Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region.

BACKGROUND: Our objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer. METHODS: Utilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR). RESULTS: Nationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction. CONCLUSIONS: Nationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.

Comparing treatment patterns of hepatocellular carcinoma at academic centers and non-academic centers within the Mountain Region.

BACKGROUND: Our objective is to explore differences in survival and treatment approaches for hepatocellular carcinoma (HCC) between academic centers (ACs) and non-academic centers (NACs), which may contribute to disparities in the Mountain Region (MR). METHODS: Using the National Cancer Database, HCC cases from 2004 to 2015 in the MR were divided into AC and NAC subgroups. Cox-proportional hazard regression and binary logistic regression were performed to analyze survival, compare treatment patterns, and examine the effect of facility type and surgical approach on margin status. RESULTS: Treatment at ACs, compared to NACs, is associated with improved survival. At ACs, the odds of surgical or systemic treatment were higher. The odds of receiving radiation and positive margins was lower. Overall, the odds of positive margins was higher with laparoscopic compared to open or an unspecified surgical approach; this relationship persisted on subgroup analysis of NACs, but not ACs. CONCLUSIONS: Treatment of HCC at an AC in the MR increases the odds of surgery and improves survival. A laparoscopic approach increases the odds of positive margins, irrespective of center type.

Enhancement of Viable Adipose-Derived Stem Cells in Lipoaspirate by Buffering Tumescent with Sodium Bicarbonate.

BACKGROUND: Fat grafting is a growing field within plastic surgery. Adipose-derived stem cells (ASCs) and stromal vascular fracture (SVF) may have a role in fat graft survival. Our group previously demonstrated a detrimental effect on ASC survival by the lidocaine used in tumescent solution. Sodium bicarbonate (SB) buffers the acidity of lidocaine. The purpose of this study was to determine whether SB buffering is a practical method to reduce ASC and SVF apoptosis and necrosis seen with common lidocaine-containing tumescent solution. METHODS: Human patients undergoing bilateral liposuction for any indication were included in this study. An internally controlled, split-body design was utilized. Tumescent liposuction on one side of the body was conducted with tumescent containing lidocaine. On the opposite side, liposuction was conducted by adding SB to the tumescent. Tumescent solution and lipoaspirate pH were measured. Lipoaspirate from each side was processed for SVF isolation and ASC culture. The number of viable ASCs was counted and SVF apoptosis/necrosis was examined. RESULTS: The pH of the SB-buffered tumescent was significantly higher than that of the standard tumescent, an effect also seen in the lipoaspirate. Adipose-derived stem cell survival in the SB-buffered lipoaspirate was approximately 53% higher. However, there was no significant difference in SVF apoptosis and necrosis between the groups. CONCLUSIONS: The acidic standard tumescent solution commonly used in liposuction diminishes ASC viability from lipoaspirates. Sodium bicarbonate buffering tumescent solution can enhance ASC viability, but does not affect SVF apoptosis and necrosis. We recommend buffering tumescent with SB to potentially improve fat graft take. Our findings advocate for further research investigating mechanisms and optimal harvest techniques that maximize SVF/ASC survival and the clinical effect on overall fat graft viability.

Random flap survival with hyperbaric oxygen: daily versus twice-daily treatments.

PURPOSE: Hyperbaric oxygen (HBO2) therapy is used to improve the survival of compromised flaps. Compromised flaps are complications encountered postsurgically, or in traumatic degloving or avulsion injuries. Failed flaps lead to persistence of the defect, requirement of another donor site, and psychosocial sequelae. Although evidence of the benefit of HBO2 therapy is significant, there is no consensus on the optimal treatment regimen. The purpose of this study is to examine whether twice-daily treatments (BID HBO2) provide additional benefit compared to daily treatments (QD HBO2) in a rat compromised random flap model. METHODS: A rat random flap model was used with subjects divided into three groups: 1) control group; 2) QD HBO2; and 3) BID HBO2, where HBO2 was performed with 100% oxygen at 2.5 atmospheres absolute/ATA (253 kPa) for 90 minutes. After 10 days, areas of flap necrosis were measured and biopsies were taken for histologic analysis. Statistical analysis was performed using ANOVA and paired t-tests. A P-value ⟨0.05 was considered significant. RESULT: Both treatment groups had significantly increased mean flap survival compared to controls (P⟨0.05). There was no significant difference in flap survival between the QD and BID groups. Capillary proliferation in the QD group was increased compared with controls. CONCLUSION: Both QD and BID HBO2 protocols can significantly decrease random flap necrosis. However, the results of this study suggest there is no additional benefit gained with BID treatments. Clinical studies are warranted to confirm these findings and assist in formalization of protocols for the use of HBO2in treating compromised random flaps.

PURA syndrome: clinical delineation and genotype-phenotype study in 32 individuals with review of published literature.

BACKGROUND: De novo mutations in PURA have recently been described to cause PURA syndrome, a neurodevelopmental disorder characterised by severe intellectual disability (ID), epilepsy, feeding difficulties and neonatal hypotonia. OBJECTIVES: To delineate the clinical spectrum of PURA syndrome and study genotype-phenotype correlations. METHODS: Diagnostic or research-based exome or Sanger sequencing was performed in individuals with ID. We systematically collected clinical and mutation data on newly ascertained PURA syndrome individuals, evaluated data of previously reported individuals and performed a computational analysis of photographs. We classified mutations based on predicted effect using 3D in silico models of crystal structures of Drosophila-derived Pur-alpha homologues. Finally, we explored genotype-phenotype correlations by analysis of both recurrent mutations as well as mutation classes. RESULTS: We report mutations in PURA (purine-rich element binding protein A) in 32 individuals, the largest cohort described so far. Evaluation of clinical data, including 22 previously published cases, revealed that all have moderate to severe ID and neonatal-onset symptoms, including hypotonia (96%), respiratory problems (57%), feeding difficulties (77%), exaggerated startle response (44%), hypersomnolence (66%) and hypothermia (35%). Epilepsy (54%) and gastrointestinal (69%), ophthalmological (51%) and endocrine problems (42%) were observed frequently. Computational analysis of facial photographs showed subtle facial dysmorphism. No strong genotype-phenotype correlation was identified by subgrouping mutations into functional classes. CONCLUSION: We delineate the clinical spectrum of PURA syndrome with the identification of 32 additional individuals. The identification of one individual through targeted Sanger sequencing points towards the clinical recognisability of the syndrome. Genotype-phenotype analysis showed no significant correlation between mutation classes and disease severity.

Tumescent Liposuction without Lidocaine.

BACKGROUND: Our previous study demonstrated that lidocaine has a negative impact on adipose-derived stem cell (ASC) survival. Currently for large-volume liposuction, patients often undergo general anesthesia; therefore, lidocaine subcutaneous anesthesia is nonessential. We hypothesized that removing lidocaine from tumescent might improve stromal vascular fraction (SVF) and ASC survival from the standard tumescent with lidocaine. Ropivacaine is also a commonly used local anesthetic. The effect of ropivacaine on ASC survival was examined. METHODS: Adults who underwent liposuction on bilateral body areas were included (n = 10). Under general anesthesia, liposuction on 1 area was conducted under standard tumescent with lidocaine. On the contralateral side, liposuction was conducted under the modified tumescent without lidocaine. Five milliliters of lipoaspirate were processed for the isolation of SVF. The adherent ASCs were counted after 24 hours of SVF culture. Apoptosis and necrosis of SVF cells were examined by Annexin/propidium iodide staining and analyzed by flow cytometry. RESULTS: Average percentage of live SVF cells was 68.0% ± 4.0% (28.5% ± 3.8% of apoptosis and 3.4% ± 1.0% of necrosis) in lidocaine group compared with 86.7% ± 3.7% (11.5% ± 3.1% of apoptosis and 1.8% ± 0.7% of necrosis) in no-lidocaine group (P = 0.002). Average number of viable ASC was also significantly lower (367,000 ± 107) in lidocaine group compared with that (500,000 ± 152) in no-lidocaine group (P = 0.04). No significant difference was found between lidocaine and ropivacaine on ASC cytotoxicity. CONCLUSIONS: Removing lidocaine from tumescent significantly reduced SVF and ASC apoptosis in the lipoaspirate. We recommend tumescent liposuction without lidocaine, particularly if patient's lipoaspirate will be used for fat grafting.

Research: Testing of a Novel Portable Body Temperature Conditioner Using a Thermal Manikin.

A battery-operated active cooling/heating device was developed to maintain thermoregulation of trauma victims in austere environments while awaiting evacuation to a hospital for further treatment. The use of a thermal manikin was adopted for this study in order to simulate load testing and evaluate the performance of this novel portable active cooling/heating device for both continuous (external power source) and battery power. The performance of the portable body temperature conditioner (PBTC) was evaluated through cooling/heating fraction tests to analyze the heat transfer between a thermal manikin and circulating water blanket to show consistent performance while operating under battery power. For the cooling/heating fraction tests, the ambient temperature was set to 15°C ± 1°C (heating) and 30°C ± 1°C (cooling). The PBTC water temperature was set to 37°C for the heating mode tests and 15°C for the cooling mode tests. The results showed consistent performance of the PBTC in terms of cooling/heating capacity while operating under both continuous and battery power. The PBTC functioned as intended and shows promise as a portable warming/cooling device for operation in the field.

Elimination of reperfusion-induced microcirculatory alterations in vivo by adipose-derived stem cell supernatant without adipose-derived stem cells.

BACKGROUND: In the present study, the authors hypothesized that adipose-derived stem cells in cell culture may secrete multiple cytokines in the supernatant, which might have a significant impact in vivo on the reperfusion-induced microcirculatory alterations and endothelial dysfunction. METHODS: Fat tissue was surgically harvested from rat flanks and processed for adipose-derived stem cell isolation; cells (1 × 10(6)) were subcultured for 3, 6, 9, and 12 days without passage. The postcultivated medium was harvested with medium change every 3 days. After centrifugation, the supernatant was collected and stored at -20°C. Supernatant collected on day 9 was analyzed for eight oxidative stress cytokines by an enzyme-linked immunosorbent assay strip. The effect of the supernatant on the reperfusion-induced microcirculatory alterations was examined in the vascular pedicle of isolated rat cremaster muscles subjected to 4 hours of ischemia followed by 2 hours of reperfusion. RESULTS: Enzyme-linked immunosorbent assay results demonstrated that adipose-derived stem cells produced several highly expressed cytokines in the supernatant. The average concentration of interleukin-6, in particular, was 5-fold higher compared with control. The reperfusion-induced vasospasm, arteriole stagnation, and the capillary no-reflow that often appear in the early phase of reperfusion were eliminated by adipose-derived stem cell supernatant. CONCLUSIONS: Adipose-derived stem cells in cell culture display cytokine secretory properties that enable the cells to act through paracrine signaling. The supernatant even without cells could be used as a paracrine agent to interfere with the reperfusion-induced microcirculatory alterations and endothelial dysfunction.

Targeted amino acid supplementation in diabetic foot wounds: pilot data and a review of the literature.

BACKGROUND: Diabetic foot wounds are a highly morbid and costly complication of diabetes mellitus. Targeted amino acid supplementation, by increasing tissue hydroxyproline concentrations, has been implicated in improved wound outcomes in surgical incisions and chronic wounds, and after radiation injury. A major component of collagen, hydroxyproline is a surrogate marker used commonly for tissue collagen concentrations. This paper reviews the literature pertaining to amino acid supplementation and wound healing, and also evaluates our pilot data relating to supplementation with arginine, glutamine, and beta-hydroxy-beta-methylbutyrate (HMB) in the treatment of diabetic foot ulcers. METHODS: For the pilot study, nine patients scheduled to undergo wound debridement for diabetic foot ulcers were randomized prospectively to be a part of either a placebo group or a treatment group that received supplementation twice daily for 2 wks. Tissue samples were collected both before and after 2 wk of supplementation. The results of assay of the samples for hydroyproline were then analyzed via a one tailed Student t-test to evaluate tissue concentrations of hydroxyproline. For the literature review in the study, the MEDLINE/PubMed database was reviewed, using search terms contained in the Medical Subject Headings (MeSH). RESULTS: The treatment group in the study exhibited a significantly greater hydroxyproline concentration after supplementation than before it (p=0.03). The mean percent change in the tissue hydroxyproline concentration for arginine, glutamine, and HMB group was +67.8%, with a standard deviation (SD) of 129.89. The mean percent change for the corresponding amino acids in the placebo group was -78.4%, with an SD of 20.55. The review of the MEDLINE/PubMed literature revealed only two human studies of amino acid supplementation in patients with diabetic foot wounds, one of which found a significant improvement in wound-depth and wound-appearance scores. CONCLUSIONS: Given the results of our pilot study, and on the basis of a review of the literature, the administration of a simple amino acid supplement may improve the healing of diabetic foot wounds via increased collagen production.

Lidocaine-induced ASC apoptosis (tumescent vs. local anesthesia).

BACKGROUND: The purpose for the present study was to determine which anesthetic method, local anesthesia versus tumescent, is superior for liposuction in terms of adipose-derived stem cell (ASC) survival in lipoaspirate; which component, lidocaine versus lidocaine with epinephrine, in anesthetic solutions could affect ASC survival; and which mechanism, necrosis versus apoptosis, is involved in lidocaine-induced ASC death. METHODS: Human lipoaspirates were harvested using standard liposuction technique. Individuals scheduled for liposuction on bilateral body areas gave consent and were included in the study. On one area, liposuction was conducted under local anesthesia with lidocaine/epinephrine. On the contralateral area, liposuction was accomplished with tumescent wetting solution containing lidocaine/epinephrine. Lipoaspirates were processed for the isolation of stromal vascular fraction (SVF). ASC survival was determined by the number of adherent ASCs after 24 h of SVF culture. Lidocaine dose-response (with or without epinephrine) on cultured ASCs was examined. Lidocaine-induced ASC apoptosis and necrosis was determined by Annexin V-FITC/Propidium Iodide (PI) assay and analyzed by flow cytometry. RESULTS: All of the participants were female adults. The average age was 45 ± 4.0 years (±SEM) and the average BMI was 28 ± 1.0 (±SEM). Lipoaspirate samples (n = 14) treated by local anesthesia (n = 7/group) or tumescent anesthesia (n = 7/group) were investigated. Liposuction sites were located in the hip or thigh. The average number of adherent ASCs was 1,057 ± 146 k in the local anesthesia group, which was significantly lower than the 1,571 ± 111 k found in the tumescent group (P = 0.01). ASC survival was significantly lower in the lidocaine group and in a dose-dependent manner as compared to the correspondent PBS controls (P < 0.05 or P < 0.01). ASC survival was significantly lower in both the lidocaine and lidocaine with epinephrine groups when compared to PBS controls. Annexin/PI assay showed that ASC apoptosis (but not necrosis) in the lidocaine group was significantly higher than that in the corresponding PBS control (P = 0.026). CONCLUSIONS: Tumescent anesthesia is the superior method for liposuction with respect to ASC preservation compared to local anesthesia. Lidocaine could cause significant ASC apoptosis.

The effect of lipoaspirates cryopreservation on adipose-derived stem cells.

BACKGROUND: Autologous fat grafting has gained popularity, particularly with the discovery of adipose-derived stem cells (ADSC). The possibility of freezing lipoaspirates (LA) for later use has intriguing clinical potential. However, the effect of LA cryopreservation on ADSC is unclear. OBJECTIVES: The authors explore the effect of LA cryopreservation on ADSC viability. METHODS: Human LA (n = 8) were harvested using a standard technique. Lipoaspirate samples were either processed immediately as fresh LA (A) or stored at -20°C and then at -80°C for 30 days with (B) or without (C) freezing medium. Stromal vascular fraction (SVF) was separated from adipocytes and either cultured to obtain purified ADSC or processed for the isolation of 3 distinct ADSC subpopulations (CD90(+)/CD45(-), CD105(+)/CD45(-), and CD34(+)/CD31(-)). Apoptosis and necrosis were determined by an annexin V/propidium iodide assay and quantified by flow cytometry. The capability of ADSC for long-term proliferation and differentiation was also examined. RESULTS: There were no significant differences in the apoptosis and necrosis of adipocytes, SVF, or ADSC between groups A and B. However, cell viability in SVF and ADSC was significantly compromised in group C as compared with group B (P < .01) due to higher ADSC apoptosis but not necrosis. The viable ADSC isolated from fresh or frozen LA were cultured for more than 20 passages and demonstrated similar patterns and speed of proliferation with strong capability to differentiate, evidenced by cell doubling time and positive staining with Oil Red O (Sigma-Aldrich, St Louis, Missouri) and alkaline phosphatase. CONCLUSIONS: Lipoaspirates cryopreservation had a significant impact on ADSC apoptosis but not on ADSC necrosis, proliferation, or differentiations. Freezing medium provides significant protection against ADSC apoptosis.

Analysis for apoptosis and necrosis on adipocytes, stromal vascular fraction, and adipose-derived stem cells in human lipoaspirates after liposuction.

BACKGROUND: Adipose-derived stem cells have become the most studied adult stem cells. The authors examined the apoptosis and necrosis rates for adipocyte, stromal vascular fraction, and adipose-derived stem cells in fresh human lipoaspirates. METHODS: Human lipoaspirate (n = 8) was harvested using a standard liposuction technique. Stromal vascular fraction cells were separated from adipocytes and cultured to obtain purified adipose-derived stem cells. A panel of stem cell markers was used to identify the surface phenotypes of cultured adipose-derived stem cells. Three distinct stem cell subpopulations (CD90/CD45, CD105/CD45, and CD34/CD31) were selected from the stromal vascular fraction. Apoptosis and necrosis were determined by annexin V/propidium iodide assay and analyzed by flow cytometry. RESULTS: The cultured adipose-derived stem cells demonstrated long-term proliferation and differentiation evidenced by cell doubling time and positive staining with oil red O and alkaline phosphatase. Isolated from lipoaspirates, adipocytes exhibited 19.7 ± 3.7 percent apoptosis and 1.1 ± 0.3 percent necrosis; stromal vascular fraction cells revealed 22.0 ± 6.3 percent of apoptosis and 11.2 ± 1.9 percent of necrosis; stromal vascular fraction cells had a higher rate of necrosis than adipocytes (p < 0.05). Among the stromal vascular fraction cells, 51.1 ± 3.7 percent expressed CD90/CD45, 7.5 ± 1.0 percent expressed CD105/CD45, and 26.4 ± 3.8 percent expressed CD34/CD31. CD34/CD31 adipose-derived stem cells had lower rates of apoptosis and necrosis compared with CD105/CD45 adipose-derived stem cells (p < 0.05). CONCLUSIONS: Adipose-derived stem cells had a higher rate of apoptosis and necrosis than adipocytes. However, the extent of apoptosis and necrosis was significantly different among adipose-derived stem cell subpopulations.

High-resolution array CGH defines critical regions and candidate genes for microcephaly, abnormalities of the corpus callosum, and seizure phenotypes in patients with microdeletions of 1q43q44.

Microdeletions of 1q43q44 result in a recognizable clinical disorder characterized by moderate to severe intellectual disability (ID) with limited or no expressive speech, characteristic facial features, hand and foot anomalies, microcephaly (MIC), abnormalities (agenesis/hypogenesis) of the corpus callosum (ACC), and seizures (SZR). Critical regions have been proposed for some of the more prominent features of this disorder such as MIC and ACC, yet conflicting data have prevented precise determination of the causative genes. In this study, the largest of pure interstitial and terminal deletions of 1q43q44 to date, we characterized 22 individuals by high-resolution oligonucleotide microarray-based comparative genomic hybridization. We propose critical regions and candidate genes for the MIC, ACC, and SZR phenotypes associated with this microdeletion syndrome. Three cases with MIC had small overlapping or intragenic deletions of AKT3, an isoform of the protein kinase B family. The deletion of only AKT3 in two cases implicates haploinsufficiency of this gene in the MIC phenotype. Likewise, based on the smallest region of overlap among the affected individuals, we suggest a critical region for ACC that contains ZNF238, a transcriptional and chromatin regulator highly expressed in the developing and adult brain. Finally, we describe a critical region for the SZR phenotype which contains three genes (FAM36A, C1ORF199, and HNRNPU). Although ~90% of cases in this study and in the literature fit these proposed models, the existence of phenotypic variability suggests other mechanisms such as variable expressivity, incomplete penetrance, position effects, or multigenic factors could account for additional complexity in some cases.

Nitrite attenuates ischemia-reperfusion-induced microcirculatory alterations and mitochondrial dysfunction in the microvasculature of skeletal muscle.

BACKGROUND: Recently, nitrite has been rediscovered as a physiologically relevant storage reservoir of nitric oxide in blood and it can readily be converted to nitric oxide under hypoxic and acidic conditions. In this study, the authors evaluated the therapeutic efficacy of nitrite on reperfusion-induced microcirculatory alterations and mitochondrial dysfunction in the microvasculature of skeletal muscle. METHODS: The authors used a vascular pedicle isolated rat cremaster model that underwent 4 hours of warm ischemia followed by 2 hours or 17 hours of reperfusion. At 5 minutes before reperfusion, normal saline, sodium nitrite (0.20 µM/minute/kg), or nitrite mixed with 2-(4-carboxyphenyl)-4,5-dihydro-4,4,5,5-tetramethylimidazoline-3-oxide-1-oxyl (potassium salt) (0.2 mg/minute/kg) was infused into the microcirculation of ischemic cremaster by means of intraarterial infusion. Ischemia-reperfusion-induced microcirculatory alterations were measured after 2 hours of reperfusion. Microvasculature of the cremaster muscle including the vascular pedicle was harvested to determine the mitochondrial dysfunction. The blood concentration of methemoglobin was also measured to determine the toxicity of nitrite. RESULTS: The authors found that nitrite significantly attenuated ischemia-reperfusion-induced vasoconstriction, arteriole stagnation, and capillary no-reflow in the early phase of reperfusion and the depolarization of mitochondrial membrane potential and cytochrome c release in the late phase of reperfusion. Nitrite-induced protection was significantly blocked by a nitric oxide scavenger (potassium salt). The methemoglobin results showed that the doses of nitrite we used in the present study were safe. CONCLUSION: The supplementation of a low dose of nitrite, directly into the microcirculation of ischemic muscle through local intraarterial infusion, significantly attenuated ischemia-reperfusion-induced microcirculatory alterations in vivo and mitochondrial dysfunction in vitro in the microvasculature of skeletal muscle.

Optimal fluid resuscitation: timing and composition of intravenous fluids.

BACKGROUND: Recent data suggest that the timing of fluid resuscitation and the type of fluid used to treat hemorrhagic shock contribute to the inflammatory response as well as cell death. METHODS: Rats were bled of 40% of their total blood volume and then resuscitated in either early or delayed fashion. Treatment was assigned randomly and consisted of lactated Ringer's solution, normal saline, bicarbonate Ringer's solution, hypertonic saline, or no resuscitation. The first four groups were subdivided into early and late resuscitation. After a 5-h observation period, lung and liver samples were evaluated for apoptosis, and blood was collected for measurements of the cytokines interleukin (IL)-6, IL-10, and IL-1beta. RESULTS: The rats that were not resuscitated had significantly more apoptosis in liver tissue. In the lung, bicarbonate Ringer's solution, when given early, was associated with significantly less apoptosis. Non-resuscitated rats had significantly higher IL-6 concentrations than all other groups. Animals receiving hypertonic saline early had significantly higher IL-6 concentrations than those given any other fluid. The concentration of IL-1beta was significantly higher in the non-resuscitated rats than in those receiving bicarbonate Ringer's, lactated Ringer's, or normal saline for early resuscitation. Interleukin-10 was elevated significantly in non-resuscitated rats. CONCLUSIONS: Cellular destruction and a pro-inflammatory response follow hemorrhagic shock. Early resuscitation with isotonic crystalloid fluids decreases these responses.

Extended follow-up of a randomized controlled trial of the Lidcombe Program of Early Stuttering Intervention.

BACKGROUND: In the Lidcombe Program of Early Stuttering Intervention, parents present verbal contingencies for stutter-free and stuttered speech in everyday situations. A previous randomized controlled trial of the programme with preschool-age children from 2005, conducted in two public speech clinics in New Zealand, showed that the odds of attaining clinically minimal levels of stuttering 9 months after randomization were more than seven times greater for the treatment group than for the control group. AIMS: To follow up the children in the trial to determine extended long-term outcomes of the programme. METHODS & PROCEDURES: An experienced speech-language therapist who was not involved in the original trial talked with the children on the telephone, audio recording the conversations using a telephone recording jack. Parental reports were gathered in addition to the children's speech samples in order to obtain a balance of objective data and reports from a wide range of situations. OUTCOMES & RESULTS: At the time of this follow-up, the children were aged 7-12 years, with a mean of 5 years post-randomization in the 2005 trial. Twenty of the 29 children in the treatment arm and eight of the 25 children in the control (no treatment) arm were able to be contacted. Of the children in the treatment group, one (5%) failed to complete treatment and 19 had completed treatment successfully and had zero or near-zero frequency of stuttering. Three of the children (16%) who had completed treatment successfully had relapsed after 2 or more years of speech that was below 1% syllables stuttered. Meaningful comparison with the control group was not possible because an insufficient number of control children were located and some of them received treatment after completing the trial. CONCLUSIONS & IMPLICATIONS: The majority of preschool children are able to complete the Lidcombe Program successfully and remain below 1% syllables stuttered for a number of years. However, a minority of children do relapse and will require their parents to reinstate the treatment procedures.

Effects of altered auditory feedback (AAF) on stuttering frequency during monologue speech production.

UNLABELLED: The present study investigated the immediate effects of eight altered auditory feedback (AAF) parameters on stuttering frequency during monologue speech production on two occasions. One of the modern commercially available portable anti-stuttering devices, "The Pocket Speech Lab" (Casa Futura Technologies) was used in the study to produce the auditory feedback alterations. Six types of combined delayed auditory feedback (DAF) and frequency shifted auditory feedback (FAF) and two types of DAF alone were tested for eight participants aged 16-55 years, with stuttering severity ranging from mild to severe. The present study found that AAF is an effective means to reduce stuttering frequency during monologue speech production. All eight AAF experimental conditions reduced stuttering frequency, however, there was substantial variability in the stuttering reduction effect across experimental conditions and across participants. There was also instability in stuttering reduction across the two testing sessions. On average, a 75 ms time delay on its own and a combination of the 75 ms time delay and a half octave downward frequency shift were found to be more effective than other combinations of AAF parameters that were investigated. EDUCATIONAL OBJECTIVES: After reading this paper, the reader should be able to (1) summarize the research investigating the effect of altered auditory feedback on stuttering frequency during monologue speech production; (2) describe the stuttering reduction effect of the eight parameters of AAF tested during monologue speech production; and (3) discuss the possible clinical implications of the use of AAF for stuttering treatment.

Recombinant activated protein C induces dose-dependent changes in inflammatory mediators, tissue damage, and apoptosis in in vivo rat model of sepsis.

BACKGROUND: Sepsis is the tenth leading cause of death in the U.S. and creates a $16.7 billion burden on the healthcare system every year. Sepsis is characterized by a severe uncontrolled inflammatory response to the infection. Various cells and mediators are activated, and the result is a complex interaction between the inflammation and coagulation cascades leading to capillary leakage and end-organ ischemia. Current therapeutic strategies, such as recombinant human activated protein C, focus on this interplay. However, this drug's precise mechanism of action is not well understood. The aim of this study was to assess cytokine production, tissue damage, and apoptosis in a rat model of sepsis in response to various doses of this drug. METHODS: Sprague-Dawley rats were divided into eight groups, including negative control, sham, sepsis only, and five treatment groups. The sepsis and treatment groups were given Escherichia coli. Each of the treatment groups received a different dose of recombinant activated protein C to complete 30-min or 270-min infusion times from the onset of sepsis. Serum and tissue samples were collected. Interleukin (IL)-6 concentrations were measured, and serum malondialdehyde (MDA) concentrations were determined to assess generalized tissue damage. Apoptosis in the lung was evaluated using a semi-quantitative ligation-mediated polymerase chain reaction assay. RESULTS: The physiologic effects of recombinant activated protein C are dose dependent and determined by the duration of infusion. Higher doses of the drug were associated with less inflammation, apoptosis, and generalized tissue damage. Sepsis increased the mean concentration of MDA (2.1 vs. 10.9 pmol/mg of protein) and IL-6 (0 vs. 10,763 pg/mL) compared with sham-treated animals, as well as the magnitude of apoptosis in lung (2,037 vs. 8,709 pixels) (all p < 0.05). Infusion of recombinant activated protein C attenuated these responses in a dose-response manner. Interleukin-6 and MDA concentrations were increased by lower-dose therapy, but attenuated significantly by the higher-dose infusion at 5 mg/kg/h. Apoptosis was attenuated by both the lower and the higher dose, but more so with the higher dose. CONCLUSIONS: These data can assist in establishing an optimal dose and infusion time of this drug for extrapolation to therapy of human beings. The goal now is to elucidate these findings further so that the maximum benefit of the drug may be achieved with the least possible harmful effects.