Multiparametric MRI and [18F]fluorodeoxyglucose positron emission tomography imaging is a potential prognostic imaging biomarker in recurrent glioblastoma

Purpose/objectivesMultiparametric advanced MR and [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET) imaging may be important biomarkers for prognosis as well for distinguishing recurrent glioblastoma multiforme (GBM) from treatment-related changes.Methods/materialsWe retrospectively evaluated 30 patients treated with chemoradiation for GBM and underwent advanced MR and FDG-PET for confirmation of tumor progression. Multiparametric MRI and FDG-PET imaging metrics were evaluated for their association with 6-month overall (OS) and progression-free survival (PFS) based on pathological, radiographic, and clinical criteria.Results17 males and 13 females were treated between 2001 and 2014, and later underwent FDG-PET at suspected recurrence. Baseline FDG-PET and MRI imaging was obtained at a median of 7.5 months [interquartile range (IQR) 3.7–12.4] following completion of chemoradiation. Median follow-up after FDG-PET imaging was 10 months (IQR 7.2–13.0). Receiver-operator characteristic curve analysis identified that lesions characterized by a ratio of the SUVmax to the normal contralateral brain (SUVmax/NB index) >1.5 and mean apparent diffusion coefficient (ADC) value of ≤1,400 × 10−6 mm2/s correlated with worse 6-month OS and PFS. We defined three patient groups that predicted the probability of tumor progression: SUVmax/NB index >1.5 and ADC ≤1,400 × 10−6 mm2/s defined high-risk patients (n = 7), SUVmax/NB index ≤1.5 and ADC >1,400 × 10−6 mm2/s defined low-risk patients (n = 11), and intermediate-risk (n = 12) defined the remainder of the patients. Median OS following the time of the FDG-PET scan for the low, intermediate, and high-risk groups were 23.5, 10.5, and 3.8 months (p < 0.01). Median PFS were 10.0, 4.4, and 1.9 months (p = 0.03). Rates of progression at 6-months in the low, intermediate, and high-risk groups were 36, 67, and 86% (p = 0.04).ConclusionRecurrent GBM in the molecular era is associated with highly variable outcomes. Multiparametric MR and FDG-PET biomarkers may provide a clinically relevant, non-invasive and cost-effective method of predicting prognosis and improving clinical decision making in the treatment of patients with suspected tumor recurrence

From LCME probation to compliance: the Marshall University Joan C Edwards School of Medicine experience

The Joan C Edwards School of Medicine (Marshall University, Huntington, WV, USA) was placed on probation by the Liaison Committee on Medical Education (LCME) in June 2011. In the following 2 years, extensive changes were made to address the numerous citations that resulted in this probation. In October 2013, the LCME lifted probation. In this article, we detail the challenges and solutions identified relevant to our struggle with compliance

Intensification of North American Megadroughts through Surface and Dust Aerosol Forcing

Tree-ring-based reconstructions of the Palmer drought severity index (PDSI) indicate that, during the Medieval Climate Anomaly (MCA), the central plains of North America experienced recurrent periods of drought spanning decades or longer. These megadroughts had exceptional persistence compared to more recent events, but the causes remain uncertain. The authors conducted a suite of general circulation model experiments to test the impact of sea surface temperature (SST) and land surface forcing on the MCA megadroughts over the central plains. The land surface forcing is represented as a set of dune mobilization boundary conditions, derived from available geomorphological evidence and modeled as increased bare soil area and a dust aerosol source (32deg-44degN, 105deg-95degW). In the experiments, cold tropical Pacific SST forcing suppresses precipitation over the central plains but cannot reproduce the overall drying or persistence seen in the PDSI reconstruction. Droughts in the scenario with dust aerosols, however, are amplified and have significantly longer persistence than in other model experiments, more closely matching the reconstructed PDSI. This additional drying occurs because the dust increases the shortwave planetary albedo, reducing energy inputs to the surface and boundary layer. The energy deficit increases atmospheric stability, inhibiting convection and reducing cloud cover and precipitation over the central plains. Results from this study provide the first model-based evidence that dust aerosol forcing and land surface changes could have contributed to the intensity and persistence of the central plains megadroughts, although uncertainties remain in the formulation of the boundary conditions and the future importance of these feedbacks

Redundancy of information: lowering dimension

Let At denote the set of infinite sequences of effective dimension t. We determine both how close and how far an infinite sequence of dimension s can be from one of dimension t, measured using the Besicovitch pseudometric. We also identify classes of sequences for which these infima and suprema are realized as minima and maxima. When t < s, we find d(X,At) is minimized when X is a Bernoulli p-random, where H(p)=s, and maximized when X belongs to a class of infinite sequences that we call s-codewords. When s < t, the situation is reversed.Comment: 28 pages, 3 figure

Predicting Medical Student Success on Licensure Exams

Many schools seek to predict performance on national exams required for medical school graduation using prematriculation and medical school performance data. The need for targeted intervention strategies for at-risk students has led much of this interest. Assumptions that preadmission data and high stakes in-house medical exams correlate strongly with national standardized exam performance needs to be examined. Looking at prematriculation data for predicting USMLE Step 1 performance, we found that MCAT exam totals and math-science GPA had the best prediction from a set of prematriculation values (adjusted R 2 = 11.7 %) for step 1. The addition of scores from the first medical school exam improved our predictive capabilities with a linear model to 27.9 %. As we added data to the model, we increased our predictive values as expected. However, it was not until we added data from year 2 exams that we started to get step 1 prediction values that exceeded 50 %. Stepwise addition of more exams in year two resulted in much higher predictive values but also led to the exclusion of many early variables. Therefore, our best step 1 predictive value of around 76.7 % consisted of three variables from a total of 37. These data suggest that the preadmission information is a relatively poor predictor of licensure exam performance and that including class exam scores allows for much more accurate determination of students who ultimately proved to be at risk for performance on their licensure exams. The continuous use of this data, as it becomes available, for assisting at-risk students is discussed (251)

Emergency Department and Radiological Cost of Delayed Diagnosis of Cannabinoid Hyperemesis.

Background. Chronic cannabis use has become prevalent with decriminalization, medical prescription, and recreational legalization in numerous US states. With this increasing incidence of chronic cannabis use a new clinical syndrome has become apparent in emergency departments and hospitals across the country, termed Cannabinoid Hyperemesis (CH). CH has been described as cyclical vomiting and abdominal pain in the setting of chronic cannabis use, which is often temporarily relieved by hot showers. CH presents a diagnostic challenge to clinicians who do not have a high clinical suspicion for the syndrome and can result in high costs and resource utilization for hospitals and patients. This study investigates the expenditures associated with delayed CH evaluation and delayed diagnosis. Methods. This is a retrospective observational study of 17 patients diagnosed with CH at three medical centers in the United States from 2010 to 2015, consisting of two academic centers and a community hospital. Emergency department (ED) costs were calculated and analyzed for patients eventually diagnosed with CH. Results. For the 17 patients treated, the total cost for combined ED visits and radiologic evaluations was an average of $76,920.92 per patient. On average these patients had 17.9 ED visits before the diagnosis of CH was made. Conclusion. CH provides a diagnostic challenge to clinicians without a high suspicion of the syndrome and may become increasingly prevalent with current trends toward cannabis legalization. The diagnosis of CH can be made primarily through a thorough history and physical examination. Awareness of this syndrome can save institutions money, prevent inappropriate utilization of healthcare resources, and save patients from unnecessary diagnostic tests

The Type Ic Supernova 1994I in M51: Detection of Helium and Spectral Evolution

We present a series of spectra of SN 1994I in M51, starting 1 week prior to maximum brightness. The nebular phase began about 2 months after the explosion; together with the rapid decline of the optical light, this suggests that the ejected mass was small. Although lines of He I in the optical region are weak or absent, consistent with the Type Ic classification, we detect strong He I λ10830 absorption during the first month past maximum. Thus, if SN 1994I is a typical Type Ic supernova, the atmospheres of these objects cannot be completely devoid of helium. The emission-line widths are smaller than predicted by the model of Nomoto and coworkers, in which the iron core of a low-mass carbon-oxygen star collapses. They are, however, larger than in Type Ib supernovae

Yersinia pestis insecticidal-like toxin complex (Tc) family proteins: characterization of expression, subcellular localization, and potential role in infection of the flea vector

BACKGROUND: Toxin complex (Tc) family proteins were first identified as insecticidal toxins in Photorhabdus luminescens and have since been found in a wide range of bacteria. The genome of Yersinia pestis, the causative agent of bubonic plague, contains a locus that encodes the Tc protein homologues YitA, YitB, YitC, and YipA and YipB. Previous microarray data indicate that the Tc genes are highly upregulated by Y. pestis while in the flea vector; however, their role in the infection of fleas and pathogenesis in the mammalian host is unclear. RESULTS: We show that the Tc proteins YitA and YipA are highly produced by Y. pestis while in the flea but not during growth in brain heart infusion (BHI) broth at the same temperature. Over-production of the LysR-type regulator YitR from an exogenous plasmid increased YitA and YipA synthesis in broth culture. The increase in production of YitA and YipA correlated with the yitR copy number and was temperature-dependent. Although highly synthesized in fleas, deletion of the Tc proteins did not alter survival of Y. pestis in the flea or prevent blockage of the proventriculus. Furthermore, YipA was found to undergo post-translational processing and YipA and YitA are localized to the outer membrane of Y. pestis. YitA was also detected by immunofluorescence microscopy on the surface of Y. pestis. Both YitA and YipA are produced maximally at low temperature but persist for several hours after transfer to 37°C. CONCLUSIONS: Y. pestis Tc proteins are highly expressed in the flea but are not essential for Y. pestis to stably infect or produce a transmissible infection in the flea. However, YitA and YipA localize to the outer membrane and YitA is exposed on the surface, indicating that at least YitA is present on the surface when Y. pestis is transmitted into the mammalian host from the flea