Anisotropic Two-Dimensional Disordered Wigner Solid.

The interplay between the Fermi sea anisotropy, electron-electron interaction, and localization phenomena can give rise to exotic many-body phases. An exciting example is an anisotropic two-dimensional (2D) Wigner solid (WS), where electrons form an ordered array with an anisotropic lattice structure. Such a state has eluded experiments up to now as its realization is extremely demanding: First, a WS entails very low densities where the Coulomb interaction dominates over the kinetic (Fermi) energy. Attaining such low densities while keeping the disorder low is very challenging. Second, the low-density requirement has to be fulfilled in a material that hosts an anisotropic Fermi sea. Here, we report transport measurements in a clean (low-disorder) 2D electron system with anisotropic effective mass and Fermi sea. The data reveal that at extremely low electron densities, when the r_{s} parameter, the ratio of the Coulomb to the Fermi energy, exceeds ≃38, the current-voltage characteristics become strongly nonlinear at small dc biases. Several key features of the nonlinear characteristics, including their anisotropic voltage thresholds, are consistent with the formation of a disordered, anisotropic WS pinned by the ubiquitous disorder potential.

Spontaneous Valley Polarization of Itinerant Electrons.

Memory or transistor devices based on an electron's spin rather than its charge degree of freedom offer certain distinct advantages and comprise a cornerstone of spintronics. Recent years have witnessed the emergence of a new field, valleytronics, which seeks to exploit an electron's valley index rather than its spin. An important component in this quest would be the ability to control the valley index in a convenient fashion. Here we show that the valley polarization can be switched from zero to 1 by a small reduction in density, simply tuned by a gate bias, in a two-dimensional electron system. This phenomenon, which is akin to Bloch spin ferromagnetism, arises fundamentally as a result of electron-electron interaction in an itinerant, dilute electron system. Essentially, the kinetic energy favors an equal distribution of electrons over the available valleys, whereas the interaction between electrons prefers single-valley occupancy below a critical density. The gate-bias-tuned transition we observe is accompanied by a sudden, twofold change in sample resistance, making the phenomenon of interest for potential valleytronic transistor device applications. Our observation constitutes a quintessential demonstration of valleytronics in a very simple experiment.

Observation of spontaneous ferromagnetism in a two-dimensional electron system.

What are the ground states of an interacting, low-density electron system? In the absence of disorder, it has long been expected that as the electron density is lowered, the exchange energy gained by aligning the electron spins should exceed the enhancement in the kinetic (Fermi) energy, leading to a (Bloch) ferromagnetic transition. At even lower densities, another transition to a (Wigner) solid, an ordered array of electrons, should occur. Experimental access to these regimes, however, has been limited because of the absence of a material platform that supports an electron system with very high quality (low disorder) and low density simultaneously. Here we explore the ground states of interacting electrons in an exceptionally clean, two-dimensional electron system confined to a modulation-doped AlAs quantum well. The large electron effective mass in this system allows us to reach very large values of the interaction parameter [Formula: see text], defined as the ratio of the Coulomb to Fermi energies. As we lower the electron density via gate bias, we find a sequence of phases, qualitatively consistent with the above scenario: a paramagnetic phase at large densities, a spontaneous transition to a ferromagnetic state when [Formula: see text] surpasses 35, and then a phase with strongly nonlinear current-voltage characteristics, suggestive of a pinned Wigner solid, when [Formula: see text] exceeds [Formula: see text] However, our sample makes a transition to an insulating state at [Formula: see text], preceding the onset of the spontaneous ferromagnetism, implying that besides interaction, the role of disorder must also be taken into account in understanding the different phases of a realistic dilute electron system.

Precise Experimental Test of the Luttinger Theorem and Particle-Hole Symmetry for a Strongly Correlated Fermionic System.

A fundamental concept in physics is the Fermi surface, the constant-energy surface in momentum space encompassing all the occupied quantum states at absolute zero temperature. In 1960, Luttinger postulated that the area enclosed by the Fermi surface should remain unaffected even when electron-electron interaction is turned on, so long as the interaction does not cause a phase transition. Understanding what determines the Fermi surface size is a crucial and yet unsolved problem in strongly interacting systems such as high-T_{c} superconductors. Here we present a precise test of the Luttinger theorem for a two-dimensional Fermi liquid system where the exotic quasiparticles themselves emerge from the strong interaction, namely, for the Fermi sea of composite fermions (CFs). Via direct, geometric resonance measurements of the CFs' Fermi wave vector down to very low electron densities, we show that the Luttinger theorem is obeyed over a significant range of interaction strengths, in the sense that the Fermi sea area is determined by the density of the minority carriers in the lowest Landau level. Our data also address the ongoing debates on whether or not CFs obey particle-hole symmetry, and if they are Dirac particles. We find that particle-hole symmetry is obeyed, but the measured Fermi sea area differs quantitatively from that predicted by the Dirac model for CFs.

Low-dose corticosteroid and mycophenolate for primary treatment of minimal change disease.

BACKGROUND: Mycophenolate has been shown to be effective in glomerular disease. However, the role of mycophenolate in the first-line treatment of adult-onset idiopathic minimal change disease (MCD) has not been systematically studied in a randomized fashion. AIM: To evaluate the therapeutic efficacy of enteric-coated mycophenolate sodium combined with low-dose corticosteroid as first-line treatment for MCNS. DESIGN: A prospective, open-label, randomized clinical trial. METHODS: Twenty adult patients with biopsy proven MCD were recruited and randomly assigned to receive either enteric-coated Mycophenolate Sodium (EC-MPS) plus low-dose prednisolone (Group 1: Prednisolone 0.25 mg/kg/day, n = 10) or standard-dose prednisolone (Group 2: Prednisolone 1 mg/kg/day, n = 10). RESULTS: After 24 weeks of therapy, eight patients in Group 1 vs. seven of patients in Group 2 achieved complete remission (P = 0.606). Both groups showed a significant reduction of urine protein excretion (P < 0.05) and increased serum albumin (P < 0.001) vs. baseline levels. However, no significant between-group differences were demonstrated. The relapse rate was also similar in both groups. Both treatment regimens were well tolerated but there were more patient reported adverse effects in the standard-dose prednisolone group. CONCLUSION: EC-MPS plus low-dose prednisolone is non-inferior to standard-dose prednisolone therapy in inducing clinical remission and preventing relapse in adult-onset idiopathic MCD and is associated with better tolerability and less adverse effects. This trial is registered with the ClinicalTrials.gov number NCT01185197.

Serum immunoglobulin G level in patients with lupus nephritis and the effect of treatment with corticosteroids and mycophenolate mofetil.

BACKGROUND: Reduced serum IgG level is associated with increased risk of infection. We investigated the circulating IgG level and its determining factors in active lupus nephritis patients treated with corticosteroids and mycophenolate mofetil (MMF). METHODS: This was a retrospective study on the longitudinal IgG profile in Class III/IV ± V lupus nephritis patients treated with prednisolone and MMF. RESULTS: 46 patients were included. At baseline, 34 (73.9%) patients (Group I) had normal or elevated IgG (1444.0 ± 600.5 mg/dL) while 12 (26.1%) (Group II) had IgG levels (567.8 ± 160.9 mg/dL) below the lower limit of normal. IgG levels at baseline, three, six and 12 months after treatment were 1215.4 ± 649.7 mg/dL, 843.9 ± 347.6 mg/dL, 914.5 ± 362.4 mg/dL and 1034.6 ± 452.5 mg/dL respectively. Treatment with prednisolone and MMF led to a significant drop in IgG after two weeks, reaching a nadir at eight weeks, followed by gradual normalization. Similar changes in IgG were observed in Group I patients but there was non-significant change in Group II within the first 24 weeks. Eighteen (39.1%) patients had low IgG by six months, and only one patient had IgG <300 mg/dL, at both three and six months. IgG level was negatively associated with proteinuria at six months (r = -0.711, p = 0.010). Five of 18 patients with low IgG had infections within the first year, while IgG levels below the lower limit of normal did not increase infection risk (relative risk 1.863; 95% confidence interval 0.466 to 6.818, p = 0.280). CONCLUSION: Reduced IgG occurred in 26% of active lupus nephritis patients and the IgG levels are significantly influenced by the severity of proteinuria. Treatment with prednisolone and MMF does not result in clinically important suppression of IgG.

Superior mesenteric artery syndrome complicating dialysis patients with peritoneal failure--report of 3 cases.

We report 3 cases of superior mesenteric artery syndrome in patients previously on maintenance peritoneal dialysis converted to hemodialysis after peritoneal failure. All 3 patients presented with repeated vomiting and severe malnutrition. It is postulated that complications arising from peritoneal dialysis such as peritoneal sclerosis, adhesions and collections after CAPD peritonitis may be important contributing factors for the SMA syndrome in these 3 patients. All of them succumbed within six months of diagnosis. The first 2 patients received gastrointestinal bypass surgery and died post-operatively due to impaired wound healing and nosocomial sepsis. The 3rd patient was treated conservatively with nasoduodenal feeding but succumbed to aspiration pneumonia. It is postulated that complications arising from peritoneal dialysis including peritoneal sclerosis, adhesions and collections after CAPD peritonitis may contribute to the SMA syndrome in these patients. Our experience suggests that SMA syndrome in end-stage renal disease patients is associated with high surgical morbidity and mortality possibly related to their poor pre-morbid condition and pre-existing malnutrition. Aggressive parenteral nutrition should be considered to build up the general status before proceeding to surgical intervention.

Phase I study of pegylated liposomal doxorubicin and the multidrug-resistance modulator, valspodar.

Valspodar, a P-glycoprotein modulator, affects pharmacokinetics of doxorubicin when administered in combination, resulting in doxorubicin dose reduction. In animal models, valspodar has minimal interaction with pegylated liposomal doxorubicin (PEG-LD). To determine any pharmacokinetic interaction in humans, we designed a study to determine maximum tolerated dose, dose-limiting toxicity (DLT), and pharmacokinetics of total doxorubicin, in PEG-LD and valspodar combination therapy in patients with advanced malignancies. Patients received PEG-LD 20-25 mg m(-2) intravenously over 1 h for cycle one. In subsequent 2-week cycles, valspodar was administered as 72 h continuous intravenous infusion with PEG-LD beginning at 8 mg m(-2) and escalated in an accelerated titration design to 25 mg m(-2). Pharmacokinetic data were collected with and without valspodar. A total of 14 patients completed at least two cycles of therapy. No DLTs were observed in six patients treated at the highest level of PEG-LD 25 mg m(-2). The most common toxicities were fatigue, nausea, vomiting, mucositis, palmar plantar erythrodysesthesia, diarrhoea, and ataxia. Partial responses were observed in patients with breast and ovarian carcinoma. The mean (range) total doxorubicin clearance decreased from 27 (10-73) ml h(-1) m(-2) in cycle 1 to 18 (3-37) ml h(-1) m(-2) with the addition of valspodar in cycle 2 (P=0.009). Treatment with PEG-LD 25 mg m(-2) in combination with valspodar results in a moderate prolongation of total doxorubicin clearance and half-life but did not increase the toxicity of this agent.

Hydroxychloroquine for the prevention of acute graft-versus-host disease after unrelated donor transplantation.

Hydroxychloroquine (HCQ) is an immunosuppressive agent that interferes with antigen presentation and with activity against graft-versus-host disease (GVHD). In a phase II trial assessing the GVHD prophylactic effects of HCQ, 51 consecutive unrelated donor transplant recipients received HCQ in addition to cyclosporin A, methylprednisolone, and methotrexate. HCQ was initiated on pretransplantation day -21 at 800 mg/d and continued until day +100 after transplantation. HCQ was extremely well tolerated and was not associated with side effects. Pharmacokinetic analyses demonstrated large inter- and intrapatient variability. The addition of HCQ did not affect posttransplantation immune recovery. Grade II to IV acute GVHD was observed in 56% of patients, and grade III and IV GVHD was observed in 17%. Day +100 mortality was 22%. When compared with a matched cohort of patients reported to the International Bone Marrow Transplant Registry, patients receiving HCQ had comparable cumulative incidences of grade II to IV acute GVHD. However, lower incidences of grades III and IV GVHD and better GVHD-free survival were observed in HCQ-treated patients (P =.01). We conclude that prophylactic HCQ is well tolerated and associated with a low incidence of severe acute GVHD. An ongoing placebo-controlled randomized trial will further determine what role HCQ plays in preventing GVHD after allografting.

Lessons learned from the irinotecan metabolic pathway.

Irinotecan, a camptothecin analogue, is a prodrug which requires bioactivation to form the active metabolite SN-38. SN-38 acts as a DNA topoisomerase I poison. Irinotecan has been widely used in the treatment of metastatic colorectal cancer, small cell lung cancer and several other solid tumors. However, large inter-patient variability in irinotecan and SN-38 disposition, as well as severe but unpredictable diarrhea limits the clinical potential of irinotecan. Intense clinical pharmacology studies have been conducted to elucidate its complicated metabolic pathways and to provide scientific rationale in defining strategies to optimize drug therapy. Irinotecan is subjected to be shunted between CYP3A4 mediated oxidative metabolism to form two inactive metabolites APC or NPC and tissue carboxylesterase mediated hydrolysis to form SN-38 which is eventually detoxified via glucuronidation by UGT1A1 to form SN-38G. The pharmacology of this compound is further complicated by the existence of genetic inter-individual differences in activation and deactivation enzymes of irinotecan (e.g., CYP3A4, CYP3A5, UGT1A1) and sharing competitive elimination pathways with many concomitant medications, such as anticonvulsants, St. John's Wort, and ketoconazole. Efflux of the parent compound and metabolites out of cells by several drug transporters (e.g., Pgp, BCRP, MRP1, MRP2) also occurs. This review highlights the latest findings in drug activation, transport mechanisms, glucuronidation, and CYP3A-mediated drug-drug interactions of irinotecan in order to unlock some of its complicated pharmacology and to provide ideas for relevant future studies into optimization of this promising agent.

Sudden death among patients with acute promyelocytic leukemia treated with arsenic trioxide.

Arsenic trioxide has been shown to be effective in treating acute promyelocytic leukemia (APL), with minimal overall toxicity reported to date. A phase I/II study was initiated in June 1998 using arsenic trioxide for relapsed APL to determine the maximum tolerated or minimal effective dose and to determine the efficacy of treatment at that dose. Ten patients received 1 to 4 monthly cycles of treatment with 0.1 mg/kg per day intravenous arsenic trioxide. Six of 7 patients evaluable for response achieved cytogenetic or molecular complete remission. However, 3 patients died suddenly during the first cycle of treatment. Autopsies obtained on 2 of these failed to identify a cause of sudden death, despite evidence of pulmonary hemorrhage in one. A third patient, for whom an autopsy was not performed, became asystolic and died while on continuous cardiac telemetry. These observations suggest that arsenic trioxide may be significantly or even fatally toxic at doses currently used and that caution is warranted in its use.

Activation of CPT-11 in mice: identification and analysis of a highly effective plasma esterase.

The camptothecin prodrug CPT-11 (irinotecan, 7-ethyl-10-[4-(1-piperidino)-1-piperidino]carbonyloxycamptothecin) is converted by esterases to yield the potent topoisomerase I poison SN-38 (7-ethyl-10-hydroxycamptothecin). Recently, a mouse strain (Es1(e)) has been identified that demonstrates reduced plasma esterase activity, and we have monitored the ability of plasma from these mice to metabolize CPT-11. Total plasma esterase activity was reduced 3-fold in Esl(e)mice in comparison to control mice, and this resulted in a 200-fold reduction in SN-38 production after incubation with CPT-11 in vitro. In addition, pharmacokinetic studies of CPT-11 and SN-38 in these animals demonstrated approximately 5-fold less conversion to SN-38. However, extracts derived from tissues from Es1(e) animals revealed total esterase activities similar to those of control mice, and these extracts metabolized CPT-11 with equal efficiency. Northern analysis of RNA isolated from organs indicated that the liver was the primary source of Es-1 gene expression and that very low levels of Es-1 RNA were present in Es1(e) mice. These results suggest that the reduced levels of Es-1 esterase present in Es1(e) mice are due to down-regulation of gene transcription, and that this plasma esterase is responsible for the majority of CPT-11 metabolism in mice.

Pharmacokinetics of irinotecan and its metabolites SN-38 and APC in children with recurrent solid tumors after protracted low-dose irinotecan.

Irinotecan (IRN), a topoisomerase I interactive agent, has significant antitumor activity in early Phase I studies in children with recurrent solid tumors. However, the disposition of IRN and its metabolites, SN-38 and APC, in children has not been reported. Children with solid tumors refractory to conventional therapy received IRN by a 1-h i.v. infusion at either 20, 24, or 29 mg/m2 daily for 5 consecutive days for 2 weeks. Serial blood samples were collected after doses 1 and 10 of the first course. IRN, SN-38, and APC lactone concentrations were determined by an isocratic high-performance liquid chromatography assay. A linear four-compartment model was fit simultaneously to the IRN, SN-38, and APC plasma concentration versus time data. Systemic clearance rate for IRN was 58.7 +/- 18.8 liters/h/m2 (mean +/- SD). The mean +/- SD ng/ml x h single-day lactone SN-38 area under the concentration-time curve (AUC(0-->6) was 90.9 +/- 96.4, 103.7 +/- 62.4, and 95.3 +/- 63.9 at IRN doses of 20, 24, and 29 mg/m2, respectively. The relative extent of IRN conversion to SN-38 and metabolism to APC measured after dose 1 were 0.49 +/- 0.33 and 0.29 +/- 0.17 (mean +/- SD). No statistically significant intrapatient difference was noted for SN-38 area under the concentration-time curve. Large interpatient variability in IRN and metabolite disposition was observed. The relative extent of conversion and the SN-38 systemic exposure achieved with this protracted schedule of administration were much greater than reported in adults or children receiving larger intermittent doses.

Direct translation of a protracted irinotecan schedule from a xenograft model to a phase I trial in children.

PURPOSE: In a preclinical model of neuroblastoma, administration of irinotecan daily 5 days per week for 2 consecutive weeks ([qd x 5] x 2) resulted in greater antitumor activity than did a single 5-day course with the same total dose. We evaluated this protracted schedule in children. PATIENTS AND METHODS: Twenty-three children with refractory solid tumors were enrolled onto a phase I study. Cohorts received irinotecan by 1-hour intravenous infusion at 20, 24, or 29 mg/m(2) (qd x 5) x 2 every 21 days. RESULTS: The 23 children (median age, 14.1 years; median prior regimens, two) received 84 courses. Predominant diagnoses were neuroblastoma (n = 5), osteosarcoma (n = 5), and rhabdomyosarcoma (n = 4). The dose-limiting toxicity was grade 3/4 diarrhea and/or abdominal cramps in six of 12 patients treated at 24 mg/m(2), despite aggressive use of loperamide. The maximum-tolerated dose (MTD) on this schedule was 20 mg/m(2)/d. Five patients had partial responses and 16 had disease stabilization. On day 1, the median systemic exposure to SN-38 (the active metabolite of irinotecan) at the MTD was 106 ng-h/mL (range, 41 to 421 ng-h/mL). CONCLUSION: This protracted schedule is well tolerated in children. The absence of significant myelosuppression and encouraging clinical responses suggest compellingly that irinotecan be further evaluated in children using the (qd x 5) x 2 schedule, beginning at a dose of 20 mg/m(2). These results imply that data obtained from xenograft models can be effectively integrated into the design of clinical trials.

Use of the phrenic nerve for brachial plexus reconstruction.

To examine the clinical effectiveness and safety of phrenic nerve neurotization for brachial plexus reconstruction, the authors retrospectively analyzed the surgically treated cases within the period between August 1970 and March 1990. There was a total of 180 patients who sustained brachial plexus injuries and had phrenic nerve transfer. The phrenic nerve was identified and traced distally to give the longest possible length and sectioned. The proximal stump was coapted to the distal segment of the musculocutaneous nerve, either directly or through a nerve graft. Sixty-five patients who were seen in followup for >2 years were studied. The time taken for the return of a muscle power rating of 3 (M3) in the biceps muscle ranged from 3 to 30 months; the average time was 9.5 months. Of the patients, 84.6% regained biceps power to M3 and greater strength. Only 1 patient had a transient respiratory problem after surgery. Pulmonary function tests showed decreased pulmonary capacities within 1 year of operation, improving toward 2 years. Thus, it is concluded that phrenic nerve neurotization can be accepted as a sound option for the restoration of biceps function in brachial plexus injury.

Nerve transfer for treatment of root avulsion of the brachial plexus: experimental studies in a rat model.

In order to evaluate the effects of various nerve transfers, experimental rat models simulating root avulsions of the brachial plexus were created, using four different types of nerve transfers. Four groups of 160 rats were randomly divided, and phrenic nerves, double intercostal nerves, accessory nerves, and single intercostal nerves were transferred. Electrophysiologic and histologic examinations and functional evaluations were performed at different postoperative intervals. Phrenic nerve transfer was found to be superior to the other types most likely on the basis of superior neural regeneration. A single phrenectomy in the rat was found to have no apparent effect on pulmonary function.

Drill biopsy of the thyroid gland.

Needle drill biopsies were performed on 360 patients presenting with thyroid swellings. The indications and technique are discussed. Surgical treatment was carried out for 154 of the 225 solitary nodules and 82 of the 129 nodular goitres. The overall success rate in obtaining thyroid tissue was 74%. The accuracy rate was 100% in lymphocytic thyroiditis, anaplastic carcinoma and medullary carcinoma. With adenoma, 66% of those presenting as solitary nodules and 44-4% as nodular goitres were correctly diagnosed. Two-thirds of papillary carcinomas were correctly diagnosed by drill biopsy. Only 28-6% of follicular carcinomas were diagnosed before operation. The drill biopsy proved to be a simple procedure, with few complications, and served the purpose of selecting patients for operative treatment.

Cystic thyroid nodules.

Among 300 patients with thyroid nodules subjected to a needle drill biopsy, 62 were found to contain cystic lesions. Analysis of these 62 showed that in 17 the swelling had completely disappeared after the biopsy. The remaining 45 had residual or recurrent swellings. Operative treatment was carried out in 35, which consisted of 28 (80 per cent) nodular goitres, 6 (17-1 per cent) adenomas and 1 (2-9 per cent) carcinoma.