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Importance: The introduction of the cardiotocogram (CTG) during labor has not been found to improve neonatal outcome. The search for a more reliable, less invasive, and patient-friendly technique is ongoing. The noninvasive fetal electrocardiogram (NI-fECG) has been proposed as one such alternative.Objectives: The aim of this study was to review the literature on the performance of NI-fECG for fetal monitoring during labor. Following the PRISMA guidelines, a systematic search in MEDLINE, EMBASE, and Cochrane Library was performed. Studies involving original research investigating the performance of NI-fECG during labor were included. Animal studies and articles in languages other than English, Dutch, or German were excluded. The QUADAS-2 checklist was used for quality assessment. A descriptive analysis of the results is provided.Results: Eight articles were included. Pooled analysis of the results of the separate studies was not possible due to heterogeneity. All studies demonstrate that it is possible to apply NI-fECG during labor. Compared with Doppler ultrasound, NI-fECG performs equal or better in most studies.Conclusions and Relevance: NI-fECG for fetal monitoring is a promising noninvasive and patient-friendly technique that provides accurate information. Future studies should focus on signal quality throughout labor, with the aim to further optimize technical development of NI-fECG.

Introduction and importance: The caesarean section is a widely spread procedure and 29.7 million times performed every year inn 169 countries in the world. Overall, complications are seen in 6% for elective caesarean to 15% for emergency caesarean. Case presentation We here report a case which was initially diagnosed as a postoperative paralytic ileus. After a complicated caesarean section caused by bleeding and problems with haemostasis, a healthy child was born with full mother recovery for the first 24 hours after surgery. Unfortunately, her condition deteriorated between 24 and 48 hours and she reported progressive nausea and painful bloating. Laboratory tests and CT imaging showed progressive signs of inflammation and distention of the caecum and colon. A second CT scan the next day revealed signs of perforation. An ileocecal resection was performed with a primary anastomosis. Full recovery occurred two weeks later. Clinical discussion With an estimated incidence of only 0,08%, bowel perforations due to caesarean section, are rare. Moreover, is the clinical presentation diverse and computed topography is essential during the diagnostic process. To avoid potential morbidity and mortality, the surgeon must consider performing a laparotomy in case of a deteriorating patient in non-invasive treatment fails. Conclusion Caecal perforation must be considered as complication after a caesarean section. An ileocecal resection is necessary in this situation. This case report shows that a primary anastomosis is a possible option in a healthy patient that is hemodynamically stable during the operation. In case of an unhealthy or hemodynamic unstable patient, the safest option is a temporary ileostomy., Highlights 1. Caecal perforation is a possible complication of a complicated caesarean section and should be part of the differential diagnosis in clinical detoriation. 2. If the condition of the women deteriorates do not hesitate to repeat CT or to perform an immediate surgical inspection. 3. A primary ileo-colic anastomosis could be a safe option in an otherwise healthy patient that is hemodynamically stable during surgery.

Pinprick-evoked brain potentials (PEPs) have been proposed as a technique to investigate secondary hyperalgesia and central sensitization in humans. However, the signal-to-noise (SNR) of PEPs is low. Here, using time-frequency analysis, we characterize the phase-locked and non-phase-locked EEG responses to pinprick stimulation, before and after secondary hyperalgesia.Secondary hyperalgesia was induced using high-frequency electrical stimulation (HFS) of the left/right forearm skin in 16 volunteers. EEG responses to 64 and 96mN pinprick stimuli were elicited from both arms, before and 20min after HFS.Pinprick stimulation applied to normal skin elicited a phase-locked low-frequency (5Hz) response followed by a reduction of alpha-band oscillations (7-10Hz). The low-frequency response was significantly increased when pinprick stimuli were delivered to the area of secondary hyperalgesia. There was no change in the reduction of alpha-band oscillations. Whereas the low-frequency response was enhanced for both 64 and 96mN intensities, PEPs analyzed in the time domain were only significantly enhanced for the 64mN intensity.Time-frequency analysis may be more sensitive than conventional time-domain analysis in revealing EEG changes associated to secondary hyperalgesia.Time-frequency analysis of PEPs can be used to investigate central sensitization in humans.

Contains fulltext : 171436.pdf (Publisher’s version ) (Open Access) Triple-negative breast cancer is associated with early recurrence and low survival rates. Several trials investigate the safety of a more conservative approach of axillary treatment in clinically T1-2N0 breast cancer. Triple-negative breast cancer comprises only 15 % of newly diagnosed breast cancers, which might result in insufficient power for representative results for this subgroup. We aimed to provide a nationwide overview on the occurrence of (regional) recurrences in triple-negative breast cancer patients with a clinically T1-2N0 status. For this cohort study, 2548 women diagnosed between 2005 and 2008 with clinically T1-2N0 triple-negative breast cancer were selected from the Netherlands Cancer Registry. Follow-up data until 2014 were analyzed using Kaplan-Meier. Sentinel lymph node biopsy was performed in 2486 patients, and (completion) axillary lymph node dissection in 562 patients. Final pathologic nodal status was pN0 in 78.5 %, pN1mi in 4.5 %, pN1 in 12.3 %, pN2-3 in 3.6 %, and pNx in 1.1 %. During a follow-up of 5 years, regional recurrence occurred in 2.9 %, local recurrence in 4.2 % and distant recurrence in 12.2 %. Five-year disease-free survival was 78.7 %, distant disease-free survival 80.5 %, and 5-year overall survival 82.3 %. Triple-negative clinically T1-2N0 breast cancer patients rarely develop a regional recurrence. Their disease-free survival is more threatened by distant recurrence, affecting their overall survival. Consequently, it seems justified to include triple-negative breast cancer patients in randomized controlled trials investigating the safety of minimizing axillary staging and treatment.

Background The effect of extended adjuvant aromatase inhibition in hormone-positive breast cancer after sequential tamoxifen, aromatase inhibitor treatment of 5 years was recently investigated by the DATA study. This study found no statistically significant effect of prolonged aromatase therapy. However, subgroup analysis showed post hoc statistically significant benefits in certain sub-populations. The trans-DATA study is a translational sub-study aiming to identify DNA methylation markers prognostic of patient outcome. Methods Patients from the DATA study are included in the trans-DATA study. Primary breast tumour tissue will be collected, subtyped and used for DNA isolation. A genome-wide DNA methylation discovery assay will be performed on 60 patients that had a distant recurrence and 60 patients that did not have a distant recurrence using the Infinium Methylation EPIC Bead Chip platform. Differentially methylated regions of interest will be selected based on Akaike’s Information Criterion, Gene Ontology Analysis and correlation between methylation and expression levels. Selected candidate genes will subsequently be validated in the remaining patients using qMSP. Discussion The trans-DATA study uses a cohort derived from a clinical randomised trial. This study was designed to avoid common pitfalls in marker discovery studies such as selection bias, confounding and lack of reproducibility. In addition to the usual clinical risk factors, the results of this study may identify predictors of high recurrence risk in hormone receptor-positive breast cancer patients treated with sequential tamoxifen and aromatase inhibitor therapy.

Background The multifactorial pathogenesis leading to dilated cardiomyopathy (DCM) makes stratification difficult. The recent MOGE(S) (morphofunctional, organ involvement, genetic or familial, etiology, stage) classification addresses this issue. Objectives The purpose of this study was to investigate the applicability and prognostic relevance of the MOGE(S) classification in patients with DCM. Methods This study used patients from the Maastricht Cardiomyopathy Registry in the Netherlands and excluded patients with ischemic, valvular, hypertensive, and congenital heart disease. All other patients underwent a complete diagnostic work-up, including genetic evaluation and endomyocardial biopsy. Results A total of 213 consecutive patients with DCM were included: organ involvement was demonstrated in 35 (16%) and genetic or familial DCM in 70 (33%) patients, including 16 (8%) patients with a pathogenic mutation. At least 1 cause was found in 155 (73%) patients, of whom 48 (23%) had more than 1 possible cause. Left ventricular reverse remodeling was more common in patients with nongenetic or nonfamilial DCM than in patients with genetic or familial DCM (40% vs. 25%; p = 0.04). After a median follow-up of 47 months, organ involvement and higher New York Heart Association functional class were associated with adverse outcome (p Conclusions The MOGE(S) classification in DCM is applicable, and each attribute or the gene-environment interaction is associated with outcome. Importantly, the presence of multiple attributes was a strong predictor of adverse outcome. Finally, adaptation of the MOGE(S) involving multiple possible etiologies is recommended.

Background. The impact of drug prescriptions in real life as opposed to strict clinical trial prescription is only rarely assessed, although it is well recognized that incorrect use may harm patients and may have a significant impact on health care resources. We investigated the use and effectiveness of adjuvant trastuzumab in daily practice compared with the effectiveness in clinical trials. Methods. We included all patients with stage I–III invasive breast cancer, irrespective of human epidermal growth factor receptor 2 (HER2) status, diagnosed in five hospitals in the southeast of The Netherlands in 2005–2007. We aimed to assess the actual use of adjuvant trastuzumab in early HER2-positive breast and its efficacy in daily practice. Results. Of 2,684 patients included, 476 (17.7%) had a HER2-positive tumor. Of these, 251 (52.7%) patients had an indication for trastuzumab treatment of which 196 (78.1%) patients actually received it. Of the 225 patients without an indication, 34 (15.1%) received trastuzumab. Five-year disease-free survival was 80.7% for (n = 230) patients treated with versus 68.2% for (n = 246) patients not treated with trastuzumab (p = .0023), and 5-year overall survival rates were 90.7% and 77.4%, respectively (p = .0002). The hazard ratio for disease recurrence was 0.63 (95% confidence interval, 0.37–1.06) for trastuzumab when adjusting for potential confounders. Conclusion. This study shows that in real life, patients treated with trastuzumab in early-stage HER2-positive breast cancer had a 5-year disease-free and overall survival comparable to prior randomized trials. For informative decision making, real-life data are of additional value, providing insight on outcome of patients considered ineligible for treatment.

Current genome-wide methods to detect DNA-methylation in healthy and diseased tissue require high-quality DNA from fresh-frozen (FF) samples. However, well-annotated clinical samples are mostly available as formalin-fixed, paraffin-embedded (FFPE) tissues containing poor-quality DNA. To overcome this limitation, we here aimed to evaluate a DNA restoration protocol for usage with the genome-wide Infinium HumanMethylation450 BeadChip assay (HM-450K). Sixty-six DNA samples from normal colon (n = 9) and breast cancer (n = 11) were interrogated separately using HM-450K. Analyses included matched FF/FFPE samples and technical duplicates. FFPE DNA was processed with (FFPEr) or without a DNA restoration protocol (Illumina). Differentially methylated genes were finally validated in 24 additional FFPE tissues using nested methylation-specific PCR (MSP). In summary, beta-values correlation between FFPEr duplicates was high (rho = 0.9927 (s.d. +/- 0.0015)). Matched FF/FFPEr correlation was also high (rho = 0.9590 (s.d. +/- 0.0184)) compared with matched FF/FFPE (rho = 0.8051 (s.d. +/- 0.1028). Probe detection rate in FFPEr samples (98.37%, s.d. +/- 0.66) was comparable to FF samples (99.98%, s.d. +/- 0.019) and substantially lower in FFPE samples (82.31%, s.d. +/- 18.65). Assay robustness was not decreased by sample archival age up to 10 years. We could also demonstrate no decrease in assay robustness when using 100 ng of DNA input only. Four out of the five selected differentially methylated genes could be validated by MSP. The gene failing validation by PCR showed high variation of CpG beta-values in primer-binding sites. In conclusion, by using the FFPE DNA restoration protocol, HM-450K assays provide robust, accurate and reproducible results with FFPE tissue-derived DNA, which are comparable to those obtained with FF tissue. Most importantly, differentially methylated genes can be validated using more sensitive techniques, such as nested MSP, altogether providing an epigenomics platform for molecular pathological epidemiology research on archived samples with limited tissue amount.

Background The lifetime risk of developing breast cancer is 1 in 8 for women in the Netherlands. Breast cancer care in the Netherlands is of high quality, resulting in low 5-year local recurrence rates of 1.5% after breast conserving therapy and 2.7% after mastectomy. Although good endpoints of breast cancer treatment are obtained, it is expected that further improvement of care can be achieved since unexplained variation in a number of treatment aspects was found between hospitals in the Netherlands. Clinical audits provide an important tool for quality assessment. Worldwide, only a few nationwide clinical audits for breast cancer care are currently running. In the Netherlands, a nationwide multidisciplinary clinical audit started three years ago. Material and methods The multidisciplinary national NABON Breast Cancer Audit (NBCA) started collecting data of all Dutch hospitals in 2011, facilitated by Comprehensive Cancer Centre the Netherlands (IKNL) and Dutch Institute for Clinical Auditing (DICA). The NBCA has several purposes: nation-wide evaluation of quality parameters, evaluation of guideline adherence, and providing weekly updated feedback to participating institutions. Results All Dutch hospitals (n=92) participate by providing data regarding delivered breast cancer care resulting in a database of more than 42.000 breast cancer patients (5.745 DCIS and 36.396 invasive carcinomas) in three years time. Eighty-nine percent of invasive breast cancer patients were treated with primary surgery of which 62% (n=19.885) with breast conserving surgery. Within three years time, several quality assessments improved such as guideline compliance for pre- and postoperative multidisciplinary team meetings, percentage of patients starting surgery within five weeks (see table). The percentage of patients that were treated with preoperative systemic treatment (12%; 95% CI: 0 – 47%) and patients receiving an immediate reconstruction after ablative surgery (19%; 95% CI 0 – 73%) still remained low with a large variation between hospitals. At the conference, results will be substantiated by funnelplots. Other quality indicators will be presented as well. Table 1. Quality indicator results and their improvement over years.20112013Preoperative MDT81%96%Postoperative MDT90%98%Time to operation ≤5 weeks (immediate reconstruction after mastectomy excluded)80%85%Tumor positive margins invasive breast cancer (without PST)6.1%5.0%Tumor positive margins DCIS25%20%PST for invasive breast cancer10%12%Immediate reconstruction after ablative surgery for invasive breast cancer15%19%Immediate reconstruction after ablative surgery for DCIS39%44%MDT= Multi-disciplinary team meeting; PST= Primary Systemic Treatment; DCIS= Ductal Carcinoma In Situ Conclusions The continuous cycle of registration and providing feedback by clinical auditing provides a powerful tool for quality monitoring and improving breast cancer care. Improvements of monodisciplinairy surgical and pathological aspects of care have been reached in a relatively short time period. However, for more complicated multidisciplinary issues like the use of primary systemic treatment and immediate reconstruction, detailed analyses of the variation between hospitals is needed to further improve these aspects of breast cancer care. Citation Format: Annelotte C van Bommel, Marie-Jeanne T Baas-Vrancken Peeters, Margriet van der Heiden - van der Loo, Thijs van Dalen, Emiel J Rutgers, Michel W Wouters, Marc B Lobbes, Ruud M Pijnappel, Marc A Mureau, Pieter J Westenend, Bart de Vries, Carolien H Smorenburg, Agnes Jager, John H Maduro, Henk Struikmans, Carol Richel, Marga Schrieks, Maike Schepens, Sabine Siesling, Vivianne C Tjan-Heijnen. The NABON breast cancer audit; quality improvement in three years' time [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-18.

Background Previous quality assessments in oncology focused on surgical issues such as number of annual operations per hospital. However, high-quality of care depends on an excellent interplay between all disciplines involved in cancer care. The NABON (National Breast Cancer Organisation of the Netherlands) has, therefore, developed a multidisciplinary set of 30 quality indicators to check and improve breast cancer care. Health insurers have recently decided to use this information for purchasing. Methods The NABON Breast Cancer Audit (NBCA) started in 2011. Data on all newly diagnosed patients with invasive breast cancer in the Netherlands are collected by the Netherlands Cancer Registry (n=61 hospitals) or by the physicians themselves (n=31 hospitals). Data capture is facilitated using a web-based portal and feedback to participating hospitals on their own data is being done every week. Since 2012 all Dutch hospitals participate. A set of quality indicators on process and outcome was selected following established clinical guidelines and is being supervised by a multidisciplinary steering committee. Results Data of all 41,958 breast cancer patients treated between 2011 and 2013 were collected. In 2013, 94% of patients were discussed in the multidisciplinary team prior to first treatment and 98% after surgery. BI-RADS score was used in 98% of radiological reports. After neo-adjuvant chemotherapy, 7.6% of patients had positive specimen margins following first breast conserving surgery compared to 5.0% and 20% of patients following primary breast conserving surgery for invasive cancer and ductal carcinoma in situ, respectively. Eighteen percent and 36% of patients underwent immediate breast reconstruction after mastectomy for invasive cancer and ductal carcinoma in situ, respectively. Pathological analysis showed 12% of patients had HER2 positive and 85% had ER positive disease. Neo-adjuvant or adjuvant systemic therapy was given to 63% of patients and neo-adjuvant or adjuvant chemotherapy to 39% of patients. Time between diagnosis and first treatment was generally short: 49% to 85% underwent primary surgery with and without immediate reconstruction, respectively, and 76% underwent neo-adjuvant chemotherapy within 5 weeks from first biopsy. At the conference we will show that variation between hospitals was not related to annual surgical volume per hospital. Conclusion The NBCA is a unique national system to provide and confirm quality assessment in breast cancer and to drive improvements in quality of multidisciplinary breast cancer care. Present results show an overall high quality of care in the Netherlands and provide insight in items of improvement. Citation Format: Vivianne C Tjan-Heijnen, Annelotte C van Bommel, Margriet van der Heiden-van der Loo, Pieter Westenend, Bart de Vries, Carolien H Smorenburg, Agnes Jager, Marc B Lobbes, Ruud M Pijnappel, John H Maduro, Henk Struikmans, Marc A Mureau, Marga Schrieks, Carol Richel, Maike Schepens, Thijs van Dalen, Michel W Wouters, Marie-Jeanne T Vrancken Peeters, Emiel J Rutgers, Sabine Siesling. Multidisciplinary breast cancer care registry and quality control system in the Netherlands: The NABON breast cancer audit [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-11-03.

Purpose To evaluate the diagnostic performance of unenhanced axillary T2-weighted and diffusion-weighted (DW) magnetic resonance (MR) imaging for axillary nodal staging in patients with newly diagnosed breast cancer, with node-by-node and patient-by-patient validation. Materials and Methods Institutional review board approval and informed consent were obtained. Fifty women (mean age, 60 years; range, 22-80 years) underwent high-spatial-resolution axillary 3.0-T T2-weighted imaging without fat suppression and DW imaging (b = 0, 500, and 800 sec/mm2), followed by either sentinel lymph node biopsy (SLNB) or axillary lymph node dissection. Two radiologists independently scored each lymph node on a confidence level scale from 0 (benign) to 4 (malignant), first on T2-weighted MR images, then on DW MR images. Two researchers independently measured the mean apparent diffusion coefficient (ADC) of each lymph node. Diagnostic performance parameters were calculated on the basis of node-by-node and patient-by-patient validation. Results With respective node-by-node and patient-by-patient validation, T2-weighted MR imaging had a specificity of 93%-97% and 87%-95%, sensitivity of 32%-55% and 50%-67%, negative predictive value (NPV) of 88%-91% and 86%-89%, positive predictive value (PPV) of 60%-70% and 62%-75%, and area under the receiver operating characteristic curve (AUC) of 0.78 and 0.80-0.88, with good interobserver agreement (kappa = 0.70). The addition of DW MR imaging resulted in lower specificity (59%-88% and 50%-84%), higher sensitivity (45%-64% and 75%-83%), comparable NPV (89% and 90%-91%), lower PPV (23%-42% and 34%-60%), and lower AUC (0.68-0.73 and 0.70-0.86). ADC measurement resulted in a specificity of 63%-64% and 61%-63%, sensitivity of 41% and 67%, NPV of 85% and 85%-86%, PPV of 18% and 35%-36%, and AUC of 0.54-0.58 and 0.69-0.74, respectively, with excellent interobserver agreement (intraclass correlation coefficient, 0.83). Conclusion Dedicated high-spatial-resolution axillary T2-weighted MR imaging showed good specificity on the basis of node-by-node and patient-by-patient validation, with good interobserver agreement. However, its NPV is still insufficient to substitute it for SLNB for exclusion of axillary lymph node metastasis. DW MR imaging and ADC measurement were of no added value. (c) RSNA, 2014.

Background - Contrast-enhanced spectral mammography (CESM) is a promising new breast imaging modality that is superior to conventional mammography for breast cancer detection. We aimed to evaluate correlation and agreement of tumor size measurements using CESM. As additional analysis, we evaluated whether measurements using an additional breast MRI exam would yield more accurate results. Methods - Between January 1st 2013 and April 1st 2014, 87 consecutive breast cancer cases that underwent CESM were collected and data on maximum tumor size measurements were gathered. In 57 cases, tumor size measurements were also available for breast MRI. Histopathological results of the surgical specimen served as gold standard in all cases. Results - The Pearson's correlation coefficients (PCC) of CESM versus histopathology and breast MRI versus histopathology were all >0.9, p1 cm between the two imaging modalities and histopathological results, we did not observe any advantage of performing an additional breast MRI after CESM in any of the cases. Conclusion - Quality of tumor size measurement using CESM is good and matches the quality of these measurement assessed by breast MRI. Additional measurements using breast MRI did not improve the quality of tumor size measurements.

BACKGROUND: Gut immaturity is linked with postnatal intestinal disorders. However, biomarkers to assess the intestinal developmental stage around birth are lacking. The aim of this study was to gain more insight on intestinal fatty acid binding protein (I-FABP) as an indicator of gut maturity. METHODS: Antenatal I-FABP distribution and release was investigated in extremely premature, moderately premature, and term lambs, and these findings were verified in human urinary samples. Heal I-FABP distribution was confirmed in autopsy material within 24h postnatally. RESULTS: Median (range) serum I-FABP levels were lower in extremely premature lambs compared with moderately premature lambs (156 (50.0-427) vs. 385 (100-1,387) pg/ml; P = 0.02). Contrarily, median early postnatal urine I-FABP levels in human infants were higher in extremely premature compared with moderately premature and term neonates (1,219 (203-15,044) vs. 256 (50-1,453) and 328 (96-1,749) pg/ml; P = 0.008 and P = 0.04, respectively). I-FABP expression was most prominent in nonvacuolated enterocytes and increased with rising gestational age (GA) in ovine and human tissue samples. The epithelial distribution pattern changed from a phenotype displaying I-FABP-positive enterocytes merely in the crypts early in gestation into a phenotype with I-FABP expressing cells exclusively present in the villus tips at term in ovine and human tissue. CONCLUSION: In this ovine and human study, increasing GA is accompanied by an increase in I-FABP tissue content. Cord I-FABP levels correlate with gestation in ovine fetuses, identifying I-FABP as a marker for gut maturation. Raised postnatal urine I-FABP levels in preterm human infants may indicate intestinal injury and/or inflammation in utero.

Background Between 20% and 42% of patients with clinically node-positive breast cancer achieve a pathologic complete response (pCR) of axillary lymph nodes after neoadjuvant chemotherapy or immunotherapy, or both, (chemo[immuno]therapy). Hypothetically, axillary lymph node dissection (ALND) may be safely omitted in these patients. This study aimed to develop a model for predicting axillary pCR in these patients. Patients and Methods We retrospectively identified patients with clinically node-positive breast cancer who were treated with neoadjuvant chemo(immuno)therapy and ALND between 2005 and 2012 in 5 hospitals. Patient and tumor characteristics, neoadjuvant chemo(immuno)therapy regimens, and pathology reports were extracted. Binary logistic regression analysis was used to predict axillary pCR with the following variables: age, tumor stage and type, hormone receptor and human epidermal growth factor receptor 2 (HER2) status, and administration of taxane and trastuzumab. The model was internally validated by bootstrap resampling. The overall performance of the model was assessed by the Brier score and the discriminative performance by receiver operating characteristic (ROC) curve analysis. Results A model was developed based on 291 patients and was internally validated with a scaled Brier score of 0.14. The area under the ROC curve of this model was 0.77 (95% confidence interval [CI], 0.71-0.82). At a cutoff value of predicted probability ≥ 0.50, the model demonstrated specificity of 88%, sensitivity of 43%, positive predictive value (PPV) of 65%, and negative predictive value (NPV) of 75%. Conclusion This prediction model shows reasonable accuracy for predicting axillary pCR. However, omitting axillary treatment based solely on the nomogram score is not justified. Further research is warranted to noninvasively identify patients with axillary pCR.

Cellular proteins and organelles such as peroxisomes are under continuous quality control. Upon synthesis in the cytosol, peroxisomal proteins are kept in an import-competent state by chaperones or specific proteins with an analogous function to prevent degradation by the ubiquitin-proteasome system. During protein translocation into the organelle, the peroxisomal targeting signal receptors (Pex5, Pex20) are also continuously undergoing quality control to enable efficient functioning of the translocon (RADAR pathway). Even upon maturation of peroxisomes, matrix enzymes and peroxisomal membranes remain subjected to quality control. As a result of their oxidative metabolism, peroxisomes are producers of reactive oxygen species (ROS), which may damage proteins and lipids. To counteract ROS-induced damage, yeast peroxisomes contain two important antioxidant enzymes: catalase and an organelle-specific peroxiredoxin. Additionally, a Lon-type protease has recently been identified in the peroxisomal matrix, which is capable of degrading nonfunctional proteins. Finally, cellular housekeeping processes keep track of the functioning of peroxisomes so that dysfunctional organelles can be quickly removed via selective autophagy (pexophagy). This review provides an overview of the major processes involved in quality control of yeast peroxisomes.

Background: The aim of this study was to evaluate the accuracy of clinical imaging of the primary breast tumour post-neoadjuvant chemotherapy (NAC) related to the post-neoadjuvant histological tumour size (gold standard) and whether this varies with breast cancer subtype. In this study, results of both magnetic resonance imaging (MRI) and ultrasound (US) were reported.Methods: Patients with invasive breast cancer were enrolled in the INTENS study between 2006 and 2009. We included 182 patients, of whom data were available for post-NAC MRI (n = 155), US (n = 123), and histopathological tumour size.Results: MRI estimated residual tumour size with Conclusions: In this study, US was at least as good as breast MRI in providing information on residual tumour size post-neoadjuvant chemotherapy. However, both modalities suffered from a substantial percentage of over- and underestimation of tumour size and in addition both showed a low negative predictive value of pathologic complete remission (Gov nr: NCT00314977).

We have analyzed the highly conserved N-terminus of Hansenula polymorpha Pex14p for its function in peroxisomal matrix protein import. The region comprising aa 10-54 of HpPex14p is predicted to contain three alpha-helices. Its alpha-helical structure was confirmed by CD analysis of a synthetic peptide, corresponding to residues 8-58. Deletion of aa 1-21 of HpPex14p, but not of aa 1-9, completely abolished PTS1 and PTS2 matrix protein import. An extensive mutational analysis of the first a-helix (aa 10-21) demonstrated that its secondary structure, as well as residues Phe20 and Leu21, are essential for PTS1 and PTS2 matrix protein import. (c) 2007 Federation of European Biochemical Societies. Published by Elsevier B.V. All rights reserved.

in this study the role of myeloperoxidase (MPO) in a murine (C57BL/6) model of ischemia and reperfusion (I/R)-induced renal failure was investigated. The renal function after I/R was analyzed in MPO-deficient (Mpo(-/-)) mice and compared with wild-type (WT) controls. A significant reduction in renal function loss (blood urea nitrogen) was observed after 24 hours of reperfusion of ischemically damaged kidneys in Mpo(-/-) mice compared with I/R WT controls (I/R MPo-/- = 31.3 +/- 1.7 mmol/L versus I/R WT = 42.8 +/- 2.1 mmol/L, sham = 7.0 +/- 0.5 mmol/L; P = 0.003). The early reperfusion phase (2 hours of reperfusion) was characterized by a substantial increase in apoptosis and early complement activation, surprisingly similar in Mpo(-/-) and WT mice. Improved renal function in Mpo(-/-) mice after extended reperfusion was accompanied by a reduced neutrophil influx (P = 0.017) compared with WT controls. Activation and deposition of complement was not significantly reduced in Mpo(-/-) mice compared with WT controls after 24 hours of reperfusion, indicating no specific in vivo role for MPO in activating complement after renal I/R. Taken together, these results demonstrated an important contribution of MPO in the induction of organ damage after renal I/R by influencing critical factors such as neutrophil extravasation but not complement activation.

The multifactorial pathogenesis leading to dilated cardiomyopathy (DCM) makes stratification difficult. The recent MOGE(S) (morphofunctional, organ involvement, genetic or familial, etiology, stage) classification addresses this issue.The purpose of this study was to investigate the applicability and prognostic relevance of the MOGE(S) classification in patients with DCM.This study used patients from the Maastricht Cardiomyopathy Registry in the Netherlands and excluded patients with ischemic, valvular, hypertensive, and congenital heart disease. All other patients underwent a complete diagnostic work-up, including genetic evaluation and endomyocardial biopsy.A total of 213 consecutive patients with DCM were included: organ involvement was demonstrated in 35 (16%) and genetic or familial DCM in 70 (33%) patients, including 16 (8%) patients with a pathogenic mutation. At least 1 cause was found in 155 (73%) patients, of whom 48 (23%) had more than 1 possible cause. Left ventricular reverse remodeling was more common in patients with nongenetic or nonfamilial DCM than in patients with genetic or familial DCM (40% vs. 25%; p = 0.04). After a median follow-up of 47 months, organ involvement and higher New York Heart Association functional class were associated with adverse outcome (p0.001 and p = 0.02, respectively). Genetic or familial DCM per se was of no prognostic significance, but when it was accompanied by additional etiologic-environmental factors such as significant viral load, immune-mediated factors, rhythm disturbances, or toxic triggers, a worse outcome was revealed (p = 0.03). A higher presence of MOGE(S) attributes (≥2 vs. ≤1 attributes) showed an adverse outcome (p = 0.007).The MOGE(S) classification in DCM is applicable, and each attribute or the gene-environment interaction is associated with outcome. Importantly, the presence of multiple attributes was a strong predictor of adverse outcome. Finally, adaptation of the MOGE(S) involving multiple possible etiologies is recommended.

We showed before that the two oppositely directed processes of peroxisome biogenesis and selective peroxisome degradation (macropexophagy) converge at the peroxisomal membrane protein Pex14p. Here we show that this protein is not required for peroxisomal degradation during nitrogen starvation-induced general autophagy, thereby limiting its function to the selective degradation process. Pex14p is present in two forms, namely an unmodified (Pex14p) and a phosphorylated form (Pex14pPi) that are differently induced during peroxisome proliferation. The data suggest that Pex14p is required for peroxisome biogenesis during organelle proliferation and Pex14pPi in macropexophagy. Finally, we show that macropexophagy is not coupled to normal peroxisome assembly and is required in only catalytic amounts to allow initiation of the selective peroxisome degradation process.

This study investigated local and systemic innate immune responses in lipopolysaccharide (LPS)-induced lung inflammation in mice. Intratracheal LPS exposure resulted in increased pulmonary mRNA expression for acute-phase reactants (APRs) alpha(1)-antitrypsin (alpha(1)-AT), alpha(1)-acid glycoprotein (AGP), and LPS-binding protein (LBP) from 4 hours post exposure. Although pulmonary serum amyloid P component (SAP) mRNA was not increased, systemic levels of SAP, AGP, and LBP were elevated from 24 hours post exposure. Systemic APRs increase was associated with hepatic mRNA expression. As in vivo neutralization of interleukin (IL)-6, but not tumor necrosis factor (TNF)-alpha, fully ablated hepatic APR mRNA expression, IL-6 may act as signaling molecule between lung and liver. In conclusion, pulmonary LPS exposure induced rapid APR expression in lung, which precedes IL-6-mediated systemic elevation of APRs associated with hepatic APRs expression.

Ischemic damage plays an important role in post-transplant organ failure. Activation of the apoptotic cascade is crucially involved in post-ischemic inflammation resulting in tissue damage and organ dysfunction. Here we investigate the initiation of the apoptotic cascade during normothermic ischemia in human kidneys using a model for normothermic ischemia with kidneys nephrectomized because of renal cell carcinoma. Ex vivo, kidneys were stored at 37 degrees C, and consecutive biopsies were taken from disease-free tissue. Pro- and anti-apoptotic proteins were assessed by Western blotting and immunofluorescence. During normothermic ischemia the pro-apoptotic proteins Bax and activated caspase-9 increased with ischemia time, whereas caspase-8 was not activated. The anti-apoptotic proteins Bcl-2 and cFLIP decreased in time. Data on Bcl-2 and Bax were supported by immunofluorescence for Bcl-2 and activated Bax. However, activation of the central effector caspase-3, essential for execution of the apoptotic process, was not detected. In conclusion, during normothermic ischemia the apoptotic cascade in the human kidney is initiated, but not fulfilled. Our data show that the duration of ischemia significantly correlates with activation of the apoptotic cascade. These findings provide insight in the initiation of apoptotic cell-death during warm ischemia and may be useful in the assessment of ischemic injury.

BACKGROUND: Warm ischemia-reperfusion (I/R) injury plays an important role in posttransplant organ failure. In particular, organs from marginal donors suffer I/R injury. Although iron has been implicated in the pathophysiology of renal I/R injury, the mechanism of iron-mediated injury remains to be established. The authors therefore investigated the role of circulating redox-active iron in an experimental model for renal I/R injury. METHODS: Male Swiss mice were subjected to unilateral renal ischemia for 45 min, followed by contralateral nephrectomy and reperfusion. To investigate the role of circulating iron, mice were treated with apotransferrin, an endogenous iron-binding protein, or iron-saturated apotransferrin (holotransferrin). RESULTS: Renal ischemia induced a significant increase in circulating redox-active iron levels during reperfusion. Apotransferrin, in contrast to holotransferrin, reduced the amount of circulating redox-active iron and abrogated renal superoxide formation. Apotransferrin treatment did not affect I/R-induced renal apoptosis, whereas holotransferrin aggravated apoptotic cell death. Apotransferrin, in contrast to holotransferrin, inhibited the influx of neutrophils. Both apo- and holotransferrin reduced I/R-induced complement deposition, indicating that the effects of transferrin are differentially mediated by its iron and protein moiety. Finally, apotransferrin, in contrast to holotransferrin, dose-dependently inhibited the loss of renal function induced by ischemia. CONCLUSIONS: Redox-active iron is released into the circulation in the course of renal I/R. Reducing the amount of circulating redox-active iron by treatment with apotransferrin protects against renal I/R injury, inhibiting oxidative stress, inflammation, and loss of function. Apotransferrin could be used in the treatment of acute renal failure, as seen after transplantation of ischemically damaged organs.

Ischemia-reperfusion (I/R) is an important cause of acute renal failure (ARF). The complement system appears to be essentially involved in I/R injury. However, via which pathway the complement system is activated and in particular whether the mannose-binding lectin (MBL)-pathway is activated is unclear. This tempted us to study the activation and regulation of the MBL-pathway in the course of experimental renal I/R injury and in clinical post-transplant ARF. Mice subjected to renal I/R displayed evident renal MBL-depositions, depending on the duration of warm ischemia, in the early reperfusion phase. Renal deposition of C3, C6 and C9 was observed in the later reperfusion phase. The deposition of MBL-A and -C completely co-localized with the late complement factor C6, showing that MBL is involved in complement activation in the course of renal I/R injury. Moreover, the degree of early MBL-deposition correlated with complement activation, neutrophil-influx, and organ-failure observed in the later reperfusion phase. In serum of mice subjected to renal I/R MBL-A, levels increased in contrast to MBL-C levels, which dropped evidently. In line, liver mRNA levels for MBL-A increased, whereas MBL-C levels decreased. Renal MBL mRNA levels rapidly dropped in the course of renal I/R. Finally, in human biopsies, MBL-depositions were observed early after transplantation of ischemically injured kidneys. In line with our experimental data, in ischemically injured grafts displaying post-transplant organ-failure extensive MBL depositions were observed in peritubular capillaries and tubular epithelial cells. In conclusion, in experimental renal I/R injury and clinical post-transplant ARF the MBL-pathway is activated, followed by activation of the complement system. These data indicate that the MBL-pathway is involved in ischemia-induced complement activation.

Lysophosphatidic acid prevents renal ischemia-reperfusion injury by inhibition of apoptosis and complement activation.de Vries B, Matthijsen RA, van Bijnen AA, Wolfs TG, Buurman WA.Department of General Surgery, Nutrition, and Toxicology Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.Renal ischemia-reperfusion (I/R) injury is an important cause of acute renal failure as observed after renal transplantation, major surgery, trauma, and septic as well as hemorrhagic shock. We previously showed that the inhibition of apoptosis is protective against renal I/R injury, indicating that apoptotic cell-death is an important feature of I/R injury. Lysophosphatidic acid (LPA) is an endogenous phospholipid growth factor with anti-apoptotic properties. This tempted us to investigate the effects of exogenous LPA in a murine model of renal I/R injury. LPA administered at the time of reperfusion dose dependently inhibited renal apoptosis as evaluated by the presence of internucleosomal DNA cleavage. I/R-induced renal apoptosis was only present in tubular epithelial cells with evident disruption of brush border as assessed by immunohistochemistry for active caspase-7 and filamentous actin, respectively. LPA treatment specifically prevented tubular epithelial cell apoptosis but also reduced the I/R-induced loss of brush-border integrity. Besides, LPA showed strong anti-inflammatory effects, inhibiting the renal expression of tumor necrosis factor-alpha and abrogating the influx of neutrophils. Next, LPA dose dependently inhibited activation of the complement system. Moreover, treatment with LPA abrogated the loss of renal function in the course of renal I/R. This study is the first to show that administration of the phospholipid LPA prevents I/R injury, abrogating apoptosis and inflammation. Moreover, exogenous LPA is capable of preventing organ failure because of an ischemic insult and thus may provide new means to treat clinical conditions associated with I/R injury in the kidney and potentially also in other organs

Background Complement has been implicated in the pathophysiology of renal ischemia-reperfusion (I/R) injury. However, the mechanism underlying complement-mediated renal I/R injury is thus far unknown. To investigate the involvement of complement in I/R injury, we studied the activation and deposition of complement in a murine model of renal I/R injury. Furthermore, we examined the effect of inhibition of complement-factor C5 on renal I/R injury. Methods. Mice were subjected to 45 min of unilateral ischemia and subsequent contralateral nephrectomy and reperfusion for 2, 12, or 24 hr. Mice were control treated or treated with BB5.1, a monoclonal antibody that prevents cleavage of complement factor C5, thereby preventing C5a generation and formation of the membrane attack complex (MAC). Results. Renal I/R induced extensive deposition of C3 early after reperfusion, whereas C6 and C9 deposition (MAC formation) occurred relatively late. I/R-induced complement deposition was mainly localized to tubular epithelium. Treatment with BB5.1 totally prevented MAC formation but also reduced C3 deposition. Inhibition of C5 strongly inhibited late inflammation, as measured by neutrophil influx and induction of the murine CXC chemokines macrophage inflammatory protein-2, KC, and lipopolysaccharide-induced CXC chemokine. Anti-C5 treatment furthermore abrogated late I/R; induced apoptosis, whereas early apoptosis was not affected. Moreover, BB5.1 treatment significantly protected against I/R-induced renal dysfunction. Conclusions. Renal LIR is followed by activation of the complement system and intrarenal deposition of C3 and MAC. Complement activation plays a crucial role in the regulation of inflammation and late apoptosis. Complement inhibition, by preventing C5 activation, abrogates late apoptosis and inflammation, being strongly protective against renal function loss.

Complement factor C5a mediates renal ischemia-reperfusion injury independent from neutrophils.de Vries B, Kohl J, Leclercq WK, Wolfs TG, van Bijnen AA, Heeringa P, Buurman WA.Department of General Surgery, Nutrition and Toxicology Research Institute Maastricht, The Netherlands.The complement system has been shown to mediate renal ischemia-reperfusion (I/R) injury. However, the contribution of complement factor C5a to I/R injury, in particular in the kidney, remains to be established. In this study, we investigated the impact of blocking the C5aR pathway on the inflammatory response and on the renal function in a murine model of I/R injury. First, we analyzed C5aR expression in kidneys of healthy mice. Intriguingly, we found expression on mesangial, as well as on tubular epithelial, cells. After I/R injury, C5aR expression was up-regulated in tubular epithelial cells. In addition, mRNA levels of CXC chemokines and TNF-alpha increased significantly and kidneys were heavily infiltrated by neutrophils. Blocking the C5aR pathway by a specific C5a receptor antagonist (C5aRA) abrogated up-regulation of CXC chemokines but not of TNF-alpha and reduced neutrophil infiltration by >50%. Moreover, application of the C5aRA significantly reduced loss of renal function. This improvement of function was independent of the presence of neutrophils because neutrophil depletion by mAb NIMP-R14 did not affect the protective effect of C5aRA treatment. Furthermore, blocking of the C5aR pathway had no influence on renal apoptosis. These data provide evidence that C5a is crucially involved in the pathogenesis of renal I/R injury by modulation of neutrophil-dependent as well as neutrophil-independent pathways, which include the regulation of CXC chemokines but not TNF-alpha or apoptotic pathways.

In vivo expression of Toll-like receptor 2 and 4 by renal epithelial cells: IFN-gamma and TNF-alpha mediated up-regulation during inflammation.Wolfs TG, Buurman WA, van Schadewijk A, de Vries B, Daemen MA, Hiemstra PS, van 't Veer C.Nutrition and Toxicology Research Institute Maastricht, Department of General Surgery, University of Maastricht, 6200 MD Maastricht, The Netherlands.The reported requirement of functional Toll-like receptor (TLR)4 for resistance to Gram-negative pyelonephritis prompted us to localize the expression of TLR2 and TLR4 mRNA in the kidney at the cellular level by in situ hybridization. The majority of the constitutive TLR2 and TLR4 mRNA expression was found to be strategically located in the renal epithelial cells. Assuming that the TLR mRNA expression is representative of apical protein expression, this suggests that these cells are able to detect and react with bacteria present in the lumen of the tubules. To gain insight in the regulation of TLR expression during inflammation, we used a model for renal inflammation. Renal inflammation evoked by ischemia markedly enhanced synthesis of TLR2 and TLR4 mRNA in the distal tubular epithelium, the thin limb of Henle's loop, and collecting ducts. The increased renal TLR4 mRNA expression was associated with significant elevation of renal TLR4 protein expression as evaluated by Western blotting. Using RT-PCR, the enhanced TLR2 and TLR4 mRNA expression was shown to be completely dependent on the action of IFN-gamma and TNF-alpha. These results indicate a potential mechanism of increased immunosurveillance during inflammation at the site in which ascending bacteria enter the kidney tissue, i.e., the collecting ducts and the distal part of the nephron.

Apoptosis and inflammation in renal reperfusion injury.Daemen MA, de Vries B, Buurman WA.Department of General Surgery, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands.Ischemia followed by reperfusion (I/R) has cardinal implications in the pathogenesis of organ transplantation and rejection. Apoptosis and inflammation are central mechanisms leading to organ damage in the course of renal I/R. General aspects of apoptosis, morphology, induction, and biochemistry are discussed. Activated caspases, the classical effector enzymes of apoptosis, are able to induce not only apoptosis but also inflammation after I/R in experimental models. This redefines the involvement of apoptosis in I/R injury toward a central and functional role in the development of organ damage. Our purpose is to assess aspects of apoptosis and inflammation in terms of involvement in the pathogenesis of I/R-induced organ damage. Moreover, the implications of recent experimental advances for diagnosis and treatment of renal I/R injury in clinical practice will be discussed.

In this paper we present a model that can be used to calculate hot carrier degradation in LDMOS devices within a circuit reliability simulation environment. The model is suitable for both nLDMOS and pLDMOS devices. We show experimental evidence on the applicability of this model over a broad range of V GS and V DS biases as well as temperature.

INTRODUCTION: Cyclooxygenase-2 (COX-2) is frequently over-expressed in primary breast cancer. In transgenic breast cancer models, over-expression of COX-2 leads to tumour formation while COX-2 inhibition exerts anti-tumour effects in breast cancer cell lines. To further determine the effect of COX-2 inhibition in primary breast cancer, we aimed to identify transcriptional changes in breast cancer tissues of patients treated with the selective COX-2 inhibitor celecoxib. METHODS: In a single-centre double-blind phase II study, thirty-seven breast cancer patients were randomised to receive either pre-operative celecoxib (400 mg) twice daily for two to three weeks (n = 22) or a placebo according to the same schedule (n = 15). Gene expression in fresh-frozen pre-surgical biopsies (before treatment) and surgical excision specimens (after treatment) was profiled by using Affymetrix arrays. Differentially expressed genes and altered pathways were bioinformatically identified. Expression of selected genes was validated by quantitative PCR (qPCR). Immunohistochemical protein expression analyses of the proliferation marker Ki-67, the apoptosis marker cleaved caspase-3 and the neo-angiogenesis marker CD34 served to evaluate biological response. RESULTS: We identified 972 and 586 significantly up- and down-regulated genes, respectively, in celecoxib-treated specimens. Significant expression changes in six out of eight genes could be validated by qPCR. Pathway analyses revealed over-representation of deregulated genes in the networks of proliferation, cell cycle, extracellular matrix biology, and inflammatory immune response. The Ki-67 mean change relative to baseline was -29.1% (P = 0.019) and -8.2% (P = 0.384) in the treatment and control arm, respectively. Between treatment groups, the change in Ki-67 was statistically significant (P = 0.029). Cleaved caspase-3 and CD34 expression were not significantly different between the celecoxib-treated and placebo-treated groups. CONCLUSIONS: Short-term COX-2 inhibition by celecoxib induces transcriptional programs supporting anti-tumour activity in primary breast cancer tissue. The impact on proliferation-associated genes is reflected by a reduction of Ki-67 positive cells. Therefore, COX-2 inhibition should be considered as a treatment strategy for further clinical testing in primary breast cancer. TRIAL REGISTRATION: ClinicalTrials.gov NCT01695226.

OBJECTIVES: The objectives of this study were to evaluate whether the axillary lymph nodes show enhancement on magnetic resonance imaging (MRI) after gadofosveset administration, to assess the time to peak enhancement, and to determine the diagnostic performance of gadofosveset-enhanced MRI for axillary nodal staging. MATERIALS AND METHODS: Ten women whose conditions had been diagnosed with invasive breast cancer (>2 cm) underwent both nonenhanced and gadofosveset-enhanced 3-dimensional T1-weighted axillary MRI. Signal intensity of the axillary lymph nodes and different adjacent tissues was measured, and relative signal intensity (rSI) was calculated. A Wilcoxon signed rank test was used to compare results of rSI between different time intervals. A radiologist evaluated all lymph nodes with regard to size, morphologic features, and gadofosveset uptake. All MRI-depicted lymph nodes were matched with the lymph nodes that were removed during surgery. Nodal status was investigated by a pathologist. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of gadofosveset-enhanced MRI for axillary lymph node staging were calculated. RESULTS: After contrast administration, a significant signal increase was observed in the lymph nodes (P < 0.05). When compared with muscle or fat, rSI of the lymph nodes demonstrated a significant postcontrast peak enhancement between 11 minutes and 30 seconds and 20 minutes and 50 seconds (P < 0.05). A total of 152 lymph nodes were harvested during sentinel lymph node biopsy or axillary lymph node dissection, of which 116 were matched with the lymph nodes that were depicted on MRI. Histopathological examination resulted in 21 macrometastases and 8 micrometastases. Using contrast-enhanced MRI, 20 lymph nodes were rated as true positive; 83 as true negative; 4 as false positive; and 9 as false negative. This resulted in an overall node-by-node sensitivity, specificity, PPV, and NPV of 69%, 95%, 83%, and 90%, respectively. If the micrometastases were excluded from the analysis, MRI showed a sensitivity of 86% and a specificity of 94%. Calculated PPV and NPV were 75% and 97%, respectively. CONCLUSIONS: The axillary lymph nodes show enhancement on MRI after gadofosveset administration, with a peak enhancement between 11 minutes and 30 seconds and 20 minutes and 50 seconds. Diagnostic performance of gadofosveset-enhanced axillary lymph node imaging in patients with breast cancer is promising, but further studies need to confirm these results.

AIMS: Thrombospondin-2 (TSP-2) modulates matrix integrity and myocyte survival in the hypertensive or ageing heart. Whether TSP-2 may affect cardiac inflammation and injury, in particular during acute viral myocarditis, is completely unknown. METHODS AND RESULTS: Therefore, mortality, cardiac inflammation, and function were assessed in TSP-2-null (KO) and wild-type (WT) mice in human Coxsackie virus B3 (CVB3)-induced myocarditis. TSP-2 KO had an increased mortality when compared with WT mice during viral myocarditis. The absence of TSP-2 resulted in increased cardiac inflammation and injury at 14 days, which resulted in depressed systolic function [fractional shortening (FS); 34 ± 2.6 in WT vs. 24 ± 1.8 in KO mice, P

This chapter focuses on the lattice site location of rare earth (RE) ions introduced into group III-nitrides either by ion implantation or doped in situ during growth by molecular beam epitaxy (MBE). The lattice site occupied will, to a large extent, govern the luminescence properties of the optically doped semiconductors. An overview of the various possible sites that exist in the wurtzite nitride lattice and of the techniques that can be used to accurately determine the occupied sites will be given. Particular attention will be devoted to channelling techniques, both ion beam channelling and electron emission channelling, which offer direct evidence of the lattice site without the need of further modelling.

We report a detailed crystal field analysis of ${\mathrm{Pm}}^{3+}$ and ${\mathrm{Sm}}^{3+}$ as well as lattice location studies of $^{147}\mathrm{Pm}$ and $^{147}\mathrm{Nd}$ in 2H-aluminum nitride $(w\text{\ensuremath{-}}\mathrm{AlN})$. The isotopes of mass 147 were produced by nuclear fission and implanted at an energy of $60\phantom{\rule{0.3em}{0ex}}\mathrm{keV}$. The decay chain of interest in this work is $^{147}\mathrm{Nd}\ensuremath{\rightarrow}^{147}\mathrm{Pm}\ensuremath{\rightarrow}^{147}\mathrm{Sm}$ (stable). Lattice location studies applying the emission channeling technique were carried out using the ${\ensuremath{\beta}}^{\ensuremath{-}}$ particles and conversion electrons emitted in the radioactive decay of $^{147}\mathrm{Nd}\ensuremath{\rightarrow}^{147}\mathrm{Pm}$. The samples were investigated as implanted, and also they were investigated after annealing to temperatures of $873\phantom{\rule{0.3em}{0ex}}\mathrm{K}$ as well as $1373\phantom{\rule{0.3em}{0ex}}\mathrm{K}$. The main fraction of about 60% of both $^{147}\mathrm{Pm}$ as well as $^{147}\mathrm{Nd}$ atoms was located on substitutional Al sites in the $\mathrm{AlN}$ lattice; the remainder of the ions were located randomly within the $\mathrm{AlN}$ lattice. Following radioactive decay of $^{147}\mathrm{Nd}$, the cathodoluminescence spectra of ${\mathrm{Pm}}^{3+}$ and ${\mathrm{Sm}}^{3+}$ were obtained between $500\phantom{\rule{0.3em}{0ex}}\mathrm{nm}$ and $1050\phantom{\rule{0.3em}{0ex}}\mathrm{nm}$ at sample temperatures between $12\phantom{\rule{0.3em}{0ex}}\mathrm{K}$ and $300\phantom{\rule{0.3em}{0ex}}\mathrm{K}$. High-resolution emission spectra, representing intra-4$f$ electron transitions, were analyzed to establish the crystal-field splitting of the energy levels of ${\mathrm{Sm}}^{3+}\phantom{\rule{0.3em}{0ex}}(4{f}^{5})$ and ${\mathrm{Pm}}^{3+}\phantom{\rule{0.3em}{0ex}}(4{f}^{4})$ in cationic sites having ${C}_{3v}$ symmetry in the $\mathrm{AlN}$ lattice. Using crystal-field splitting models, we obtained a rms deviation of $6\phantom{\rule{0.3em}{0ex}}{\mathrm{cm}}^{\ensuremath{-}1}$ between 31 calculated-to-experimental energy (Stark) levels for ${\mathrm{Sm}}^{3+}$ in $\mathrm{AlN}$. The results are similar to those reported for ${\mathrm{Sm}}^{3+}$ implanted into $\mathrm{GaN}$. Using a set of crystal-field splitting parameters ${B}_{nm},$ for ${\mathrm{Pm}}^{3+}$ derived from the present ${\mathrm{Sm}}^{3+}$ analysis, we calculated the splitting for the $^{5}F_{1}$, $^{5}I_{4}$, and $^{5}I_{5}$ multiplet manifolds in ${\mathrm{Pm}}^{3+}$ and obtained good agreement between the calculated and the experimental Stark levels. Temperature-dependent lifetime measurements are also reported for the emitting levels $^{4}F_{5∕2}\phantom{\rule{0.3em}{0ex}}({\mathrm{Sm}}^{3+})$ and $^{5}F_{1}\phantom{\rule{0.3em}{0ex}}({\mathrm{Pm}}^{3+})$.

A previously healthy 50-year old male suffered out-of-hospital car-diac arrest (OHCA; ventricular fibrillation). Return of spontaneouscirculation occurred after 12 min of immediate resuscitation. Upon ad-mission, recurrent ventriculartachyarrhythmias(VT) caused refractorycardiogenic shock, rescued by peripheral veno-arterial extracorporealmembrane oxygenation (VA-ECMO). Urgent echocardiography andchest CT revealed right ventricular (RV) dilation and biventricularhypokinesia (Fig. 1) in the absence of angiographic evidence of pulmo-naryembolismorcoronarydisease.RVendomyocardialbiopsies(EMB)demonstrated extensive inflammatory infiltrates with multinucleatedgiant-cellsindicatinggiant-cellmyocarditis(GCM;Fig. 1).Furthermore,reverse-transcriptase polymerase chain reaction showed presence oflow-loadhumanherpesvirus-6(HHV-6;18 copies/μgDNA)andparvo-virus B19 (PVB19; 82 copies/μg DNA), lacking serological indication foractive cardiotropic viruses. Sarcoidosis and ANCA granulomatosis wereexcluded by serologic analysis and chest CT. The initiated immunosup-pressive therapy (methylprednisolone 1000 mg iv q.d. and cyclophos-phamide 200 mg iv q.d.) was discontinued due to intercurrent sepsisafter 5 days. On day 11, clinical signs of neurologic recovery were evi-dent and VA-ECMO was converted to a biventricular assist device(BiVAD; Berlin Heart Excor®) due to persistent VT and predominantRV failure. After a complicated ICU stay, immunosuppressants (cyclo-sporine 100 mg bid, azathioprine 50 mg qd) were reinitiated onday72, after serialEMBrevealed ongoingGCM and progressive fibrosis(Appendix1).Onday101,hewasweanedfromventilation,followedbyICU and hospital discharge without any neurologic sequelae on days104 and 210, respectively. Finally, after 8 months of BiVAD support,heart transplant was performed on day 265 and follow-up was un-eventful beyond 1 year including return to former occupation.GCMisarareanddevastatingdiseas ewitha1-yearmortalityandrateof transplant of ~70% [1]. A majority (~75%) presents with heart failure,whereasonly~14%exhibitsVTorsuddencardiacdeath(SCD) [1].There-portedmediantimefromonsetofsym ptomstopresentationis~3 weeks[1]. However, detailed history taking in this patient revealed flu-likesymptomssuchasmalaiseandarthralgia N12 monthsbeforeSCD.Impor-tantly, our patient, a passionate race cyclist ( N15 years, N6000 km annu-ally), experienced a subtle decline in exercise tolerance during hiscontinued endurance training. Strikingly, cycling power, as registered bya bike computer in the months preceding SCD, showed a steady descentfollowed by a rapid deterioration in the weeks prior to his OHCA ( Fig. 2).His long-term, vigorous endurance training may have resulted inoverload-induced RV cardiomyopathy, as well-described [2].Hypotheti-cally, this remodeling process may have modulazted the immune re-sponse and caused enhanced susceptibility and sustained response todangersignalssuchasvirusinducedinjuryandlocalischemia.Inthecon-textofhis flu-likesymptomsmonthsbeforeSCD,itisindeedtemptingtospeculate that RV remodeling has set the stage for the adverse immuneresponsetoviralpresence.Therapidfunctionaldeteriorationnoticedbe-fore SCD (Fig. 2) may well be the result of exaggerating RV overloadunder continued exercise and sustained myocardial inflammation

Complement has been implicated in the pathophysiology of renal ischemia-reperfusion (I/R) injury. However, the mechanism underlying complement-mediated renal I/R injury is thus far unknown. To investigate the involvement of complement in I/R injury, we studied the activation and deposition of complement in a murine model of renal I/R injury. Furthermore, we examined the effect of inhibition of complement-factor C5 on renal I/R injury.Mice were subjected to 45 min of unilateral ischemia and subsequent contralateral nephrectomy and reperfusion for 2, 12, or 24 hr. Mice were control treated or treated with BB5.1, a monoclonal antibody that prevents cleavage of complement factor C5, thereby preventing C5a generation and formation of the membrane attack complex (MAC).Renal I/R induced extensive deposition of C3 early after reperfusion, whereas C6 and C9 deposition (MAC formation) occurred relatively late. I/R-induced complement deposition was mainly localized to tubular epithelium. Treatment with BB5.1 totally prevented MAC formation but also reduced C3 deposition. Inhibition of C5 strongly inhibited late inflammation, as measured by neutrophil influx and induction of the murine CXC chemokines macrophage inflammatory protein-2, KC, and lipopolysaccharide-induced CXC chemokine. Anti-C5 treatment furthermore abrogated late I/R-induced apoptosis, whereas early apoptosis was not affected. Moreover, BB5.1 treatment significantly protected against I/R-induced renal dysfunction.Renal I/R is followed by activation of the complement system and intrarenal deposition of C3 and MAC. Complement activation plays a crucial role in the regulation of inflammation and late apoptosis. Complement inhibition, by preventing C5 activation, abrogates late apoptosis and inflammation, being strongly protective against renal function loss.

A 64-year-old woman presented with typical angina during exercise for 2 weeks. An exercise treadmill test provoked similar chest pain and showed abnormal ST segments suggestive of myocardial ischemia during peak exercise. A prospectively ECG-triggered adaptive dual-source coronary computed tomography angiography ruled out coronary artery disease. Instead it demonstrated a nonenhanced clover-like structure …