Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart.

BACKGROUND: Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later. METHODS: Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia. RESULTS: Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1. CONCLUSIONS: We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications. TRIAL REGISTRATION: Not Applicable.

British Military surgical key performance indicators: time for an update?

BACKGROUND: Key performance indicators (KPIs) are metrics that compare actual care against an ideal structure, process or outcome standard. KPIs designed to assess performance in deployed military surgical facilities have previously been published. This study aimed to review the overall performance of surgical trauma care for casualties treated at Role 3 Camp Bastion, Medical Treatment Facility, Afghanistan, in light of the existing Defence Medical Services (DMS) KPIs. The secondary aims were to assess the utility of the surgical KPIs and make recommendations for future surgical trauma care review. METHODS: Data on 22 surgical parameters were prospectively collected for 150 injured patients who had primary surgery at Camp Bastion between 1 May 2013 and 20 August 2013. Additional information for these patients was obtained using the Joint Theatre Trauma Register. The authors assessed data recording, applicability and compliance with the KPIs. RESULTS: Median data recording was 100% (IQR 98%-100%), median applicability was 56% (IQR 10%-99%) and median compliance was 78% (IQR 58%-93%). One KPI was not applicable to any patient in our population. Eleven KPIs achieved >80% compliance, five KPIs had 80%-60% compliance and five KPIs had <60% compliance. Recommendations are made for minor modifications to the current KPIs. CONCLUSION: 78% compliance with the DMS KPIs provides a snapshot of the performance of the surgical aspect of military trauma care in 2013. The KPIs highlight areas for improvement in service delivery. Individual KPI development should be driven by evidence and reflect advances in practice and knowledge. A method of stakeholder consultation, and sequential refinement following evidence review, may be the right process to develop the future set of DMS KPIs.

High-throughput microfluidic single-cell digital polymerase chain reaction.

Here we present an integrated microfluidic device for the high-throughput digital polymerase chain reaction (dPCR) analysis of single cells. This device allows for the parallel processing of single cells and executes all steps of analysis, including cell capture, washing, lysis, reverse transcription, and dPCR analysis. The cDNA from each single cell is distributed into a dedicated dPCR array consisting of 1020 chambers, each having a volume of 25 pL, using surface-tension-based sample partitioning. The high density of this dPCR format (118,900 chambers/cm(2)) allows the analysis of 200 single cells per run, for a total of 204,000 PCR reactions using a device footprint of 10 cm(2). Experiments using RNA dilutions show this device achieves shot-noise-limited performance in quantifying single molecules, with a dynamic range of 10(4). We performed over 1200 single-cell measurements, demonstrating the use of this platform in the absolute quantification of both high- and low-abundance mRNA transcripts, as well as micro-RNAs that are not easily measured using alternative hybridization methods. We further apply the specificity and sensitivity of single-cell dPCR to performing measurements of RNA editing events in single cells. High-throughput dPCR provides a new tool in the arsenal of single-cell analysis methods, with a unique combination of speed, precision, sensitivity, and specificity. We anticipate this approach will enable new studies where high-performance single-cell measurements are essential, including the analysis of transcriptional noise, allelic imbalance, and RNA processing.

High-throughput tracking of single yeast cells in a microfluidic imaging matrix.

Time-lapse live cell imaging is a powerful tool for studying signaling network dynamics and complexity and is uniquely suited to single cell studies of response dynamics, noise, and heritable differences. Although conventional imaging formats have the temporal and spatial resolution needed for such studies, they do not provide the simultaneous advantages of cell tracking, experimental throughput, and precise chemical control. This is particularly problematic for system-level studies using non-adherent model organisms such as yeast, where the motion of cells complicates tracking and where large-scale analysis under a variety of genetic and chemical perturbations is desired. We present here a high-throughput microfluidic imaging system capable of tracking single cells over multiple generations in 128 simultaneous experiments with programmable and precise chemical control. High-resolution imaging and robust cell tracking are achieved through immobilization of yeast cells using a combination of mechanical clamping and polymerization in an agarose gel. The channel and valve architecture of our device allows for the formation of a matrix of 128 integrated agarose gel pads, each allowing for an independent imaging experiment with fully programmable medium exchange via diffusion. We demonstrate our system in the combinatorial and quantitative analysis of the yeast pheromone signaling response across 8 genotypes and 16 conditions, and show that lineage-dependent effects contribute to observed variability at stimulation conditions near the critical threshold for cellular decision making.

Comprehensive microRNA expression profiling of the hematopoietic hierarchy.

The hematopoietic system produces a large number of highly specialized cell types that are derived through a hierarchical differentiation process from a common stem cell population. miRNAs are critical players in orchestrating this differentiation. Here, we report the development and application of a high-throughput microfluidic real-time quantitative PCR (RT-qPCR) approach for generating global miRNA profiles for 27 phenotypically distinct cell populations isolated from normal adult mouse hematopoietic tissues. A total of 80,000 RT-qPCR assays were used to map the landscape of miRNA expression across the hematopoietic hierarchy, including rare progenitor and stem cell populations. We show that miRNA profiles allow for the direct inference of cell lineage relations and functional similarity. Our analysis reveals a close relatedness of the miRNA expression patterns in multipotent progenitors and stem cells, followed by a major reprogramming upon restriction of differentiation potential to a single lineage. The analysis of miRNA expression in single hematopoietic cells further demonstrates that miRNA expression is very tightly regulated within highly purified populations, underscoring the potential of single-cell miRNA profiling for assessing compartment heterogeneity.

Dynamic analysis of MAPK signaling using a high-throughput microfluidic single-cell imaging platform.

Cells have evolved biomolecular networks that process and respond to changing chemical environments. Understanding how complex protein interactions give rise to emergent network properties requires time-resolved analysis of cellular response under a large number of genetic perturbations and chemical environments. To date, the lack of technologies for scalable cell analysis under well-controlled and time-varying conditions has made such global studies either impossible or impractical. To address this need, we have developed a high-throughput microfluidic imaging platform for single-cell studies of network response under hundreds of combined genetic perturbations and time-varying stimulant sequences. Our platform combines programmable on-chip mixing and perfusion with high-throughput image acquisition and processing to perform 256 simultaneous time-lapse live-cell imaging experiments. Nonadherent cells are captured in an array of 2,048 microfluidic cell traps to allow for the imaging of eight different genotypes over 12 h and in response to 32 unique sequences of stimulation, generating a total of 49,000 images per run. Using 12 devices, we carried out >3,000 live-cell imaging experiments to investigate the mating pheromone response in Saccharomyces cerevisiae under combined genetic perturbations and changing environmental conditions. Comprehensive analysis of 11 deletion mutants reveals both distinct thresholds for morphological switching and new dynamic phenotypes that are not observed in static conditions. For example, kss1Delta, fus3Delta, msg5Delta, and ptp2Delta mutants exhibit distinctive stimulus-frequency-dependent signaling phenotypes, implicating their role in filtering and network memory. The combination of parallel microfluidic control with high-throughput imaging provides a powerful tool for systems-level studies of single-cell decision making.

Short communication: Cultivation of Lentinus edodes mycelia using whey permeate as an alternative growth substrate.

The major objective of this research was to use whey permeate as an alternative growth medium for the cultivation of mycelia of the edible mushroom Lentinus edodes and to find an optimum condition for solid-state cultivation. Response surface analysis was applied to determine the combination of substrate concentration (40 to 60 g of lactose/L), temperature (20 to 30 degrees C), and pH (4 to 6) resulting in a maximal mycelial growth rate. The radial extension rates, estimated by measuring the diameters of growing colonies on the Petri dishes, were used as the growth rate of the mycelia at different conditions. The conditions predicted to maximize the mycelial growth of 6.41 +/- 0.47 mm/d were determined to be 40 g of lactose/L, temperature 23.6 degrees C, and pH 5.0. It was concluded that a partial cubic equation could accurately model the response surface of, and predict optimal growth conditions for, L. edodes mycelia using whey permeate because the model prediction agreed with the experimental growth rate, 6.39 +/- 0.22 mm/d. The results suggest that whey permeate could be utilized as a growth substrate for the cultivation of mycelia from the edible mushroom L. edodes, enhancing the use of this by-product by the cheese manufacturing industry.

Effect of sodium citrate on structure-function relationships of Cheddar cheese.

The objective of this study was to determine the effect of sodium citrate on the structure and functionality of Cheddar cheese. The hypothesis was that citrate (sodium citrate) injection would affect cheese properties mainly through its effect on bound calcium (calculated as the difference between total calcium and the water-soluble calcium content of a cheese extract). A 9-kg block of Cheddar cheese was made, vacuum-packaged, and then stored for 2 wk at 4 degrees C. After storage, the cheese was cut into 0.5- to 0.6-kg blocks that were vacuum-packaged and stored for 1 wk at 4 degrees C prior to injection. Cheese blocks were then high-pressure injected with a buffer solution (pH 5.27) containing 40% (wt/ wt) citric acid trisodium dihydrate and 6.25% (wt/wt) anhydrous citric acid, from zero (control) to five times (successive injections performed 24 h apart). Increased citric acid content of cheese from 0.22 (uninjected) to 1.39% (after five injections) caused phosphate solubilization. Thus, the calculated bound phosphate content of cheese decreased from 0.54 to 0.45 mmol/g of protein. However, unexpectedly, the soluble calcium content decreased from 0.34 (control) to 0.28 mmol/g of protein (after five injections), whereas the bound calcium content remained unchanged (0.42 mmol/g of protein). The decrease in soluble calcium probably resulted from the formation and concentration of crystals in the cheese surface, which was not included in samples for analysis, and from the expulsion of serum from within the cheese. Higher concentration of solutes in the water phase of cheese would increase the volume of serum, but the cheese had limited holding capacity and serum was expelled. Citrate injection increased the sodium content of cheese from 0.63 to 0.93%, but it had no effect on cheese pH (5.2). After five injections, the protein matrix expanded, occupying an increased area of cheese matrix (83 vs. 78%). Even though citrate injection had no effect on bound calcium, and thus the rate and extent of cheese flow were unaffected, increased phosphate solubilization, and possibly decreased ionic calcium content, resulted in expansion of the protein matrix and increased cheese hardness.

Effect of pH on the chemical composition and structure-function relationships of cheddar cheese.

The objectives of this study were to determine the effect of pH on chemical, structural, and functional properties of Cheddar cheese, and to relate changes in structure to changes in cheese functionality. Cheddar cheese was obtained from a cheese-production facility and stored at 4 degrees C. Ten days after manufacture, the cheese was cut into blocks that were vacuum-packaged and stored for 4 d at 4 degrees C. Cheese blocks were then high-pressure injected one, three, or five times with a 20% (wt/wt) glucono-delta-lactone solution. Successive injections were performed 24 h apart. Cheese blocks were then analyzed after 40 d of storage at 4 degrees C. Acidulant injection decreased cheese pH from 5.3 in the uninjected cheese to 4.7 after five injections. Decreased pH increased the content of soluble calcium and slightly decreased the total calcium content of cheese. At the highest level, injection of acidulant promoted syneresis. Thus, after five injections, the moisture content of cheese decreased from 34 to 31%, which resulted in decreased cheese weight. Lowered cheese pH, 4.7 compared with 5.3, also resulted in contraction of the protein matrix. Acidulant injection decreased cheese hardness and cohesiveness, and the cheese became more crumbly. The initial rate of cheese flow increased when pH decreased from 5.3 to 5.0, but it decreased when cheese pH was further lowered to 4.7. The final extent of cheese flow also decreased at pH 4.7. In conclusion, lowering the pH of Cheddar cheese alters protein interactions, which then affects cheese functionality. At pH greater than 5.0, calcium solubilization decreases protein-to-protein interactions. In contrast, at pH lower than 5.0, the acid precipitation of proteins overcomes the opposing effect caused by increased calcium solubilization and decreased calcium content of cheese, and protein-to-protein interactions increase.

Effect of salt on structure-function relationships of cheese.

Our objective was to determine the effect of salt on structural and functional properties of cheese. Unsalted Muenster cheese was obtained on 1 d, vacuum packaged, and stored for 10 d at 4 degrees C. The cheese was then cut into blocks that were vacuum packaged. After 4 d of storage at 4 degrees C, cheese blocks were high-pressure injected one, three, or five times, with a 20% (wt/wt) sodium chloride solution. Successive injections were performed 24 h apart. After 40 d of storage at 4 degrees C, cheese blocks were analyzed for chemical, structural, and functional attributes. Injecting sodium chloride increased the salt content of cheese, from 0.1% in the control, uninjected cheese to 2.7% after five injections. At the highest levels, salt injection promoted syneresis, and, after five injections, the moisture content of cheese decreased from 41 to 38%. However, the increased salt content caused a net weight gain. Cheese pH, soluble nitrogen, and total and soluble calcium content were unaffected. Cheese injected five times had a 4% increased area of cheese occupied by protein matrix compared with uninjected cheese. Hardness, adhesiveness, and initial rate of cheese flow increased, and cohesiveness decreased upon salt injection. However, the final extent of cheese flow, or melting was unaffected. We concluded that adding salt to cheese alters protein interactions, such that the protein matrix becomes more hydrated and expands. However, increasing the salt content of cheese did not cause an exchange of calcium with sodium. Therefore, calcium-mediated protein interactions remain a major factor controlling cheese functionality.

Effect of calcium and water injection on structure-function relationships of cheese.

Our objectives were to determine the effect of calcium and water injection on cheese structure and to relate changes in structure to changes in functional properties of cheese. Cheese with fat and moisture content similar to that of low-moisture part-skim Mozzarella was made according to a direct-acid, stirred/pressed-curd procedure. The cheese was then cut into blocks that were high-pressure-injected from one to five times, with either water or a 40% calcium chloride solution. Successive injections were performed 24 h apart. After 42 d of refrigerated storage, cheese microstructure and functionality were analyzed. When injected three or more times, water tended to increase cheese weight. The control, uninjected cheese, had the typical structure of a stirred/pressed-curd cheese: protein matrix interspersed with areas that originally contained fat and/or serum. Injecting water increased the area of cheese matrix occupied by protein, but it did not affect textural properties or melting of cheese. In contrast, when calcium was injected, a decrease in cheese weight was observed that was manifested through syneresis. The moisture content and pH of the cheese decreased as well. Calcium injection also decreased the area of cheese matrix occupied by protein. Cheese hardness increased, and cohesiveness and melting of cheese decreased upon calcium injection. We concluded that adding calcium to cheese alters how the proteins interact, which is manifested as changes in cheese microstructure. Such changes in cheese structure provide an understanding of changes in functional attributes of the cheese.

Complete genome sequence of a virulent isolate of Streptococcus pneumoniae.

The 2,160,837-base pair genome sequence of an isolate of Streptococcus pneumoniae, a Gram-positive pathogen that causes pneumonia, bacteremia, meningitis, and otitis media, contains 2236 predicted coding regions; of these, 1440 (64%) were assigned a biological role. Approximately 5% of the genome is composed of insertion sequences that may contribute to genome rearrangements through uptake of foreign DNA. Extracellular enzyme systems for the metabolism of polysaccharides and hexosamines provide a substantial source of carbon and nitrogen for S. pneumoniae and also damage host tissues and facilitate colonization. A motif identified within the signal peptide of proteins is potentially involved in targeting these proteins to the cell surface of low-guanine/cytosine (GC) Gram-positive species. Several surface-exposed proteins that may serve as potential vaccine candidates were identified. Comparative genome hybridization with DNA arrays revealed strain differences in S. pneumoniae that could contribute to differences in virulence and antigenicity.

Topoisomerase II alpha: prognostic predictor and cell cycle marker in surface epithelial neoplasms of the ovary and peritoneum.

Immunohistochemistry for Topoisomerase II alpha (TopoIIa), a nuclear protein important for the separation of chromosomes and deoxyribonucleic acid replication, provides insight into the molecular events in the cell cycle and the response to chemotherapeutic agents, which target TopoIIa. We test the hypothesis that the percentage of TopoIIa immunoreactive nuclei (TopoIIaI) aids in the treatment and prognostic evaluation of ovarian and primary peritoneal surface epithelial neoplasms (SENs) and correlates with established cell cycle control markers: p53, p21WAF1/CIP1 (p21), and Ki67. Paraffin sections from a retrospective surgical series of 108 SENs were immunostained with anti-TopoIIa, anti-p53, anti-p21, and anti-Ki67. The TopoIIaI, the Ki67 proliferation index (Ki67PI), and the immunoreactivity score for p53 and p21 (IMS: S1, S2, S3 < 10%, 10 to 50%, > 50% of strong staining cells, respectively) were evaluated manually. TopoIIaI and Ki67PI ranged from 5 to 84% and 4 to 88% (mean/median: 31/30 and 44/46%), respectively, and were correlated (coefficient 0.62, p < 10(-11)). IMS of 108 SENs was as follows: p53 50% + (2S1, 52S3) and p21 66% + (38S1, 12S2, 21S3). The TopoIIaI associated directly with p53 (p < 10(-5) and inversely with p21 (p < 0.005) IMS. TopoIIaI correlated with SEN architectural/nuclear grade (p < 10(-5)/10(-7)), but not histologic type. Sixty-seven patients had disease at last follow-up, 55 were dead from disease at 2 to 67 months (mean/median 24/21), and 14 were alive with disease at 31 to 230 months (mean/median 73/59). Forty-one patients were disease free at 5 to 228 months (mean/median 75/54). TopoIIaI correlated with presence of disease (p < 0.01) and poor survival (p < 1 x 10(-9), even when only 93 invasive SEN cases are considered (p < 0.005). TopoIIaI correlates with poor prognosis and other cell cycle control markers. The patients in this retrospective series of SEN were treated primarily with platinum-based chemotherapy. These data may suggest further prospective studies in which patients with SENs exhibiting high TopoIIaI are treated with chemotherapy targeted against TopoIIa (e.g., etoposide). In this retrospective series, high SEN TopoIIaI predicted poor survival when treated with platinum-based chemotherapy, which does not target TopoIIa.

Effect of patient obesity on the accuracy of thallium-201 myocardial perfusion imaging.

The effects of patient habitus (e.g., breast attenuation in women and diaphragmatic attenuation in men) have long been recognized as factors that reduce the accuracy of myocardial perfusion imaging. Although it has long been assumed that patient obesity effects accuracy, this has never been formally evaluated. We studied the effects of patient obesity, defined as a body mass index (BMI) > or = 30, on 607 patients who underwent exercise thallium-201 single-photon emission computed tomography (SPECT). Because the effects of obesity are most likely mediated through increased photon attenuation and scatter, we also evaluated the effects of other markers of patient size: body surface area (BSA) and patient weight. Accuracy was determined by performing quantitative analysis and measuring the area under the receiver operating characteristic curve (AUC). Obesity was associated with significantly lower accuracy (AUC 0.86 +/- 0.03 vs 0.92 +/- 0.02, p <0.05) despite similar estimates of maximal coronary blood flow (as estimated by heart rate and rate-pressure product at peak exercise) and severity of coronary disease. There were no significant differences attributable to either patient weight or BSA. Weight and BSA correlated significantly with left ventricular chamber size whereas BMI did not. We conclude that the accuracy of quantitative SPECT thallium-201 is significantly reduced by patient obesity and that although BSA and weight are also associated with increased attenuation, they have no effect on accuracy, which is most likely due to the compensating effects of increased chamber size.

Attenuation smear: a 'paradoxical' increase in counts due to attenuation artifact.

BACKGROUND: Attenuation is a well recognized cause of reconstruction artifacts in SPECT imaging. Occasionally, we have noted an increase in activity extending from the apical septal portion of the ventricle in women with significant breast attenuation. Although the idea that attenuation can produce an increase in activity on the reconstructed images seems paradoxical at first, it is consistent with the process of filtered back projection. METHODS: We filled a cardiac phantom with 1 mCi of Technetium-99m, placed it in a water filled anthropomorphic torso phantom and imaged it over a 180 degree orbit. Next, a breast phantom designed to simulate a significant degree of breast attenuation was placed on the torso phantom and imaging was repeated. The images were reconstructed first using conventional filtered back projection then with maximum likelihood. RESULTS: When the phantoms with and without breast attenuation were reconstructed using filtered back projection and compared, the phantom with breast attenuation had a large 'smear' of activity extending anteriorly from the apical septal wall which was very similar to the abnormalities previously noted in clinical images; the phantom without breast attenuation had no such defect. This artifact was significantly less prominent when the images were reconstructed using the maximum likelihood technique. CONCLUSIONS: Attenuation artifact can also produce a seemingly paradoxical increase in counts on the reconstructed image but this phenomenon is consistent with the workings of filtered back projection.

Immunohistochemical markers of cell cycle control applied to ovarian and primary peritoneal surface epithelial neoplasms: p21(WAF1/CIP1) predicts survival and good response to platinin-based chemotherapy.

Immunohistochemistry for p53, p21(WAF1/CIP1), and Ki-67 provides insight into the molecular events controlling the cell cycle. We tested the hypothesis that these cell cycle markers will aid in the clinical evaluation of ovarian and primary peritoneal surface epithelial neoplasms (SENs). Paraffin sections from a retrospective surgical series of 117 SENs were immunostained with anti-p53 (clone DO7, Novacastra Laboratories, UK), anti-p21(WAF1/CIP1) (clone EA10, Oncogene Science, Cambridge, MA), and anti-Ki-67 (clone MIB-1, Immunotech, Westbrook, ME). The Ki-67 proliferation index (Ki-67PI) and immunoreactivity were evaluated. One hundred seventeen SENs reacted as follows: p53 50%+ and p21(WAF1/CIP1) 65%+. Ki-67PI ranged from 4% to 88% (mean/median = 44/46%). p53 reactivity associated with transitional cell histology, decreased p21(WAF1/CIP1) staining, increased Ki-67PI, architectural/nuclear grade, and stage (P < .05, 1 x 10(-7), .01, .05/.0001, .001,). p21(WAF1/CIP1) staining was associated with endometrioid/clear cell histology, decreased Ki-67PI, architectural/nuclear grade, and stage (P < 05/.05, .05, .01/1 x 10(-8), 1 x 10(-5)). Ki-67PI associated with increased architectural/nuclear grade but not mucinous histology (P < 1 x 10(-5)/1 x 10(-6), .01). Sixty-seven patients had disease at last follow-up; 53 were dead of disease at 0 to 67 months (mean/median, 21/18), and 14 were alive with disease at 12 to 224 months (mean/median, 56/40). Fifty patients were disease free at 5 to 214 months (mean/median, 59/41). Predictors of survival include decreased Ki-67PI, stage, architectural/nuclear grade (P < 1 x 10(-6), 1 x 10(-10), 1 x 10(-10)/.005) and p21(WAF1/CIP1) IMS (multivariate P < 1 x 10(-6)). p21(WAF1/CIP1), a potent inhibitor of cyclin-dependent kinases necessary for cell cycle progression, functions as a key checkpoint in cell cycle control. Immunoreactivity for p21(WAF1/CIP1) provides prognostic information independent of other histological and clinical predictors, p53 IMS, and Ki-67PI in this series of 117 PTs with SENs. Our preliminary data suggest an interrelationship between p21(WAF1/CIP1) expression and an effective clinical response to platinin-based chemotherapy, both associated with apoptosis. Further investigation seems warranted.

Lower accuracy of TI-201 SPECT in women is not improved by size-based normal databases or Wiener filtering.

BACKGROUND: We have shown that the diagnostic accuracy of quantitative single photon emission computed tomography (SPECT) thallium 201 myocardial perfusion imaging is lower in women than in men and that much of the difference can be explained by the smaller size of the left ventricle in women. Therefore attempts at improving the accuracy of myocardial perfusion imaging in women should focus on the problem of lower accuracy in patients with small chamber size. We evaluated two strategies for this: size- and gender-based normal databases and inverse filtering with the Wiener filter. METHODS AND RESULTS: We identified 618 patients undergoing exercise SPECT TI-201 who either had a low pre-test probability of coronary artery disease or had catheterization-documented disease. Their images were analyzed on the basis of gender and chamber size: both gender and size- and gender-based normal databases were created. The studies were analyzed quantitatively, and the accuracy was evaluated by use of the area under the receiver operating characteristic (ROC) curve. Chamber size was significantly lower in women (size index 69+/-22 women vs 96+/-28 men; P < .0001). The accuracy of myocardial perfusion imaging was lower in women compared with men (ROC area: 0.92+/-0.01 men vs 0.85+/-0.03 women; P = .03), and there was an even greater difference in accuracy between patients with large versus small chamber size (ROC area: 0.94+/-0.01 large vs 0.81+/-0.03 small; P < .001). There was no improvement in the diagnostic accuracy either in women or in patients with small chamber size when a size- and gender-based normal database, Wiener filter, or the Wiener filter with a size- and gender-based normal database was used. CONCLUSION: The left ventricular chamber size in women is smaller than that in men. There is a significant difference in the accuracy of quantitative SPECT TI-201 between men and women and an even greater difference between patients with large versus small chamber size. Neither size- and gender-based databases nor Wiener filtering significantly improves accuracy in women or in patients with small chamber size.

Comparison of pulmonary uptake with transient cavity dilation after exercise thallium-201 perfusion imaging.

OBJECTIVES: The purpose of the study was to evaluate the relationship between elevated lung/heart ratio (LHR) and transient ischemic dilation (TID) after stress thallium-201 myocardial perfusion imaging and to provide further insight into the mechanism of cavity dilation. BACKGROUND: Because both LHR and TID have been identified as adjunctive markers of severe coronary disease they should be found in the same patients. Although the mechanism of LHR has been defined, that of transient dilation has not. METHODS: We identified 4,618 consecutive patients undergoing maximal exercise perfusion imaging with thallium-201. Lung/heart ratio and a dilation index were derived and compared to each other and to relevant clinical parameters. RESULTS: There was a very weak relationship between the LHR and dilation index (r = 0.15, p < 0.001). Defining a dilation index > or =1.10 and LHR > or =50% as abnormal revealed that 322 of the patients (7%) had TID only, 351 (7.8%) had LHR only and 40 (0.9%) had both. When compared to patients without these findings both TID and LHR had higher thallium stress defect and redistribution scores. When comparing subjects who had elevated LHR uptake to those who had TID, it was found that those with LHR were more likely to have had prior myocardial infarction (MI) (29% vs. 9%), coronary artery bypass grafting (22% vs. 8%), lower ejection fraction (34+/-17% vs. 55+/-11%) and had more evidence of ischemia based on thallium stress defect and redistribution scores. However, patients with cavity dilation had a higher frequency of positive electrocardiographic response (31% vs. 19%) despite lower scintigraphic markers. CONCLUSIONS: Although pulmonary uptake and transient cavity dilation have both been associated with severe coronary disease, they have a very weak correlation, which, in combination with the different clinical parameters associated with each, suggests that they represent different pathophysiologic responses to exercise-induced ischemia. Our data support the hypothesis that TID represents transient subendocardial ischemia rather than physical dilation from increased end-diastolic pressure.

Severe transmural myocardial ischemia after dipyridamole administration implicating coronary steal.

Myocardial perfusion imaging with coronary vasodilators is routinely used for patients with suspected coronary disease who are unable to exercise. Since these agents work by increasing blood flow without significantly changing myocardial oxygen demand, they generally do not produce ischemia. A minority of patients show evidence of ischemia which some investigators suggest is due to a coronary steal phenomenon, but this has been challenged by several investigators. We present the case of a patient who developed severe transmural myocardial ischemia manifested by ST-segment elevation and severe perfusion defects which occurred after dipyridamole administration and which were reversed with aminophylline and nitroglycerin. This case supports the notion that coronary vasodilation with dipyridamole can induce a coronary steal.