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Ultrasmall gold nanoparticles (1.5 nm) were covalently conjugated with doxorubicin (AuDox) and AlexaFluor647 (AuAF647) to assess their biodistribution and their efficiency toward brain tumors (glioblastoma). A thorough characterization by transmission electron microscopy, small-angle X-ray scattering, and differential centrifugal sedimentation confirmed their uniform ultrasmall nature which makes them very mobile in the body. Each nanoparticle carried either 13 doxorubicin molecules (AuDox) or 2.7 AlexaFluor-647 molecules (AuAF647). The firm attachment of the ligands to the nanoparticles was demonstrated by their resilience to extensive washing, followed by centrifugation. The particles easily entered mammalian cells (HeLa, T98-G, brain endothelial cells, and human astrocytes) due to their small size. The intravenously delivered fluorescing AuAF647 nanoparticles crossed the blood-brain barrier with ∼23% accumulation in the brain tumor in an orthotopic U87 brain tumor model in nude mice. This was confirmed by elemental analysis (gold; inductively coupled plasma optical emission spectroscopy) in various organs. The doxorubicin-loaded AuDox nanoparticles inhibited brain tumor growth and prolonged animal survival without adverse side effects. Most of the nanoparticles (84%) had been excreted from the animal after 24 h, indicating a high mobility in the body.

The clinical need for bone adhesives as an alternative to osteosynthesis is evident. However, this is a challenging problem due to the moist environment in surgical sites with bone surfaces covered with blood and biomolecules like lipids or proteins. A nanoparticle-loaded hydrogel that is based on a freeze-dried powder of silica-coated calcium phosphate/carboxymethyl cellulose nanoparticles (CaP/CMC/SiO 2 ) and an aqueous solution of sodium alginate (2 wt%) was developed and optimized with respect to the gluing ability in air and in water. The final paste was crosslinked within about one minute by calcium ions released from the calcium phosphate nanoparticles and contained about 20 wt% nanoparticles and 80 wt% water. The mechanical properties of the hydrogel were determined by extensive rheological tests. The thixotropic pasty hydrogel can be applied with a syringe. The adhesion strength was about 84 kPa between moist bone fragments in air. The hydrogel kept fragments of cortical bone well connected for >3 months during complete submersion in water. Besides water, the material consists only of biocompatible and biodegradable components (calcium phosphate, CMC, alginate). It carries only a very low dose of these materials into the bone site (mainly calcium phosphate nanoparticles). In-vitro cell culture with hMSCs that differentiated to osteoblasts confirmed a good biocompatibility of the bone adhesive formulation., (© 2024. The Author(s).)

Background: Postoperative gastrointestinal dysfunction (POGD) remains a common morbidity after gastrointestinal surgery. POGD is associated with delayed hospital recovery, increased length of stay, poor patient satisfaction and experience, and increased economic hardship. The I-FEED scoring system was created by a group of experts to address the lack of a consistent objective definition of POGD. However, the I-FEED tool needs clinical validation before it can be adopted into clinical practice. The scope of this phase 1 Quality Improvement initiative involves the feasibility of implementing percussion into the nursing workflow without additional burden. Methods: All gastrointestinal/colorectal surgical unit registered nurses underwent comprehensive training in abdominal percussion. This involved understanding the technique, its application in postoperative gastrointestinal dysfunction assessment, and its integration into the existing nursing documentation in the Electronic Health Record (EHR). After six months of education and practice, a six-question survey was sent to all inpatient GI surgical unit nurses about incorporating the percussion assessment into their routine workflow and documentation. Results: Responses were received from 91% of day-shift nurses and 76% of night-shift registered nurses. Overall, 95% of the nurses were confident in completing the abdominal percussion during their daily assessment. Conclusion: Nurses' effective use of the I-FEED tool may help improve patient outcomes after surgery. The tool could also be an effective instrument for the early identification of postoperative gastrointestinal dysfunction (POGD) in surgical patients.

Among brain tumors, glioblastoma (GBM) is very challenging to treat as chemotherapeutic drugs can only penetrate the brain to a limited extent due to the blood-brain barrier (BBB). Nanoparticles can be an attractive solution for the treatment of GBM as they can transport drugs across the BBB into the tumor. In this study, normal and GBM organoids comprising six brain cell types were developed and applied to study the uptake, BBB penetration, distribution, and efficacy of fluorescent, ultrasmall gold nanoparticles (AuTio-Dox-AF647s) conjugated with doxorubicin (Dox) and AlexaFluor-647-cadaverine (AF647) by confocal laser scanning microscopy (CLSM), using a mixture of dissolved doxorubicin and fluorescent AF647 molecules as a control. It was shown that the nanoparticles could easily penetrate the BBB and were found in normal and GBM organoids, while the dissolved Dox and AF647 molecules alone were unable to penetrate the BBB. Flow cytometry showed a reduction in glioblastoma cells after treatment with AuTio-Dox nanoparticles, as well as a higher uptake of these nanoparticles by GBM cells in the GBM model compared to astrocytes in the normal cell organoids. In summary, our results show that ultrasmall gold nanoparticles can serve as suitable carriers for the delivery of drugs into organoids to study BBB function.

Introduction: During tissue repair or regeneration, several bioactive molecules are released and interact with each other and act as complex additives or inhibitors for tissue reconstruction. In this study, the bone-healing effects of the combination treatment with tumor necrosis factor-α (TNF-α) inhibition, vascular endothelial growth factor A (VEGF-A) and bone morphogenetic protein-7 (BMP-7) release by gene silencing, and gene transfection with calcium phosphate nanoparticles (CaP) in the rat femoral head was histologically, morphologically, and biochemically evaluated., Methods: A triple-functionalized paste of CaP carrying plasmid DNA encoding for BMP-7 and for VEGF), and siRNA against TNF-α was developed and denoted as CaP3mix. To compare the effects of 3mixCaP, CaP with plasmid DNA encoding BMP-7, VEGF, or siRNA encoding TNF-α was prepared and denoted as CaP/PEI/pBMP-7/SiO 2 , CaP/PEI/pVEGF/SiO 2 , or CaP/PEI/siRNA-TNF-α/SiO 2 , respectively. The bone healing in bone defects in the rat femoral head was investigated after 10 and 21 days of implantation., Results: The levels of bone formation-related markers OCN, Runx2, and SP7 increased at the protein and gene levels in 3mixCaP after 10 days, and 3mixCaP significantly accelerated bone healing compared with the other treatments after 21 days of implantation., Conclusion: The triple-functionalized CaP paste loading plasmid DNA encoding BMP-7 and VEGF and siRNA encoding TNF-α is a promising bioactive material for bone tissue repair., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Japanese Society for Regenerative Medicine. Production and hosting by Elsevier B.V.)

Superfluid helium nanodroplets are an ideal environment for the formation of metastable, self-organized dopant nanostructures. However, the presence of vortices often hinders their formation. Here, we demonstrate the generation of vortex-free helium nanodroplets and explore the size range in which they can be produced. From x-ray diffraction images of xenon-doped droplets, we identify that single compact structures, assigned to vortex-free aggregation, prevail up to 10^{8} atoms per droplet. This finding builds the basis for exploring the assembly of far-from-equilibrium nanostructures at low temperatures.

Most clinically applied cancer immunotherapies rely on the ability of CD8 + cytolytic T cells to directly recognize and kill tumour cells 1-3 . These strategies are limited by the emergence of major histocompatibility complex (MHC)-deficient tumour cells and the formation of an immunosuppressive tumour microenvironment 4-6 . The ability of CD4 + effector cells to contribute to antitumour immunity independently of CD8 + T cells is increasingly recognized, but strategies to unleash their full potential remain to be identified 7-10 . Here, we describe a mechanism whereby a small number of CD4 + T cells is sufficient to eradicate MHC-deficient tumours that escape direct CD8 + T cell targeting. The CD4 + effector T cells preferentially cluster at tumour invasive margins where they interact with MHC-II + CD11c + antigen-presenting cells. We show that T helper type 1 cell-directed CD4 + T cells and innate immune stimulation reprogramme the tumour-associated myeloid cell network towards interferon-activated antigen-presenting and iNOS-expressing tumouricidal effector phenotypes. Together, CD4 + T cells and tumouricidal myeloid cells orchestrate the induction of remote inflammatory cell death that indirectly eradicates interferon-unresponsive and MHC-deficient tumours. These results warrant the clinical exploitation of this ability of CD4 + T cells and innate immune stimulators in a strategy to complement the direct cytolytic activity of CD8 + T cells and natural killer cells and advance cancer immunotherapies., (© 2023. The Author(s).)

Hard dental tissue pathologies, such as caries, are conventionally managed through replacement by tooth-colored inert biomaterials. Tissue engineering provides novel treatment approaches to regenerate lost dental tissues based on bioactive materials and/or signaling molecules. While regeneration in the form of reparative dentin (osteo-dentin) is feasible, the recapitulation of the tubular microstructure of ortho-dentin and its special features is sidelined. This study characterized in vitro, and in vivo human EDTA-treated, freeze-dried dentin matrices (HTFD scaffolds) conditioned with calcium phosphate nanoparticles (NPs) bearing plasmids encoding dentinogenesis-inducing factors (pBMP2/NPs or pDMP1/NPs). The uptake and transfection efficiency of the synthesized NPs on dental pulp stem cells (DPSCs) increased in a concentration- and time-dependent manner, as evaluated qualitatively by confocal laser microscopy and transmission electron microscopy, and quantitatively by flow cytometry, while, in parallel, cell viability decreased. HTFD scaffolds conditioned with the optimal transfectability-to-viability concentration at 4 µg Ca/mL of each of the pBMP2/NPs or pDMP1/NPs preserved high levels of cell viability, evidenced by live/dead staining in vitro and caused no adverse reactions after implantation on C57BL6 mice in vivo. HTFD/NPs constructs induced rapid and pronounced odontogenic shift of the DPSCs, as evidenced by relevant gene expression patterns of RunX2, ALP, BGLAP, BMP-2, DMP-1, DSPP by real-time PCR, and acquirement of polarized meta-mitotic phenotype with cellular protrusions entering the dentinal tubules as visualized by scanning electron microscopy. Taken together, HTFD/NPs constitute a promising tool for customized reconstruction of the ortho-dentin/odontoblastic layer barrier and preservation of pulp vitality. STATEMENT OF SIGNIFICANCE: In clinical dentistry, the most common therapeutic approach for the reconstruction of hard dental tissue defects is the replacement by resin-based restorative materials. Even modern bioactive materials focus on reparative dentinogenesis, leading to amorphous dentin-bridge formation in proximity to the pulp. Therefore, the natural microarchitecture of tubular ortho-dentin is not recapitulated, and the sensory and defensive role of odontoblasts is sidelined. This study approaches the reconstruction at the dentin-pulp interface using a construct of human treated dentin (HTFD) scaffold and plasmid-carrying nanoparticles (NPs) encoding dentinogenic factors (DMP-1 or BMP-2) with excellent in vitro and in vivo properties. As a future perspective, the HTFD/NPs constructs could act as bio-fillings for personalized reconstruction of the dentin-pulp interface., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

The structure and dynamics of isolated nanosamples in free flight can be directly visualized via single-shot coherent diffractive imaging using the intense and short pulses of x-ray free-electron lasers. Wide-angle scattering images encode three-dimensional (3D) morphological information of the samples, but its retrieval remains a challenge. Up to now, effective 3D morphology reconstructions from single shots were only achieved via fitting with highly constrained models, requiring a priori knowledge about possible geometries. Here, we present a much more generic imaging approach. Relying on a model that allows for any sample morphology described by a convex polyhedron, we reconstruct wide-angle diffraction patterns from individual silver nanoparticles. In addition to known structural motives with high symmetries, we retrieve imperfect shapes and agglomerates that were not previously accessible. Our results open unexplored routes toward true 3D structure determination of single nanoparticles and, ultimately, 3D movies of ultrafast nanoscale dynamics.

Currently available COVID-19 vaccines include inactivated virus, live attenuated virus, mRNA-based, viral vectored and adjuvanted protein-subunit-based vaccines. All of them contain the spike glycoprotein as the main immunogen and result in reduced disease severity upon SARS-CoV-2 infection. While we and others have shown that mRNA-based vaccination reactivates pre-existing, cross-reactive immunity, the effect of vector vaccines in this regard is unknown. Here, we studied cellular and humoral responses in heterologous adenovirus-vector-based ChAdOx1 nCOV-19 (AZ; Vaxzeria, AstraZeneca) and mRNA-based BNT162b2 (BNT; Comirnaty, BioNTech/Pfizer) vaccination and compared it to a homologous BNT vaccination regimen. AZ primary vaccination did not lead to measurable reactivation of cross-reactive cellular and humoral immunity compared to BNT primary vaccination. Moreover, humoral immunity induced by primary vaccination with AZ displayed differences in linear spike peptide epitope coverage and a lack of anti-S2 IgG antibodies. Contrary to primary AZ vaccination, secondary vaccination with BNT reactivated pre-existing, cross-reactive immunity, comparable to homologous primary and secondary mRNA vaccination. While induced anti-S1 IgG antibody titers were higher after heterologous vaccination, induced CD4 + T cell responses were highest in homologous vaccinated. However, the overall TCR repertoire breadth was comparable between heterologous AZ-BNT-vaccinated and homologous BNT-BNT-vaccinated individuals, matching TCR repertoire breadths after SARS-CoV-2 infection, too. The reasons why AZ and BNT primary vaccination elicits different immune response patterns to essentially the same antigen, and the associated benefits and risks, need further investigation to inform vaccine and vaccination schedule development., Competing Interests: The authors UR, PH, ME, KS are employees, HW is the CEO of JPT. LL, LH, JB and AT are named on a filed patent application regarding the usage of CD3 downregulation as method for direct analysis of functional avidity of T cells and a patent application regarding the usage of iCope as method for the direct analysis of SARS-CoV-2 immune responses. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Henze, Braun, Meyer-Arndt, Jürchott, Schlotz, Michel, Grossegesse, Mangold, Dingeldey, Kruse, Holenya, Mages, Reimer, Eckey, Schnatbaum, Wenschuh, Timmermann, Klein, Nitsche, Giesecke-Thiel, Loyal and Thiel.)

Variants in RAC3, encoding a small GTPase RAC3 which is critical for the regulation of actin cytoskeleton and intracellular signal transduction, are associated with a rare neurodevelopmental disorder with structural brain anomalies and facial dysmorphism. We investigated a cohort of 10 unrelated participants presenting with global psychomotor delay, hypotonia, behavioural disturbances, stereotyped movements, dysmorphic features, seizures and musculoskeletal abnormalities. MRI of brain revealed a complex pattern of variable brain malformations, including callosal abnormalities, white matter thinning, grey matter heterotopia, polymicrogyria/dysgyria, brainstem anomalies and cerebellar dysplasia. These patients harboured eight distinct de novo RAC3 variants, including six novel variants (NM_005052.3): c.34G > C p.G12R, c.179G > A p.G60D, c.186_188delGGA p.E62del, c.187G > A p.D63N, c.191A > G p.Y64C and c.348G > C p.K116N. We then examined the pathophysiological significance of these novel and previously reported pathogenic variants p.P29L, p.P34R, p.A59G, p.Q61L and p.E62K. In vitro analyses revealed that all tested RAC3 variants were biochemically and biologically active to variable extent, and exhibited a spectrum of different affinities to downstream effectors including p21-activated kinase 1. We then focused on the four variants p.Q61L, p.E62del, p.D63N and p.Y64C in the Switch II region, which is essential for the biochemical activity of small GTPases and also a variation hot spot common to other Rho family genes, RAC1 and CDC42. Acute expression of the four variants in embryonic mouse brain using in utero electroporation caused defects in cortical neuron morphology and migration ending up with cluster formation during corticogenesis. Notably, defective migration by p.E62del, p.D63N and p.Y64C were rescued by a dominant negative version of p21-activated kinase 1. Our results indicate that RAC3 variants result in morphological and functional defects in cortical neurons during brain development through variant-specific mechanisms, eventually leading to heterogeneous neurodevelopmental phenotypes., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Single-shot coherent diffraction imaging (CDI) is a powerful approach to characterize the structure and dynamics of isolated nanoscale objects such as single viruses, aerosols, nanocrystals and droplets. Using X-ray wavelengths, the diffraction images in CDI experiments usually cover only small scattering angles of a few degrees. These small-angle patterns represent the magnitude of the Fourier transform of the 2D projection of the sample's electron density, which can be reconstructed efficiently but lacks any depth information. In cases where the diffracted signal can be measured up to scattering angles exceeding ∼10°, i.e. in the wide-angle regime, some 3D morphological information of the target is contained in a single-shot diffraction pattern. However, the extraction of the 3D structural information is no longer straightforward and defines the key challenge in wide-angle CDI. So far, the most convenient approach relies on iterative forward fitting of the scattering pattern using scattering simulations. Here the Scatman is presented, an approximate and fast numerical tool for the simulation and iterative fitting of wide-angle scattering images of isolated samples. Furthermore, the open-source software implementation of the Scatman algorithm, PyScatman , is published and described in detail. The Scatman approach, which has already been applied in previous work for forward-fitting-based shape retrieval, adopts the multi-slice Fourier transform method. The effects of optical properties are partially included, yielding quantitative results for small, isolated and weakly interacting samples. PyScatman is capable of computing wide-angle scattering patterns in a few milliseconds even on consumer-level computing hardware, potentially enabling new data analysis schemes for wide-angle coherent diffraction experiments., (© Alessandro Colombo et al. 2022.)

Background: SARS-CoV-2 mRNA vaccination of healthy individuals is highly immunogenic and protective against severe COVID-19. However, there are limited data on how disease-modifying therapies (DMTs) alter SARS-CoV-2 mRNA vaccine immunogenicity in patients with autoimmune diseases., Methods: As part of a prospective cohort study, we investigated the induction, stability and boosting of vaccine-specific antibodies, B cells and T cells in patients with multiple sclerosis (MS) on different DMTs after homologous primary, secondary and booster SARS-CoV-2 mRNA vaccinations. Of 126 patients with MS analysed, 105 received either anti-CD20-based B cell depletion (aCD20-BCD), fingolimod, interferon-β, dimethyl fumarate, glatiramer acetate, teriflunomide or natalizumab, and 21 were untreated MS patients for comparison., Results: In contrast to all other MS patients, and even after booster, most aCD20-BCD- and fingolimod-treated patients showed no to markedly reduced anti-S1 IgG, serum neutralising activity and a lack of receptor binding domain-specific and S2-specific B cells. Patients receiving fingolimod additionally lacked spike-reactive CD4 + T cell responses. The duration of fingolimod treatment, rather than peripheral blood B and T cell counts prior to vaccination, determined whether a humoral immune response was elicited., Conclusions: The lack of immunogenicity under long-term fingolimod treatment demonstrates that functional immune responses require not only immune cells themselves, but also access of these cells to the site of inoculation and their unimpeded movement. The absence of humoral and T cell responses suggests that fingolimod-treated patients with MS are at risk for severe SARS-CoV-2 infections despite booster vaccinations, which is highly relevant for clinical decision-making and adapted protective measures, particularly considering additional recently approved sphingosine-1-phosphate receptor antagonists for MS treatment., Competing Interests: Competing interests: PH and UR are employed by JPT Peptide Technologies., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Ultrasmall gold nanoparticles (2 nm) easily penetrate the membranes of intestinal murine epithelial cells (MODE-K) and colorectal cancer cells (CT-26). They are also taken up by 3D spheroids (400 µm) of these cell types and primary gut organoids (500 µm). In contrast, dissolved dyes are not taken up by any of these cells or 3D structures. The distribution of fluorescent ultrasmall gold nanoparticles inside cells, spheroids, and gut organoids is examined by confocal laser scanning microscopy. Nanoparticles conjugated with the cytostatic drug doxorubicin and a fluorescent dye exhibit significantly greater cytotoxicity toward CT-26 tumor spheroids than equally concentrated dissolved doxorubicin, probably because they enter the interior of a spheroid much more easily than dissolved doxorubicin. Comprehensive analyses show that the cellular uptake of ultrasmall gold nanoparticles occurs by different endocytosis pathways., (© 2022 The Authors. Small published by Wiley-VCH GmbH.)

Aim of the Study:  Fetal alcohol spectrum disorders (FASD) are quite common and, due to the risk of psychiatric comorbidities, highly relevant until adulthood. Diagnostic clarification in adulthood is a prerequisite for targeted treatment and needs-based support., Methods:  In a German metropolitan region, 80 people with suspicion of FASD were assessed from May 2015 to July 2020. The results of this interdisciplinary diagnostic assessment were systematically evaluated and the clinical characteristics of the persons with or without FASD were analysed., Results: Approximately 70% of the population accessing relevant health care was diagnosed with an entity from the FAS spectrum. People with FASD were more likely to have learning disabilities (50 vs. 33%) or intellectual disabilities (40 vs. 10%), while there were no group differences for age and gender. Psychiatric comorbidities, particularly depression (39%) and addiction disorders (31%), were common in both groups., Conclusion: As part of a multi-professional standardized diagnosis, FASD clarification is also possible and necessary in adulthood. The diagnostic criteria for FASD should be further evaluated and specified for adults., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery., Design: Retrospective, propensity-score matched analysis SETTING: Enhanced Recovery After Surgery (ERAS) program., Participants: Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020., Interventions: Continuous infusion of dexmedetomidine and ketamine., Measurements & Main Results: The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722)., Conclusions: There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery., Competing Interests: Conflict of Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Gabriel Mena receives an academic grant from Pacira Pharmaceuticals. The rest of authors do not have potential conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Advanced age is a main risk factor for severe COVID-19. However, low vaccination efficacy and accelerated waning immunity have been reported in this age group. To elucidate age-related differences in immunogenicity, we analyzed human cellular, serological, and salivary SARS-CoV-2 spike glycoprotein-specific immune responses to the BNT162b2 COVID-19 vaccine in old (69-92 y) and middle-aged (24-57 y) vaccinees compared with natural infection (COVID-19 convalescents, 21-55 y of age). Serological humoral responses to vaccination excee-ded those of convalescents, but salivary anti-spike subunit 1 (S1) IgA and neutralizing capacity were less durable in vaccinees. In old vaccinees, we observed that pre-existing spike-specific CD4 + T cells are associated with efficient induction of anti-S1 IgG and neutralizing capacity in serum but not saliva. Our results suggest pre-existing SARS-CoV-2 cross-reactive CD4 + T cells as a predictor of an efficient COVID-19 vaccine-induced humoral immune response in old individuals., (Copyright © 2022 by The American Association of Immunologists, Inc.)

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative treatment plans aimed at improving recovery time in patients following surgery using a multidisciplinary team approach. These protocols have been shown to optimize pain control, improve mobility, and decrease postoperative ileus and other surgical complications, thereby leading to a reduction in length of stay and readmission rates. To date, no ERAS-based protocols have been developed specifically for pediatric patients undergoing oncologic surgery. Our objective is to describe the development of a novel protocol for pediatric, adolescent, and young adult surgical oncology patients. Our protocol includes the following components: preoperative counseling, optimization of nutrition status, minimization of opioids, meticulous titration of fluids, and early mobilization. We describe the planning and implementation challenges and the successes of our protocol. The effectiveness of our program in improving perioperative outcomes in this surgical population could lead to the adaptation of such protocols for similar populations at other centers and would lend support to the use of ERAS in the pediatric population overall.

The functional relevance of preexisting cross-immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a subject of intense debate. Here, we show that human endemic coronavirus (HCoV)–reactive and SARS-CoV-2–cross-reactive CD4 + T cells are ubiquitous but decrease with age. We identified a universal immunodominant coronavirus-specific spike peptide (S816-830) and demonstrate that preexisting spike- and S816-830–reactive T cells were recruited into immune responses to SARS-CoV-2 infection and their frequency correlated with anti–SARS-CoV-2-S1-IgG antibodies. Spike–cross-reactive T cells were also activated after primary BNT162b2 COVID-19 messenger RNA vaccination and displayed kinetics similar to those of secondary immune responses. Our results highlight the functional contribution of preexisting spike–cross-reactive T cells in SARS-CoV-2 infection and vaccination. Cross-reactive immunity may account for the unexpectedly rapid induction of immunity after primary SARS-CoV-2 immunization and the high rate of asymptomatic or mild COVID-19 disease courses.

Background and Objective: With the inclusion of Enhanced Recovery Programs (ERPs) into routine clinical practice, scaling programs across an institution is important to drive sustainable change in a patient-centric care delivery paradigm. A review of ERP implementation within a large institution was performed to understand key components that hinder or facilitate success of scaling an ERP., Methods: From January 2018 to March 2018, a needs assessment was completed to review implementation of enhanced recovery across the institution. Implementation progress was categorized into one of 5 phases including Define, Implement, Measure, Analyze, and Optimize., Results: Only 25% of service line ERPs reached the optimization phase within 5 years. One hundred percent of respondents reported more strengths (n = 41) and opportunities (n = 41) than weaknesses or threats (n = 25 and 14, respectively). Commonly identified strengths included established enhanced recovery pathways, functional team databases, and effective provider education. Weaknesses identified were inconsistencies in data quality/collection and a lack of key personnel participation including buy-in and time availability. Respondents perceived the need for data standardization to be an opportunity, while personnel factors were viewed as key threats., Conclusion: Identification of strengths, weaknesses, opportunities, and threats could prove beneficial in helping scale an ERP across an institution. Successful optimization and expansion of ERPs require robust data management for continuous quality improvement efforts among clinicians, administrators, executives, and patients., Competing Interests: The authors have no conflicts of interest or financial disclosures to report., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Enhanced recovery after surgery (ERAS) pathways are well established in certain surgical specialties because findings have shown significant improvements in outcomes. Convincing literature in head and neck cancer (HNC) surgery is lacking. This study aimed to assess the effect of an ERAS pathway on National Surgical Quality Improvement Program (NSQIP)-based occurrences and pain-related outcomes in HNC surgery., Methods: The study matched 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between 1 March 2016 and 31 March 2019 with control subjects (1:1 ratio) during the same period. Demographic and perioperative data collected from the NSQIP database were extracted. Pain scores and medication usage were electronically extracted from our electronic medical record system and compared. Risk factors for high opioid usage also were assessed., Results: Both groups were statistically similar in baseline characteristics. The ERAS group had fewer planned intensive care unit (ICU) admissions (4% vs. 14%; p < 0.001), a shorter mean hospital stay (7.2 ± 2.3 vs. 8.7 ± 4.2 days; p < 0.001), and fewer overall complications (18.6% vs. 27.0%; p = 0.045). Morphine milligram equivalent requirements over 72 h were significantly reduced during 72 h in the ERAS group (138.8 ± 181.5 vs. 207.9 ± 205.5; p < 0.001). In the multivariate analysis, the risk factors for high opioid analgesic usage included preoperative opioid usage, age younger than 65 years, race, patient-controlled analgesia use, and ICU admission., Conclusion: The study findings showed that ERAS in HNC surgery can result in improved outcomes and resource use, and that these results are sustainable. The outcomes described in this report can be further used to optimize ERAS pathways.

The prevailing 'division of labor' concept in cellular immunity is that CD8 + T cells primarily utilize cytotoxic functions to kill target cells, while CD4 + T cells exert helper/inducer functions. Multiple subsets of CD4 + memory T cells have been characterized by distinct chemokine receptor expression. Here, we demonstrate that analogous CD8 + memory T-cell subsets exist, characterized by identical chemokine receptor expression signatures and controlled by similar generic programs. Among them, Tc2, Tc17 and Tc22 cells, in contrast to Tc1 and Tc17 + 1 cells, express IL-6R but not SLAMF7, completely lack cytotoxicity and instead display helper functions including CD40L expression. CD8 + helper T cells exhibit a unique TCR repertoire, express genes related to skin resident memory T cells (T RM ) and are altered in the inflammatory skin disease psoriasis. Our findings reveal that the conventional view of CD4 + and CD8 + T cell capabilities and functions in human health and disease needs to be revised.

Objectives: Enhanced Recovery After Surgery (ERAS) protocols are gaining traction in the field of head and neck surgery following success in other specialties. Various institutions have reported on the feasibility of implementation and early outcomes in their centers. We report our experience of setting up an ERAS program in a high-volume tertiary cancer care center, including the challenges faced and overcome., Methods: With multidisciplinary input, an ERAS protocol was developed consisting of pre-, intra-, and post-operative interventions based on current evidence. We then assessed an initial series of 104 patients on the ERAS protocol and tracked the compliance rates for various interventions., Results: Compliance rates to interventions including pre-operative medication (84.6%), multimodal analgesia (84.6%95.1%), early removal of urinary catheters (76.0%) and early mobilization (56.7%) show a wide variation. However, response rates in the assessment of patient-reported outcomes are low. We discuss factors surrounding the feasibility of implementing an ERAS protocol and tracking outcomes in a diverse, high volume center., Discussion: While there are challenges in implementation, results indicate that a successful ERAS pathway in major head and neck oncologic surgery is feasible. Engaging shareholders and making full use of technology in the form of electronic medical systems are essential to this success., Implications for Practice: ERAS pathways should be encouraged in head and neck surgery, given their proven feasibility in a range of institutions. Further study is needed to confirm this program's impact on outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the rapidly unfolding coronavirus disease 2019 (COVID-19) pandemic 1,2 . Clinical manifestations of COVID-19 vary, ranging from asymptomatic infection to respiratory failure. The mechanisms that determine such variable outcomes remain unresolved. Here we investigated CD4 + T cells that are reactive against the spike glycoprotein of SARS-CoV-2 in the peripheral blood of patients with COVID-19 and SARS-CoV-2-unexposed healthy donors. We detected spike-reactive CD4 + T cells not only in 83% of patients with COVID-19 but also in 35% of healthy donors. Spike-reactive CD4 + T cells in healthy donors were primarily active against C-terminal epitopes in the spike protein, which show a higher homology to spike glycoproteins of human endemic coronaviruses, compared with N-terminal epitopes. Spike-protein-reactive T cell lines generated from SARS-CoV-2-naive healthy donors responded similarly to the C-terminal region of the spike proteins of the human endemic coronaviruses 229E and OC43, as well as that of SARS-CoV-2. This results indicate that spike-protein cross-reactive T cells are present, which were probably generated during previous encounters with endemic coronaviruses. The effect of pre-existing SARS-CoV-2 cross-reactive T cells on clinical outcomes remains to be determined in larger cohorts. However, the presence of spike-protein cross-reactive T cells in a considerable fraction of the general population may affect the dynamics of the current pandemic, and has important implications for the design and analysis of upcoming trials investigating COVID-19 vaccines.

Fetal alcohol spectrum disorders (FASD) are a common cause of a congenital developmental disability acquired in the womb due to alcohol consumption by the mother during pregnancy. The physical and mental consequences persist into adulthood. The 4‑digit code is an evidence-based method for diagnosing the full spectrum of outcomes, i.e. the full picture of fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD). The four key diagnostic features are (1) growth disorder, (2) facial dysmorphia, (3) central nervous system (CNS) structural and functional abnormalities and (4) prenatal alcohol exposure. Even if the disorder cannot be cured, supportive therapeutic interventions can improve the quality of life and independence and psychiatric comorbidities can be treated.

Background: Enhanced recovery after surgery (ERAS) programs are being used increasingly in microvascular breast reconstruction. However, it is unclear as to what extent the benefits outweigh the costs. We hypothesized that an ERAS pathway for microvascular breast reconstruction would be cost-effective relative to the standard of care., Study Design: A decision-analytic model was made incorporating clinically relevant health states after microvascular breast reconstruction with ERAS vs standard of care. Probabilities and utility scores were abstracted from published sources, and a third-party payer perspective was adopted. Time-driven activity-based costing was used to map and estimate costs attributed to ERAS. Sensitivity analyses were performed to examine the robustness of the results., Results: The results of 5 studies, totaling 986 patients, were pooled to generate health state probabilities. ERAS was found to be dominant, being both less expensive and more effective than standard of care. On sensitivity analysis, ERAS becomes cost-ineffective (incremental cost-utility ratio > $50,000/quality-adjusted life year) at an amount > $19,336.75. Length of stay would have to be reduced from 5.96 days to 3.36 days for standard of care to become cost-effective. Monte-Carlo analysis demonstrated ERAS to be the more cost-effective option across a range of willingness-to-pay values., Conclusions: Despite the increased medication and personnel costs attributed to ERAS, it is less costly overall and associated with superior outcomes compared with standard of care. These findings lend additional support to the value of ERAS implementation in microvascular breast reconstruction. Time-driven activity-based costing provides granular estimates and are useful in quality-improvement initiatives., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

BACKGROUND Indigestible foreign material in the bowel can develop into bezoars. Intestinal obstruction can occur secondary to these bezoars. Phytobezoars specifically refer to those which accumulate as a result of undigested plant or other food material. CASE REPORT A 42-year-old woman presented to the Emergency Department with a several-month history of right-sided abdominal pain associated with bouts of vomiting. She had no other significant medical history. Labs and computed tomography were unrevealing. Gastroenterology was consulted and performed endoscopy. A foreign body resembling an undigested mini bell pepper was found near the terminal ileum. This was removed, and the patient later reported significant improvement in her symptoms. CONCLUSIONS Phytobezoars can lead to symptoms consistent with intestinal obstruction. The underlying pathology (e.g., masses, gastritis, adhesions, or dysmotility) can precipitate obstructions in the setting of bezoar formation. Surgical removal if often necessary for small-bowel obstructions secondary to bezoars, but in our case, fortunately, the foreign body was successfully removed during endoscopy.

Background: Previous clinical trials with birch pollen subcutaneous immunotherapy have been conducted over a 1- to 2-year treatment period and involved mostly a single geographic location., Objective: This study (EudraCT-Number: 2005-000025-35) intended to evaluate the effect of subcutaneous immunotherapy with high-dose hypoallergenic birch pollen allergoid in patients with confirmed moderate to severe seasonal allergic rhinitis/rhinoconjunctivitis over a 3-year course in 19 European centres., Methods: Adults with confirmed birch pollen allergy (n = 253) were randomized to preseasonal placebo (n = 129) or active treatment (n = 124). Primary endpoint was change in Symptom Medication Score after 2 years treatment (2007)., Results: The change in Symptom Medication Score of active- vs placebo-treated patients for the Full Analysis Set (n = 227, 15.2% reduction, P = 0.0710) and Per-Protocol Set (n = 216, 16.7% reduction, P = 0.0523) showed a positive trend, although significance was not achieved. The primary endpoint, assessed in 2007, coincided with the lowest pollination during the study period. In a subgroup analysis of patients in the north-eastern region (n = 102), where birch is the major tree and consequently patients' exposure is higher, changes in Symptom Medication Score (32.7% reduction, P = 0.0034) and median number of well days (P = 0.0232) were highly significant in favour of the active group. During the open-label third year of treatment, the mean Symptom Medication Score of active-treated patients was further reduced despite an increased pollen count. Subcutaneous immunotherapy was well tolerated and consistent with the known safety profile., Conclusions and Clinical Relevance: Although the primary endpoint was not reached for the Full Analysis Set, a significant and clinically relevant effect on Symptom Medication Score was clearly demonstrated for the subgroup of patients in the north-eastern region of Europe, where birch is the predominant tree species. Proving efficacy of birch allergen subcutaneous immunotherapy is challenging due to the numerous factors influencing birch pollen allergen exposure in field studies., (© 2019 The Authors. Clinical & Experimental Allergy Published by John Wiley & Sons Ltd.)

BACKGROUND Mirizzi syndrome is an uncommon but clinically important complication of gallbladder disease that occurs when there is extrinsic compression of the common hepatic duct from gallstones within the cystic duct or from within the gallbladder itself. Obstructive jaundice and cholangitis may ensue. In severe cases, bile duct erosion or gallbladder rupture occur. CASE REPORT A demented 80-year-old woman presented to the Emergency Department (ED) with fever and right upper-quadrant abdominal guarding and tenderness. Computed tomography of the abdomen revealed a markedly dilated and thickened gallbladder with hyperdensity in the region of the gallbladder neck. The mass effect of these gallstones caused central intrahepatic biliary ductal dilatation from extrinsic compression of the extrahepatic biliary duct, consistent with Mirizzi syndrome. Additionally, there were 2 areas of focal rupture of the gallbladder wall. General Surgery recommended non-operative management and temporizing the patient with a cholecystostomy tube. She remained in the hospital on IV antibiotics and discharged to follow-up as an outpatient with General Surgery. CONCLUSIONS Significant morbidity and mortality can be associated with the disease states of Mirizzi syndrome, and it is imperative for the ED physician to promptly recognize and treat such clinical entities. In general, treatment requires a multidisciplinary approach, using the history and physical examination to guide appropriate consultation with General Surgery, Gastroenterology, or Interventional Radiology. The prognosis of Mirizzi syndrome is related to the degree of concomitant complications. Aggressive treatment is appropriate for most patients, with surgical intervention being individualized based on the stage and severity of the disease.

Objective: FOXG1 syndrome is a rare neurodevelopmental disorder associated with heterozygous FOXG1 variants or chromosomal microaberrations in 14q12. The study aimed at assessing the scope of structural cerebral anomalies revealed by neuroimaging to delineate the genotype and neuroimaging phenotype associations., Methods: We compiled 34 patients with a heterozygous (likely) pathogenic FOXG1 variant. Qualitative assessment of cerebral anomalies was performed by standardized re-analysis of all 34 MRI data sets. Statistical analysis of genetic, clinical and neuroimaging data were performed. We quantified clinical and neuroimaging phenotypes using severity scores. Telencephalic phenotypes of adult Foxg1 +/- mice were examined using immunohistological stainings followed by quantitative evaluation of structural anomalies., Results: Characteristic neuroimaging features included corpus callosum anomalies (82%), thickening of the fornix (74%), simplified gyral pattern (56%), enlargement of inner CSF spaces (44%), hypoplasia of basal ganglia (38%), and hypoplasia of frontal lobes (29%). We observed a marked, filiform thinning of the rostrum as recurrent highly typical pattern of corpus callosum anomaly in combination with distinct thickening of the fornix as a characteristic feature. Thickening of the fornices was not reported previously in FOXG1 syndrome. Simplified gyral pattern occurred significantly more frequently in patients with early truncating variants. Higher clinical severity scores were significantly associated with higher neuroimaging severity scores. Modeling of Foxg1 heterozygosity in mouse brain recapitulated the associated abnormal cerebral morphology phenotypes, including the striking enlargement of the fornix., Interpretation: Combination of specific corpus callosum anomalies with simplified gyral pattern and hyperplasia of the fornices is highly characteristic for FOXG1 syndrome., Competing Interests: Nothing to report.

Background: Mechanistic target of rapamycin (mTOR) regulates lipid and glucose metabolism thus playing a key role in metabolic diseases like type 2 diabetes mellitus (T2DM). Recently, we demonstrated a functional interaction of microRNA-496 (miR-496) with mTOR and its impact on the regulation of human ageing., Objectives: As T2DM is most prevalent in older adults, we hypothesized that miR-496 may also have an impact on mTOR regulation in T2DM., Methods: Based on real-time PCR and enzyme-linked immunosorbent assay, mTOR gene and protein expression as well as miR-496 expression were monitored in peripheral blood mononuclear cells (PBMC) from T2DM patients (median age: 71) and healthy age- and BMI matched controls (median age: 69). -Results: We demonstrated significant upregulation of phospho-mTOR and P70S6 Kinase (P70S6K) levels and significant downregulation of miR-496 in PBMC from elderly T2DM patients in comparison to a BMI and age-matched control cohort. Moreover, significant upregulation of phospho-mTOR protein and significant downregulation of miR-496 were observed in advanced stages of obesity., Conclusions: BMI-dependent upregulation of mTOR and the inverse expression profile of miR-496 observed in elderly T2DM patients suggest a correlation with T2DM. Hence, our results indicate a potential association of miR-496 with mTOR expression in elderly T2DM patients and obesity. Since phosphorylation of P70S6K was also elevated in T2DM patients, we conclude that mTOR signaling through TORC1 may be affected in the regulation of T2DM., (© 2019 S. Karger AG, Basel.)

Introduction: This study aimed to assess the prevalence and clinical characteristics of dementia in a clinical sample of adults with Down syndrome. Consequences for clinical practice were deduced., Methods: Patient characteristics and prevalence rates of dementia were evaluated in adults with Down syndrome who were admitted to psychiatry from 2005 to 2012 (N = 75)., Results: In every third patient with Down syndrome, dementia was diagnosed in a second assessment 6 to 12 months after initial hospital admission. Patients with dementia were older and more often female, while no association was found with the level of intellectual disability. Thyroid function and calcium values were often abnormal in those with and without dementia., Discussion: In persons with Down syndrome, dementia is a prevalent cause for admission to psychiatry, especially in females and those of advanced age. Services should be adapted to the increased demands., Competing Interests: Die Autoren erklären, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aims: To analyze the robustness of randomized controlled trials (RCTs) referenced in the American Diabetes Association's Standards of Medical Care in Diabetes-2017 using the Fragility Index (FI) and Fragility Quotient (FQ)., Methods: We performed a systematic survey of all RCTs referenced in the Standards of Medical Care in Diabetes-2017. One investigator screened for trials and then recorded data from them, including sample size per group, event rate per group, and the dichotomous outcome analyzed by trialists. The FI and FQ for each outcome were calculated. Outcomes were then surveyed to determine whether the outcome used for analysis aligned with the guideline recommendation., Results: Thirty-five RCTs were included in this study. Thirty-three of 35 (94%) FIs were based on the trial outcomes referenced in the clinical practice guideline. The median sample size was 2548 participants ([IQR], 522-6946). The median total number of events for each outcome was 403 (IQR, 86-969). Nineteen (54%) P Values were below 0.05, 8 (22.4%) were below 0.01. The median FI for all trials was 16 (IQR, 4-29). The median FQ was 0.007 (IQR, 0.003-0.014). FI was not related to risk of bias or Science Citation Index but was significantly correlated with sample size (for significant trials; r=0.77, P < .001, for neutral trials; r=0.76, P < .001)., Conclusions: We found that the robustness of RCTs varied, but on the whole were not robust in nature. Most trials demonstrated a modest FI and FQ. As a result, conclusions drawn from these trials should take this information into account., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Although poliomyelitis has almost been eradicated worldwide, cases of a polio-like disease with asymmetrical flaccid paralysis of variable severity have been seen repeatedly in recent years., Methods: Data were collected on children treated in hospitals in the German federal states of Bavaria and Lower Saxony in 2016. The frequency of disease across Germany was estimated on the basis of voluntary reporting to the Robert Koch Institute. 16 cases were registered there for the entire year 2016., Results: 7 children with flaccid paralysis of acute onset were treated in the participating hospitals in the summer and fall of 2016. We describe two illustrative cases, one with a mild course and one with a severe course. Rapid diagnosis requires not only clinical neurological assessment but also neurophysiological studies, magnetic resonance imaging (MRI), and targeted microbiological testing. The characteristic features include damage to the anterior horn of the spinal cord that can be seen on MRI and/or electrophysiologically demonstrable abnormalities indicating motor neuron damage. A pathogen can hardly ever be identified in the cerebrospinal fluid, but the epidemiological context and the detection of viruses in the stool or respiratory secretions indicate that entero - viruses may be responsible., Conclusion: The prognosis of this disease cannot be reliably assessed at first, and no specific treatment is currently available.

Several brain regions appear to play a role in representing different body identities. The specific contribution of each of these regions is still unclear, however. Here we investigated which brain areas enable the visual distinction between self and other bodies of different familiarity, and between familiar and unfamiliar other individuals, and moreover, where identity-specific information on the three individuals was encoded. Participants were confronted with standardized headless human body stimuli either showing the participant's own, a personally familiar or an unfamiliar other body, while performing a luminance discrimination task. Employing multivariate pattern analysis, we were able to identify areas that allowed for the distinction of self from personal familiar other bodies within the medial prefrontal cortex (mPFC) and posterior cingulate cortex/precuneus. Successful distinction of self from unfamiliar others was possible in the left middle frontal gyrus, the right inferior frontal gyrus, the left pre-supplementary motor area and the right putamen. Personally familiar others could be distinguished from unfamiliar others in the right temporoparietal junction (TPJ). An analysis of identity-specific information revealed a spatial gradient ranging from inferior posterior to superior anterior portions of the mPFC that was associated with encoding identity-related information for self via familiar to unfamiliar other bodies, respectively. Furthermore, several midline and frontal regions encoded information on more than one identity. The TPJ's role in deviance detection was underlined, as only identity-specific information on unfamiliar others was encoded here. Together, our findings suggest substantial spatial overlap in neural correlates of self and other body representation and thus, support the hypothesis of a socially-related representation of the self., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Donor alloantigen infusion induces T cell regulation and transplant tolerance in small animals. Here, we study donor splenocyte infusion in a large animal model of pulmonary transplantation. Major histocompatibility complex-mismatched single lung transplantation was performed in 28 minipigs followed by a 28-day course of methylprednisolone and tacrolimus. Some animals received a perioperative donor or third party splenocyte infusion, with or without low-dose irradiation (IRR) before surgery. Graft survival was significantly prolonged in animals receiving both donor splenocytes and IRR compared with controls with either donor splenocytes or IRR only. In animals with donor splenocytes and IRR, increased donor cell chimerism and CD4(+) CD25(high+) T cell frequencies were detected in peripheral blood associated with decreased interferon-γ production of leukocytes. Secondary third-party kidney transplants more than 2 years after pulmonary transplantation were acutely rejected despite maintained tolerance of the lung allografts. As a cellular control, additional animals received third-party splenocytes or donor splenocyte protein extracts. While animals treated with third-party splenocytes showed significant graft survival prolongation, the subcellular antigen infusion showed no such effect. In conclusion, minipigs conditioned with preoperative IRR and donor, or third-party, splenocyte infusions may develop long-term donor-specific pulmonary allograft survival in the presence of high levels of circulating regulatory T cells., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objectives: To analyze factors that influence the timing of adjuvant chemotherapy in patients who are candidates for breast-conservation therapy (BCT) but elect mastectomy with immediate reconstruction (M-IR)., Methods: We identified 35 consecutively treated patients with stage I or II breast cancer between 2004 and 2009 who underwent M-IR and adjuvant chemotherapy from the University of Louisville Cancer Registry. We matched these patients for age and AJCC stage to 35 controls who underwent BCT and adjuvant chemotherapy. We examined the timing and delay of initiation of chemotherapy using univariate logistic regression and McNemar test for matched pairs., Results: For the 70 patients evaluated, the median age was 46 years (range, 30 to 65 y), and the distribution for stage I, IIA, and IIB was 22.9%, 65.7%, and 11.4%, respectively. The 2 groups were well balanced in terms of race, rural/urban status, smoking, diabetes, insurance coverage, and histology. For BCT and M-IR, the median time to chemotherapy initiation was 38 days (range, 25 to 103 d) and 55 days (range, 30 to 165 d), respectively. Patients undergoing M-IR were more likely to experience any delay (>45 d; 54.3% vs. 22.9%; P<0.001) and/or significant delay (>90 d; 20.0% vs. 2.9%; P<0.001). On univariate logistic regression analysis, surgery type had a major impact on delay of chemotherapy (odds ratio=8.35; 95% confidence interval, 2.86-24.4; P<0.001)., Conclusions: The use of M-IR in breast-conservation candidates independently predicts for delay in initiation of adjuvant chemotherapy. Further study is needed to qualify the causes and clinical significance of these delays.

Background: Recently, involvement of the chemokine/receptor system CCL20/CCR6 in colorectal cancer (CRC) progression was shown. Here, we analyzed the functional interaction of miRNA-518-5p (miR-518a-5p) with CCR6 and its impact on CCR6 expression in CRC cells., Methods: MiR-518a-5p was identified by computer software to potentially interact with CCR6. Hence, functional implications of miR-518a-5p with the 3'UTR of CCR6 were analyzed using the Dual Luciferase Reporter assay system. Confirmation of the predicted target site for miR-518a-5p was achieved by site-directed mutagenesis of the seed sequence in the 3'UTR of CCR6 and subsequent application of the mutated seed sequence in a luciferase assay with miR-518a-5p mimics. Accordingly, two CRC cell lines (Caco-2 and HT-29) were transfected with miR-518a-5p miRNA mimics and gene and protein expression of CCR6 was monitored using qRT PCR and immunocytochemistry, respectively., Results: Addition of miR-518a-5p led to significant down-regulation of luciferase activity (P < 0.05), which was significantly reversed in a reporter test system containing the mutated seed sequences in the 3'UTR of CCR6. Following transfection of CRC cell lines with miR-518a-5p mimics and subsequent monitoring of CCR6 expression showed significant down-regulation of CCR6 mRNA and CCR6 protein expression in both CRC cell lines under investigation (P < 0.05)., Conclusions: We have shown that miR-518a-5p functionally interacts with CCR6 and that transfection of CRC cells with miR-518a-5p leads to significant CCR6 down-regulation. Consequently, CCR6 expression is regulated by miR-518a-5p in CRC cells indicating that regulation of CCR6 expression by miR-518a-5p might be a regulatory mechanism involved in CRC pathogenesis.

Objective: Measurement of rectal temperature is the most common method and considered gold standard for obtaining body temperature in dogs. So far, no study has been performed comparing agreement between rectal and auricular measurements in a large case series. The purpose of the study was to assess agreement between rectal and auricular temperature measurement in normothermic, hypothermic, and hyperthermic dogs with consideration of different environmental conditions and ear conformations., Materials and Methods: Reference values for both methods were established using 62 healthy dogs. Three hundred dogs with various diseases (220 normothermic, 32 hypothermic, 48 hyperthermic) were enrolled in this prospective study. Rectal temperature was compared to auricular temperature and differences in agreement with regard to environmental temperature, relative humidity, and different ear conformations (pendulous versus prick ears) were evaluated using Pearson's correlation coefficient and Bland-Altman analysis., Results: Correlation between rec- tal and auricular temperature was significant (r: 0.892; p  <  0.01). However, Bland-Altman plots showed an inacceptable variation of values (bias: 0.300 °C; limits of agreement: -0.606 to 1.206 °C). This variation was above a maximal clinical tolerance of 0.3 °C, which was established by experts' opinion (n = 16). Relative humidity had a significant influence (p   =   0.001), whereas environmental temperature did not., Conclusion: Variation between the two methods of measuring body temperature was clinically unacceptable., Clinical Relevance: Although measurement of auricular temperature is fast, simple, and well tolerated, this method provides a clinically unacceptable difference to the rectal measurement.

Background: First-line surgical options for early-stage breast cancer include breast-conserving surgery (BCS) or mastectomy. We analyzed factors that influence the receipt of mastectomy and resultant trends over time., Methods: We analyzed the rates of mastectomy and BCS for 1634 women who underwent upfront surgical treatment for AJCC stage 0, I, or II breast cancer between 1995 and 2008 using data from the University of Louisville James Graham Brown Cancer Center Tumor Registry. We examined the trend of treatment over time and assessed the probability of receiving mastectomy using multivariate logistic regression., Results: Overall, 65.9% of women received BCS, and 34.1% received mastectomy over a 14-year period (annual BCS rate range, 38.6% to 77.7%). The mastectomy rate substantially decreased from 43.5% in 1995 to 22.5% in 2004 (P = 0.0007) but then increased to 51.7% in 2008 (P < 0.0001). During the years between 2004 and 2008 (vs. 1995 to 2003), there was a significant increase in the rates of mastectomy performed in conjunction with immediate reconstruction (IR: 35.7% vs. 8.4%; P < 0.0001) and/or contralateral prophylactic mastectomy (CPM: 22.9% vs. 3.3%; P < 0.0001). On the basis of the multivariate analysis, the rate of receiving mastectomy was drastically higher for patients treated since 2004 (vs. before 2004), uninsured and government-insured (vs. privately insured) patients, patients with pT2 disease (vs. pTis or pT1), patients with pN1 disease (vs. pNX or pN0)., Conclusions: In this longitudinal registry study, major independent determinants of mastectomy for early-stage breast cancer include year of diagnosis, insurance status, and stage. Mastectomy rates declined until 2004, but have since increased in conjunction with immediate reconstruction and contralateral prophylactic mastectomy. Additional study is needed to identify the underlying reasons for and unintended consequences of the reemergence of radical surgery for early-stage breast cancer in the era of multidisciplinary care.

Purpose: Rasmussen encephalitis (RE) leads to progressive tissue and function loss of one brain hemisphere and often intractable epilepsy. This is the first randomized prospective treatment trial in RE., Methods: Germany-wide, patients with suspected recent-onset RE were recruited and if eligible randomized to tacrolimus or intravenous immunoglobulins (IVIGs). A loss of motor function or hemispheric volume by ≥ 15% (in patients >12 years at disease onset: ≥ 8%) led to study exit. Untreated patients served as a historical control group., Key Findings: Over 6.3 years, 21 patients with recent-onset RE were identified. Sixteen were randomized to tacrolimus (n = 9) or IVIG (n = 7). Immunotreated patients had a longer "survival" than the historical controls. Neither treatment was more efficacious than the other. Two tacrolimus patients experienced serious adverse events. No immunotreated but several untreated patients developed intractable epilepsy. No patient with refractory epilepsy became treatment-responsive under immunotherapy., Significance: The countrywide incidence rate of diagnosed RE is estimated as 2.4 cases/10⁷ people ≤ age 18/year. Treatment with tacrolimus or IVIG may slow down tissue and function loss and prevent development of intractable epilepsy. However, immunotherapy may "arrest" patients in a dilemma state of pharmacoresistant epilepsy but too good function to be offered functional hemispherectomy. These compounds may therefore contribute to the therapeutic armamentarium for RE patients without difficult-to-treat epilepsies., (Wiley Periodicals, Inc. © 2012 International League Against Epilepsy.)

A 2-year-old female spayed Epagneul-Breton dog was presented with ecchymoses, but an undisturbed general condition. Clinical examination additionally revealed petechia and a haematoma. Travel history included Italy and Denmark. Laboratory abnormalities were moderate thrombocytopenia, prolonged PT, aPTT and TT, and elevated d-dimers. Initial therapy consisted of plasma transfusions, fluids, doxycycline and famotidine administration. Babesiosis, ehrlichiosis, leishmaniosis, dirofilariosis or anaplasmosis could not be confirmed. Abdominal ultrasound was unremarkable, while thoracic radiographs showed a bronchointerstitial pattern. Faecal samples collected over 3 days were positive for Angiostrongylus vasorum after examination using the Baermann lungworm test. The A. vasorum infection was successfully treated with fenbendazole, whereupon thrombocytopenia and prolonged coagulation times were resolved. In regions of low prevalence, an infection with A. vasorum should also be considered as a differential diagnosis in dogs with coagulation abnormalities. Respiratory signs can be absent with this disease. The patient may have acquired the infection abroad or in Germany.

Introduction: In keeping with recently documented national trends, a significant and increasing number of patients will have chosen contralateral prophylactic mastectomy (CPM) based on personal preference, without traditional clinical or pathological indication., Methods: Women who underwent CPM at the University of Louisville from 2003 to 2009 were selected for this study. Descriptive factors were evaluated such as age, race, family history of breast cancer, laterality, hormone receptor status, stage, grade and histology of the index breast lesion. Statistical analysis was used to compute predictive factors for occult contralateral pathology., Results: A total of 107 patients underwent CPM and had adequate medical information to be included in this study. The median age was 48 years, with 88% being white and 12% being African American. Seventy-six percent of the index breast cancers were infiltrating ductal carcinoma and 12% were infiltrating lobular carcinoma. Five "significant" occult pathologies were found in the prophylactically removed breast. Two of the lesions were ductal carcinoma in situ, 2 were lobular carcinoma in situ and 1 was an invasive mucinous carcinoma. On bivariate analysis, there were no factors identified predictive for occult contralateral pathology., Conclusions: In line with previously reported data, we noted that fewer than 5% of patients who underwent CPM had pathology in the contralateral breast. We were unable to correlate any clinical or pathological characteristics in women who presented with contralateral breast cancer. This study raises serious questions regarding the clinical utility of CPM in detecting synchronous clinically and radiographically occult contralateral primaries.

Purposes: Outcomes following lung transplantation are limited by bronchiolitis obliterans syndrome (BOS). As the number of circulating regulatory T cells (Treg) is lower in lung recipients with BOS than in stable lung recipients, we hypothesized that Treg is also correlated with lung function in the early post-transplantation period., Methods: This prospective study included 18 consecutive patients whose lung function parameters were recorded 3 weeks and 3 months after transplantation, between February and July 2007. Peripheral blood mononuclear cells were stained with anti-CD3, -CD4, -CD8, -CD19, -CD25, -CD28, -CD45RA, -CD45RO, -CD69, -CD127, -CTLA4, and -Foxp3 antibodies and FACS assays were performed. In addition, intracellular cytokines were stained for FACS., Results: Treg-specific markers (Foxp3, CD127(lo), and CTLA4) in the CD25+ CD4+ population were correlated with both forced expiratory volume in 1 s and forced vital capacity. Th1-cytokine secretion was more dominant in CD4+ CD25+ T cells than in CD4+ CD25- T cells. In contrast, Th2 and Treg cytokine secretion was the dominant response in stable recipients., Conclusions: The frequency of Treg cells was positively correlated with good lung function in the early period after lung transplantation.

Background and Aims: Morbidity and Mortality meetings are an accepted tool for quality management in many hospitals. However, it is not proven whether these meetings increase quality. It was the aim of this study to investigate whether Morbidity and Mortality meetings as part of a PDCA cycle (Plan, Do, Check, Act) can improve the rate of anastomotic failure in colorectal surgery., Materials and Methods: From January 1, 2004, to December 31, 2009, data for all anastomotic failures in patients operated on for colorectal diseases in the Department of Surgery (Klinikum Friedrichshafen, Germany) were prospectively collected. The events were discussed in Morbidity and Mortality meetings. On the basis of these discussions, a strategy to prevent anastomotic leaks and a new target were defined (i.e. 'Plan'). This strategy was implemented in the following period (i.e. 'Do') and results were prospectively analysed. A new strategy was established when the results differed from the target, and a new standard was defined when the target was achieved (i.e. 'Check, Act')., Results: The year 2004 was set as the base year. In 2005 and 2006, new strategies were established. Comparing this period with the period of strategy conversion (2007-2009), we found a significant decrease in the anastomotic failure rate in colorectal surgery patients (5.7% vs 2.8%; p = 0.05), whereas the risk factors for anastomotic failure were unchanged or unfavourable., Conclusions: If Morbidity and Mortality meetings are integrated in a PDCA cycle, they can decrease anastomotic failure rates and improve quality of care in colorectal surgery. Therefore, the management tool 'PDCA cycle' should be considered also for medical issues.

Background: Antibiotics generally are recommended to treat hemorrhagic gastroenteritis (HGE). Inappropriate use of antibiotics may promote risk of antimicrobial resistance and unnecessary adverse drug reactions. The necessity of antimicrobial therapy in dogs with HGE has not been demonstrated., Objective: The purpose of this prospective, placebo-controlled, blinded study was to evaluate whether treatment with amoxicillin/clavulanic acid improves the clinical course and outcome of HGE in dogs that show no signs of sepsis., Animals: The study included 60 dogs diagnosed with HGE between 2007 and 2009 at the Clinic of Small Animal Medicine, LMU University of Munich, Germany. The inclusion criterion was the presence of acute hemorrhagic diarrhea (<3 days). Dogs pretreated with antibiotics, with signs of sepsis, or diagnosed with any disease known to cause bloody diarrhea were excluded from the study., Methods: Patients were randomly divided into treatment (amoxicillin/clavulanic acid for 7 days) and placebo groups. To evaluate treatment efficacy, severity of clinical signs (based on a newly developed HGE index), duration of hospitalization, and mortality rate were compared between the 2 groups., Results: Fifty-three of 60 dogs completed the study. No significant difference between treatment groups concerning mortality rate, dropout rate, duration of hospitalization, or severity of clinical signs, either on any individual day or over the course of disease, was observed., Conclusions and Clinical Importance: In some dogs with HGE that show no signs of sepsis, antibiotics may not change the case outcome or time to recovery., (Copyright © 2011 by the American College of Veterinary Internal Medicine.)

Purpose: To examine the impact of radiotherapy on breast cancer patients with triple-negative (ER-, PR-, HER2/neu-) disease., Materials and Methods: A prospectively collected database of 152 triple negative breast cancer patients was initiated in 2004. A total of 77 patients who had all phases of their therapy (surgery, chemotherapy, and radiotherapy) at our institution with a minimum of 2-months follow-up are included. Patients with all types of surgery (lumpectomy or mastectomy), chemotherapy (neoadjuvant or adjuvant), and radiotherapy (tangents only or comprehensive nodal irradiation) are included. Patients received radiotherapy in the setting of breast-conservation and in the postmastectomy setting for ≥5 cm primary tumors and/or ≥4 positive lymph nodes. Patients were divided into 2 groups for statistical analysis, based on whether they received radiotherapy or not., Results: In the cohort, 53 (69%) received radiotherapy, 24 (31%) received no radiotherapy. The median follow-up was 23.2 months (range, 2.0-63.1). In the alive patients, the median follow-up time was 25.6 (range, 2.0-63.1) months. Patients who received radiotherapy were significantly more likely to be of a higher AJCC stage (P < 0.001) than patients who did not receive radiotherapy. Of the patients who received radiotherapy, 33 (61.1%) did so for breast conservation. For the entire group, 1- and 3-year overall survivals are 90.9% and 86.3%, respectively. The 3-year actuarial locoregional relapse-free survival probability for patients who received radiation was higher than those who did not receive radiation (79.6% vs. 57.9%, P = 0.049)., Conclusions: Despite significantly lower AJCC stage, patients with triple-negative breast cancer who do not undergo radiotherapy have a significantly higher risk of locoregional recurrence.