Quantitative functional imaging of the pigeon brain: implications for the evolution of avian powered flight.

The evolution of flight is a rare event in vertebrate history, and one that demands functional integration across multiple anatomical/physiological systems. The neuroanatomical basis for such integration and the role that brain evolution assumes in behavioural transformations remain poorly understood. We make progress by (i) generating a positron emission tomography (PET)-based map of brain activity for pigeons during rest and flight, (ii) using these maps in a functional analysis of the brain during flight, and (iii) interpreting these data within a macroevolutionary context shaped by non-avian dinosaurs. Although neural activity is generally conserved from rest to flight, we found significant increases in the cerebellum as a whole and optic flow pathways. Conserved activity suggests processing of self-movement and image stabilization are critical when a bird takes to the air, while increased visual and cerebellar activity reflects the importance of integrating multimodal sensory information for flight-related movements. A derived cerebellar capability likely arose at the base of maniraptoran dinosaurs, where volumetric expansion and possible folding directly preceded paravian flight. These data represent an important step toward establishing how the brain of modern birds supports their unique behavioural repertoire and provide novel insights into the neurobiology of the bird-like dinosaurs that first achieved powered flight.

A novel method for in silico assessment of Methionine oxidation risk in monoclonal antibodies: Improvement over the 2-shell model.

Over the past decade, therapeutic monoclonal antibodies (mAbs) have established their role as valuable agents in the treatment of various diseases ranging from cancers to infectious, cardiovascular and autoimmune diseases. Reactive groups of the amino acids within these proteins make them susceptible to many kinds of chemical modifications during manufacturing, storage and in vivo circulation. Among these reactions, the oxidation of methionine residues to their sulfoxide form is a commonly observed chemical modification in mAbs. When the oxidized methionine is in the complementarity-determining region (CDR), this modification can affect antigen binding and thus abrogate biological activity. For these reasons, it is essential to identify oxidation liabilities during the antibody discovery and development phases. Here, we present an in silico method, based on protein modeling and molecular dynamics simulations, to predict the oxidation-liable residues in the variable region of therapeutic antibodies. Previous studies have used the 2-shell water coordination number descriptor (WCN) to identify methionine residues susceptible to oxidation. Although the WCN descriptor successfully predicted oxidation liabilities when the residue was solvent exposed, the method was much less accurate for partially buried methionine residues. Consequently, we introduce a new descriptor, WCN-OH, that improves the accuracy of prediction of methionine oxidation susceptibility by extending the theoretical framework of the water coordination number to incorporate the effects of polar amino acids side chains in close proximity to the methionine of interest.

PET Imaging of Leg Arteries for Determining the Input Function in PET/MRI Brain Studies Using a Compact, MRI-compatible PET System.

In this study, we used a compact, high-resolution, and MRI-compatible PET camera (VersaPET) to assess the feasibility of measuring the image-derived input function (IDIF) from arteries in the leg with the ultimate goal of enabling fully quantitative PET brain imaging without blood sampling. We used this approach in five 18F-FDG PET/MRI brain studies in which the input function was also acquired using the gold standard of serial arterial blood sampling. After accounting for partial volume, dispersion, and calibration effects, we compared the metabolic rates of glucose (MRglu) quantified from VersaPET IDIFs in 80 brain regions to those using the gold standard and achieved a bias and variability of <5% which is within the range of reported test-retest values for this type of study. We also achieved a strong linear relationship (R2 >0.97) against the gold standard across regions. The results of this preliminary study are promising and support further studies to optimize methods, validate in a larger cohort, and extend to the modeling of other radiotracers.

Deep learning-based synthetic CT generation for MR-only radiotherapy of prostate cancer patients with 0.35T MRI linear accelerator.

PURPOSE: To develop a deep learning model to generate synthetic CT for MR-only radiotherapy of prostate cancer patients treated with 0.35 T MRI linear accelerator. MATERIALS AND METHODS: A U-NET convolutional neural network was developed to translate 0.35 T TRUFI MRI into electron density map using a novel cost function equalizing the contribution of various tissue types including fat, muscle, bone, and background air in training. The impact of training time, dataset size, image standardization, and data augmentation approaches was also quantified. Mean absolute error (MAE) between synthetic and planning CTs was calculated to measure the goodness of the model. RESULTS: With 20 patients in training, our U-NET model has the potential to generate synthetic CT with a MAE of about 29.68 ± 4.41, 16.34 ± 2.67, 23.36 ± 2.85, and 105.90 ± 22.80 HU over the entire body, fat, muscle, and bone tissues, respectively. As expected, we found that the number of patients used for training and MAE are nonlinearly correlated. Data augmentation and our proposed loss function were effective to improve MAE by ~9% and ~18% in bony voxels, respectively. Increasing the training time and image standardization did not improve the accuracy of the model. CONCLUSION: A U-NET model has been developed and tested numerically to generate synthetic CT from 0.35T TRUFI MRI for MR-only radiotherapy of prostate cancer patients. Dosimetric evaluation using a large and independent dataset warrants the validity of the proposed model and the actual number of patients needed for the safe usage of the model in routine clinical workflow.

Does utilization of an intubation safety checklist reduce omissions during simulated resuscitation scenarios: a multi-center randomized controlled trial.

OBJECTIVES: Checklists have been used to decrease adverse events associated with medical procedures. Simulation provides a safe setting in which to evaluate a new checklist. The objective of this study was to determine if the use of a novel peri-intubation checklist would decrease practitioners' rates of omission of tasks during simulated airway management scenarios. METHODS: Fifty-four emergency medicine (EM) practitioners from two academic centers were randomized to either their usual approach or use of our checklist, then completed three simulated airway management scenarios. A minimum of two assessors documented the number of tasks omitted and the time until definitive airway management. Discrepancies between assessors were resolved by single assessor video review. Participants also completed a post-simulation survey. RESULTS: The average percentage of omitted tasks over three scenarios was 45.7% in the control group (n = 25) and 13.5% in the checklist group (n = 29)-an absolute difference of 32.2% (95% CI 27.8, 36.6%). Time to definitive airway management was longer in the checklist group in the first two of three scenarios (difference of 110.0 s, 95% CI 55.0 to 167.0; 83.0 s, 95% CI 35.0 to 128.0; and 36.0 s, 95% CI -18.0 to 98.0 respectively). CONCLUSIONS: In this dual-center, randomized controlled trial, use of an airway checklist in a simulated setting significantly decreased the number of important airway tasks omitted by EM practitioners, but increased time to definitive airway management.

RéSUMé: OBJECTIFS: Des listes de contrôle ont été utilisées pour réduire les événements indésirables associés aux procédures médicales. La simulation offre un cadre sûr pour évaluer une nouvelle liste de contrôle. L'objectif de cette étude était de déterminer si l'utilisation d'une nouvelle liste de contrôle de péri-intubation permettrait de réduire les taux d'omission de tâches des praticiens lors de scénarios de gestion des voies aériennes simulés. MéTHODES: Cinquante-quatre praticiens de médecine d'urgence de deux centres universitaires ont été randomisés selon leur approche habituelle ou l'utilisation de notre liste de contrôle, puis ont réalisé trois scénarios de gestion des voies aériennes simulés. Un minimum de deux évaluateurs ont documenté le nombre de tâches omises et le délai avant la gestion définitive des voies respiratoires. Les divergences entre les évaluateurs ont été résolues par la revue vidéo d'un seul évaluateur. Les participants ont également rempli une enquête post-simulation. RéSULTATS: Le pourcentage moyen de tâches omises sur trois scénarios était de 45,7 % dans le groupe témoin (n = 25) et de 13,5 % dans le groupe liste de contrôle (n = 29) - une différence absolue de 32,2 % (IC à 95 %: 27,8 %, 36,6 %). Le délai de prise en charge définitive des voies respiratoires était plus long dans le groupe liste de contrôle dans les deux premiers des trois scénarios (différence de 110,0 s, IC à 95% : 55,0 à 167,0 ; 83,0 s, IC à 95 % : 35,0 à 128,0 ; et 36,0 s, IC à 95 % : -18,0 à 98,0 respectivement). CONCLUSIONS: Dans cet essai contrôlé randomisé à double centre, l'utilisation d'une liste de contrôle des voies respiratoires dans un environnement simulé a considérablement réduit le nombre de tâches importantes des voies respiratoires omises par les praticiens de médecine d'urgence, mais a prolongé le délai de prise en charge définitive des voies aérienne.

Cortical thickness and functional connectivity changes in Chinese chess experts.

BACKGROUND: Repeated practice to acquire expertise could result in the structural and functional changes in relevant brain circuits as a result of long-term potentiation, neurogenesis, glial genesis, and remodeling. PURPOSE: The goal of this study is to use surface-based morphology (SBM) to study cortical thickness differences in Chinese chess experts and novices, and to use regions of cortical thickness differences as seeds to guide a resting state connectivity analysis of the same population. METHODS: A raw public dataset from Huaxi MR Research Center consisting of 29 Chinese chess experts and 29 novices was used in this study, with both T1-weighted and resting state functional MRI. Surface based morphometry was performed on the T1 images with the Freesurfur pipeline, with a vertex significance threshold of p<0.05 and a cluster false discovery rate of α < 0.05. Regions with significant differences were used in a seed-based comparison of resting state functional connectivity carried out with Statistical Parameter Mapping (SPM) and the Connectivity Toolbox (CONN). Regions of connectivity differences within groups were computed with a voxel significance threshold of p<0.05 and a cluster false discovery rate of α < 0.01. RESULTS: Ten regions of the cortex of Chinese chess experts were found to be thinner than chess novices, including regions involved in visual processing, attention, working and episodic memory, and mental imagery, as well as several regions in the prefrontal cortex. There were no regions where experts' cortices were thicker than novices. Three of the thinner regions exhibited increased functional connectivity to distant brain regions in chess experts. CONCLUSIONS: Brain regions that are structurally affected by chess training are associated with processes that would likely have a high utility in chess expertise. Using a hierarchical control model, we hypothesize that the functional changes linked with some of these structural changes are related to the professionally trained chess players' ability to perceive and use contextual information, visuospatial perception, and outcome prediction in the domain of chess, all contributing to their exceptional performance.

Functional, anatomical and diffusion tensor MRI study of radiology expertise.

BACKGROUND: Repeated practice to acquire expertise could result in the structural and functional changes in relevant brain circuits as a result of long-term potentiation, neurogenesis, glial genesis, and remodeling. PURPOSE: The goal of this study is to use task fMRI to study the brain of expert radiologists performing a diagnosis task where a series of medical images were presented during fMRI acquisition for 12s and participants were asked to choose a diagnosis. Structural and diffusion-tensor MRI were also acquired. METHODS: Radiologists (N = 12, 11M, 38.2±10.3 years old) and non-radiologists (N = 17, 15M, 30.6±5.5 years old) were recruited with informed consent. Medical images were presented for 12 s and three multiple choices were displayed and the participants were asked to choose a diagnosis. fMRI, structural and diffusion-tensor MRI were acquired. fMRI analysis used FSL to determine differences in fMRI responses between groups. Voxel-wise analysis was performed to determine if subcortical volume, cortical thickness and fractional anisotropy differed between groups. Correction for multiple comparisons used false discovery rate. RESULTS: Radiologists showed overall lower task-related brain activation than non-radiologists. Radiologists showed significantly lower activation in the left lateral occipital cortex, left superior parietal lobule, occipital pole, right superior frontal and precentral gyri, lingual gyrus, and the left intraparietal sulcus (p<0.05). There were no significant differences between groups in cortical thickness, subcortical volume and fractional anisotropy (p>0.05). CONCLUSIONS: Radiologists and non-radiologists had no significant difference in structural metrics. However, in diagnosis tasks, radiologists showed markedly lower task-related brain activations overall as well as a number of high-order visual and non-visual brain regions than non-radiologists. Some brain circuits appear to be uniquely associated with differential-diagnosis paradigm expertise that are not involved in simpler object-recognition cases. Improved understanding of the brain circuitry involved in acquisition of expertise might be used to design optimal training paradigms.

Behavioral neuroimaging in birds using PET.

BACKGROUND: Birds comprise the most diverse group of terrestrial vertebrates. This success likely is related to the evolution of powered flight over 75 mya. Modern approaches for studying brain function, however, have yet to be fully adapted and applied to birds, especially as they relate to specific behaviors including flight. New method: We have developed a comprehensive set of in vivo experimental methods utilizing PET imaging with F-18 labeled fluorodeoxyglucose (FDG) to study regional changes in metabolism specifically related to flight, yet applicable to other behaviors as well. It incorporates approaches for selection of species, behavioral/imaging paradigm, animal preparation, radiotracer injection route, image quantification, and image analysis via an enhanced brain atlas. We also carried out preliminary modeling studies to better understand tracer kinetics. RESULTS: The methods were successful in identifying brain regions statistically associated with flight using only 8 animals. Peak brain uptake of FDG between birds and rodents is similar despite much higher blood glucose levels in birds. We also confirmed that brain uptake of FDG steadily decreases after the initial peak and provide evidence that it may be related to greater dephosphorylation of FDG phosphate than that observed in mammals. Comparison with existing methods: FDG PET has been used in only a few studies of the bird brain. We introduce a new species, more realistic flight behavior, paired (test/retest) design, and improved quantification and analysis approaches. CONCLUSIONS: The proposed imaging protocol is non-invasive yet sensitive to regional metabolic changes in the bird brain related to behavior.

Arabinosylation of recombinant human immunoglobulin-based protein therapeutics.

Protein glycosylation is arguably the paramount post-translational modification on recombinant glycoproteins, and highly cited in the literature for affecting the physiochemical properties and the efficacy of recombinant glycoprotein therapeutics. Glycosylation of human immunoglobulins follows a reasonably well-understood metabolic pathway, which gives rise to a diverse range of asparagine-linked (N-linked), or serine/threonine-linked (O-linked) glycans. In N-linked glycans, fucose levels have been shown to have an inverse relationship with the degree of antibody-dependent cell-mediated cytotoxicity, and high mannose levels have been implicated in potentially increasing immunogenicity and contributing to less favorable pharmacokinetic profiles. Here, we demonstrate a novel approach to potentially reduce the presence of high-mannose species in recombinant human immunoglobulin preparations, as well as facilitate an approximate 100% replacement of fucosylation with arabinosylation in Chinese hamster ovary cell culture through media supplementation with D-arabinose, an uncommonly used mammalian cell culture sugar substrate. The replacement of fucose with arabinose was very effective and practical to implement, since no cell line engineering or cellular adaptation strategies were required. Arabinosylated recombinant IgGs and the accompanying reduction in high mannose glycans, facilitated a reduction in dendritic cell uptake, increased FcγRIIIa signaling, and significantly increased the levels of ADCC. These aforementioned effects were without any adverse changes to various structural or functional attributes of multiple recombinant human antibodies and a bispecific DVD-Ig. Protein arabinosylation represents an expansion of the N-glycan code in mammalian expressed glycoproteins.

Identifying low-level sequence variants via next generation sequencing to aid stable CHO cell line screening.

Developing stable Chinese hamster ovary (CHO) cell lines for biotherapeutics is an irreversible process and therefore, key quality attributes, such as sequence variants, must be closely monitored during cell line development (CLD) to avoid delay in the developmental timeline, and more importantly, to assure product safety and efficacy. Sequence variants, defined as unintended amino acid substitution in recombinant protein primary structure, result from alteration at either the DNA or the protein level. Here, for the first time, we report the application of transcriptome sequencing (RNAseq) in an IgG1 monoclonal antibody (mAb) CLD campaign to detect, identify, and eliminate cell lines containing low-level point mutations in recombinant coding sequence. Among the top eleven mAb producers chosen from transfectant, clone or subclone stages, three of the cell lines contained either missense or nonsense point mutations at a low level of less than 2%. Subsequent LC/MS/MS characterization detected ∼3% sequence variants with an amino acid change from Ser to Leu at residue 117 in the heavy chain of transfectants 11 and 27. This substitution is consistent with the RNAseq finding of a C/T mutation located at 407 base pair (TCA→TTA) in the heavy chain coding sequence. Here we demonstrate that RNAseq is a rapid and highly sensitive method to identify low-level genetic mutation de novo corresponding to the amino acid substitution that elicits sequence variant(s). Its implementation in CLD constitutes an early and effective step in identifying desired CHO expression cell lines.

Cell culture media supplementation of uncommonly used sugars sucrose and tagatose for the targeted shifting of protein glycosylation profiles of recombinant protein therapeutics.

Protein glycosylation is an important post-translational modification toward the structure and function of recombinant therapeutics. The addition of oligosaccharides to recombinant proteins has been shown to greatly influence the overall physiochemical attributes of many proteins. It is for this reason that protein glycosylation is monitored by the developer of a recombinant protein therapeutic, and why protein glycosylation is typically considered a critical quality attribute. In this work, we highlight a systematic study toward the supplementation of sucrose and tagatose into cell culture media for the targeted modulation of protein glycosylation profiles on recombinant proteins. Both sugars were found to affect oligosaccharide maturation resulting in an increase in the percentage of high mannose N-glycan species, as well as a concomitant reduction in fucosylation. The latter effect was demonstrated to increase antibody-dependent cell-mediated cytotoxicity for a recombinant antibody. These aforementioned results were found to be reproducible at different scales, and across different Chinese hamster ovary cell lines. Through the selective supplementation of these described sugars, the targeted modulation of protein glycosylation profiles is demonstrated, as well as yet another tool in the cell culture toolbox for ensuring product comparability.

Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate.

BACKGROUND: Delayed splenic rupture is the Achilles' heel of nonoperative management (NOM) for blunt splenic injury (BSI). Early computed tomographic (CT) scanning for features suggesting high risk of nonoperative failure, splenic pseudoaneurysms (SPAs), and arterial extravasation (AE), in concert with the appropriate use of splenic arterial embolization (SAE) is a viable method to reduce rates of failure of NOM. We report our 12-ear experience with a protocol for mandatory repeat CT evaluation at 48 hours and selective SAE. METHODS: A retrospective cohort analysis was performed on all consecutive adult trauma patients with BSI between 1995 and 2012. We evaluated an early/control (1995-1999) and a present/intervention (2000-2012) cohort in which SAE became available and 48-hour CT scans were implemented. RESULTS: The study included 773 patients (157 early vs. 616 present) with BSI. The proportion of patients managed nonoperatively (53% vs. 77%, p < 0.01) and overall splenic salvage rate (46% vs. 77%, p < 0.01) were improved in the present cohort. Among patients selected for NOM, there was a significant improvement in the failure rate of NOM (12% vs. 0.6%, p < 0.01) as well as in the length of hospital stay (8 days vs. 6 days, p < 0.01). Delayed development of SPA and/or AE was detected in 6% of BSI in the present cohort and was distributed among all grades of injury. CONCLUSION: The delayed development of SPA and AE is not an entirely rare event following BSI. Reevaluation with CT at 48 hours following admission and the use of SAE significantly decrease the failure rate of NOM. LEVEL OF EVIDENCE: Therapeutic study, level III.

Comparison of the in vitro and in vivo stability of a succinimide intermediate observed on a therapeutic IgG1 molecule.

Deamidation of asparagine residues, a post-translational modification observed in proteins, is a common degradation pathway in monoclonal antibodies (mAbs). The kinetics of deamidation is influenced by primary sequence as well as secondary and tertiary folding. Analytical hydrophobic interaction chromatography (HIC) is used to evaluate hydrophobicity of candidate mAbs and uncover post-translational modifications. Using HIC, we discovered atypical heterogeneity in a highly hydrophobic molecule (mAb-1). Characterization of the different HIC fractions using LC/MS/MS revealed a stable succinimide intermediate species localized to an asparagine-glycine motif in the heavy chain binding region. The succinimide intermediate was stable in vitro at pH 7 and below and increased on storage at 25°C and 40°C. Biacore evaluation showed a decrease in binding affinity of the succinimide intermediate compared with the native asparagine molecule. In vivo studies of mAb-1 recovered from a pharmacokinetic study in cynomolgus monkeys revealed an unstable succinimide species and rapid conversion to aspartic/iso-aspartic acid. Mutation from asparagine to aspartic acid led to little loss in affinity. This study illustrates the importance of evaluating modifications of therapeutic mAbs both in vitro and in serum, the intended environment of the molecule. Potential mechanisms that stabilize the succinimide intermediate in vitro are discussed.

MR Spectroscopic Imaging of Peripheral Zone in Prostate Cancer Using a 3T MRI Scanner: Endorectal versus External Phased Array Coils.

Magnetic resonance spectroscopic imaging (MRSI) detects alterations in major prostate metabolites, such as citrate (Cit), creatine (Cr), and choline (Ch). We evaluated the sensitivity and accuracy of three-dimensional MRSI of prostate using an endorectal compared to an external phased array "receive" coil on a 3T MRI scanner. Eighteen patients with prostate cancer (PCa) who underwent endorectal MR imaging and proton (1H) MRSI were included in this study. Immediately after the endorectal MRSI scan, the PCa patients were scanned with the external phased array coil. The endorectal coil-detected metabolite ratio [(Ch+Cr)/Cit] was significantly higher in cancer locations (1.667 ± 0.663) compared to non-cancer locations (0.978 ± 0.420) (P < 0.001). Similarly, for the external phased array, the ratio was significantly higher in cancer locations (1.070 ± 0.525) compared to non-cancer locations (0.521 ± 0.310) (P < 0.001). The sensitivity and accuracy of cancer detection were 81% and 78% using the endorectal 'receive' coil, and 69% and 75%, respectively using the external phased array 'receive' coil.

A high throughput capillary electrophoresis method to obtain pharmacokinetics and quality attributes of a therapeutic molecule in circulation.

Therapeutic proteins circulating in blood are in a highly crowded, redox environment at high temperatures of ~37°C. These molecules circulate in the presence of enzymes and other serum proteins making it difficult to predict from in vitro studies the stability, aggregation or pharmacokinetics of a therapeutic protein in vivo. Here, we describe use of a high throughput capillary electrophoresis based microfluidic device (LabChip GXII) to obtain pharmacokinetics (PK) of a fluorescently labeled human mAb directly from serum. The non-labeled and labeled mAbs were evaluated in single dose rat PK studies using a traditional ELISA method or LabChip GXII, respectively. The fluorescent dye did not significantly alter clearance of this particular mAb, and PK parameters were comparable for labeled and unlabeled molecules. Further, from the CE profile we concluded that the mAb was resistant to fragmentation or aggregation during circulation. In a follow-up experiment, dimers were generated from the mAb using photo-induced cross-linking of unmodified proteins (PICUP) and labeled with the same fluorophore. The extent of dimerization was incomplete and some monomer and higher molecular weight species were found in the preparation. In rat PK studies, the serum concentration-time profile of the three entities present in the dimer preparation could be followed simultaneously with the GXII technology. While further studies are warranted, we believe this method could be adapted to obtain PK of different forms of antibodies (oxidized, deamidated or various glycosylated species) and other proteins.

Increased serum clearance of oligomannose species present on a human IgG1 molecule.

The role of Fc glycans on clearance of IgG molecule has been examined by various groups in experiments where specific glycans have been enriched or the entire spectrum of glycans was studied after administration in pre-clinical or clinical pharmacokinetic (PK) studies. The overall conclusions from these studies are inconsistent, which may result from differences in antibody structure or experimental design. In the present study a well-characterized recombinant monoclonal IgG1 molecule (mAb-1) was analyzed from serum samples obtained from a human PK study. mAb-1 was recovered from serum using its ligand cross-linked to Sepharose beads. The overall purity and recovery of all isoforms were carefully evaluated using a variety of methods. Glycans were then enzymatically cleaved, labeled using 2-aminobenzamide and analyzed by normal phase high performance liquid chromatography. The assays for recovering mAb-1 from serum and subsequent glycan analysis were rigorously qualified at a lower limit of quantitation of 15 µg/mL, thus permitting analysis to day 14 of the clinical PK study. Eight glycans were monitored and classified into two groups: (1) the oligomannose type structures (M5, M6 and M7) and (2) fucosylated biantennary oligosaccharides (FBO) structures (NGA2F, NA1F, NA2F, NA1F-GlcNAc and NGA2F-GlcNAc). We observed that the oligomannose species were cleared at a much faster rate (40%) than FBOs and conclude that high mannose species should be carefully monitored and controlled as they may affect PK of the therapeutic; they should thus be considered an important quality attribute. These observations were only possible through the application of rigorous analytical methods that we believe will need to be employed when comparing innovator and biosimilar molecules.

Pulmonary embolism.

Pulmonary embolism (PE) remains one of the most challenging medical diseases in the emergency department. PE is a potentially life threatening diagnosis that is seen in patients with chest pain and/or dyspnea but can span the clinical spectrum of medical presentations. In addition, it does not have any particular clinical feature, laboratory test, or diagnostic modality that can independently and confidently exclude its possibility. This article offers a review of PE in the emergency department. It emphasizes the appropriate determination of pretest probability, the approach to diagnosis and management, and special considerations related to pregnancy and radiation exposure.

Additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department.

OBJECTIVE: To measure the predictive value of nuclear medicine studies (cerebrospinal fluid [CSF] shuntograms) and radiographic studies (computed tomographic [CT] scans) in a cohort of children undergoing evaluation for suspected shunt obstruction in a tertiary care pediatric emergency department (ED). METHODS: A retrospective chart review was conducted on patients younger than 18 years who presented to the pediatric ED of the Children's Hospital of Western Ontario and had both CT of the head and a CSF shuntogram ordered by the attending pediatric emergency medicine physician between December 1998 and April 2003 because of suspected shunt obstruction. RESULTS: A total of 69 patients were evaluated for suspected shunt obstruction in the ED during this period with both a CT and a CSF shuntogram. Twenty-seven patients (39.1%) subsequently required corrective surgery for suspected shunt obstruction that was confirmed intraoperatively. The CT scans showed abnormalities suggestive of CSF shunt obstruction in 21 of the patients who required surgery (sensitivity, 77.8%; negative predictive value, 82.4%), whereas the CSF shuntograms showed abnormalities suggestive of CSF obstruction in 25 of the patients who required surgery (sensitivity, 92.6%; negative predictive value, 92.6%). The CT scans and the shuntograms combined revealed abnormalities suggestive of CSF shunt obstruction in 26 of the 27 patients who required surgery (sensitivity, 96.3%; negative predictive value, 97.4%). CONCLUSIONS: Over one third of pediatric ED patients evaluated with CT and CSF shuntograms required surgical management. Sensitivity was increased with CT and CSF shuntogram compared with CT alone. Prospective studies are required to assess the use of radiographic and nuclear medicine tests for the shunt evaluation in conjunction with the development of a clinical prediction rule for the pediatric emergency physician.

Elevated cleavage of human immunoglobulin gamma molecules containing a lambda light chain mediated by iron and histidine.

Monoclonal antibodies in liquid formulation undergo nonenzymatic hydrolysis when stored at 5 degrees C for extended periods. This hydrolysis is enhanced at extreme pH and high temperature. In this study we discover that iron in the presence of histidine also enhanced cleavage of human immunoglobulin gamma (IgG) molecules containing a lambda light chain when incubated at 40 degrees C. The level of cleavage was concentration dependent on both iron and histidine levels. Enhanced cleavage with iron and histidine was not observed on IgG molecules containing a kappa light chain. Using CE-SDS to quantify levels of Fab+Fc, the Fab arm, and free light chain (LC) and heavy chain (HC) fragments, we show that cleavage resulted in elevated levels of free light and heavy chain fragments. Using MS we find elevated scission between residues E/C on the LC resulting in LC fragment 1-215. We also observed enhanced cleavage between S/C residues of the HC resulting in HC fragment 1-217. The corresponding Fab+Fc fragment beginning with cys-218 was not found. Instead, we find elevation of a Fab+Fc fragment that began with aspartic acid (cleavage between C/D). Further studies to understand how iron and histidine enhance cleavage of lambda light chain IgG molecules are ongoing.

A new technique to anchor stents for exact placement in ostial stenoses: the stent tail wire or Szabo technique.

This report describes a technique for correct positioning of a stent in an ostial stenosis by using a second wire passed through the last cell of a stent. The anchor wire technique, first described by Szabo et al. [Szabo S, Abramowitz B, Vaitkus PT. Am J Cardiol 2005;96:212H], will facilitate precise ostial stent placement and eliminate errors of positioning inside or outside the ostial narrowing.