic herpes simplex virus kills stem-like tumor-initiating colon cancer cells.

Stem-like tumor-initiating cells (TICs) are implicated in cancer progression and recurrence, and can be identified by sphere-formation and tumorigenicity assays. Oncolytic viruses infect, replicate in, and kill a variety of cancer cells. In this study, we seek proof of principle that TICs are susceptible to viral infection. HCT8 human colon cancer cells were subjected to serum-free culture to generate TIC tumorspheres. Parent cells and TICs were infected with HSV-1 subtype NV1066. Cytotoxicity, viral replication, and Akt1 expression were assessed. TIC tumorigenicity was confirmed and NV1066 efficacy was assessed in vivo. NV1066 infection was highly cytotoxic to both parent HCT8 cells and TICs. In both populations, cell-kill of >80% was achieved within 3 days of infection at a multiplicity of infection (MOI) of 1.0. However, the parent cells required 2-log greater viral replication to achieve the same cytotoxicity. TICs overexpressed Akt1 in vitro and formed flank tumors from as little as 100 cells, growing earlier, faster, larger, and with greater histologic atypia than tumors from parent cells. Treatment of TIC-induced tumors with NV1066 yielded tumor regression and slowed tumor growth. We conclude that colon TICs are selected for by serum-free culture, overexpress Akt1, and are susceptible to oncolytic viral infection.

How sick are dialysis patients undergoing cholecystectomy? Analysis of 92,672 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Although cholecystectomy is one of the most common surgical procedures performed in the United States, there is an absence of data on the risks of cholecystectomy in dialysis patients. Our objective was to analyze the outcomes of cholecystectomy in dialysis patients. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we selected all patients who underwent cholecystectomy from 2005 to 2010. Univariate analysis was performed and logistic and linear regression models were used to obtain risk-adjusted outcomes. The main outcomes were morbidity, mortality, and length of stay. RESULTS: Dialysis was associated with a higher risk of 30-day postoperative morbidity (16.1% vs 3.8%, adjusted odds ratio 1.91, 95% confidence interval 1.18 to 3.10), but not mortality. The average length of stay following any cholecystectomy was 4.1 days longer for dialysis patients (5.5 vs 1.4 days, P < .0001). CONCLUSION: Patients on dialysis who undergo cholecystectomy are at a higher risk for postoperative morbidity, but not mortality.

A novel oncolytic viral therapy and imaging technique for gastric cancer using a genetically engineered vaccinia virus carrying the human sodium iodide symporter.

BACKGROUND: Gastric cancers have poor overall survival despite recent advancements in early detection methods, endoscopic resection techniques, and chemotherapy treatments. Vaccinia viral therapy has had promising therapeutic potential for various cancers and has a great safety profile. We investigated the therapeutic efficacy of a novel genetically-engineered vaccinia virus carrying the human sodium iodide symporter (hNIS) gene, GLV-1 h153, on gastric cancers and its potential utility for imaging with (99m)Tc pertechnetate scintigraphy and ¹²4I positron emission tomography (PET). METHODS: GLV-1 h153 was tested against five human gastric cancer cell lines using cytotoxicity and standard viral plaque assays. In vivo, subcutaneous flank tumors were generated in nude mice with human gastric cancer cells, MKN-74. Tumors were subsequently injected with either GLV-1 h153 or PBS and followed for tumor growth. (99m)Tc pertechnetate scintigraphy and ¹²4I microPET imaging were performed. RESULTS: GFP expression, a surrogate for viral infectivity, confirmed viral infection by 24 hours. At a multiplicity of infection (MOI) of 1, GLV-1 h153 achieved > 90% cytotoxicity in MNK-74, OCUM-2MD3, and AGS over 9 days, and >70% cytotoxicity in MNK- 45 and TMK-1. In vivo, GLV-1 h153 was effective in treating xenografts (p < 0.001) after 2 weeks of treatment. GLV-1 h153-infected tumors were readily imaged by (99m)Tc pertechnetate scintigraphy and ¹²4I microPET imaging 2 days after treatment. CONCLUSIONS: GLV-1 h153 is an effective oncolytic virus expressing the hNIS protein that can efficiently regress gastric tumors and allow deep-tissue imaging. These data encourages its continued investigation in clinical settings.

Irreversible electroporation facilitates gene transfer of a GM-CSF plasmid with a local and systemic response.

BACKGROUND: Electroporation uses an electric field to induce pores in the cell membrane that can transfer macromolecules into target cells. Modulation of electrical parameters leads to irreversible electroporation (IRE), which is being developed for tissue ablation. We sought to evaluate whether the application of IRE may induce a lesser electric field in the periphery where reversible electroporation may occur, facilitating gene transfer of a granulocyte macrophage colony-stimulating factor (GM-CSF) plasmid to produce its biologic response. METHODS: Yorkshire pigs underwent laparotomy, and IRE of the liver was performed during hepatic arterial infusion of 1 or 7 mg of a naked human GM-CSF plasmid. The serum, liver, lymph nodes, and bone marrow were harvested for analysis. RESULTS: Human GM-CSF level rose from undetectable to 131 pg/mL in the serum at 24 hours after IRE and plasmid infusion. The liver demonstrated an ablation zone surrounded by an immune infiltrate that had greater macrophage intensity than when treated with IRE or plasmid infusion alone. This dominance of macrophages was dose dependent. Distant effects of GM-CSF were found in the bone marrow, where proliferating myeloid cells increased from 14% to 25%. CONCLUSION: IRE facilitated gene transfer of the GM-CSF plasmid and brought about a local and systemic biologic response. This technique holds potential for tumor eradication and immunotherapy of residual cancer.

Endoscopic spray cryotherapy for genitourinary malignancies: safety and efficacy in a porcine model.

OBJECTIVE: To examine the effects and safety of using endoscopic spray cryotherapy (ESC) on bladder, ureteral, and renal pelvis urothelium in a live porcine model. SUBJECTS AND METHODS: ESC treatments were systematically applied to urothelial sites in the bladder, ureter, and renal pelvis of eight female Yorkshire swine in a prospective trial. Freeze-thaw cycles ranged from 5 to 60 s/cycle for one to six cycles using a 7 French cryotherapy catheter. Tissue was evaluated histologically for treatment-related effects. Acute physiologic effects were evaluated with pulse oximetry, Doppler sonography, and postmortem findings. RESULTS: In bladder, treatment depth was inconsistent regardless of dose, demonstrating urothelial necrosis in one, muscularis propria depth necrosis in two, and full thickness necrosis in all remaining samples. In ureter, full thickness necrosis was seen in all samples, even with the shortest spray duration (5 s/cycle for six cycles or 30 s/cycle for one cycle). Treatment to the renal pelvis was complicated by adiabatic gas expansion of liquid nitrogen to its gaseous state, resulting in high intraluminal pressures requiring venting to avoid organ perforation, even at the lowest treatment settings. At a planned dose of 5 s/cycle for six cycles of the first renal pelvis animal, treatment was interrupted by sudden and unrecoverable cardiopulmonary failure after three cycles. Repeated studies replicated this event. Ultrasound and immediate necropsy confirmed the creation of a large gaseous embolism and reproducible cardiopulmonary effects. CONCLUSION: ESC in a porcine urothelial treatment model results in full-thickness tissue necrosis in bladder, ureter, and renal pelvis at a minimal treatment settings of 5 s/cycle for six cycles. Adiabatic gas expansion may result in fatal pyelovenous gas embolism and collateral organ injury, as seen in both animals receiving treatment to the renal pelvis in this study. These results raise safety concerns for use of ESC as a treatment modality in urothelial tissues with current device settings.

Gold nanoparticles provide bright long-lasting vascular contrast for CT imaging.

OBJECTIVE: Iodinated contrast agent for CT has a short half-life in the vasculature. As the field of interventional procedures expands, a more durable contrast agent would be highly useful. Our study investigated whether gold nanoparticles are feasible as a long-lasting vascular contrast agent for CT. MATERIALS AND METHODS: Gold nanoparticles were synthesized by a modified Turkevich method, coated with methoxy-polyethylene glycol-thiol chains, and compared with an iodine-based contrast agent used in mice. Contrast agents were imaged in tubes by CT at 40, 60, and 140 kVp and then were tested in vivo by tail vein injection. Nine mice received gold nanoparticles, two received iodine-based contrast agent, and one received saline. CT of mice was performed at 60 kVp immediately, 6 hours, and 24 hours after injection. RESULTS: In an isolated form in tubes, gold nanoparticles had greater radiographic density than did iodine-based contrast agent at 40 kVp and were comparable at the other CT voltages. In mice, gold nanoparticles provided bright contrast enhancement that enabled clear visualization of the abdominal aorta and renal arteries, which could not be distinguished without contrast agent. This persisted up to 24 hours, which was the last time point assessed. Contrast enhancement of the vasculature by iodine-based contrast agent was present immediately after injection but had disappeared by 6 hours. CONCLUSION: Gold nanoparticles can provide clear and durable contrast enhancement of the vasculature even at 24 hours. These findings merit further study of gold nanoparticles for their potential as a contrast agent in CT and CT-guided interventional procedures.

Irreversible electroporation ablation of the liver can be detected with ultrasound B-mode and elastography.

BACKGROUND: Irreversible electroporation (IRE) is a novel ablation technique that induces permanent membrane permeability and cell death. We are interested in ultrasound B-mode and elastography to monitor IRE ablation in the liver. METHODS: Yorkshire pigs underwent IRE ablation of the liver and were imaged with ultrasound B-mode and elastography. Histologic evaluation of cell death by triphenyltetrazolium chloride and hematoxylin and eosin staining was performed. RESULTS: Elastography showed that liver ablated by IRE exhibited increased tissue stiffness with a peak strain ratio of 2.22. The IRE lesion had a discrete border without bubble artifact, and the lesion size significantly correlated with area of cell death on histology. IRE ablation was unaffected by presence of large blood vessels or bile ducts. CONCLUSION: IRE ablation led to increased tissue stiffness that was detectable by elastography and indicative of cell death. Elastography may complement B-mode ultrasonography to monitor IRE ablation of the liver.

Imaging characteristics, tissue distribution, and spread of a novel oncolytic vaccinia virus carrying the human sodium iodide symporter.

INTRODUCTION: Oncolytic viruses show promise for treating cancer. However, to assess therapy and potential toxicity, a noninvasive imaging modality is needed. This study aims to determine the in vivo biodistribution, and imaging and timing characteristics of a vaccinia virus, GLV-1h153, encoding the human sodium iodide symporter (hNIS. METHODS: GLV-1h153 was modified from GLV-1h68 to encode the hNIS gene. Timing of cellular uptake of radioiodide (131)I in human pancreatic carcinoma cells PANC-1 was assessed using radiouptake assays. Viral biodistribution was determined in nude mice bearing PANC-1 xenografts, and infection in tumors confirmed histologically and optically via Green Fluorescent Protein (GFP) and bioluminescence. Timing characteristics of enhanced radiouptake in xenografts were assessed via (124)I-positron emission tomography (PET). Detection of systemic administration of virus was investigated with both (124)I-PET and 99m-technecium gamma-scintigraphy. RESULTS: GLV-1h153 successfully facilitated time-dependent intracellular uptake of (131)I in PANC-1 cells with a maximum uptake at 24 hours postinfection (P<0.05). In vivo, biodistribution profiles revealed persistence of virus in tumors 5 weeks postinjection at 10(9) plaque-forming unit (PFU)/gm tissue, with the virus mainly cleared from all other major organs. Tumor infection by GLV-1h153 was confirmed via optical imaging and histology. GLV-1h153 facilitated imaging virus replication in tumors via PET even at 8 hours post radiotracer injection, with a mean %ID/gm of 3.82 ± 0.46 (P<0.05) 2 days after intratumoral administration of virus, confirmed via tissue radiouptake assays. One week post systemic administration, GLV-1h153-infected tumors were detected via (124)I-PET and 99m-technecium-scintigraphy. CONCLUSION: GLV-1h153 is a promising oncolytic agent against pancreatic cancer with a promising biosafety profile. GLV-1h153 facilitated time-dependent hNIS-specific radiouptake in pancreatic cancer cells, facilitating detection by PET with both intratumoral and systemic administration. Therefore, GLV-1h153 is a promising candidate for the noninvasive imaging of virotherapy and warrants further study into longterm monitoring of virotherapy and potential radiocombination therapies with this treatment and imaging modality.

Spray cryotherapy is effective for bronchoscopic, endoscopic and open ablation of thoracic tissues.

OBJECTIVES: Spray cryotherapy (SCT) delivers a liquid nitrogen spray via a catheter to produce cellular death. This study seeks to determine the histological changes after bronchoscopic, endoscopic and open SCT on tissues in the thoracic cavity. METHODS: Yorkshire pigs underwent flexible bronchoscopy, endoscopy and thoracotomy for SCT of the airway, oesophagus and other intrathoracic structures, respectively. Variations in the duration and number of spray cycles for the same dosimetry were compared. RESULTS: Bronchoscopic SCT of the airway resulted in cellular death up to the cartilage layer. Endoscopic SCT of the oesophagus led to cell death up to the adventitial layer. Tissue necrosis was severe in the lung, of full thickness in the pleura, but very superficial in the great vessels. The extracellular matrix (ECM) of treated tissues remained well-preserved. Having shorter but more cycles of SCT decreased the depth of the cellular necrosis. One pig developed ventricular fibrillation during the surgery and expired. CONCLUSIONS: SCT causes reproducible tissue injury with the preserved ECM of most tissues within the thoracic cavity, making it enticing for ablation around vital structures like the great vessels with a decreased long-term risk. Further study is warranted to investigate the adverse events during SCT.

Bioluminescence imaging serves as a dynamic marker for guiding and assessing thermal treatment of cancer in a preclinical model.

BACKGROUND: Bioluminescence has been harnessed as a dynamic imaging technique in research. This is a proof of principle study examining feasibility of using bioluminescent proteins as a marker to guide therapeutic ablation. METHODS: Mesothelioma cancer cells (MSTO-Td) were transfected with a retroviral vector bearing firefly luciferase gene, plated in serial dilutions, and imaged to compare bioluminescence signal to cell number, determining threshold of bioluminescence detection. MSTO-Td cells were subjected to thermal treatment in a heated chamber; the bioluminescence signal and number of remaining live cancer cells were determined. Mice with MSTO-Td xenografts underwent electrocautery tumor ablation guided by bioluminescence imaging; bioluminescence signal and tumor size were monitored for 3 weeks. RESULTS: MSTO-Td cells emitted a bright, clear, bioluminescence signal that amplified with the cell number (P < .001) and was detectable with as few as 10 cells in cell culture. Bioluminescence decreased in a dose-dependent fashion upon thermal treatment as temperature increased from 37 to 70 °C (P < .001) and as treatment duration increased from 5 to 20 min (P < .001). This correlated with the number of remaining live MSTO-Td cells (Pearson coefficient = 0.865; P < .001). In mice, the bioluminescence signal correlated with tumor size posttreatment and effectively guided the ablation procedure to completion, achieving 0 % tumor recurrence. CONCLUSIONS: Bioluminescence imaging is a sensitive, real-time imaging approach; bioluminescence reporters such as firefly luciferase can assess and guide thermal treatment of cancer. This encourages research into bioluminescence imaging as a molecular technique with potential to target tumors via biomarkers and optimize thermal treatment procedures in a clinical setting.

Flexible CO2 laser and submucosal gel injection for safe endoluminal resection in the intestines.

BACKGROUND: The CO(2) laser's unique wavelength of 10.6 µm has the advantage of being readily absorbed by water but historically limited it to line-of-sight procedures. Through recent technological advances, a flexible CO(2) laser fiber has been developed and holds promise for endoluminal surgery. We examined whether this laser, along with injection of a water-based gel in the submucosal space, will allow safe dissection of the intestines and enhance the potential of this tool for minimally invasive surgery. METHODS: Using an ex vivo model with porcine intestines, spot ablation was performed with the flexible CO(2) laser at different power settings until transmural perforation. Additionally, excisions of mucosal patches were performed by submucosal dissection with and without submucosal injection of a water-based gel. RESULTS: With spot ablation at 5 W, none of the specimens was perforated by 5 min, which was the maximum recorded time. The time to perforation was significantly shorter with increased laser power, and gel pretreatment protected the intestines against spot ablation, increasing the time to perforation from 6 to 37 s at 10 W and from 1 to 7 s at 15 W. During excision of mucosal patches, 56 and 83% of untreated intestines perforated at 5 and 10 W, respectively. Gel pretreatment prior to excision protected all intestines against perforation. These specimens were verified to be intact by inflation with air to over 100 mmHg. Furthermore, excision of the mucosal patch was complete in gel-pretreated specimens, whereas 22% of untreated specimens had residual islands of mucosa after excision. CONCLUSION: The flexible CO(2) laser holds promise as a precise dissection and cutting tool for endoluminal surgery of the intestines. Pretreatment with a submucosal injection of a water-based gel protects the intestines from perforation during ablation and mucosal dissection.

Irreversible electroporation is a surgical ablation technique that enhances gene transfer.

BACKGROUND: Reversible electroporation has long been used to transfer macromolecules into target cells in the laboratory by using an electric field to induce transient membrane permeability. Recently, the electric field has been modulated to produce permanent membrane permeability and cell death. This novel technique, irreversible electroporation (IRE), is being developed for nonthermal cancer ablation. We hypothesize that outside the central zone of IRE exists a peripheral zone of reversible electroporation where gene transfer may occur. METHODS: IRE of the liver was performed in a Yorkshire pig model with administration of a plasmid expressing the marker gene green fluorescent protein (GFP) by bolus or primed infusion through the hepatic artery or portal vein. After 6 hours, livers were harvested for fluorescent microscopy and histologic examination. RESULTS: Of 36 liver specimens treated with IRE and the GFP plasmid, 31 demonstrated strong green fluorescence. Liver ablation by IRE was demarcated clearly on histology. CONCLUSION: IRE is a promising technique not only for operative tissue ablation but also for gene therapy. Because IRE ablation may leave behind intact tumor antigens, these findings encourage clinical studies of tumor ablation with delivery of immunostimulatory plasmids for combined local eradication and systemic immunotherapy.

Insertion of the human sodium iodide symporter to facilitate deep tissue imaging does not alter oncolytic or replication capability of a novel vaccinia virus.

INTRODUCTION: Oncolytic viruses show promise for treating cancer. However, to assess therapeutic efficacy and potential toxicity, a noninvasive imaging modality is needed. This study aimed to determine if insertion of the human sodium iodide symporter (hNIS) cDNA as a marker for non-invasive imaging of virotherapy alters the replication and oncolytic capability of a novel vaccinia virus, GLV-1h153. METHODS: GLV-1h153 was modified from parental vaccinia virus GLV-1h68 to carry hNIS via homologous recombination. GLV-1h153 was tested against human pancreatic cancer cell line PANC-1 for replication via viral plaque assays and flow cytometry. Expression and transportation of hNIS in infected cells was evaluated using Westernblot and immunofluorescence. Intracellular uptake of radioiodide was assessed using radiouptake assays. Viral cytotoxicity and tumor regression of treated PANC-1tumor xenografts in nude mice was also determined. Finally, tumor radiouptake in xenografts was assessed via positron emission tomography (PET) utilizing carrier-free 124I radiotracer. RESULTS: GLV-1h153 infected, replicated within, and killed PANC-1 cells as efficiently as GLV-1h68. GLV-1h153 provided dose-dependent levels of hNIS expression in infected cells. Immunofluorescence detected transport of the protein to the cell membrane prior to cell lysis, enhancing hNIS-specific radiouptake (P < 0.001). In vivo, GLV-1h153 was as safe and effective as GLV-1h68 in regressing pancreatic cancer xenografts (P < 0.001). Finally, intratumoral injection of GLV-1h153 facilitated imaging of virus replication in tumors via 124I-PET. CONCLUSION: Insertion of the hNIS gene does not hinder replication or oncolytic capability of GLV-1h153, rendering this novel virus a promising new candidate for the noninvasive imaging and tracking of oncolytic viral therapy.

Trichobezoar: A rare cause of bowel obstruction.

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. A trichobezoar is a bezoar made up of hair and is a rare cause of bowel obstruction of the proximal gastrointestinal tract. They are seen mostly in young women with trichotillomania and trichotillophagia and symptoms include epigastric pain, nausea, loss of appetite and bowel or gastric outlet obstruction. We herein describe a case of a trichobezoar that presented as a gastric outlet obstruction and was subsequently successfully removed via a laparotomy.

Compartment syndrome after endoscopic harvest of the great saphenous vein during coronary artery bypass grafting.

Compartment syndrome is a limb-threatening condition often associated with traumatic, crush, burn, and reperfusion injuries. It is characterized by the development of disproportionately severe pain, paresthesias, decreased range of motion, loss of pulse, and a tense, edematous limb. In addition, measured compartment pressures and creatine phosphokinase values are often elevated. The definitive treatment is a decompressive fasciotomy. Compartment syndrome after coronary artery bypass grafting, however, is rare. The few reported cases all occurred in the vein donor leg after open harvest. We present a patient with compartment syndrome after endoscopic harvest of the saphenous vein for coronary artery bypass grafting.

Carcinosarcoma of the oesophagus - a rare mixed type of tumor.

Oesophageal carcinosarcoma is a rare type of oesophageal cancer composed of both squamous cells and sarcomatous cells. We report a case of a 71 year old man presenting with dysphagia and weight loss. Oesophagogastroduodenoscopy revealed a bulky mass with a preliminary diagnosis of only oesophageal carcinoma, and the oesophageal mass was resected with a transhiatal oesophagectomy. On surgical pathology, it was discovered that the tumor had both squamous cell and sarcomatous cell components, and the final diagnosis was changed to oesophageal carcinosarcoma. We discuss the presentation, differential diagnosis, treatment, and prognosis of this unique entity.

Tympanometric characteristics of Chinese school-aged children.

OBJECTIVES: To investigate the tympanometric characteristics of Chinese school-aged children with normal middle ear function. DESIGN: Measurements were made for four tympanometric variables [peak, compensated static acoustic admittance (peak Ytm); equivalent ear canal volume (Vec); tympanometric width (TW); and tympanometric peak pressure] from 278 Chinese children aged between 6 and 15 yrs. Data from the right ear were compared across age groups with those of Chinese young adults and with Western children of comparable ages. Data from the left ear were used to examine specificity using tympanometric screening criteria suggested in the present study. RESULTS: The developmental pattern in tympanometric variables found with the Chinese school-aged children in the study was similar to that found with white children in Western studies. Increasing age was accompanied by an increase in peak Ytm and Vec values, a decrease in TW values, and less negative and less varied tympanometric peak pressure values. The lower limit of peak Ytm 90% range of the Chinese school-aged children in the study was lower and their TW values were wider than those of white children. Age-specific data also suggested that the upper Vec limits of children between 6 and 7 yrs of age differed from those of older children. Racial differences in peak Ytm and TW values were noted, in that the Chinese school-aged children had a lower peak Ytm limit and wider TW values than white children. The use of ASHA 1997 guidelines for identifying ears for referral with respect to Chinese school-aged children may therefore not be highly sensitive and specific. Gender differences noted in peak Ytm and Vec values were too small to be of clinical significance. CONCLUSIONS: To increase the accuracy of tympanometry in determining ears to be referred for further assessment, the use of the tympanometric characteristics observed in the Chinese school-aged children in the present study (i.e., peak Ytm lower limit < 0.2 mmhos and Vec upper limit > 1.5 cm3) should be considered in addition to ASHA 1997 tympanometric screening guidelines.

Access to adequate nutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individuals in Rwanda.

Despite the massive expansion of antiretroviral drugs in Africa, little is known about the resulting changes in sexual behavior or obstacles to antiretroviral therapy (ART) adherence. Our evaluation of Rwandan adults on ART found no increase in risky sexual behaviors, but an obstacle to ART initiation and adherence for 76% of patients was a fear of developing too much appetite without enough to eat. Access to adequate nutrition may be a major determinant for long-term adherence to ART.