A template for the authoring of statistical analysis plans.

A number of principal investigators may have limited access to biostatisticians, a lack of biostatistical training, or no requirement to complete a timely statistical analysis plan (SAP). SAPs completed early will identify design or implementation weak points, improve protocols, remove the temptation for p-hacking, and enable proper peer review by stakeholders considering funding the trial. An SAP completed at the same time as the study protocol might be the only comprehensive method for at once optimizing sample size, identifying bias, and applying rigor to study design. This ordered corpus of SAP sections with detailed definitions and a variety of examples represents an omnibus of best practice methods offered by biostatistical practitioners inside and outside of industry. The article presents a protocol template for clinical research design, enabling statisticians, from beginners to advanced.

A Prospective, Double-Blind, Randomized, Placebo-Controlled, Crossover Study Using an Orally Administered Oxalate Decarboxylase (OxDC).

Background: Hyperoxaluria is typically associated with excessive oxalate intake in the diet, decreased dietary calcium, hyperabsorption of oxalate, or increased endogenous production of oxalate. The disorder spectrum extends from recurrent kidney stones to ESKD. This clinical trial sought to evaluate the effectiveness of an acid stable oxalate decarboxylase (OxDC) to reduce urinary oxalate in healthy subjects on a high-oxalate diet. Methods: In this prospective, double-blind, randomized, placebo-controlled, crossover clinical trial, 33 healthy volunteers were randomized into two crossover sequences separated by a 2-day washout period. A controlled high-oxalate diet (750-800 mg oxalate, 500-550 mg calcium daily) was utilized, and six 24-hour urine collections were measured. Subjects were given approximately 1000 U (micromoles per minute per milligram) of OxDC or placebo with meals three times daily during the 4 days of treatment. Results: Urinary oxalate significantly decreased with OxDC treatment. The baseline corrected within-subject mean reduction in 24-hour urinary excretion (after OxDC dosing versus high-oxalate baseline preceding treatment) was 12.5 mg or 29% (P<0.001). OxDC treatment was effective (>5% reduction) in 31 of 33 subjects (94%). Compared with placebo, OxDC produced a 24% reduction (P<0.001) in 24-hour oxalate excretion. Other urinary parameters (creatinine, uric acid, citrate, magnesium, calcium) were not affected by OxDC. No serious adverse events and no product-related adverse events occurred. Conclusions: An orally administered OxDC is capable of significantly reducing urinary oxalate levels in healthy volunteers on a high-oxalate diet without affecting creatinine clearance, urine creatinine, or other solutes related to supersaturation of calcium oxalate. Clinical Trial registry name and registration number: Evaluation of Nephure, and the Reduction of Dietary Oxalate, in Healthy Volunteers, NCT03661216.

Roots and Nodules Response Differently to P Starvation in the Mediterranean-Type Legume Virgilia divaricata.

Virgilia divaricata is a tree legume that grows in the Cape Floristic Region (CFA) in poor nutrient soils. A comparison between high and low phosphate growth conditions between roots and nodules was conducted and evaluated for the plants ability to cope under low phosphate stress conditions in V. divaricata. We proved that the plant copes with low phosphate stress through an increased allocation of resources, reliance on BNF and enhanced enzyme activity, especially PEPC. Nodules had a lower percentage decline in P compared to roots to uphold its metabolic functions. These strategies partly explain how V. divaricata can sustain growth despite LP conditions. Although the number of nodules declined with LP, their biomass remained unchanged in spite of a plant decline in dry weight. This is achieved via the high efficiency of BNF under P stress. During LP, nodules had a lower % decline at 34% compared to the roots at 88%. We attribute this behavior to P conservation strategies in LP nodules that imply an increase in a metabolic bypass that operates at the PEP branch point in glycolysis. The enhanced activities of nodule PEPC, MDH, and ME, whilst PK declines, suggests that under LP conditions an adenylate bypass was in operation either to synthesize more organic acids or to mediate pyruvate via a non-adenylate requiring metabolic route. Both possibilities represent a P-stress adaptation route and this is the first report of its kind for legume trees that are indigenous to low P, acid soils. Although BNF declined by a small percentage during LP, this P conservation was evident in the unchanged BNF efficiency per weight, and the increase in BNF efficiency per mol of P. It appears that legumes that are indigenous to acid soils, may be able to continue their reliance on BNF via increased allocation to nodules and also due to increase their efficiency for BNF on a P basis, owing to P-saving mechanisms such as the organic acid routes.

Evaluation of pulsed electromagnetic field therapy for the treatment of chronic postoperative pain following lumbar surgery: a pilot, double-blind, randomized, sham-controlled clinical trial.

BACKGROUND: The incidence of chronic postoperative pain following lumbar spinal surgery has increased with the overall increase in the prevalence of lumbar surgery. This study was conducted to evaluate the analgesic effectiveness of pulsed electromagnetic field (PEMF) therapy in subjects with persistent pain following lumbar surgery. PATIENTS AND METHODS: A randomized, double-blind, sham-controlled, multicenter study in 36 subjects with persistent low-back and/or radiating leg pain after lumbar surgery was conducted. Eligible subjects were randomized (1:1:1) to receive one of two doses of therapy (42-µs or 38-µs pulse width) or treatment with a sham device. Subjects self-treated twice daily for 60 days. The primary end point was change in pain intensity (∆PI) using the Numerical Pain Rating Scale between average baseline (Days -5 to -1) and end of treatment (Days 56-60) for lumbar and radiating leg pain. Secondary outcome measures included the Oswestry Disability Index, Beck Depression Inventory-II, Patient Global Impression of Change, and consumption of analgesics. RESULTS: Low-back pain scores for the 42-µs group decreased by 40.2% (p = 0.028), compared to 18.6% for the 38-µs pulse width group (p = 0.037) and 25.6% for the sham group (p = 0.013 per protocol population). Average leg pain scores decreased by 45.0% (42 µs, p = 0.009), 17.0% (38 µs, p = 0.293), and 24.5% (sham, p = 0.065). The proportion of subjects responding to therapy, time to 30% reduction in pain scores, and Patient Global Impression of Change were improved with the PEMF 42-µs device over the sham control, although results were associated with p-values >0.05. CONCLUSION: PEMF therapy (42-µs pulse width) was associated with trends for a reduction in pain, compared to sham treatment. Secondary endpoints were consistent with an overall beneficial effect of the PEMF 42-µs pulse width device.

Intraarticular Injection of a Cross-Linked Sodium Hyaluronate Combined with Triamcinolone Hexacetonide (Cingal) to Provide Symptomatic Relief of Osteoarthritis of the Knee: A Randomized, Double-Blind, Placebo-Controlled Multicenter Clinical Trial.

OBJECTIVE: To evaluate the efficacy and safety of an intraarticular injection of Cingal (Anika Therapeutics, Inc., Bedford, MA) compared with Monovisc (Anika Therapeutics, Inc., Bedford, MA) or saline for the treatment of knee osteoarthritis. DESIGN: This multicenter, double-blind, saline-controlled clinical trial randomized subjects with knee osteoarthritis (Kellgren-Lawrence grades I-III) to a single injection of Cingal (4 mL, 88 mg hyaluronic acid [HA] plus 18 mg triamcinolone hexacetonide [TH]), Monovisc (4 mL, 88 mg HA), or saline (4 mL, 0.9%). The primary efficacy outcome was change in WOMAC (Western Ontario and McMaster Universities Arthritis Index) Pain Score through 12 weeks with Cingal versus saline. Secondary outcomes included Patient and Evaluator Global Assessments, OMERACT-OARSI Responder index, and WOMAC Total, Stiffness, and Physical Function scores through 26 weeks. RESULTS: A total of 368 patients were treated (Cingal, n = 149; Monovisc, n = 150; saline, n = 69). Cingal improvement from baseline was significantly greater than saline through 12 weeks ( P = 0.0099) and 26 weeks ( P = 0.0072). WOMAC Pain was reduced by 70% at 12 weeks and by 72% at 26 weeks with Cingal. Significant improvements were found in most secondary endpoints for pain and function at most time points through 26 weeks. At 1 and 3 weeks, Cingal was significantly better than Monovisc for most endpoints; Cingal and Monovisc were similar from 6 weeks through 26 weeks. A low incidence of related adverse events was reported. CONCLUSIONS: Cingal provides immediate and long-term relief of osteoarthritis-related pain, stiffness, and function, significant through 26 weeks compared to saline. Cingal had similar immediate advantages compared with HA alone, while showing benefit comparable to HA at 6 weeks and beyond.

Inducing hardening and healability in poly(ethylene-co-acrylic acid) via blending with complementary low molecular weight additives.

The design and synthesis of low molecular weight additives based on self-assembling nitroarylurea units, and their compatibility with poly(ethylene-co-acrylic acid) copolymers are reported. The self-assembly properties of the low molecular weight additives have been demonstrated in a series of gelation studies. Upon blending at low percentage weights (≤5%) with poly(ethylene-co-acrylic acid) the additives were capable of increasing the stress and strain to failure when compared to the parent copolymer. By varying the percentage weight of the additive as well as the type of additive the mechanical properties of poly(ethylene-co-acrylic acid) could be tailored. Finally, the healability characteristics of the blends were improved when compared to the original polymer via the introduction of a supramolecular 'network within a network'.

Diversity of burial rates in convergent settings decreased as Earth aged.

The evolution and the growth of the continental crust is inextricably linked to the evolution of Earth's geodynamic processes. The detrital zircon record within the continental crust, as well as the isotopic composition of this crust, indicates that the amount of juvenile felsic material decreased with time and that in geologically recent times, the generation of new crust is balanced by recycling of the crust back into the mantle within subduction zones. However it cannot always have been so; yet the nature of the crust and the processes of crustal reworking in the Precambrian Earth are not well constrained. Here we use both detrital zircon ages and metamorphic pressure-temperature-time (P-T-t) information from metasedimentary units deposited in proposed convergent settings from Archaean, Proterozoic and Phanerozoic terrains to characterize the evolution of minimum estimates of burial rate (km.Ma(-1)) as a function of the age of the rocks. The demonstrated decrease in burial rate correlates positively with a progressive decrease in the production of juvenile felsic crust in the Archaean and Proterozoic. Burial rates are also more diverse in the Archaean than in modern times. We interpret these features to reflect a progressive decrease in the diversity of tectonic processes from Archaean to present, coupled with the emergence of the uniquely Phanerozoic modern-style collision.

Diagnostic performance of a dedicated 1.5-T breast MR imaging system.

PURPOSE: To assess diagnostic performance of dedicated breast magnetic resonance (MR) imaging at breast imaging centers by using a dedicated 1.5-T breast MR system that used high-spatial-resolution, high-contrast-resolution spiral trajectory acquisitions. MATERIALS AND METHODS: The study was institutional review board approved and HIPAA compliant, with waiver of informed consent. Diagnostic performance was retrospectively assessed for 934 consecutive screening (n=347) and diagnostic (n=587) examinations performed from April 2006 to December 2007 in women aged 25-89 years old from four sites for which dedicated breast MR imaging reports and ground truth (biopsy for cancer cases, 1-year follow-up with negative results for cases with negative findings) were available. The sensitivity, specificity, and receiver operating characteristic (ROC) for breast MR imaging were determined. RESULTS: The sensitivity and specificity for the dedicated breast MR imaging system were 92% (92 of 100) and 88.8% (741 of 834). For all cases, the negative predictive value (NPV) was 98.9% (741 of 749). The NPV for screening cases was 100% (326 of 326). The area under the ROC curve was 0.942. Of the 93 cases with false-positive findings seen at dedicated breast MR imaging, 25 (27%) were high-risk histologic findings for which excision is often recommended. The false-positive rate was 93 of 834 (11.2%) for all cases, but only 16 of 326 (4.9%) for the screening cohort. CONCLUSION: High accuracy was achieved by using dedicated breast MR imaging.

Bovine tuberculosis in a nebraska herd of farmed elk and fallow deer: a failure of the tuberculin skin test and opportunities for serodiagnosis.

In 2009, Mycobacterium bovis infection was detected in a herd of 60 elk (Cervus elaphus) and 50 fallow deer (Dama dama) in Nebraska, USA. Upon depopulation of the herd, the prevalence of bovine tuberculosis (TB) was estimated at ∼71-75%, based upon histopathology and culture results. Particularly with elk, gross lesions were often severe and extensive. One year ago, the majority of the elk had been tested for TB by single cervical test (SCT), and all were negative. After initial detection of a tuberculous elk in this herd, 42 of the 59 elk were tested by SCT. Of the 42 SCT-tested elk, 28 were TB-infected with only 3/28 reacting upon SCT. After SCT, serum samples were collected from the infected elk and fallow deer from this herd at necropsy and tested by three antibody detection methods including multiantigen print immunoassay, cervidTB STAT-PAK, and dual path platform VetTB (DPP). Serologic test sensitivity ranged from 79 to 97% depending on the test format and host species. Together, these findings demonstrate the opportunities for use of serodiagnosis in the rapid detection of TB in elk and fallow deer.

Cardiac toxicity screening by echocardiography in healthy volunteers: a study of the effects of diurnal variation and use of a core laboratory on the reproducibility of left ventricular function measurement.

BACKGROUND: In investigational medicinal products testing centers (IMP), reliable methods for monitoring early signs of cardiotoxicity of a potential new drug in healthy volunteers are essential. This study examines what levels of left ventricular ejection fraction (LVEF) variance can be achieved with two-dimensional echocardiography (2DE) in a core laboratory versus a site laboratory. Diurnal variability of LVEF and diastolic parameters were also reviewed. METHODS AND RESULTS: 64 healthy males, (age range 18-40 years), with optimal echo windows were recruited. Two-dimensional and tissue Doppler (TDI) echocardiography was performed by one dedicated sonographer using an Acuson Sequoia C256 machine. Heart rate and blood pressure were recorded simultaneously. Echocardiograms were performed at set time points (0, 1, 4, and 20 hours) on all subjects. The images were analyzed independently by one on-site, unblinded, sonographer reader (site lab) and one experienced off-site blinded physician over reader (core lab). The core lab showed significantly less variance in LVEF measurements than the site lab (5.5% vs. 19.9%). There was no significant diurnal variation in mean blood pressure, LVEF or E:A ratio measurements over 20 hours. CONCLUSIONS: The core lab had better reproducibility and significantly less variance in LVEF measurements by 2DE than the site lab. There was no diurnal variation in LV function measurement.

Laser in situ keratomileusis for spherical hyperopia and hyperopic astigmatism using the NIDEK EC-5000 excimer laser.

PURPOSE: To assess the efficacy, predictability, and safety of LASIK for the surgical correction of low to moderate hyperopia and hyperopic astigmatism using the NIDEK EC-5000 excimer laser. METHODS: In a multicenter United States Food and Drug Administration (FDA) regulated study of LASIK, 7 centers enrolled 293 eyes with manifest refraction sphere that ranged from +0.50 to +6.00 diopters (D) with or without astigmatism up to 3.00 D. The intended outcome was plano in all eyes. Patients were treated bilaterally. One year postoperative outcomes are reported. RESULTS: The mean spherical equivalent refraction (MRSE) for all eyes changed from +3.51 +/- 1.45 [corrected] D (range: +0.50 to +6.63 D) preoperatively to +0.35 +/- 0.54 D (range: +1.63 [corrected] to +2.00 D) 1 year [corrected] Overall, 61% (170/279) of eyes achieved distance uncorrected visual acuity (UCVA) of 20/20 or better, 82% (228/279) of eyes saw 20/25 or better, and 99% (277/279) of eyes saw 20/40 or better. Refractive accuracy was demonstrated as 63.1% (176/279) of eyes achieved a MRSE within +/- 0.50 D and 90.3% (252/279) of eyes within +/- 1.00 D. Less than 2% (4/279) of eyes lost 2 lines of distance best spectacle-corrected visual acuity. Stability of refraction was demonstrated by 6 months, with a mean hyperopic shift of < 0.03 D from 3 to 6 months. CONCLUSIONS: The NIDEK EC-5000 corrected hyperopia and hyperopic astigmatism with UCVA, refractive accuracy, 1-year stability, and safety that surpassed all FDA criteria.

The effect of acetaminophen on the international normalized ratio in patients stabilized on warfarin therapy.

STUDY OBJECTIVE: To determine whether an interaction exists between acetaminophen and warfarin that alters the international normalized ratio (INR). DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Anticoagulation clinic at a Veterans Affairs Medical Center. PATIENTS: Thirty-six adult patients receiving warfarin with stable INRs, defined as two consecutive INRs at least 3 weeks apart that were within the therapeutic range. INTERVENTION: Patients were randomly assigned to receive acetaminophen 1 g twice/day along with matching placebo twice/day (12 patients), acetaminophen 1 g 4 times/day (12 patients), or matching placebo 4 times/day (12 patients) for 4 weeks. MEASUREMENTS AND MAIN RESULTS: The primary end point was the difference in mean INR between groups at weekly intervals. Secondary end points were the percentages of patients in each group with supratherapeutic (INR > or = 0.3 above the upper limit of their therapeutic range) or subtherapeutic (INR > or = 0.2 or 0.3 below the lower limit of their respective therapeutic range of 2.0-3.0 or 2.5-3.5) INRs, and the difference in mean serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels between groups at biweekly intervals. Slow enrollment and a preliminary observation that 15 patients experienced an elevated INR prompted early termination of the study. At week 2, the group receiving acetaminophen 2 g/day had a significantly higher mean INR versus the placebo group (p=0.01). At weeks 1, 2, and 3, the acetaminophen 4-g/day group had significantly higher mean INRs compared with those in the placebo group (p=0.04, p=0.01, p=0.01, respectively). In addition, 13 (54%) of 24 patients in the acetaminophen groups combined exceeded the upper limit of their therapeutic range by 0.3 or greater compared with only 2 (17%) of 12 patients in the placebo group. No statistically significant differences in serum ALT or AST levels between either acetaminophen group versus the placebo group were found at week 4; however, there was a statistically significant increase in mean ALT level at week 2 in the acetaminophen 4-g/day group versus the placebo group. CONCLUSION: These findings support the existence of a clinically significant interaction between warfarin and daily use of acetaminophen 2-4 g, necessitating close monitoring of patients who receive this drug combination. Whether this interaction occurs when acetaminophen is taken in lower doses or is used sporadically requires further study.

Topographically guided LASIK for myopia using the Nidek CXII customized aspheric treatment zone (CATz).

PURPOSE: To assess the efficacy, predictability, and safety of topography-guided laser in situ keratomileusis (LASIK) for the surgical correction of low to moderate myopia with astigmatism using the Nidek CXIII excimer laser equipped with the customized aspheric treatment zone (CATz) algorithm. METHODS: In a multicenter US Food and Drug Administration study of topography-guided LASIK, 4 centers enrolled 135 eyes with manifest refraction sphere that ranged from -0.50 to -7.00 D (mean, -3.57 +/- 1.45) with up to -4.00 D of astigmatism (mean, -1.02 +/- 0.64 D). The intended outcome was plano in all eyes. Refractive outcomes and higher-order aberrations were analyzed preoperatively and postoperatively. Patient satisfaction was assessed using both the validated Refractive Status and Vision Profile (RSVP) questionnaire and a questionnaire designed for this study. Six-month postoperative outcomes are reported here. RESULTS: By 6 months postoperatively, the manifest refraction spherical equivalent (MRSE) for all eyes was -0.09 +/- 0.31 D. Six months postoperatively, 116 of 131 eyes (88.55%) had an uncorrected visual acuity of 20/20 or better, and 122 of 131 eyes (93.13%) had a MRSE within +/-0.50 D. Distance best spectacle-corrected visual acuity (BSCVA) increased by 2 or more lines in 21 of 131 eyes (19.01%), and no eyes lost 2 lines or more of BSCVA. The total ocular higher-order aberrations root-mean-square increased by 0.04 microm postoperatively. Patients reported significantly fewer night driving and glare and halo symptoms postoperatively than preoperatively. CONCLUSIONS: Nidek CXIII CATz treatment of myopia with astigmatism is safe, efficacious, and predictable, and it reduces patient symptoms associated with night driving and glare and halo symptoms.

Radiographic evaluation of the Zurich cementless total hip acetabular component.

OBJECTIVE: To radiographically evaluate the Zurich cementless total hip (ZCTH) cup and correlate lucency with clinical signs of implant instability, time since surgery, and implant generation, using zonal analysis. STUDY DESIGN: Retrospective study. ANIMALS: Client-owned dogs (n = 53). METHODS: Radiographs of dogs that had ZCTH arthroplasty (>1 year) were evaluated using zonal analysis, for lucency surrounding the cup-bone interface (number of zones, length, area). Dogs were examined for clinical signs of implant instability (lameness, hip pain). Lucency was correlated with lameness, time after surgery, and implant generation. RESULTS: Radiographs of 68 implants (18 generation I, 50 generation II) were evaluated. Eight dogs were lame (11.8%). Dogs with lameness were more likely to have lucency in > or =2 zones of analysis (per view), have >2 times the average curvilinear length of lucency, and have >4 times the average area of lucency surrounding the implant compared with non-lame dogs. A weak relationship was observed between time after surgery and implant generation; however, there was no relationship between time after surgery and lucency. CONCLUSIONS: Dogs with lameness after ZCTH arthroplasty were more likely to have lucency at the cup-bone interface. Lucency was better evaluated by radiographic projection than zonal analysis. Temporal progression of lucency was weakly correlated with implant generation. CLINICAL RELEVANCE: Dogs with lucency in > or =2 zones of analysis should be evaluated more frequently for clinical signs of implant loosening. Further investigation of serial radiographs after ZCTH arthroplasty is warranted.

Record of mid-Archaean subduction from metamorphism in the Barberton terrain, South Africa.

Although plate tectonics is the central geological process of the modern Earth, its form and existence during the Archaean era (4.0-2.5 Gyr ago) are disputed. The existence of subduction during this time is particularly controversial because characteristic subduction-related mineral assemblages, typically documenting apparent geothermal gradients of 15 degrees C km(-1) or less, have not yet been recorded from in situ Archaean rocks (the lowest recorded apparent geothermal gradients are greater than 25 degrees C km(-1)). Despite this absence from the rock record, low Archaean geothermal gradients are suggested by eclogitic nodules in kimberlites and circumstantial evidence for subduction processes, including possible accretion-related structures, has been reported in Archaean terrains. The lack of spatially and temporally well-constrained high-pressure, low-temperature metamorphism continues, however, to cast doubt on the relevance of subduction-driven tectonics during the first 1.5 Gyr of the Earth's history. Here we report garnet-albite-bearing mineral assemblages that record pressures of 1.2-1.5 GPa at temperatures of 600-650 degrees C from supracrustal amphibolites from the mid-Archaean Barberton granitoid-greenstone terrain. These conditions point to apparent geothermal gradients of 12-15 degrees C-similar to those found in recent subduction zones-that coincided with the main phase of terrane accretion in the structurally overlying Barberton greenstone belt. These high-pressure, low-temperature conditions represent metamorphic evidence for cold and strong lithosphere, as well as subduction-driven tectonic processes, during the evolution of the early Earth.

Opening plugged tympanostomy tubes: effect of biofilm formation.

OBJECTIVE: To determine if the presence of a bacterial biofilm impacts the rate of clearing of mucoid plugs from tympanostomy tubes (TTs). STUDY DESIGN AND SETTING: Ex vivo model. Stainless steel Reuter Bobbin TTs (n = 18) were placed in growth medium with Pseudomonas aeruginosa and Streptococcus pneumoniae for 12 days to promote biofilm formation. Tympanostomy tubes (n = 18) placed in growth medium, without bacteria, for 12 days served as controls. Biofilm formation was assessed by scanning electron microscopy. All TTs were filled with middle ear mucus and allowed to dry, thereby forming a plug. TTs were placed in a model ear chamber, covered with ofloxacin otic solution, and the time to clear each plug was recorded. RESULTS: Biofilm formation was consistently encountered on TTs exposed to bacteria but in no TTs in the control group. There was a significant effect of the biofilm on plug clearance, favoring TTs without a biofilm (P = 0.0333). Although there was no significant difference in the proportion of unplugged TTs (P = 0.264), TTs with a biofilm did not clear plugs as rapidly as TTs without a biofilm (P = 0.0416). CONCLUSIONS: The presence of a biofilm may slow the time to clear mucoid TT plugs, but it does not seem to affect the overall proportion of TTs that are unplugged.

Effects of hypoxia on megakaryocyte progenitors obtained from the umbilical cord blood of term and preterm neonates.

BACKGROUND: Placental insufficiency is associated with early-onset thrombocytopenia in preterm neonates. Prior studies demonstrated a reduction in circulating megakaryocyte (Mk) progenitors, suggesting decreased platelet production. We hypothesized that decreased Mk production is the result of a direct inhibitory effect of hypoxia on the proliferation of Mk progenitors, or a hypoxia-induced change in the fetal hematopoietic environment. OBJECTIVE: To test the effects of hypoxia on the clonogenic maturation of Mk progenitors obtained from term and preterm cord blood CD34(pos) cells, either cultured alone or in conjunction with CD34(neg) light density mononuclear cells (LDMCs). METHODS: CD34(pos) cells and CD34(neg) LDMCs were isolated from the cord blood of term and preterm deliveries, and mobilized peripheral blood CD34(pos) cells were obtained from healthy adults. CD34(pos) cells were then cultured alone or co-cultured with CD34(neg) LDMCs in a semisolid, serum-free media containing rTpo, IL-3, and IL-6. Cultures were exposed to 20%, 5%, or 1% oxygen for 10-12 days. Mk colonies were then quantified following immunohistochemical staining. RESULTS: Pure CD34(pos) cells from preterm (n = 5) and term (n = 5) neonates and from adults (n = 4) generated similar numbers of Mk colonies in all three oxygen concentrations. However, the number of Mk colonies in preterm co-cultures was progressively lower with decreasing O(2) concentrations. CONCLUSIONS: Hypoxia did not appear to directly inhibit colony formation of Mk progenitors from preterm and term cord blood CD34(pos) cells. However, co-culture studies showed a decrease in Mk colony formation with hypoxia, suggesting an indirect inhibitory effect of hypoxia on Mk clonogenic maturation mediated by non-progenitor cells in the hematopoietic microenvironment.

Risk for post-transplant lymphoproliferative disorder after polyclonal antibody induction in kidney transplantation.

The adjusted relative risk (aRR) for development of post-transplant lymphoproliferative disorder (PTLD) is higher in kidney transplant recipients receiving monoclonal antibody induction therapy, but the aRR between the different available polyclonal agents has not been investigated in detail. We analyzed data from the United Network of Organ Sharing registry on all kidney transplants performed between 1987 and 2003. The aRR for PTLD development was calculated using SAS 9.0 statistical software and Cox proportional hazards modeling, adjusting for multiple covariates. There were 539 cases of PTLD among 84 907 kidney transplant recipients, who received either polyclonal antibody induction or no induction therapy. In adjusted analysis, the aRR for PTLD development (vs. no induction) was significantly higher with use of equine anti-thymocytic globulin (E-ATG; aRR = 1.61, p = 0.0003) or anti-lymphocytic globulin (ALG; aRR = 1.35, p = 0.0055) but not with rabbit anti-thymocytic globulin (R-ATG; aRR = 1.17, p = 0.29, NS). Median follow up times were significantly shorter in the R-ATG cohort than the ALG or E-ATG cohort (median 368 vs. 1433 and 2055 day). However, in an analysis restricted to pediatric recipients, where median times to PTLD are less than 200 days, only E-ATG was associated with a higher aRR for PTLD (aRR = 2.16, p = 0.0078), while R-ATG and ALG were not. There is a higher aRR for PTLD after kidney transplantation with E-ATG, but not R-ATG. This may only partially be explained by shorter follow up time and may represent differential hazard for PTLD among the agents.

Benign lichenoid keratosis: a clinical and pathologic reappraisal of 1040 cases.

Benign lichenoid keratosis, otherwise known as lichen planus-like keratosis, is a common, cutaneous entity that is often confused with cutaneous malignancy. Few studies have examined the multiple clinical and pathologic guises of this entity, particularly within the context of clinical pathologic correlation or magnitude of this study. We examined the epidemiologic, clinical, and pathologic attributes of 1040 consecutive cases of benign lichenoid keratosis referred for pathologic examination at a busy laboratory over an entire year. Clinical parameters assessed included the age, anatomic location, gender, and multiplicity of the lesions. Pathologic attributes were assessed yielding discernment of five different subtypes that included a classic type, bullous type, atypical type with cytologically atypical lymphocytes, an early or interface type, and a late regressed or atrophic type. The results yielded an average age at presentation of 59.5 years with an age range of 36 to 87 years. The gender frequency was 76% female, 24% male. The trunk was the most common location (76%), followed by the extremities (33%) and head and neck (7%); 8% of patients presented with two lesions and less than 1% with three lesions prompting consideration of lichen planus. The classic, atypical, and bullous forms of the disease clinically presented with erythematous papule/plaque(s). The early or interface type showed erythematous to hyperpigmented brown macules and the regressed or atrophic type presented as violaceous papules or irregularly distributed macular pigmentation; 81% of the lesions showed the classic histology consisting of epidermal acanthosis with a band-like lichenoid lymphocytic infiltrate. Variable numbers of plasma cells, eosinophils, and neutrophils were identified as well as epidermal parakeratosis distinguishing these lesions from typical lichen planus. The bullous variant showed intraepidermal or subepidermal bullous cavities with a dense associated lymphocytic infiltrate and increased numbers of necrotic basilar layer keratinocytes. The atypical variant showed features of the classic type with scattered enlarged CD-3, CD-30 (+) lymphocytes possessing hyperchromatic, irregular nuclei. The early interface type showed single lymphocytes aligned along the dermoepidermal junction without epidermal acanthosis and adjacent lentigo. The regressed or atrophic variant showed epidermal atrophy with papillary dermal scarring, patchy lymphocytic infiltrates and melanin incontinence. The clinicopathologic spectrum of benign lichenoid keratosis is broad and encompasses several unrelated entities. An awareness of its expanded presentation is essential to avoid misdiagnosis and may serve as an important forerunner of pathogenic discernment.

Preoperative antibiotic and steroid therapy and hearing loss caused by semicircular canal transection in pseudomonas otitis media.

OBJECTIVE: The purpose of this experiment was to determine whether preoperative administration of antibiotics and corticosteroids can attenuate the severity of hearing loss (HL) with semicircular canal (SC) transection in a guinea pig model of Pseudomonas aeruginosa (PA) otitis media (OM). Study design and setting Prospective and controlled. METHODS: OM was induced in 64 pigmented guinea pigs by bilateral, transtympanic injection of PA. Two to 4 days later, 1 horizontal SC was randomly transected. In the 1st series, antibiotic therapy was initiated either immediately before or after surgery. In the 2nd series, all animals received preoperative antibiotics, and half received dexamethasone before surgery. Hearing was tested before and after surgery. RESULTS: PA was recovered in all ears. SC transection was associated with significant HL. HL was better in animals given antibiotics preoperatively (clicks, 16 versus 32 dB, P = 0.0220). Addition of preoperative steroids did not significantly further reduce HL (7 versus 14 dB for clicks, P = 0.6919). CONCLUSIONS: HL caused by SC transection in PA OM may be attenuated with preoperative antibiotic therapy in the guinea pig.