Postmastectomy Radiation Therapy Planning After Immediate Implant-based Reconstruction Using the European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice Consensus Guidelines for Target Volume Delineation.

AIMS: To evaluate how common radiation therapy techniques perform in the setting of the new European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) delineation recommendations for immediate breast reconstruction (IBR). MATERIALS AND METHODS: Seven Danish radiation therapy centres and six international European centres participated in this project. Two breast cancer cases (one left-sided and one right-sided) with a retropectoral implant were chosen for radiation therapy planning using deep-inspiration breath-hold. Target volumes were delineated according to ESTRO-ACROP delineation recommendations. The centres were asked to plan the cases using any radiation therapy technique according to the Danish Breast Cancer Group plan objectives. RESULTS: In total, 35 treatment plans were collected. Half of the submitted plans, for both the left-sided and the right-sided case, used the field-in-field (FiF) technique (nine for each), a quarter used volumetric arc radiation therapy (VMAT; five for right-sided, four for left-sided) and the remaining quarter was a mix of inverse intensity-modulated radiation therapy (IMRT), helicoidal therapy and hybrid (combined open fields and VMAT) techniques. Mean clinical target volume doses were in the range 99-102% of the prescribed dose. The median FiF mean heart dose (MHD) for right-sided radiation therapy was 1 Gy (range 0.8-3.7) and 5.2 Gy for left-sided radiation therapy (range 2.2-6.5). For right-sided radiation therapy, the median VMAT MHD was 3.42 Gy, for IMRT was 2.3 Gy and for helicoidal therapy was 5.1 Gy. For left-sided radiation therapy, the median VMAT MHD was 6.3 Gy, for IMRT was 7.8 Gy and for helicoidal therapy was 7.3 Gy. CONCLUSIONS: Different radiation therapy techniques could be used to plan radiation therapy in the setting of IBR. FiF provided good coverage with acceptable organ at risk doses. The best dose distribution results as a trade-off between the objectives of target volume coverage and high-dose organ at risk inclusion. The radiation therapy technique affects the interplay between these objectives.

Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients.

BACKGROUND: Emerging research on surgeons and the opioid epidemic have focused on the adult population. Consequently, little is known regarding opioid-prescribing practices in the pediatric population. The goal of this study is to examine postoperative opioid-prescribing and consumption patterns, as well as storage and disposal trends for specific pediatric urologic procedures. STUDY DESIGN: Patients undergoing surgery associated with specified Current Procedural Terminology codes were retrospectively identified, and details regarding opioid medications were obtained through our pharmacy database. Patients' guardians were contacted two weeks postoperatively to determine opioid usage. Opioids were prescribed at a standard dosing of 0.1 mg/kg per dose or the equivalent. RESULTS: Of the 171 identified patients, 117 patients were successfully contacted, with 67 (39%) completing telephone surveys. The 3 most common pediatric urology procedures were inguinal hernia repair (N = 39), circumcision (N = 27), and cystoscopy (N = 16). Across all procedures, there was an average excess of 9.8 doses prescribed, corresponding to an overprescription rate of 64%. Of the patients prescribed opioids, 41 (62%) had leftover opioid medication two weeks postoperatively. Thirty-two of 41 (78%) patients did not dispose of their leftover medication. Only 13 patients received perioperative counseling on appropriate storage and disposal of opiates. DISCUSSION: Prescribing practices for an array of pediatric urologic procedures are non-standardized and often generously excessive. We show universal overprescribing for all our reviewed urologic procedures. Sixty-two percent of pediatric urology patients did not use their entire prescribed opiate, leaving a significant pool of medicine within the pediatric family home. Given the low incidence of perioperative education, unsurprisingly a majority of our patients improperly handled and disposed off excess opioid medication. CONCLUSION: There is general overprescription of postoperative opioids and poor perioperative opioid education in the pediatric urology population.

Should Europe follow the US and declare obesity a disease?: a discussion of the so-called utilitarian argument.

In 2013, the American Medical Association (AMA) decided to recognize obesity as a disease. One of the main arguments presented in favor of this was broadly 'utilitarian': the disease label would, it was claimed, provide more benefits than harms and thereby serve the general good. Several individuals and groups have argued that this reasoning is just as powerful in the European context. Drawing mainly on a review of relevant social science research, we discuss the validity of this argument. Our conclusion is that in a Western European welfare state, defining obesity as a disease will not on balance serve the general good, and that it is therefore more appropriate to continue to treat obesity as a risk factor. The main reasons presented in favor of this conclusion are: It is debatable whether a disease label would lead to better access to care and preventive measures and provide better legal protection in Europe. Medicalization and overtreatment are possible negative effects of a disease label. There is no evidence to support the claim that declaring obesity a disease would reduce discrimination or stigmatization. In fact, the contrary is more likely, since a disease label would categorically define the obese body as deviant.

No geographic variation in thermoregulatory colour plasticity and limited variation in heat-avoidance behaviour in Battus philenor caterpillars.

Phenotypic plasticity can help organisms cope with variation in their current environment, including temperature variation, but not all environments are equally variable. In the least variable or extreme environments, plasticity may no longer be used. In this case, the plasticity could be lost altogether, or it could persist with either the same or an altered reaction norm, depending on factors such as the plasticity's costs. In the pipevine swallowtail caterpillar (Battus philenor), I tested for changes in two forms of heat-avoidance plasticity, colour change and refuge-seeking behaviour, across the species' range in the United states, including the cooler eastern parts of its range where colour change has not been observed and is unlikely to be needed. I found that both heat-avoidance behaviour and colour change persisted in all surveyed populations. Indeed, the reaction norm for colour change remained nearly unaltered, whereas the threshold for refuge-seeking only changed slightly across populations. These results suggest that the costs of these plastic traits are low enough for them to be maintained by whatever minimal gene flow the population receives. I show that plasticity can be maintained unaltered in populations where it is not used and discuss the potential consequences of this persistence for both the ecology and evolution of plasticity.

Muscle wound healing in rainbow trout (Oncorhynchus mykiss).

We followed the progression of healing of deep excisional biopsy punch wounds over the course of 365 days in rainbow trout (Oncorhynchus mykiss) by monitoring visual wound healing and gene expression in the healing muscle at regular intervals (1, 3, 7, 14, 38 and 100 days post-wounding). In addition, we performed muscle texture analysis one year after wound infliction. The selected genes have all previously been investigated in relation to vertebrate wound healing, but only few specifically in fish. The selected genes were interleukin (IL)-1ß, IL-6, transforming growth factor (TGF)-ß1 and -ß3, matrix metalloproteinase (MMP) -9 and -13, inducible nitric oxide synthase (iNOS), fibronectin (FN), tenascin-C (TN-C), prolyl 4-hydroxylase α1-chain (P4Hα1), lysyl oxidase (LOX), collagen type I α1-chain (ColIα1), CD41 and CD163. Wound healing progressed slowly in the presented study, which is at least partially due to the low temperature of about 8.5 °C during the first 100 days. The inflammation phase lasted more than 14 days, and the genes relating to production and remodeling of new extracellular matrix (ECM) exhibited a delayed but prolonged upregulation starting 1-2 weeks post-wounding and lasting until at least 100 days post-wounding. The gene expression patterns and histology reveal limited capacity for muscle regeneration in rainbow trout, and muscle texture analyses one year after wound infliction confirm that wounds heal with fibrosis. At 100 dpw epidermis had fully regenerated, and dermis partially regenerated. Scales had not regenerated even after one year. CD163 is a marker of "wound healing"-type M2c macrophages in mammals. M2 macrophage markers are as yet poorly described in fish. The pattern of CD163 expression in the present study is consistent with the expected timing of presence of M2c macrophages in the wound. CD163 may thus potentially prove a valuable marker of M2 macrophages - or a subset hereof - in fish. We subjected a group of fish to bathing in an immunomodulatory ß-glucan product during wound healing, but found this to have very limited effect on wound healing in contrast to a previously published study on common carp.

Gonadotropin-releasing hormone agonist overuse: urologists' response to reimbursement and characteristics associated with persistent overuse.

BACKGROUND: Medicare reimbursement cuts have been associated with declining gonadotropin-releasing hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse. METHODS: We matched American Medical Association physician data for 2138 urologists to Surveillance, Epidemiology and End Result-Medicare data for 12,943 men diagnosed with early-stage and lower-grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multilevel modeling to control for patient and provider characteristics. RESULTS: Three distinct patterns of GnRH agonist overuse were observed. Urologists' time in practice was not associated with GnRH agonist overuse (odds ratio (OR) 0.89; 95% confidence interval (CI): 0.75-1.05). However, solo practice type (OR 1.65; 95% CI: 1.34-2.02), medical school affiliation (OR 0.65; 95% CI: 0.55-0.77) and patient race were. Compared with non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI: 1.37-2.27), Hispanics (OR 1.41; 95% CI: 1.12-1.79) and men of 'other' race (OR 1.44; 95% CI: 1.04-1.99) had greater odds of receiving unnecessary GnRH agonists. CONCLUSIONS: GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.

In a class of their own: the Danish public considers obesity less deserving of treatment compared with smoking-related diseases.

BACKGROUND/OBJECTIVES: This study examined public support for publicly funded treatment of obesity (weight-loss surgery and medical treatment) and two pulmonary diseases (chronic obstructive pulmonary disease (COPD) and lung cancer) in Denmark. It also investigated whether beliefs about the causes of lifestyle-related diseases (external environment, genetic disposition and lack of willpower) and agreement that 'people lack responsibility for their life and welfare' influenced support. SUBJECTS/METHODS: This was a questionnaire study in which a sample of 1003 Danes (age 18-65 years) drawn from an Internet database were surveyed. RESULTS: Approximately one in three supported publicly funded weight-loss surgery (30%) and medical treatment of obesity (34.4%). A large majority supported treatment for lung cancer (86.1%), and a clear majority also supported treatment for COPD, whether it was framed as 'smoker's lung' (61.9%) or COPD (71.2%). The belief that lifestyle-related diseases are caused by the external environment or genetic disposition did not systematically influence support. Agreement that 'people lack responsibility for their life and welfare' reduced support significantly for all treatment types. However, in contrast with pulmonary diseases, support for publicly funded obesity treatments decreased considerably when beliefs about individual failure (that is that people lack 'willpower' and 'individual responsibility') were detected. CONCLUSIONS: Support for publicly funded COPD and lung cancer treatment is considerably higher than that for obesity treatment. This could encourage institutional discrimination through policies that involve charging patients for the treatment of obesity but not for the treatment of other lifestyle-related diseases.

ß-glucan enriched bath directly stimulates the wound healing process in common carp (Cyprinus carpio L.).

Wound healing is a complex and well-organized process in which physiological factors and immune mechanisms are involved. A number of different immune modulators have been found to enhance the non-specific defence system in vertebrates, among which ß-glucans are the most powerful and extensively investigated. The aim of the present study was to investigate the biological impact of two different commercially available ß glucan containing products on the wound healing process in carp. Throughout a two week experiment fish were kept either untreated (control), or in water supplemented with the two different types of ß-glucans. The wound healing process was monitored using a multispectral visualisation system. The correlation between wound closure and immune response was investigated by measuring the gene expression patterns of IL-1ß, IL-6 family member M17, IL-8 and Muc5b, and measurement of production of radical oxygen species. PAMPs/DAMPs stimulation caused by the wounding and or ß-glucans resulted in an inflammatory response by activating IL-1ß, IL-6 family member M17 and IL-8 and differences in the expression pattern were seen depending on stimuli. IL-1ß, IL-6 family member M17 and IL-8 were activated in all wounds regardless of treatment. Expression of all three interleukins was highly up regulated in control wounded muscle already at day 1 post-wounding and decreased at subsequent time-points. The reverse was the case with control wounded skin, where expression increased from day 1 through day 14. The results for the ß-glucan treated wounds were more complex. The images showed significantly faster wound contraction in both treated groups compared to the control. The obtained results clearly demonstrated that a ß glucan enriched bath promotes the closure of wounds in common carp and induce a local change in cytokine expression.

Comparative study of ß-glucan induced respiratory burst measured by nitroblue tetrazolium assay and real-time luminol-enhanced chemiluminescence assay in common carp (Cyprinus carpio L.).

The respiratory burst is an important feature of the immune system. The increase in cellular oxygen uptake that marks the initiation of the respiratory burst is followed by the production of reactive oxygen species (ROS) such as superoxide anion and hydrogen peroxide which plays a role in the clearance of pathogens and tissue regeneration processes. Therefore, the respiratory burst and associated ROS constitute important indicators of fish health status. This paper compares two methods for quantitation of ROS produced during the respiratory burst in common carp: the widely used, single-point measurement based on the intracellular reduction of nitroblue tetrazolium (NBT) and a real-time luminol-enhanced assay based on the detection of native chemiluminescence. Both assays allowed for detection of dose-dependent changes in magnitude of the respiratory burst response induced by ß-glucans in head kidney cells of carp. However, whereas the NBT assay was shown to detect the production of only superoxide anions, the real-time luminol-enhanced assay could detect the production of both superoxide anions and hydrogen peroxide. Only the chemiluminescence assay could reliably record the production of ROS on a real-time scale at frequent and continual time intervals for time course experiments, providing more detailed information on the respiratory burst response. The real-time chemiluminescence assay was used to measure respiratory burst activity in macrophage and neutrophilic granulocyte-enriched head kidney cell fractions and total head kidney cell suspensions and proved to be a fast, reliable, automated multiwell microplate assay to quantitate fish health status modulated by ß-glucans.

Carp head kidney leukocytes display different patterns of oxygen radical production after stimulation with PAMPs and DAMPs.

Wound healing and tissue regeneration are essential mechanisms to ensure the survival and health of any organism. Despite this, only a few studies have been devoted to study tissue regeneration during wound healing in fish. Reactive oxygen species (ROS), in particular hydrogen peroxide, play an important dual role both for promoting tissue repair, but also for eradication of pathogens. This study aims at dissecting the contribution of PAMPs (using ß-glucan) and DAMPs in the respiratory burst response of carp head kidney-derived leukocytes, and address their contribution to wound healing processes. Consistent with a pathogen eradication strategy, ROS responses to PAMP stimulation (ß-glucan) was fast, vigorous and highly dominated by production of superoxide anion. In contrast, stimulation with DAMPs led to a slow, subtle but long-lasting production of oxygen radicals dominated by hydrogen peroxide. Using an in vitro model of scratch-wounded CCB fibroblast cell cultures and a novel PhotoID proliferation assay, stimulation with low and continuous levels of hydrogen peroxide (5 µM) led to a slight increase in the percentage of wound recovery and thus promoted wound closure. In contrast, high doses of hydrogen peroxide (300 µM) impaired fibroblast scratch-wound recovery and caused cell death. These results elucidate the capacity of hydrogen peroxide to influence the fate of tissue regeneration through the establishment of environments suitable for promoting either tissue regeneration or oxidative stress and thereby potential tissue damage. Direct in vitro stimulation with ß-glucans did not impact fibroblast scratch-wound recovery, which further suggests that interaction with tissue-resident leukocytes or other components of the fish immune system are required to induce fibroblast proliferation and thus for the accelerated wound healing promoted by ß-glucan stimulation.

Concentration of activin A and follistatin in follicular fluid from human small antral follicles associated to gene expression of the corresponding granulosa cells.

The present study correlated concentrations of activin A and follistatin in follicular fluid (FF) from human small antral follicles to FF concentrations of AMH, inhibin B, progesterone, and oestradiol and to the mRNA expression of FSH-receptor (FSHR), LH-receptor (LHR), AMH-receptor2 (AMHR2), CYP19a, and androgen-receptor (AR) in the corresponding granulosa cells (GC). FF from 144 follicles (3-12 mm in diameter) was included whereas mRNA expression profiles were established in GC from 66 of the 144 follicles. Levels of follistatin remained constant in relation to follicular diameter, whereas activin A levels increased in follicles exceeding 10 mm in diameter. Levels of activin A and inhibin B showed a highly significant inverse association. Follistatin showed highly significant positive associations with AMH and inhibin B levels and with FSHR and AR gene expression in GC. This study revealed unexpected associations that probably reflect the complicated regulatory mechanisms governing human folliculogenesis.

In human granulosa cells from small antral follicles, androgen receptor mRNA and androgen levels in follicular fluid correlate with FSH receptor mRNA.

Human small antral follicles (diameter 3-9 mm) were obtained from ovaries surgically removed for fertility preservation. From the individual aspirated follicles, granulosa cells and the corresponding follicular fluid were isolated in 64 follicles, of which 55 were available for mRNA analysis (24 women). Expressions of androgen receptor (AR) mRNA levels in granulosa cells, and of androstenedione and testosterone in follicular fluid, were correlated to the expression of the FSH receptor (FSHR), LH receptor (LHR), CYP19 and anti-Müllerian Hormone-receptor II (AMHRII) mRNA in the granulosa cells and to the follicular fluid concentrations of AMH, inhibin-B, progesterone and estradiol. AR mRNA expression in granulosa cells and the follicular fluid content of androgens both showed a highly significant positive association with the expression of FSHR mRNA in granulosa cells. AR mRNA expression also correlated significantly with the expression of AMHRII, but did not correlate with any of the hormones in the follicular fluid. These data demonstrate an intimate association between AR expression in immature granulosa cells, and the expression of FSHR in normal small human antral follicles and between the follicular fluid levels of androgen and FSHR expression. This suggests that follicular sensitivity towards FSH stimulation may be augmented by stimulation of androgens via the AR.

Inflammatory and regenerative responses in salmonids following mechanical tissue damage and natural infection.

Locale responses in muscle tissue against either a sterile tissue damage or infection were compared in salmonid fish in order to examine the inflammatory responses and regeneration of tissue. From higher vertebrates both damage and infection are known to cause inflammation since DAMPs released from injured cells as well as PAMPs from the surface of pathogens are immunogenic. To examine this in salmonid fishes, Atlantic salmon (Salmo salar) were infected with Moritella viscosus, the causative agent of winter ulcer. Muscle tissue was sampled from infected fish at 4, 7 and 14 days post infection. Samples were obtained from site of lesions and from locations without clinical signs of disease and lesions. The tissue damage was performed in rainbow trout (Oncorhynchus mykiss) by applying sterile needles to skin and muscle tissue to one side of the fish. Samples were taken 7, 14, 21, 28 and 42 days post injury from the injured side and non-injured site (internal control). From both infected and damaged fish, samples were subject to real-time RT-PCR for measuring the expression of IL-1beta, IL-8, IL-10, Hsp70, iNOS, TGF-beta, TLR-5m, TLR-9, TLR-22, TGF-beta, MMP-2, CTGF, myostatin-1alphabeta and collagen-1alpha which are coding for immunological factors and tissue regeneration. Locale, inflammatory responses were seen as strong up-regulation of IL-1beta and IL-8 in both groups of fish, but it was more pronounced in infected fish. Expression of the toll-like receptors showed induction of TLR-5m following infection, but TLR-9 and TLR-22 following damage. Further, in both studies the regenerative genes TGF-beta, MMP-2, CTGF, myostatin-1alphabeta were induced, but showed different kinetics. Collagen-1alpha was only induced in infected fish, probably due to heavier tissue damage in these.

The eel immune system: present knowledge and the need for research.

The European eel, Anguilla anguilla, is one of the most important warm water fish species cultured in southern Europe and the Mediterranean as well as in northern countries including Germany, the Netherlands and Denmark. The Japanese eel, A. japonica, is an important cultured fish in several Asiatic countries including Japan, China and Taiwan. During recent decades, research has been performed to elucidate the immune response of these species against different pathogens (viruses, bacteria or parasites). Nevertheless, there is very limited information in terms of both cellular and humoral immune responses. This review summarizes the present knowledge relating to the eel immune system and includes new data.

The kinetics of antibody production in mucus and serum of European eel (Anguilla anguilla L.) after vaccination against Vibrio vulnificus: development of a new method for antibody quantification in skin mucus.

Vibrio vulnificus serovar E, a bacterial pathogen for eels cultured in intensive systems, is transmitted through water and enters into new hosts mainly via gills. The main objective of this work was to study the kinetics of antibody production to V. vulnificus in serum and mucus and their relationship with protection after vaccination. To quantify local mucus antibodies, a new "in situ" dot blot immunoassay using image analysis has been developed. This assay was applied to measure antibody production in the skin zone next to the gills. We found that (i) the immune response in mucus was faster (peak at days 3-4) and shorter in duration (titres significantly elevated up to day 5 and 11 for skin zone next to the gills and for general cutaneous mucus, respectively) than in serum (peak at day 7; titres significantly elevated for more than 25 days); (ii) the exposure of vaccinated eels with basal levels of local antibodies to sub-lethal dose of the pathogen stimulated a more lasting secreted antibody production (for more than 14 days); (iii) protection and antibody levels in serum were clearly correlated, and (iv) immunised eels with basal levels of serum antibodies and maximal levels of local antibodies were partially protected.

Is Aeromonas hydrophila the dominant motile Aeromonas species that causes disease outbreaks in aquaculture production in the Zhejiang Province of China?

The significance of Aeromonas hydrophila in association with disease outbreaks in aquaculture production in the Zhejiang province of China was investigated. Bacteriological examination of moribund fish and crabs resulted in 95 bacterial isolates: 88 bacterial isolates from fish and 7 isolates from crabs. PCR and traditional biochemical methods were used for identification of A. hydrophila. Out of 69 motile aeromonads, 35 isolates were identified as A. hydrophila by biochemical tests. However, 6 of those were not identified as A. hydrophila by a species specific PCR method. Serotyping revealed 2 dominant serotypes (O9 and O97) among A. hydrophila isolates. The data presented show that approximately 42% of the motile aeromonads isolated from disease outbreaks among various fish species were A. hydrophila. It is noteworthy that A. hydrophila accounted for more than 50% of the isolated aeromonands isolated from crucian carp Carassius carassius and Wuchang bream Megalobrama amblycephala with haemorrhagic septicaemia. Although this species was the most frequently isolated organism from internal organs of diseased fish and crabs in the present study, other motile Aeromonas spp. were also found. The PCR assay was useful in preventing misidentification of A. hydrophila, which may occur when only phenotypic tests are employed.

Control of specific gene expression by gibberellin and brassinosteroid.

We identified a recessive, brassinolide-insensitive mutant caused by a deletion allele (bri1-201) of the brassinosteroid (BR) receptor BRI1. The bri1-201 mutant displayed altered expression levels of genes differentially regulated by gibberellin (GA). RNA-blot analysis revealed that BR and GA antagonistically regulate the accumulation of mRNAs of the GA-responsive GASA1 gene, as well as the GA-repressible GA5 gene. Expression studies with cycloheximide indicated that the antagonistic effects of GA and BR on GA5 require de novo protein synthesis. Reporter transgene analyses and RNA-blot analysis showed that BR and GA modulate GA5 expression, at least in part, at the transcriptional level, and that the signals are independent and subtractive.