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AimMicropapillary carcinoma (MPC) is a recognised WHO variant of colonic carcinoma (CC), although little is known about its prognosis, immune microenvironment and molecular alterations. We investigated its clinical, pathological and immunological characteristics.MethodsWe assessed 903 consecutive CCs and used the WHO definition to identify MPC. We recorded serrated and mucinous differentiation and mismatch repair (MMR) status. We performed immunohistochemistry and quantification on tissue microarrays for HLA class I/II proteins, beta-2-microglobulin (B2MG), CD8, CD163, LAG3, PD-L1, FoxP3, PD-L1and BRAF V600E.ResultsWe classified 8.6% (N=78) of CC as MPC. Relative to non-MPC, MPC was more often high grade (p=0.03) and showed serrated morphology (pConclusionMPCs are associated with high-grade differentiation and a less active immune microenvironment than non-MPC. MPC is not associated with inferior disease-specific survival.

Serrated adenocarcinoma (SAC), a recognised WHO variant of colonic adenocarcinoma, is the purported end-product of serrated neoplasia. However, the diagnosis of SAC is infrequently rendered, and little is known about its prognosis, immune microenvironment and molecular alterations.We assessed 903 consecutive colon carcinomas and recognised tumours with ≥ 5% (n = 77) serrated and ≥ 50% serrated patterns (n = 13). We assessed precursor polyps and synchronous polyps. We recorded demographic/clinical parameters, histological features and mismatch repair (MMR) status. We performed immunohistochemistry and quantification on tissue microarray for HLA class I/II proteins, B2MG, CD8, CD163, LAG3, FoxP3, PD-L1 and BRAF V600E.We identified ≥ 5% epithelial serration prevalence in 8.5% of cases and ≥ 50% epithelial serration prevalence in 1.4% of cases. Precursor lesions were present in 21.4% of cases; these were mostly tubular adenomas with two traditional serrated adenomas identified. SAC with ≥ 5% serrations exhibited lower numbers of CD8-positive lymphocytes (P = 0.002) and lower B2MG expression (P = 0.048), although neither value was significant at ≥ 50% serration threshold. There was no difference in HLA class I/II, or PD-L1 expression on tumour cells and no difference in PD-L1, LAG3, FoxP3 and CD163 expression on immune cells. There was no association with MMR status, or BRAFV600E relative to conventional adenocarcinoma. There was improved disease-specific survival on univariate (but not multivariate) analysis between carcinomas with serrated pattern and non-mucinous conventional colonic carcinomas at ≥ 5% epithelial serrations (P = 0.04).SAC category shows a limited impact on survival, and this phenotype may harbour a unique immunological milieu.

Mucinous adenocarcinoma (MAD), the most common subtype of colonic adenocarcinoma (CA), requires50% intratumoral mucin. There is limited data regarding the impact of MAD on key lymphocyte subsets and therapeutically critical immune elements. In this study we address: (1) the definition of MAD, (2) grading of MAD, and (3) the impact of MAD and extracellular mucin on intratumoral immune milieu. Estimation of the percentage of intratumoral mucin was performed by two pathologists. Tissue microarrays were stained for immune markers including CD8, CD163, PD-L1, FoxP3, β2 microglobulin, HLA class I, and HLA class II. Immunohistochemistry for BRAF V600E was performed. MMR status was determined on immunohistochemistry for MSH2, MSH6, MLH1, PMS2. Manual and automated HALO platforms were used for quantification. The 903 CAs included 62 (6.9%) MAD and 841 CA with ≤ 50% mucin. We identified 225 CAs with mucinous differentiation, defined by ≥10% mucin. On univariate analysis neither cut point, 50% (p = 0.08) and 10% (p = 0.08) mucin, correlated with disease-specific survival (DSS). There were no differences in key clinical, histological and molecular features between MAD and CA with mucinous differentiation. On univariate analysis of patients with MAD, tumor grade correlated with DSS (p = 0.0001) while MMR status did not (p = 0.86). There was no statistically significant difference in CD8 (P = 0.17) and CD163 (P = 0.05) positive immune cells between MAD and conventional CA. However, deficient (d) MMR MADs showed fewer CD8 (P = 0.0001), CD163 (P = 0.0001) and PD-L1 (P = 0.003) positive immune cells compared to proficient (p)MMR MADs, a finding also seen with at 10% mucin cut point. Although MAD does not impact DSS, this study raises the possibility that the immune milieu of dMMR MADs and tumors with =10% mucin may differ from pMMR MADs and tumors with10% mucin, a finding that may impact immune-oncology based therapeutics.

Let (R,m,k) be a one-dimensional analytically unramified local ring with minimal prime ideals P_1,...,P_s. Our ultimate goal is to study the direct-sum behavior of maximal Cohen-Macaulay modules over R. Such behavior is encoded by the monoid C(R) of isomorphism classes of maximal Cohen-Macaulay R-modules: the structure of this monoid reveals, for example, whether or not every maximal Cohen-Macaulay module is uniquely a direct sum of indecomposable modules; when uniqueness does not hold, invariants of this monoid give a measure of how badly this property fails. The key to understanding the monoid C(R) is determining the ranks of indecomposable maximal Cohen-Macaulay modules. Our main technical result shows that if R/P_1 has infinite Cohen-Macaulay type and the residue field k is infinite, then there exist |k| pairwise non-isomorphic indecomposable maximal Cohen-Macaulay R-modules of rank (r_1,...,r_s) provided r_1 is greater than or equal to r_i for all i. This result allows us to describe the monoid C(R) when all analytic branches of R have infinite Cohen-Macaulay., Comment: 14 pages, submitted

Therapeutic plasma exchange (TPE) is a potentially life-saving procedure which effectively removes donor-specific human leukocyte antigen (HLA) antibodies from the bloodstream, allowing critically ill heart transplant recipients to receive a donor organ with less wait time, and reducing the risk of acute organ rejection. The bulk of coagulation factors is initially removed from the blood during TPE using albumin and is later replaced with allogeneic plasma. Coagulopathy may develop during TPE and then can persist due to intraoperative blood loss and hemodilution during surgery and cardiopulmonary bypass. We hereby describe the utility of rotational thromboelastometry to assess rapid coagulation changes during TPE and subsequent heart transplant (HT) surgery.

J Clin Hypertens (Greenwich). 2011;13:598–604.©2011 Wiley Periodicals, Inc. Hypertension is prevalent in the United States and remains uncontrolled. The primary objective of the study was to determine the effect of once-daily dosing of a combination therapy for blood pressure (BP) and dyslipidemia using home BP monitoring on reaching clinical BP and the effect of daily dosing of combination therapy on reaching lipid goals. The study was conducted in middle-aged, indigent, African Americans who had high-risk, resistant hypertension and dyslipidemia. Patients were randomly assigned to either the home and clinic BP group or usual care group and were followed for 6 months. The average BPs for each group were compared and used to titrate the study drug appropriately. Both groups achieved significant declines in BP, total cholesterol, and low-density lipoprotein (LDL) (P

Let (R,m) be a local ring, and let M and N be finite R-modules. In this paper we give a formula for the degree of the polynomial giving the lengths of the modules ExtiR(M,N/mnN). A number of corollaries are given, and more general filtrations are also considered.

Let R be local Noetherian ring of depth at least two. We prove that there are indecomposable R-modules which are free on the punctured spectrum of constant, arbitrarily large, rank.

J Clin Hypertens (Greenwich). 2011;13:598–604.©2011 Wiley Periodicals, Inc. Hypertension is prevalent in the United States and remains uncontrolled. The primary objective of the study was to determine the effect of once‐daily dosing of a combination therapy for blood pressure (BP) and dyslipidemia using home BP monitoring on reaching clinical BP and the effect of daily dosing of combination therapy on reaching lipid goals. The study was conducted in middle‐aged, indigent, African Americans who had high‐risk, resistant hypertension and dyslipidemia. Patients were randomly assigned to either the home and clinic BP group or usual care group and were followed for 6 months. The average BPs for each group were compared and used to titrate the study drug appropriately. Both groups achieved significant declines in BP, total cholesterol, and low‐density lipoprotein (LDL) (P