Utility of frozen section in pediatric and adolescent malignant ovarian nonseminomatous germ cell tumors: A report from the children's oncology group.

PURPOSE: In adult women, most malignant ovarian tumors are epithelial in origin. The use of intra-operative frozen section to distinguish between benign and malignant histology is reliable in guiding operative decision-making to determine the extent of surgical staging required. Pediatric and adolescent patients with ovarian masses have a much different spectrum of pathology with most tumors arising from germ cell precursors. This review was undertaken to assess the concordance between the intra-operative frozen section and the final diagnosis as an aid to guide extent of surgical staging in a group of pediatric and adolescent patients with malignant ovarian germ cell tumors. METHODS: Records of patients aged 0 to 20 years with malignant ovarian germ cell tumors enrolled on Children's Oncology Group study AGCT0132 were reviewed. Pathology reports from patients who had both intra-operative frozen section diagnosis and final paraffin section diagnosis were compared using descriptive statistics. By inclusion criteria for the study, all patients had a final diagnosis of malignancy with required yolk sac tumor, choriocarcinoma or embryonal carcinoma histology. Available central review of pathology final paraffin section slides were compared with final institution pathology reports. RESULTS: Of 131 eligible patients with ovarian germ cell tumors, 60 (45.8%) had both intra-operative frozen section and final paraffin section diagnoses available. Intra-operative frozen section diagnoses were classified as: incorrect diagnosis of benign tumor (13.3%), confirmation of malignancy (61.7%), immature teratoma (16.7%), germ cell tumor not otherwise specified (5%) and no diagnosis provided (3.3%). Intra-operative frozen section was incorrect in 23 of 60 (38.3%) patients evaluated. Central pathology review was concordant with the final institution pathology diagnosis in 76.3% of patients. Central pathology review identified additional germ cell tumor components in 23.7% of patients. CONCLUSIONS: In pediatric and adolescent patients with a confirmed final diagnosis of ovarian germ cell malignancy, intra-operative frozen section diagnosis is not reliable to inform the extent of surgical staging required. Central review by an expert germ cell tumor pathologist provides important additional information to guide therapy.

Multiplexed identification, quantification and genotyping of infectious agents using a semiconductor biochip.

The emergence of pathogens resistant to existing antimicrobial drugs is a growing worldwide health crisis that threatens a return to the pre-antibiotic era. To decrease the overuse of antibiotics, molecular diagnostics systems are needed that can rapidly identify pathogens in a clinical sample and determine the presence of mutations that confer drug resistance at the point of care. We developed a fully integrated, miniaturized semiconductor biochip and closed-tube detection chemistry that performs multiplex nucleic acid amplification and sequence analysis. The approach had a high dynamic range of quantification of microbial load and was able to perform comprehensive mutation analysis on up to 1,000 sequences or strands simultaneously in <2 h. We detected and quantified multiple DNA and RNA respiratory viruses in clinical samples with complete concordance to a commercially available test. We also identified 54 drug-resistance-associated mutations that were present in six genes of Mycobacterium tuberculosis, all of which were confirmed by next-generation sequencing.

Interrogation of gossypol therapy in glioblastoma implementing cell line and patient-derived tumour models.

BACKGROUND: Glioblastoma (GBM), being a highly vascularised and locally invasive tumour, is an attractive target for anti-angiogenic and anti-invasive therapies. The GBM/endothelial cell response to gossypol/temozolomide (TMZ) treatment was investigated with a particular aim to assess treatment effects on cancer hallmarks. METHODS: Cell viability, endothelial tube formation and GBM tumour cell invasion were variously assessed following combined treatment in vitro. The U87MG-luc2 subcutaneous xenograft model was used to investigate therapeutic response in vivo. Viable tumour response to treatment was interrogated using immunohistochemistry. Combined treatment protocols were also tested in primary GBM patient-derived cultures. RESULTS: An endothelial/GBM cell viability inhibitory effect, as well as an anti-angiogenic and anti-invasive response, to combined treatment have been demonstrated in vitro. A significantly greater anti-proliferative (P=0.020, P=0.030), anti-angiogenic (P=0.040, P<0.0001) and pro-apoptotic (P=0.0083, P=0.0149) response was observed when combined treatment was compared with single gossypol/TMZ treatment response, respectively. GBM cell line and patient-specific response to gossypol/TMZ treatment was observed. CONCLUSIONS: Our results indicate that response to a combined gossypol/TMZ treatment is related to inhibition of tumour-associated angiogenesis, invasion and proliferation and warrants further investigation as a novel targeted GBM treatment strategy.

Haematology and biochemistry of warru (Petrogale lateralis MacDonnell Ranges race) in captivity and the wild.

OBJECTIVE: Use haematology, biochemistry and protein electrophoresis analyses to establish reference values for, and describe the health status of, wild and captive colonies of critically endangered warru (black-footed rock-wallaby: Petrogale lateralis MacDonnell Ranges race). METHODS: Blood samples were taken from warru in three wild colonies (Alalka, Kalka, New Well) in the A nangu Pitjantjatjara Yankunytjatjara Lands in north-west South Australia (SA) and from captive animals at Monarto Zoo, SA. General haematology, serum biochemistry and protein electrophoresis analyses were conducted and results used to establish reference ranges. For the parameters that are indicative of a population's health, comparisons among the study sites were completed using analysis of variance. RESULTS: General haematology results suggested that warru were not experiencing chronic anaemia and the protein electrophoresis values indicated that colonies were not suffering from population-wide disease. However, the lower superoxide dismutase, retinol, total carotenoids and ascorbic acid values for New Well warru suggested those animals had a lower plane of nutrition than those at Kalka and Alalka. Higher urea concentrations in New Well and Alalka warru could be a reflection of the absence of reliable free water at these sites. CONCLUSION: The results have implications for the management of in situ colonies, including potentially using supplementary feeding to improve nutrition, and suggested that these animals were not suffering from disease. The study presents the first blood reference values for P. lateralis and, potentially, a methodology for other threatened species recovery programs to follow to establish the health of their populations.

Cardiac ryanodine receptors control heart rate and rhythmicity in adult mice.

AIMS: The molecular mechanisms controlling heart function and rhythmicity are incompletely understood. While it is widely accepted that the type 2 ryanodine receptor (Ryr2) is the major Ca(2+) release channel in excitation-contraction coupling, the role of these channels in setting a consistent beating rate remains controversial. Gain-of-function RYR2 mutations in humans and genetically engineered mouse models are known to cause Ca(2+) leak, arrhythmias, and sudden cardiac death. Embryonic stem-cell derived cardiomyocytes lacking Ryr2 display slower beating rates, but no supporting in vivo evidence has been presented. The aim of the present study was to test the hypothesis that RYR2 loss-of-function would reduce heart rate and rhythmicity in vivo. METHODS AND RESULTS: We generated inducible, tissue-specific Ryr2 knockout mice with acute ∼50% loss of RYR2 protein in the heart but not in other tissues. Echocardiography, working heart perfusion, and in vivo ECG telemetry demonstrated that deletion of Ryr2 was sufficient to cause bradycardia and arrhythmia. Our results also show that cardiac Ryr2 knockout mice exhibit functional and structural hallmarks of heart failure, including sudden cardiac death. CONCLUSION: These results illustrate that the RYR2 channel plays an essential role in pacing heart rate. Moreover, we find that RYR2 loss-of-function can lead to fatal arrhythmias typically associated with gain-of-function mutations. Given that RYR2 levels can be reduced in pathological conditions, including heart failure and diabetic cardiomyopathy, we predict that RYR2 loss contributes to disease-associated bradycardia, arrhythmia, and sudden death.

Population pharmacokinetic analysis of the active product of dipyrone.

OBJECTIVE: Pharmacokinetics of 4-methyl-amino-antipyrine (MAA), the active metabolite of the nonsteroidal anti-inflammatory agent dipyrone, whose time course correlates to the therapeutic effect of the drug, are studied. STUDY DESIGN AND SETTING: 153 patients hospitalized in the Department of Medicine at the Hadassah University Hospital, Jerusalem, Israel. INTERVENTION: Patients receiving dipyrone for the treatment of fever or pain were asked to participate in the study. Pharmacokinetics and statistical analysis: Using the population approach based on a formerly developed experimental model, the relationships between pharmacokinetic parameters and demographic and physiological covariates are explored. RESULTS: The results of the analysis show considerable variability in pharmacokinetics across the study population, and a significant decrease in clearance with age. CONCLUSION: A population pharmacokinetic analysis of MAA, the active product of dipyrone, reveals that age is a significant predictor of MAA disposition. Covariates that measure hepatic and renal function do not appear to be good predictors of the rate of MAA disposition.

Remifentanil for endotracheal intubation in neonates: a randomised controlled trial.

OBJECTIVE: To evaluate the efficacy and safety of remifentanil as a premedication in neonates undergoing elective endotracheal intubation. DESIGN: A double-blind randomised controlled trial. SETTING: Tertiary care neonatal intensive care unit. PATIENTS: Haemodynamically stable term and preterm neonates requiring elective endotracheal intubation. INTERVENTIONS: Infants in the intervention arm received remifentanil (3 microg/kg) and normal saline placebo. The control group received fentanyl (2 microg/kg) and succinylcholine (2 mg/kg). Both groups also received atropine (20 microg/kg) as part of the premedication regime. MAIN OUTCOME MEASURES: The primary outcome was time to successful intubation. Secondary outcomes included time to return of spontaneous respirations, oxygen saturation, heart rate and blood pressure changes during the procedure, adverse events and a survey of intubation conditions. RESULTS: A total of 15 infants were randomised to each group. Baseline characteristics were similar in both groups. The median time to successful intubation was not statistically different (247 s in the remifentanil group vs 156 s in the fentanyl group, p=0.88). The intubation conditions were rated more favourably with fentanyl by the intubators. Although not statistically significant, chest wall rigidity was observed more commonly with remifentanil. CONCLUSIONS: Although remifentanil is comparable to fentanyl and succinylcholine in attenuating adverse physiologic responses during neonatal intubation, muscle rigidity is a concern at doses of 3 microg/kg. Further trials are required to evaluate ideal dosing regimens and combinations of agents for use with remifentanil in neonates.

Impaired probabilistic reversal learning in youths with mood and anxiety disorders.

BACKGROUND: From an affective neuroscience perspective, our understanding of psychiatric illness may be advanced by neuropsychological test paradigms probing emotional processes. Reversal learning is one such process, whereby subjects must first acquire stimulus/reward and stimulus/punishment associations through trial and error and then reverse them. We sought to determine the specificity of previously demonstrated reversal learning impairments in youths with bipolar disorder (BD) by now comparing BD youths to those with severe mood dysregulation (SMD), major depressive disorder (MDD), anxiety (ANX), and healthy controls. METHOD: We administered the probabilistic response reversal (PRR) task to 165 pediatric participants aged 7-17 years with BD (n=35), SMD (n=35), ANX (n=42), MDD (n=18) and normal controls (NC; n=35). Our primary analysis compared PRR performance across all five groups matched for age, sex and IQ. RESULTS: Compared to typically developing controls, probabilistic reversal learning was impaired in BD youths, with a trend in those with MDD (p=0.07). CONCLUSIONS: Our results suggest that reversal learning deficits are present in youths with BD and possibly those with MDD. Further work is necessary to elucidate the specificity of neural mechanisms underlying such behavioral deficits.

A longitudinal study of gastrointestinal diseases in individuals diagnosed with infantile autism as children.

BACKGROUND: A number of studies have indicated a link between gastrointestinal (GI) diseases and autism spectrum disorders. METHOD: The objective of this study was to compare the prevalence and types of GI diseases in a clinical sample of 118 individuals diagnosed as children with infantile autism (IA) with GI diseases in 336 matched controls from the general population, based on data from the nationwide Danish National Hospital Register (DNHR). The average observation time was 30.3 years (SD 0.4) (range 27-30 years), and mean age at the end of the observation period was 42.7 years (SD 7.7) (range between 27 and 57 years of age). RESULTS: Of the 118 individuals with IA, 97 (82.2%) had been in contact with a medical hospital (inpatient hospitalization or outpatient visits) during the observation period, compared with 312/336 (92.9%) in the control group (P= 0.001). A similar proportion of members from the case and comparison group had a diagnosis of any GI disease in the DNHR: 30.5% against 30.7%, but the nature of their diseases may be somewhat different. Only diseases of oral cavity were significantly associated with IA: 20.3% against 1.2%, P < 0.0001. Otherwise, specific GI diseases occurred with low frequency in both groups. CONCLUSION: Overall, no evidence was found that patients with IA were more likely than control persons without IA to have defined GI diseases during the 30.3-year observation period.

Psychiatric disorders in adults diagnosed as children with atypical autism. A case control study.

The prevalence and types of psychiatric disorders were studied in a clinical sample of 89 individuals with atypical autism (AA) first seen as children, and 258 matched controls from the general population using data from the nationwide Danish Psychiatric Central Register. The average observation time was 36.9 years, and mean age at follow-up 45.3 years. A total of 61 persons with AA (68.5%) had been in contact with psychiatric hospitals during the follow-up period, compared with 10.9% in the comparison group. A whole range of significantly elevated psychiatric disorders was found, so AA is not seen to be associated with any specific mental disorder. Schizophrenia spectrum disorders were the most commonly associated psychiatric disorders, diagnosed at least one time in 34.8% of the AA cases. Our findings underscore that it is important for clinicians working in adult psychiatric services to be aware that AA and a wide range of psychiatric disorders often co-exist.

Estimate of the annual economic impact of treatment of cranial cruciate ligament injury in dogs in the United States.

OBJECTIVE: To estimate the economic impact to veterinary clients for the medical and surgical treatment of rupture of the cranial cruciate ligament (RCCL) in dogs for the year 2003. DESIGN: Economic impact survey. SAMPLE POPULATION: 501 diplomates of the American College of Veterinary Surgeons (ACVS) indicating that their area of surgical emphasis was small animal orthopedic surgery or small animal general and orthopedic surgery and 4,000 veterinarians indicating to the AVMA that their professional area was small animal practice exclusive or mixed animal practice (at least 80% small animal). PROCEDURE: Veterinarians were surveyed concerning the cost for medical and surgical treatment of RCCL for 2003. The economic impact was calculated by multiplying the number of RCCL surgeries performed by the mean cost of surgery. This was added to the number of RCCL cases managed medically multiplied by the mean cost of medical management. This estimate for survey responders was extrapolated to the total number of veterinarians in the study population for the ACVS or AVMA. RESULTS: Estimates for the total cost of surgery were $171,730,134.72 and $1,020,167,907 for veterinarians in the ACVS and AVMA populations, respectively. The cost of medical management was $2,885,687.86 and $126,558,155.16 for veterinarians in the ACVS and AVMA populations, respectively. After combining the ACVS and AVMA populations, we estimated that owners spent $1.32 billion for the treatment of RCCL in the United States in 2003. CONCLUSIONS AND CLINICAL RELEVANCE: RCCL is a prevalent, costly injury. Results may motivate veterinary and consumer agencies to prioritize funding for a better understanding of the injury.

Bioactive IL7-diphtheria fusion toxin secreted by mammalian cells.

A number of targeted cytotoxic agents have been developed that selectively kill malignant or otherwise pathological cells. These engineered proteins consist of a potent cytotoxic element connected to a ligand domain that binds to specific molecules on the surface of the target cell. Several of these agents have shown promise in clinical trials and one is currently administered to patients. A significant technical obstacle that has impeded the development of some of these toxins is the difficulty of preparing certain recombinant proteins in properly folded forms. These fusion proteins have generally been produced in bacteria requiring them to be denatured and renatured in vitro. For some proteins this is an efficient process whereas for others it is not. We describe here a system to produce fusion toxins rapidly and efficiently by engineering mammalian cells to secrete them as properly folded molecules which can be purified in native form from cell culture medium. We have used this system to produce highly active preparations of DAB(389)-IL7, a molecule consisting of the catalytic and transmembrane domains of diphtheria toxin fused to interleukin 7. This system is generalizable and can be used to produce and evaluate rapidly fusion toxins incorporating novel or uncharacterized ligands.

Effect of MPC-11 myeloma and MPC-11 + IL-1 receptor antagonist treatment on mouse bone properties.

This study examines the effects of an IL-6-producing murine multiple myeloma cell line on trabecular and cortical mouse bone, and evaluates the efficacy of interleukin-1 receptor antagonist (IL-1ra) in mitigating bone destruction. Six-week-old BALB/c mice were assigned to two groups: normal controls and myeloma animals (5 x 10(7) MPC-11 cells on day 0). Myeloma animals were further assigned to three unique groups: MPC-11 only; MPC-11 treated with hyaluronic acid (HA); and MPC-11 + IL-1ra/HA (100 mg/kg). Disease development was assessed at 14 and 21 days via spleen, liver, and proximal tibia histology; histomorphometry at the femoral middiaphysis; and long bone composition and mechanical testing. Histologic analysis revealed marked myeloma infiltration into organs and bone marrow and gross bone resorption of the proximal tibia. IL-1ra tended to decrease bone resorption at the proximal tibia; however, it had no effect on quantitatively measured bone parameters. Whole femur and tibia, and tibial epiphysis, percent mineralization was decreased (3.0%, 2.9%, and 6.3%, respectively) in all MPC-11 groups. The presence of myeloma did not affect long bone stiffness, strength, or length over the 3 week study. The percent of the femoral endosteal perimeter showing excessive resorption ( approximately 60%) in the MPC-11 groups increased significantly after 21 days. MPC-11 cell presence caused no change in bone formation or morphology. Normal growth mechanisms were not impacted, as the bones lengthened and increased in size and mass despite the presence of myeloma. IL-1 does not appear to be a primary factor in in vivo bone destruction caused by the MPC-11 cell line. These findings reveal the stochastic nature of bone lesions in multiple myeloma and suggest that IL-1 is not a cytokine critical to this disease pathology.

Preexisting gastric carcinoid in a gastro-omental free flap.

The authors present a 72-year-old man with an extensive medical history including stage III squamous cell carcinoma of the right pyriform sinus diagnosed approximately 10 years before this report. They were asked to evaluate the patient for esophageal reconstruction after local radiation had led to benign stricture of his esophagus and subsequent development of a large, draining esophagocutaneous fistula. A gastro-omental free flap reconstruction of the esophagus and overlying skin defect was complicated by the intraoperative diagnosis of gastric carcinoid obtained from several polyps noticed on the gastric mucosa on routine inspection. This case report signifies the importance of close inspection of all free tissue transfers before interposition. Failure to do so could result in disastrous outcomes.

Administration of interleukin-7 after allogeneic bone marrow transplantation improves immune reconstitution without aggravating graft-versus-host disease.

Prolonged immunodeficiency after allogeneic bone marrow transplantation (BMT) causes significant morbidity and mortality from infection. This study examined in murine models the effects of interleukin-7 (IL-7) given to young and middle-aged (9-month-old) recipients of major histocompatibility complex (MHC)-matched or -mismatched allogeneic BMT. Although administration of IL-7 from day 0 to 14 after syngeneic BMT promoted lymphoid reconstitution, this regimen was ineffective after allogeneic BMT. However, IL-7 administration from day 14 (or 21) to 27 after allogeneic BMT accelerated restoration of the major lymphoid cell populations even in middle-aged recipients. This regimen significantly expanded donor-derived thymocytes and peripheral T cells, B-lineage cells in bone marrow and spleen, splenic natural killer (NK) cells, NK T cells, and monocytes and macrophages. Interestingly, although recipients treated with IL-7 had significant increases in CD4(+) and CD8(+) memory T-cell populations, increases in naive T cells were less profound. Most notable, however, were the observations that IL-7 treatment did not exacerbate graft-versus-host disease (GVHD) in recipients of an MHC-matched BMT, and would ameliorate GVHD in recipients of a MHC-mismatched BMT. Nonetheless, graft-versus-leukemia (GVL) activity (measured against 32Dp210 leukemia) remained intact. Although activated and memory CD4(+) and CD8(+) T cells normally express high levels of IL-7 receptor (IL-7R, CD127), activated and memory alloreactive donor-derived T cells from recipients of allogeneic BMT expressed little IL-7R. This might explain the failure of IL-7 administration to exacerbate GVHD. In conclusion, posttransplant IL-7 administration to recipients of an allogeneic BMT enhances lymphoid reconstitution without aggravating GVHD while preserving GVL.

Defining and delineating a duty to prognosticate.

Prognostication, the process of formulating and communicating a prognosis, is no longer considered by most physicians to be an essential task in caring for patients with serious illness. Because of this fact, it is not surprising to find that when physicians attempt to engage in prognostication, they do it poorly. What may be surprising to those outside the medical community is the extent to which professional norms have developed which actively discourage physicians from engaging in prognostication. This article explores the causes of this state of affairs and the justifications offered for it. The conclusion is reached that physicians have a professional responsibility to competently engage in prognostication based upon the doctrine of informed consent, and that a failure or refusal to do so has not only potential legal ramifications, but serious negative implications for many of the core issues in bioethics, such as the use of advance directives, palliative medicine, and medical futility.

Cytokines: IL-20 - a new effector in skin inflammation.

The newly discovered cytokine interleukin-20 (IL-20) is structurally related to IL-10, yet it appears to be an autocrine factor for keratinocytes that regulates their participation in inflammation.