Sequential immunosuppressive therapy in progressive IgA nephropathy

BACKGROUNDS: Cyclophosphamide and high-dose steroids have been used as limited induction therapy in progressive IgA nephropathy (IgAN) to reduce the loss of renal function and proteinuria. We evaluated the effect of cyclophosphamide pulses (CyP) and mycophenolic acid (MPA) as sequential therapy on renal function in patients with progressive IgAN. METHODS: Twenty patients with progressive IgAN and advanced renal failure (median GFR 22 ml/min per 1.73 m2) and further disease activity (triangle downGFR -0.8 ml/min per month) after cyclophosphamide (CyP; n = 18) or steroid pulse therapy (n = 2) were treated with mycophenolate mofetil 1 g per day for a median of 27 months. RESULTS: The monthly loss of renal function was significantly reduced in linear regression analysis from -2.4 ml/min before CyP to -0.12 ml/min with CyP/MPA (p = 0.0009). Estimated renal survival time was significantly prolonged by a median of 65 months (p = 0.0014). Proteinuria decreased significantly from 1.7 to 0.4 g/l during MPA treatment (p = 0.015). In Cox regression analysis, only proteinuria >1.0 g/l was an independent risk factor for doubling of creatinine during CyP/MPA treatment (p = 0.03). CONCLUSION: A sequential therapy with CyP/MPA may arrest or slow down the loss of renal function and reduces proteinuria even in patients who passed the so called 'point of no return' with progressive IgAN.

Integration of external and internal dosimetry in Switzerland

Individual monitoring regulations in Switzerland are based on the ICRP60 recommendations. The annual limit of 20 mSv for the effective dose applies to the sum of external and internal radiation. External radiation is monitored monthly or quarterly with TLD, DIS or CR-39 dosemeters by 10 approved external dosimetry services and reported as H(p)(10) and H(p)(0.07). Internal monitoring is done in two steps. At the workplace, simple screening measurements are done frequently in order to recognise a possible incorporation. If a nuclide dependent activity threshold is exceeded then one of the seven approved dosimetry services for internal radiation does an incorporation measurement to assess the committed effective dose E(50). The dosimetry services report all the measured or assessed dose values to the employer and to the National Dose Registry. The employer records the annually accumulated dose values into the individual dose certificate of the occupationally exposed person, both the external dose H(p)(10) and the internal dose E(50) as well as the total effective dose E = H(p)(10)+E(50). Based on the national dose registry an annual report on the dosimetry in Switzerland is published which contains the statistics for the total effective dose, as well as separate statistics for external and internal exposure.

Increased plasma endothelin-1 levels in patients with progressive open angle glaucoma

AIM: To compare the plasma levels of endothelin-1 (ET-1) between patients with primary open angle glaucoma with visual field progression despite normal or normalised intraocular pressure and patients with stabile visual fields in a retrospective study. METHODS: The progressive group consisted of 16 primary open angle glaucoma patients and the group with stable visual field consisted of 15 patients. After a 30 minute rest in a supine position, venous blood was obtained for ET-1 dosing. Difference in the plasma level of ET-1 between two groups was compared by means of analysis of covariance (ANCOVA), including age, sex, and mean arterial blood pressure as covariates. RESULTS: ET-1 plasma levels were found to be significantly increased in patients with deteriorating (3.47 (SD 0.75) pg/ml) glaucoma when compared to those with stable (2.59 (SD 0.54) pg/ml) visual fields (p = 0.0007). CONCLUSIONS: Glaucoma patients with visual field progression in spite of normal or normalised intraocular pressure have been found to have increased plasma endothelin-1 levels. It remains to be determined if this is a secondary phenomenon or whether it may have a role in the progression of glaucomatous damage.

Preliminary results following reinforcement of the pulmonary autograft to prevent dilatation after the Ross procedure

OBJECTIVE: The Ross operation remains a controversially discussed procedure, because concern exists regarding late dilatation of the neoaortic root and progressive regurgitation of the autograft valve. We present our early experience with an external reinforcement of the autograft, which is inserted into a prosthetic Dacron graft with an artificial aortic root configuration. This detail should help to prevent neoaortic root dilatation. PATIENTS AND METHODS: Between 2006 and 2007, 12 patients (mean age 16 +/- 38 years; range 15-38 years) underwent a Ross procedure by this technique. Indications were aortic regurgitation (n = 2), aortic stenosis (n = 5), and combined aortic stenosis and insufficiency (n = 5). A bicuspid aortic valve was present in 9 patients. Balloon valvuloplasty had been performed in 7 patients. Follow-up was performed by clinical and echocardiographic examinations. RESULTS: No early or late deaths occurred in this small series, and freedom from reoperation is 100%. Echocardiographic follow-up confirmed absence of aortic insufficiency in 11 patients after a mean of 11 months (range 2-30 months). In 1 patient, a small asymmetric regurgitation jet was already observed at discharge echocardiography. As expected, no neoaortic root dilatation was observed during follow-up. All patients are in New York Heart Association class I. CONCLUSIONS: The present technique is a simple and reproducible technical step that does not require significant additional time. Inclusion of the autograft within a root prosthesis may be especially indicated in situations known for late autograft dilatation, namely, bicuspid aortic valve, predominant aortic insufficiency, and ascending aortic enlargement.

Effectiveness of selective dorsal rhizotomy in 2 patients with progressive spasticity due to neurodegenerative disease

Selective dorsal rhizotomy at the lumbar level is a neurosurgical procedure, which reduces spasticity in the legs. Its effect has mainly been studied in children with spastic cerebral palsy. Little is known about the outcome of selective dorsal rhizotomy in patients with neurodegenerative disorders. We report the clinical course after selective dorsal rhizotomy in 2 patients with progressive spasticity. Leg spasticity was effectively and persistently reduced in both patients, facilitating care and improving sitting comfort. However, spasticity of the arms and other motor disturbances, such as spontaneous extension spasms and the ataxia, increased gradually in time. Selective dorsal rhizotomy leads to a disappearance of leg spasticity in patients with a neurodegenerative disease. Other motor signs are not influenced and may increase due to the progressive nature of the underlying disease.

Effect of external electric field on hydrogen adsorption over activated carbon separated by dielectric materials

Energy crisis and worldwide environmental problem make hydrogen a prospective energy carrier. However, storage and transportation of hydrogen in large quantities at small volume is currently not practical. Lots of materials and devices have been developed for storage hydrogen, but to today none is able to meet the DOE targets. Activated carbon has been found to be a good hydrogen adsorbent due to its high surface area. However, the weak van der Waals force between hydrogen and the adsorbent has limited the adsorption capacity. Previous studies have found that enhanced adsorption can be obtained with applied electric field. Stronger interaction between the polarized hydrogen and the charged sorbents under high voltage is considered as the reason. This study was initiated to investigate if the adsorption can be further enhanced when the activated carbon particles are separated with a dielectric coating. Dielectric TiO2 nanoparticles were first utilized. Hydrogen adsorption measurements on the TiO2-coated carbon materials, with or without an external electric field, were made. The results showed that the adsorption capacity enhancement increased with the increasing amount of TiO2 nanoparticles with an applied electric field. Since the hydrogen adsorption capacity on TiO2 particles is very low and there is no hydrogen adsorption enhancement on TiO2 particles alone when electric field is applied, the effect of dielectric coating is demonstrated. Another set of experiments investigated the behavior of hydrogen adsorption over TiO2-coated activated carbon under various electric potentials. The results revealed that the hydrogen adsorption first increased and then decreased with the increase of electric field. The improved storage was due to a stronger interaction between charged carbon surface and polarized hydrogen molecule caused by field induced polarization of TiO2 coating. When the electric field was sufficient to cause considerable ionization of hydrogen, the decrease of hydrogen adsorption occurred. The current leak detected at 3000 V was a sign of ionization of hydrogen. Experiments were also carried out to examine the hydrogen adsorption performances over activated carbon separated by other dielectric materials, MgO, ZnO and BaTiO3, respectively. For the samples partitioned with MgO and ZnO, the measurements with and without an electric field indicated negligible differences. Electric field enhanced adsorption has been observed on the activated carbon separated with BaTiO3, a material with unusually high dielectric constant. Corresponding computational calculations using Density Functional Theory have been performed on hydrogen interaction with charged TiO2 molecule as well as TiO2 molecule, coronene and TiO2-doped coronene in the presence of an electric field. The simulated results were consistent with the observations from experiments, further confirming the proposed hypotheses.

Lateral external fixation: a new surgical technique for displaced unreducible supracondylar humeral fractures in children

BACKGROUND: Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator. METHODS: Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction. RESULTS: In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again. CONCLUSIONS: The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

External auditory canal cholesteatoma: reassessment of and amendments to its categorization, pathogenesis, and treatment in 34 patients

OBJECTIVE: External auditory canal cholesteatoma (EACC) is a rarity. Although there have been numerous case reports, there are only few systematic analyses of case series, and the pathogenesis of idiopathic EACC remains enigmatic. STUDY DESIGN: In a tertiary referral center for a population of 1.5 million inhabitants, 34 patients with 35 EACC (13 idiopathic [1 bilateral] and 22 secondary) who were treated between 1994 and 2006 were included in the study. RESULTS: EACC cardinal symptoms were longstanding otorrhea (65%) and dull otalgia (12%). Focal bone destruction in the external auditory canal with retained squamous debris and an intact tympanic membrane were characteristic. Only 27% of the patients showed conductive hearing loss exceeding 20 dB. Patients with idiopathic EACC had lesions typically located on the floor of the external auditory canal and were older, and the mean smoking intensity was also greater (p < 0.05) compared with patients with secondary EACC. The secondary lesions were assigned to categories (poststenotic [n = 6], postoperative [n = 6], and posttraumatic EACC [n = 4]) and rare categories (radiogenic [n = 2], postinflammatory [n = 1], and postobstructive EACC [n = 1]). In addition, we describe 2 patients with EACC secondary to the complete remission of a Langerhans cell histiocytosis of the external auditory canal. Thirty of 34 patients were treated surgically and became all free of recurrence, even after extensive disease. DISCUSSION: For the development of idiopathic EACC, repeated microtrauma (e.g., microtrauma resulting from cotton-tipped applicator abuse or from hearing aids) and diminished microcirculation (e.g., from smoking) might be risk factors. A location other than in the inferior portion of the external auditory canal indicates a secondary form of the disease, as in the case of 2 patients with atypically located EACC after years of complete remission of Langerhans cell histiocytosis, which we consider as a new posttumorous category and specific late complication of this rare disease.

Computational study of internal and external condensing flows and experimental synthesis to investigate their attainability and stability in ground-based and space-based environments

This doctoral thesis presents the computational work and synthesis with experiments for internal (tube and channel geometries) as well as external (flow of a pure vapor over a horizontal plate) condensing flows. The computational work obtains accurate numerical simulations of the full two dimensional governing equations for steady and unsteady condensing flows in gravity/0g environments. This doctoral work investigates flow features, flow regimes, attainability issues, stability issues, and responses to boundary fluctuations for condensing flows in different flow situations. This research finds new features of unsteady solutions of condensing flows; reveals interesting differences in gravity and shear driven situations; and discovers novel boundary condition sensitivities of shear driven internal condensing flows. Synthesis of computational and experimental results presented here for gravity driven in-tube flows lays framework for the future two-phase component analysis in any thermal system. It is shown for both gravity and shear driven internal condensing flows that steady governing equations have unique solutions for given inlet pressure, given inlet vapor mass flow rate, and fixed cooling method for condensing surface. But unsteady equations of shear driven internal condensing flows can yield different “quasi-steady” solutions based on different specifications of exit pressure (equivalently exit mass flow rate) concurrent to the inlet pressure specification. This thesis presents a novel categorization of internal condensing flows based on their sensitivity to concurrently applied boundary (inlet and exit) conditions. The computational investigations of an external shear driven flow of vapor condensing over a horizontal plate show limits of applicability of the analytical solution. Simulations for this external condensing flow discuss its stability issues and throw light on flow regime transitions because of ever-present bottom wall vibrations. It is identified that laminar to turbulent transition for these flows can get affected by ever present bottom wall vibrations. Detailed investigations of dynamic stability analysis of this shear driven external condensing flow result in the introduction of a new variable, which characterizes the ratio of strength of the underlying stabilizing attractor to that of destabilizing vibrations. Besides development of CFD tools and computational algorithms, direct application of research done for this thesis is in effective prediction and design of two-phase components in thermal systems used in different applications. Some of the important internal condensing flow results about sensitivities to boundary fluctuations are also expected to be applicable to flow boiling phenomenon. Novel flow sensitivities discovered through this research, if employed effectively after system level analysis, will result in the development of better control strategies in ground and space based two-phase thermal systems.

DEVELOPMENT OF A CONCEPTUAL MODEL AND PARAMETERIZATION OF A MATHEMATICAL MODEL FOR SEDIMENT PHOSPHORUS DIAGENESIS, SORPTION AND RELEASE FROM ONONDAGA LAKE SYRACUSE, NEW YORK

Eutrophication is a persistent problem in many fresh water lakes. Delay in lake recovery following reductions in external loading of phosphorus, the limiting nutrient in fresh water ecosystems, is often observed. Models have been created to assist with lake remediation efforts, however, the application of management tools to sediment diagenesis is often neglected due to conceptual and mathematical complexity. SED2K (Chapra et al. 2012) is proposed as a "middle way", offering engineering rigor while being accessible to users. An objective of this research is to further support the development and application SED2K for sediment phosphorus diagenesis and release to the water column of Onondaga Lake. Application of SED2K has been made to eutrophic Lake Alice in Minnesota. The more homogenous sediment characteristics of Lake Alice, compared with the industrially polluted sediment layers of Onondaga Lake, allowed for an invariant rate coefficient to be applied to describe first order decay kinetics of phosphorus. When a similar approach was attempted on Onondaga Lake an invariant rate coefficient failed to simulate the sediment phosphorus profile. Therefore, labile P was accounted for by progressive preservation after burial and a rate coefficient which gradual decreased with depth was applied. In this study, profile sediment samples were chemically extracted into five operationally-defined fractions: CaCO3-P, Fe/Al-P, Biogenic-P, Ca Mineral-P and Residual-P. Chemical fractionation data, from this study, showed that preservation is not the only mechanism by which phosphorus may be maintained in a non-reactive state in the profile. Sorption has been shown to contribute substantially to P burial within the profile. A new kinetic approach involving partitioning of P into process based fractions is applied here. Results from this approach indicate that labile P (Ca Mineral and Organic P) is contributing to internal P loading to Onondaga Lake, through diagenesis and diffusion to the water column, while the sorbed P fraction (Fe/Al-P and CaCO3-P) is remaining consistent. Sediment profile concentrations of labile and total phosphorus at time of deposition were also modeled and compared with current labile and total phosphorus, to quantify the extent to which remaining phosphorus which will continue to contribute to internal P loading and influence the trophic status of Onondaga Lake. Results presented here also allowed for estimation of the depth of the active sediment layer and the attendant response time as well as the sediment burden of labile P and associated efflux.

Motesanib diphosphate in progressive differentiated thyroid cancer

BACKGROUND: The expression of vascular endothelial growth factor (VEGF) is characteristic of differentiated thyroid cancer and is associated with aggressive tumor behavior and a poor clinical outcome. Motesanib diphosphate (AMG 706) is a novel oral inhibitor of VEGF receptors, platelet-derived growth-factor receptor, and KIT. METHODS: In an open-label, single-group, phase 2 study, we treated 93 patients who had progressive, locally advanced or metastatic, radioiodine-resistant differentiated thyroid cancer with 125 mg of motesanib diphosphate, administered orally once daily. The primary end point was an objective response as assessed by an independent radiographic review. Additional end points included the duration of the response, progression-free survival, safety, and changes in serum thyroglobulin concentration. RESULTS: Of the 93 patients, 57 (61%) had papillary thyroid carcinoma. The objective response rate was 14%. Stable disease was achieved in 67% of the patients, and stable disease was maintained for 24 weeks or longer in 35%; 8% had progressive disease as the best response. The Kaplan-Meier estimate of the median duration of the response was 32 weeks (the lower limit of the 95% confidence interval [CI] was 24; the upper limit could not be estimated because of an insufficient number of events); the estimate of median progression-free survival was 40 weeks (95% CI, 32 to 50). Among the 75 patients in whom thyroglobulin analysis was performed, 81% had decreased serum thyroglobulin concentrations during treatment, as compared with baseline levels. The most common treatment-related adverse events were diarrhea (in 59% of the patients), hypertension (56%), fatigue (46%), and weight loss (40%). CONCLUSIONS: Motesanib diphosphate can induce partial responses in patients with advanced or metastatic differentiated thyroid cancer that is progressive. (ClinicalTrials.gov number, NCT00121628.)