Dynamic tracking of stem cells in an acute liver failure model

AIM:To investigate a dual labeling technique,which would enable real-time monitoring of transplanted embryonic stem cell(ESC) kinetics,as well as long-term tracking.METHODS:Liver damage was induced in C57/BL6 male mice(n = 40) by acetaminophen(APAP) 300 mg/kg administered intraperitoneally.Green fluorescence protein(GFP) positive C57/BL6 mouse ESCs were stained with the near-infrared fluorescent lipophilic tracer 1,1-dioctadecyl-3,3,3,3-tetramethylindotricarbocyanine iodide(DiR) immediately before transplantationinto the spleen.Each of the animals in the cell therapy group(n = 20) received 5 × 10 6 ESCs 4 h following treatment with APAP.The control group(n = 20) received the vehicle only.The distribution and dynamics of the cells were monitored in real-time with the IVIS Lumina-2 at 30 min post transplantation,then at 3,12,24,48 and 72 h,and after one and 2 wk.Immunohistochemical examination of liver tissue was used to identify expression of GFP and albumin.Plasma alanine aminotransferase(ALT) was measured as an indication of liver damage.RESULTS:DiR-stained ESCs were easily tracked with the IVIS using the indocyanine green filter due to its high background passband with minimal background autofluorescence.The transplanted cells were confined inside the spleen at 30 min post-transplantation,gradually moved into the splenic vein,and were detectable in parts of the liver at the 3 h time-point.Within 24 h of transplantation,homing of almost 90% of cells was confirmed in the liver.On day three,however,the DiR signal started to fade out,and ex vivo IVIS imaging of different organs allowed signal detection at time-points when the signal could not be detected by in vivo imaging,and confirmed that the highest photon emission was in the liver(P 0.0001).At 2 wk,the DiRsignal was no longer detectable in vivo ;however,immunohistochemistry analysis of constitutively-expressed GFP was used to provide an insight into the distribution of the cells.GFP +ve cells were detected in tissue sections resembling hepatocytes and were dispersed throughout the hepatic parenchyma,with the presence of a larger number of GFP +ve cells incorporated within the sinusoidal endothelial lining.Very faint albumin expression was detected in the transplanted GFP +ve cells at 72 h;however at 2 wk,few cells that were positive for GFP were also strongly positive for albumin.There was a significant improvement in serum levels of ALT,albumin and bilirubin in both groups at 2 wk when compared with the 72 h time-point.In the cell therapy group,serum ALT was significantly(P = 0.016) lower and albumin(P = 0.009) was significantly higher when compared with the control group at the 2 wk time-point;however there was no difference in mortality between the two groups.CONCLUSION:Dual labeling is an easy to use and cheap method for longitudinal monitoring of distribution,survival and engraftment of transplanted cells,and could be used for cell therapy models.     

Tracheal Stenting has Minimal Impact on Survival in Anaplastic Thyroid Carcinoma

Background

Anaplastic thyroid carcinoma (ATC) is the most aggressive form of thyroid cancer and it has an extremely poor prognosis. Rapid airway compromise is the main cause of death in patients with ATC.

Methods

The present study is based on a retrospective review of clinical data of patients with ATC treated over the last decade in a tertiary referral center.

Results

Between January 1998 and December 2010, 31 patients (13 males: 18 females) with a mean age of 74 years (range: 54–90 years) had a diagnosis of ATC made on fine-needle aspiration (n = 29) or biopsy (n = 2). Eight patients underwent total thyroidectomy and lymph node dissection, and five patients had attempted surgery but the procedure was abandoned because of inoperability. Airway compromise was clinically apparent in 11 patients. Five patients had tracheal stents inserted, with a median survival of 2 months (range: 1–36 months). In the whole cohort, 29 patients died of the disease, with a mean survival of 7 months (range: 1–36 months).

Conclusions

Survival of patients with undifferentiated thyroid cancer is severely compromised by airway obstruction. Palliation with tracheal stenting can rescue catastrophic airway obstruction but offers minimal survival benefit.     

Combination of ventilator care bundle and regular oral care with chlorhexidine was associated with reduction in ventilator associated pneumonia

BackgroundVentilator associated pneumonia (VAP) is an important source of morbidity and mortality in patients receiving mechanical ventilation. VAP is associated with prolongation of mechanical ventilation, ICU and hospital stay and increases in costs.MethodsQuality improvement project. Mechanically ventilated patients received oral care every 8 h with chlorhexidine 2%. A formal process was developed to evaluate compliance with the following ventilator bundle initiatives: head of the bed elevation to 30–45°, daily sedation vacation and assess the readiness to extubate, providing peptic ulcer disease prophylaxis and providing deep vein thrombosis prophylaxis (unless contraindicated).ResultsThe rate of VAP before starting the project, in the first 6 months of year 1431H, was 16.2 cases/1000 ventilator days. Six month after inception of the quality improvement project, the VAP rates decreased to 5.6 cases/1000 ventilator days at the end of 1431H, and at the end of 1432H, it was 5.5 cases/1000 ventilator days. This leads to significant reduction in mortality (adjusted according to APACHE II) from 23.4% to 19.1% (p value 0.024) and the length of stay in ICU from 9.7 to 6.5 days (p value 0.00002).ConclusionThe combination of regular oral hygiene with chlorhexidine 2% and rigorous implementation of ventilator care bundle was associated with significant reduction in VAP rate in mechanically ventilated patients. This has led to reduction in length of stay in ICU from 9.7 to 6.5 days and reduction in mortality from 23.4% to 19.1%.     

Spinal cord injuries related to cervical spine fractures in elderly patients: factors affecting mortality

Background contextSpinal cord injuries (SCIs) related to cervical spine (C-spine) fractures can cause significant morbidity and mortality. Aggressive treatment often required to manage instability associated with C-spine fractures is complicated and hazardous in the elderly population.PurposeTo determine the mortality rate of elderly patients with SCIs related to C-spine fractures and identify factors that contribute toward a higher risk for negative outcomes.Study design/settingRetrospective cohort study at two Level 1 trauma centers.Patient sampleThirty-seven consecutive patients aged 60 years and older who had SCIs related to C-spine fractures.Outcome measuresLevel of injury, injury severity, preinjury medical comorbidities, treatment (operative vs. nonoperative), and cause of death.MethodsHospital medical records were reviewed independently. Baseline radiographs and computed tomography or magnetic resonance imaging scans were examined to permit categorization according to the mechanistic classification by Allen and Ferguson of subaxial C-spine injuries. Univariate logistic regression analyses were performed to identify factors related to in-hospital mortality and ambulation at discharge. There were no funding sources or potential conflicts of interest to disclose.ResultsThe in-hospital mortality rate was 38%. Respiratory failure was the leading cause of death. Preinjury medical comorbidities, age, and operative versus nonoperative treatment did not affect mortality. Injury level at or above C4 was associated with a 7.1 times higher risk of mortality compared with injuries below C4 (p=.01). Complete SCI was associated with a 5.1 times higher risk of mortality compared with incomplete SCI (p=.03). Neurological recovery was uncommon. Apart from severity of initial SCI, no other factor was related to ambulatory disposition at discharge.ConclusionsIn this elderly population, neurological recovery was poor and the in-hospital mortality rate was high. The strongest risk factors for mortality were injury level and severity of SCI. Although each case of SCI related to C-spine fractures is different, physicians may be able to use these findings to help better determine the prognosis and guide subsequent treatment.     

Impact of Psychiatrists’ Qualifications on the Rate of Compulsory Admissions

Despite efforts to reduce coercion in psychiatry, involuntary hospitalizations remain frequent, representing more than half of all admissions in some European regions. Since October 2006, only certified psychiatrists are authorized to require a compulsory admission to our facility, while before all physicians were, including residents. The aim of the present study is to assess the impact of this change of procedure on the proportion compulsory admissions. All medical records of patients admitted respectively 4 months before and 4 month after the implementation of the procedure were retrospectively analyzed. This search retrieved a total of 2,227 hospitalizations for 1,584 patients. The overall proportions of compulsory and voluntary admissions were 63.9 % and 36.1 % respectively. The average length of stay was 32 days (SD ± 64.4). During the study period, 25 % of patients experienced two hospitalizations or more. The most frequent patients’ diagnoses were affective disorders (30 %), psychotic disorders (18.4 %) and substance abuse disorders (15.7 %). Compared with the period before October 2006, patients hospitalized from October 2006 up were less likely to be hospitalized on a compulsory basis (OR = 0.745, 95 % CI: 0.596–0.930). Factors associated with involuntary admission were young age (20 years or less), female gender, a diagnosis of psychotic disorder and being hospitalized for the first time. Our results strongly suggest that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions.     

Dynamic Contrast-Enhanced Magnetic Resonance Imaging as a Diagnostic Tool in the Assessment of Tumour Angiogenesis in Urinary Bladder Cancer

PurposeThe aim of study is to assess the role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and correlation with tumour angiogenesis in evaluation of urinary bladder cancer.Material and MethodsThe study included 81 patients with recent presumed diagnosis of bladder tumour or who came for follow up after management of histopathologically proven bladder cancer. All had DCE-MRI with time–signal intensity curve. The radiologic results then correlated with the histopathologic results using both haematoxylin and eosin stain and immuno-histochemical staining for localization and evaluation of CD34 immunoreactivity as a detector for the microvessel density (MVD) and tumour angiogenesis.ResultsSeventy-one cases were pathologically proven to be malignant: 41 cases (58%) showed type III time–signal intensity curve (descending); 22 cases (31%) showed type II (plateau); and 8 cases (11%) showed type I (ascending) curve. The sensitivity of DCE-MRI in stage T1 bladder tumour was 80%; in stage T2, it was (90.9%); and in stage T3, it was (96.9%). Overall accuracy of DCE-MRI in tumour staging was 89.5% and P = .001 (significant). Values more than the cutoff value = 76.13 MVD are cystitis with sensitivity (90%), specificity (91%), and P value is .001, which is statistically highly significant.ConclusionThere is a strong positive association between DCE-MRI (staging and washout slope of the time–signal intensity curve) with histopathologic grade, tumour stage, and MVD in bladder cancer. So, DCE-MRI can be used as reliable technique in preoperative predictions of tumour behavior and affect the planning of antiangiogenetic therapy.     

Doxycycline hydrochloride-metronidazole solid lipid microparticles gels for treatment of periodontitis: development,in-vitro and in-vivo clinical evaluation

Objective: To formulate solid lipid microparticles (SLMs) encapsulating doxycycline hydrochloride (DH) and metronidazole (MT) for the treatment of periodontal diseases.

Methods: SLMs were prepared applying hot homogenization method, using different types of lipids and stabilized with various types and concentrations of surfactants. The optimized formula was subjected to freeze-drying followed by incorporation into poloxamer gel. Microbiological and clinical evaluation of the selected SLMs on patients suffering from periodontal diseases was performed.

Results: SLMs could entrap high percentage of both drugs (81.14% and 68.75 % for doxycycline hydrochloride and metronidazole respectively). Transmission electron microscopy images of SLMs showed nearly spherical particles. Freeze-dried SLMs showed satisfactory stability for three months. Combined drugs were molecularly dispersed in SLMs. Incorporation of the freeze-dried SLMs powder in poloxamer gel could control the drugs release for 72 h. In-vivo study revealed effective and safe use of SLMs gel for periodontitis treatment. Significant improvement in both microbiological and clinical parameters was observed as compared to scaling and root planing alone.

Conclusion: The formulated SLMs gel offers an applicable dosage form that can be injected directly into the periodontal pocket as adjunctive to scaling and root planing.     

Is there a place for virtual reality simulators in assessment of competency in percutaneous renal access?

Objective

To assess competency of urology post-graduate trainees (PGTs) in percutaneous renal access (PCA).

Methods

Upon obtaining ethics approval and informed consents, PGTs between post-graduate years (PGY-3 to PGY-5) from all four urology programs in Québec were recruited. PCA competency of each participant was assessed objectively by performing task 4 on the PERC Mentor? simulator, where they had to correctly access and pop 7 balloons in 7 different renal calyces and subjectively by the validated Percutaneous Nephrolithotomy—Global Rating Scale (PCNL-GRS).

Results

A total of 26 PGTs with a mean age of 29.2 ± 0.7 years participated in this study. When compared with the 21 PGTs without practice, all 5 PGTs who had practiced on the simulator were competent (p = 0.03), performed the task with significantly shorter operative time (13.9 ± 0.7 vs. 4.4 ± 0.4 min; p < 0.001) and fluoroscopy time (9.3 ± 0.6 vs. 3.4 ± 0.4 min; p < 0.001), and had significantly higher PCNL-GRS scores (13 ± 0.6 vs. 20.6 ± 1; p < 0.001) and successful attempts to access renal calyces (23 ± 5 vs. 68.7 ± 11; p = 0.001). According to a pass score of 13/25, thirteen PGTs were competent. Competent PGTs performed the task with significantly shorter fluoroscopy time (9.8 vs. 6.5 min; p = 0.01) and higher percentage of successful attempts to access renal calyces (p < 0.001), higher PCNL-GRS scores (p < 0.001), and lower complications (p = 0.01).

Conclusion

The PCNL-GRS in combination with the PERC Mentor? simulator was able to differentiate between competent and non-competent PGTs.