Quantitative cone contrast threshold testing in patients with differing pathophysiological mechanisms causing retinal diseases.

BACKGROUND: Cone contrast threshold testing (CCT) provides quantitative measurements of color and contrast function to reveal changes in vision quality that are not standard endpoints in clinical trials. We utilize CCT to measure visual function in patients with multiple sclerosis (MS), age-related macular degeneration (AMD), epiretinal membrane (ERM), and retinal vein occlusion (RVO). METHODS: Retrospective data was gathered from 237 patients of the Gavin Herbert Eye Institute. Subjects included 17 patients with MS, 45 patients with AMD, 41 patients with ERM, 11 patients with RVO, and 123 healthy controls. Patients underwent the primary measurement outcome, CCT testing, as well as Sloan visual acuity test and spectral domain optical coherence tomography during normal care. RESULTS: Color and contrast deficits were present in MS patients regardless of history of optic neuritis. AMD with intermediate or worse disease demonstrated reduced CCT scores. All 3 stages of ERM demonstrated cone contrast deficits. Despite restoration of visual acuity, RVO-affected eyes demonstrated poorer CCT performance than unaffected fellow eyes. CONCLUSIONS: CCT demonstrates color and contrast deficits for multiple retinal diseases with differing pathophysiology. Further prospective studies of CCT in other disease states and with larger samples sizes is warranted.

Does transbronchial lung cryobiopsy improve diagnostic yield of digital tomosynthesis-assisted electromagnetic navigation guided bronchoscopic biopsy of pulmonary nodules? A pilot study.

INTRODUCTION: Bronchoscopic biopsies have limited sensitivity for small, peripheral lung nodules. Electromagnetic navigation guided bronchoscopy (ENB) with fluoroscopic digital tomosynthesis and a 1.1 mm cryoprobe for transbronchial lung cryobiopsy (TBLC) may improve diagnostic yield. We evaluated the diagnostic yield and safety of this approach. METHODS: 42 patients (45 nodules) underwent sequential biopsies by transbronchial needle aspiration (TBNA), then forceps biopsy (FB), and finally TBLC. Demographic data, nodule characteristics, biopsy results, and procedural complications were recorded. RESULTS: Nodules were predominantly solid (n = 35, 78%), without a bronchus sign (n = 30, 67%), and 33% (n = 15) were <2 cm in all dimensions (mean axial: 25.7 ± 15.3 mm, coronal: 21.0 ± 10.1 mm, sagittal 25.5 ± 16.5 mm). TBNA was the most informative biopsy modality (31/45 diagnoses total, five unique, 69% modality diagnostic yield (MDY)) compared to FB (27/45, one unique, 60% MDY) or TBLC (27/45, six unique, 60% MDY). FB contributed four additional diagnoses, improving diagnostic yield to 80% (36/45). TBLC contributed six additional diagnoses for a final diagnostic yield of 93% (42/45). No bleeding that required intervention or pneumothoraxes occurred. In unadjusted logistic regression models, solid nodules had increased odds of obtaining a diagnosis with TBNA (OR: 5.06; 95% CI: 1.14-22.49) and increased axial dimension nodule size had increased odds of obtaining a diagnosis with TBLC (OR: 1.10; 95% CI: 1.02-1.19). CONCLUSION: ENB guided TBLC of lung nodules appears safe and may increase the final diagnostic yield when combined with other modalities. Future studies identifying nodule characteristics and comparing biopsy tools may clarify the most efficacious approach to maximize yield and minimize risk.

Preclinical Assessment of [68Ga]Ga-Cell Death Indicator (CDI): A Novel hsp90 Ligand for Positron Emission Tomography of Cell Death.

BACKGROUND: 4-(N-(S-glutathionylacetyl)amino) phenylarsonous acid (GSAO) when conjugated with a bifunctional chelator 2,2'-(7-(1-carboxy-4-((2,5-dioxopyrrolidin-1-yl)oxy)-4- oxobutyl)-1,4,7-triazonane-1,4-diyl)diacetic acid (NODAGA) (hereafter referred to as Cell Death Indicator [CDI]), enters dead and dying cells and binds to 90kDa heat shock proteins (hsp90). OBJECTIVE: This study assesses stability, biodistribution, imaging, and radiation dosimetry of [68Ga]- Ga-CDI for positron emission tomography (PET). METHODS: Preparation of [68Ga]Ga-CDI was performed as previously described. Product stability and stability in plasma were assessed using high-performance liquid chromatography. Biodistribution and imaging were conducted in ten healthy male Lewis rats at 1 and 2 h following intravenous [68Ga]Ga-CDI injection. Human radiation dosimetry was estimated by extrapolation for a standard reference man and calculated with OLINDA/EXM 1.1. RESULTS: Radiochemical purity of [68Ga]Ga-CDI averaged 93.8% in the product and 86.7% in plasma at 4 h post-synthesis. The highest concentration of [68Ga]Ga-CDI is observed in the kidneys; [68Ga]Ga-CDI is excreted in the urine, and mean retained activity was 32.4% and 21.4% at 1 and 2 h post-injection. Lower concentrations of [68Ga]Ga-CDI were present in the small bowel and liver. PET CT was concordant and additionally demonstrated focal growth plate uptake. The effective dose for [68Ga]Ga-CDI is 2.16E-02 mSv/MBq, and the urinary bladder wall received the highest dose (1.65E-02 mSv/Mbq). CONCLUSION: [68Ga] Ga-CDI is stable and has favourable biodistribution, imaging, and radiation dosimetry for imaging of dead and dying cells. Human studies are underway.

Quantifying Color Vision Changes Associated With Cataracts Using Cone Contrast Thresholds.

Purpose: To evaluate effects of age and simulated and real cataractous changes on color vision as measured by the high-definition cone contrast test (CCT). Methods: Twenty-four healthy volunteers from two cohort studies performed CCT using best-corrected visual acuity, filters, mydriasis, and pinhole correction. Retrospective cross-sectional study of patients seen in eye clinics evaluated the relationship between age and color vision, and age and lens status in 355 eyes. Last, 25 subjects underwent CCT before and after cataract surgery. Results: CCT scores were most reliable in the nonmydriatic condition without pinhole correction. Progressively dense brown filters produced small decreases in S-cone sensitivity. Linear regression analysis of phakic subjects showed a decline for all cone classes with age. Rate of decline was greater for S-cones (slope = -1.09; 95% confidence interval [CI], -1.30 to 0.86) than M-cones (slope = -0.80; 95% CI, -1.03 to -0.58) and L-cones (slope = -0.66; 95% CI, -0.88 to -0.44). CCT scores increased for S-cones but reduced for L- and M-cones in pseudophakic subjects compared with phakic patients. CCT scores after cataract surgery increased for S-cones, M-cones, and L-cones by 33.0 (95% CI, 8.6 to 57.4), 24.9 (95% CI, 3.8 to 46.0), and 22.0 (95% CI, -3.2 to 47.3), respectively. Conclusions: CCT assessment allows for clinically practical quantitation of color and contrast vision improvement after cataract surgery and aging patients who note poor vision despite good visual acuity. Translational Relevance: CCT testing, which quantifies hereditary and acquired color deficiency, can also quantify the degree of cataract severity and, combined with other parameters, can provide more precise guidance for cataract extraction to optimize patient care.

Granulomatous and lymphocytic interstitial lung disease diagnosed by transbronchial lung cryobiopsy.

Granulomatous and lymphocytic interstitial lung disease is a pulmonary complication of common variable immune deficiency with significant morbidity and increased mortality. Diagnosis has historically been obtained by surgical lung biopsy as transbronchial biopsy typically yields insufficient tissue for definitive diagnosis from a disease process with a patchy distribution. However, the potential for significant morbidity and mortality with surgical lung biopsy exists, necessitating the development of alternative diagnostic approaches. We present a case of granulomatous and lymphocytic interstitial lung disease confirmed through minimally invasive transbronchial lung cryobiopsy and discuss the role of this modality in diagnosing interstitial lung disease.

Neonatal alloimmune neutropaenia: Experience from an Australian paediatric health service.

AIM: To describe the presenting features and investigation findings in infants diagnosed with neonatal alloimmune neutropaenia (NAIN) within an Australian paediatric health network. The secondary aim was to describe the management and resolution of neutropaenia in infants with NAIN. METHODS: A retrospective cohort study was conducted at Monash Children's Hospital, Melbourne, Australia. Infants referred to the Victorian Transplantation and Immunogenetics Service for evaluation of NAIN were identified and medical records were reviewed. Descriptive statistical analysis of infants' clinical outcomes, investigation findings and management was performed. RESULTS: Nine infants were diagnosed with NAIN between December 2004 and June 2017. Overall incidence of NAIN was around 1 per 10 000 births. Median gestational age was 38 (range 35-40) weeks and birthweight was 2920 (2300-4445) g. Median age at NAIN work-up was 7 (2-33) days. Prior to investigation for NAIN, median absolute neutrophil count was 0.2 (0.01-0.6) × 109 cells/L. The post-natal ward was the source of presentation in most infants (78%). All except one infant were admitted to a neonatal unit and commenced on intravenous antibiotics (89%). Six infants were asymptomatic but received antibiotics for risk of infection (75%). Granulocyte-colony stimulating factor was administered to 44% of infants due to neutropaenia with presumed or confirmed infection. NAIN resolved at median age of 32 (6-200) days. CONCLUSIONS: Infants with NAIN frequently presented with severe, unexpected neutropaenia without major infection. Intravenous antibiotic therapy and granulocyte-colony stimulating factor use was common in this cohort.

Modulating the Cellular Uptake of Fluorescently Tagged Substrates of Prostate-Specific Antigen before and after Enzymatic Activation.

A series of peptides based on the prostate-specific antigen (PSA)-specific sequence histidine-serine-serine-lysine-leucine-glutamine were functionalized with an anthraquinone fluorophore at the C-terminal residue side chain using the copper(I)-catalyzed azide-alkyne cycloaddition reaction. The effect of incorporating a negatively charged N-terminal tetra-glutamic acid group into the substrate and the effect of masking the negatively charged C-terminal carboxylic acid functionality of the substrate were investigated using confocal fluorescence microscopy in two cell lines, DLD-1 and LnCaP. The addition of a tetra-glutamic acid group to the N-terminus of the intact sequence was shown to reduce cellular uptake of the intact substrate prior to activation by PSA. In contrast, masking the C-terminal carboxylic acid group of the substrate as a methyl ester was shown to improve cellular uptake of the peptide fragment after activation by PSA. The synthesized C-terminal methyl ester substrates with the anthraquinone attached to the side chain were confirmed to be cleaved by PSA in LC-MS analysis, and the cytotoxicity of the substrates was shown to increase in the presence of PSA, consistent with cleavage and uptake of the C-terminal fragment. The results indicate that C- and N-terminal functionalization of peptide substrates targeting PSA can be used to modulate the cellular uptake of peptides before and after enzymatic activation, which may thus be an important consideration in the design of tumor-activated prodrugs.

Outcomes of standardised approach to metabolic bone disease of prematurity.

AIM: To assess the current protocol of metabolic bone disease (MBD) at three Monash Health neonatal units (Melbourne, Australia). METHODS: Retrospective audit of 171 infants born at <32 weeks' gestation over 18 months. Mean gestational age was 28.6 ± 2.1 weeks, and birthweight was 1190 ± 374 g. Risk factors of MBD include intra-uterine growth retardation (n = 33, 19.3%), maternal pre-eclampsia (n = 17, 9.9%), necrotising enterocolitis (n = 9, 5.4%) and medications like methylxanthines (94.2%; mean 54.8 days), diuretics (38.6%; mean 49.2 days) and glucocorticoids (5.3%; mean 35 days). RESULTS: In total, 84.8% infants had an initial MBD screen (mean age 36.3 days), with 45% having repeated monitoring (mean age 71.9 days), and 14.2% had initial alkaline phosphatase levels >500 U/L, decreasing to 10.1% on follow-up. All infants received additional vitamin D supplementation of 400 IU/day, phosphate of 25.1% (n = 43) and calcium of 19.9% (n = 34). Fractures were identified from clinical documentation in 2.9% (n = 5) of infants. Stratifying into phosphate-treated and untreated groups revealed significant differences (P < 0.001) for gestational age and birthweight: 26.7 ± 1.7 weeks/918 ± 272 g for treated versus 29.2 ± 1.9 weeks/1283 ± 359 g for untreated. In the phosphate-treated group, improvement was seen in mean alkaline phosphatase (pre-treatment 467 ± 204 U/L and post-treatment 342 ± 221 U/L, P < 0.01) and mean phosphate levels (1.8 ± 0.4 vs. 2.2 ± 1.0 mmol/L, P < 0.01). Linear growth difference between phosphate-treated (n = 10) and untreated groups (n = 24) was insignificant at >6 months of age (P = 0.13), although this may reflect limited data. CONCLUSION: Adequate first-line supplementation with vitamin D and phosphate appeared to improve biochemical markers of MBD, but given the observational nature of this study, further longitudinal/prospective studies are required to confirm these findings.

BDNF rescues BAF53b-dependent synaptic plasticity and cocaine-associated memory in the nucleus accumbens.

Recent evidence implicates epigenetic mechanisms in drug-associated memory processes. However, a possible role for one major epigenetic mechanism, nucleosome remodelling, in drug-associated memories remains largely unexplored. Here we examine mice with genetic manipulations targeting a neuron-specific nucleosome remodelling complex subunit, BAF53b. These mice display deficits in cocaine-associated memory that are more severe in BAF53b transgenic mice compared with BAF53b heterozygous mice. Similar to the memory deficits, theta-induced long-term potentiation (theta-LTP) in the nucleus accumbens (NAc) is significantly impaired in slices taken from BAF53b transgenic mice but not heterozygous mice. Further experiments indicate that theta-LTP in the NAc is dependent on TrkB receptor activation, and that BDNF rescues theta-LTP and cocaine-associated memory deficits in BAF53b transgenic mice. Together, these results suggest a role for BAF53b in NAc neuronal function required for cocaine-associated memories, and also that BDNF/TrkB activation in the NAc may overcome memory and plasticity deficits linked to BAF53b mutations.

Radiosynthesis and 'click' conjugation of ethynyl-4-[(18)F]fluorobenzene--an improved [(18)F]synthon for indirect radiolabeling.

Reproducible methods for [(18)F]radiolabeling of biological vectors are essential for the development of new [(18)F]radiopharmaceuticals. Molecules such as carbohydrates, peptides and proteins are challenging substrates that often require multi-step indirect radiolabeling methods. With the goal of developing more robust, time saving, and less expensive procedures for indirect [(18)F]radiolabeling of such molecules, our group has synthesized ethynyl-4-[(18)F]fluorobenzene ([(18)F]2, [(18)F]EYFB) in a single step (14 ± 2% non-decay corrected radiochemical yield (ndc RCY)) from a readily synthesized, shelf stable, inexpensive precursor. The alkyne-functionalized synthon [(18)F]2 was then conjugated to two azido-functionalized vector molecules via CuAAC reactions. The first 'proof of principle' conjugation of [(18)F]2 to 1-azido-1-deoxy-ß-D-glucopyranoside (3) gave the desired radiolabeled product [(18)F]4 in excellent radiochemical yield (76 ± 4% ndc RCY (11% overall)). As a second example, the conjugation of [(18)F]2 to matrix-metalloproteinase inhibitor (5), which has potential in tumor imaging, gave the radiolabeled product [(18)F]6 in very good radiochemical yield (56 ± 12% ndc RCY (8% overall)). Total preparation time for [(18)F]4 and [(18)F]6 including [(18)F]F(-) drying, two-step reaction (nucleophilic substitution and CuAAC conjugation), two HPLC purifications, and two solid phase extractions did not exceed 70 min. The radiochemical purity of synthon [(18)F]2 and the conjugated products, [(18)F]4 and [(18)F]6, were all greater than 98%. The specific activities of [(18)F]2 and [(18)F]6 were low, 5.97 and 0.17 MBq nmol(-1), respectively.

Removing nonessential central venous catheters: evaluation of a quality improvement intervention.

INTRODUCTION: Nonessential central venous catheters (CVCs) should be removed promptly to prevent adverse events. Little is known about effective strategies to achieve this goal. The present study evaluates the effectiveness of a quality improvement (QI) initiative to remove nonessential CVCs in the intensive care unit (ICU). METHODS: A prospective observational study was performed in two ICUs following a QI intervention that included a daily checklist, education, and reminders. During 28 consecutive days, all CVCs were identified and the presence of ongoing indications for CVC placement was recorded. The proportions of nonessential CVCs and CVC days were compared with pre-intervention proportions and between the participating units. Rates of central line-associated bloodstream infections (CLABSI) were measured separately through Ontario's Critical Care Information System. RESULTS: One hundred and ten patients and 159 CVCs were reviewed. Eighty-eight (11%) of 820 catheter days showed no apparent indication for CVC placement, and compared with the pre-intervention period, the proportion of patients with any number of nonessential CVC days decreased from 51% to 26% (relative risk 0.51; 95% confidence interval 0.34 to 0.74; P < 0.001). There was no significant difference in the proportion of nonessential catheter days between participating units. Reported rates of CLABSI decreased substantially during the intervention. DISCUSSION: A checklist tool supported by a multifaceted QI intervention effectively ensured prompt removal of nonessential CVCs in two ICUs.

Synthesis and evaluation of novel Tc-99m labeled probestin conjugates for imaging APN/CD13 expression in vivo.

The enzyme aminopeptidase N (APN, also known as CD13) is known to play an important role in tumor proliferation, attachment, angiogenesis, and tumor invasion. In this study, we hypothesized that a radiolabeled high affinity APN inhibitor could be potentially useful for imaging APN expression in vivo. Here, we report synthesis, radiolabeling, and biological evaluation of new probestin conjugates containing a tripeptide, N,N-dimethylglycyl-l-lysinyl-l-cysteinylamide (N(3)S), chelator. New probestin conjugates were synthesized by solid-phase peptide synthesis method, purified by reversed-phase HPLC, and characterized by electrospray mass spectrometry. The conjugates were complexed with Re(V) and (99m)Tc(V) by transmetalation using corresponding Re(V) or (99m)Tc(V) gluconate synthon. The mass spectral analyses of ReO-N(3)S-Probestin conjugates were consistent with the formation of neutral Re(V)O-N(3)S complexes. Initial biological activity of ReO-N(3)S-Probestin conjugates determined by performing an in vitro APN enzyme assay using intact HT-1080 cells demonstrated higher inhibition of APN enzyme activity than bestatin. In vivo biodistribution and whole body planar imaging studies of (99m)TcO-N(3)S-PEG(2)-Probestin performed in nude mice xenografted with human fibrosarcoma tumors derived from HT-1080 cells demonstrated a tumor uptake value of 2.88 ± 0.64%ID/g with tumor-to-blood and tumor-to-muscle ratios of 4.8 and 5.3, respectively, at 1 h postinjection (p.i.). Tumors were clearly visible in whole body planar image obtained at 1 h p.i., but not when the APN was competitively blocked with a coinjection of excess nonradioactive ReO-N(3)S-PEG(2)-Probestin conjugate. These results demonstrate the feasibility of using high affinity APN inhibitor conjugates as targeting vectors for in vivo targeting of APN.

Compliance of antithrombotic management at a tertiary paediatric hospital with international guidelines: a 100-Day audit.

INTRODUCTION: Thromboembolic disease is a growing problem in paediatric care. American College of Chest Physicians (ACCP) guidelines for antithrombotic therapy in paediatric patients provide consensus recommendations regarding appropriate antithrombotic therapy. MATERIALS AND METHODS: This study assessed antithrombotic management practices in a tertiary paediatric centre and the level of agreement of current practice with consensus guidelines across a 100-day prospective chart audit. Details of indication for each administration of antithrombotic agent was collected and categorized as either ACCP 'recommended', 'non-listed' or 'contraindicated'. RESULTS: At least one antithrombotic medication was administered to 526 inpatients (12.8%), with a total of 5885 individual episodes of antithrombotic administration. Complete adherence to ACCP indications and dosing recommendations was observed in 2915 administrations (49.5%). A key area where there was disagreement between clinical practice and guidelines was the routine use of unfractionated heparin infusions in children with central venous lines. CONCLUSION: The level of compliance found in this study was relatively low, especially in areas where recommendations were based on 'weak' evidence. This reflects clinician confidence in the strength of evidence currently available for paediatric antithrombotic therapy. This study has identified areas where more robust research should be conducted to aid physicians in making more informed decisions for children needing antithrombotic therapy.

Pancreatitis preceding acute episodes of thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: report of five patients with a systematic review of published reports.

BACKGROUND AND OBJECTIVES: The thrombotic thrombocytopenic purpura-hemolytic uremic syndromes (TTP-HUS) have diverse etiologies, clinical manifestations, and risk factors, but the events that may trigger acute episodes are often unclear. We describe the occurrence of TTP-HUS following pancreatitis and consider whether pancreatitis may be a triggering event for acute episodes of TTP-HUS. DESIGN AND METHODS: We report on three patients from the Oklahoma Registry and two patients from Northwestern University who had an acute episode of TTP-HUS following pancreatitis. A systematic review of published case reports was performed to identify additional patients who had TTP-HUS following pancreatitis. RESULTS: In each of our five patients there was an apparent etiology of alcoholism or common bile duct obstruction for the pancreatitis and no evidence of TTP-HUS when the pancreatitis was diagnosed. Two patients had severe ADAMTS13 deficiency with an inhibitor; in one of these patients TTP-HUS recurred following a subsequent recurrent episode of pancreatitis. The systematic review identified 16 additional patients who had TTP-HUS following pancreatitis; recurrent TTP-HUS occurred in three of these patients following a subsequent episode of recurrent pancreatitis. In all 21 patients, the interval between the diagnosis of pancreatitis and TTP-HUS was short (1-13 days; median, 3 days). The three Oklahoma patients represent approximately 1% of the 356 patients in the Registry. INTERPRETATION AND CONCLUSIONS: These observations suggest that in some patients pancreatitis, a disorder that results in an intense systemic inflammatory response, may be a triggering event for acute episodes of TTP-HUS.