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Πέμπτη, 15 Φεβρουαρίου 2018

Relationship between Ischemic Injury and Patient Outcomes after Surgical or Endovascular Treatment of Ruptured Anterior Communicating Artery Aneurysms [LETTERS]



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Reply: [LETTERS]



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Clinical Validation of a Predictive Model for the Presence of Cervical Lymph Node Metastasis in Papillary Thyroid Cancer [HEAD & NECK]

BACKGROUND AND PURPOSE:

Ultrasound is a standard technique to detect lymph node metastasis in papillary thyroid cancer. Cystic changes and microcalcifications are the most specific features of metastasis, but with low sensitivity. This prospective study compared the diagnostic accuracy of a predictive model for sonographic evaluation of lymph nodes relative to the radiologist's standard assessment in detecting papillary thyroid cancer metastasis in patients after thyroidectomy.

MATERIALS AND METHODS:

Cervical lymph node sonographic images were reported by a radiologist (R method) per standard practice. The same images were independently evaluated by another radiologist using a sonographic predictive model (M method). A test was considered positive for metastasis if the R or M method suggested lymph node biopsy. The result of lymph node biopsy or surgical pathology was used as the reference standard. We estimated relative true-positive fraction and relative false-positive fraction using log-linear models for correlated binary data for the M method compared with the R method.

RESULTS:

A total of 237 lymph nodes in 103 patients were evaluated. Our analysis of relative true-positive fraction and relative false-positive fraction included 54 nodes with pathologic results in which at least 1 method (R or M) was positive. The M method had a higher relative true-positive fraction of 1.46 (95% CI, 1.12–1.91; P = .006) and a lower relative false-positive fraction of 0.58 (95% CI, 0.36–0.92; P = .02) compared with the R method.

CONCLUSIONS:

The sonographic predictive model outperformed the standard assessment to detect lymph node metastasis in patients with papillary thyroid cancer and may reduce unnecessary biopsies.



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MRI with DWI for the Detection of Posttreatment Head and Neck Squamous Cell Carcinoma: Why Morphologic MRI Criteria Matter [HEAD & NECK]

BACKGROUND AND PURPOSE:

Although diffusion-weighted imaging combined with morphologic MRI (DWIMRI) is used to detect posttreatment recurrent and second primary head and neck squamous cell carcinoma, the diagnostic criteria used so far have not been clarified. We hypothesized that precise MRI criteria based on signal intensity patterns on T2 and contrast-enhanced T1 complement DWI and therefore improve the diagnostic performance of DWIMRI.

MATERIALS AND METHODS:

We analyzed 1.5T MRI examinations of 100 consecutive patients treated with radiation therapy with or without additional surgery for head and neck squamous cell carcinoma. MRI examinations included morphologic sequences and DWI (b=0 and b=1000 s/mm2). Histology and follow-up served as the standard of reference. Two experienced readers, blinded to clinical/histologic/follow-up data, evaluated images according to clearly defined criteria for the diagnosis of recurrent head and neck squamous cell carcinoma/second primary head and neck squamous cell carcinoma occurring after treatment, post-radiation therapy inflammatory edema, and late fibrosis. DWI analysis included qualitative (visual) and quantitative evaluation with an ADC threshold.

RESULTS:

Recurrent head and neck squamous cell carcinoma/second primary head and neck squamous cell carcinoma occurring after treatment was present in 36 patients, whereas 64 patients had post-radiation therapy lesions only. The Cohen for differentiating tumor from post-radiation therapy lesions with MRI and qualitative DWIMRI was 0.822 and 0.881, respectively. Mean ADCmean in recurrent head and neck squamous cell carcinoma/second primary head and neck squamous cell carcinoma occurring after treatment (1.097 ± 0.295 x 10–3 mm2/s) was significantly lower (P < .05) than in post-radiation therapy inflammatory edema (1.754 ± 0.343 x 10–3 mm2/s); however, it was similar to that in late fibrosis (0.987 ± 0.264 x 10–3 mm2/s, P > .05). Although ADCs were similar in tumors and late fibrosis, morphologic MRI criteria facilitated distinction between the 2 conditions. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (95% CI) of DWIMRI with ADCmean < 1.22 x 10–3 mm2/s and precise MRI criteria were 92.1% (83.5–100.0), 95.4% (90.3–100.0), 92.1% (83.5–100.0), 95.4% (90.2–100.0), 19.9 (6.58–60.5), and 0.08 (0.03–0.24), respectively, indicating a good diagnostic performance to rule in and rule out disease.

CONCLUSIONS:

Adding precise morphologic MRI criteria to quantitative DWI enables reproducible and accurate detection of recurrent head and neck squamous cell carcinoma/second primary head and neck squamous cell carcinoma occurring after treatment.



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Modeling Early Postnatal Brain Growth and Development with CT: Changes in the Brain Radiodensity Histogram from Birth to 2 Years [PEDIATRICS]

BACKGROUND AND PURPOSE:

The majority of brain growth and development occur in the first 2 years of life. This study investigated these changes by analysis of the brain radiodensity histogram of head CT scans from the clinical population, 0–2 years of age.

MATERIALS AND METHODS:

One hundred twenty consecutive head CTs with normal findings meeting the inclusion criteria from children from birth to 2 years were retrospectively identified from 3 different CT scan platforms. Histogram analysis was performed on brain-extracted images, and histogram mean, mode, full width at half maximum, skewness, kurtosis, and SD were correlated with subject age. The effects of scan platform were investigated. Normative curves were fitted by polynomial regression analysis.

RESULTS:

Average total brain volume was 360 cm3 at birth, 948 cm3 at 1 year, and 1072 cm3 at 2 years. Total brain tissue density showed an 11% increase in mean density at 1 year and 19% at 2 years. Brain radiodensity histogram skewness was positive at birth, declining logarithmically in the first 200 days of life. The histogram kurtosis also decreased in the first 200 days to approach a normal distribution. Direct segmentation of CT images showed that changes in brain radiodensity histogram skewness correlated with, and can be explained by, a relative increase in gray matter volume and an increase in gray and white matter tissue density that occurs during this period of brain maturation.

CONCLUSIONS:

Normative metrics of the brain radiodensity histogram derived from routine clinical head CT images can be used to develop a model of normal brain development.



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Prediction of the Multisegment Clot Sign on Dynamic CT Angiography of Cardioembolic Stroke [ADULT BRAIN]

BACKGROUND AND PURPOSE:

The multisegment clot sign has been observed at the site of large-artery occlusion in patients with acute ischemic stroke. This study aimed to assess its occurrence rate and relationship with stroke etiologies in patients with acute intracranial large-artery occlusion.

MATERIALS AND METHODS:

We included consecutive patients with acute ischemic stroke who had acute intracranial large-artery occlusion and underwent perfusion CT within 8 hours after stroke onset. The multisegment clot sign was assessed on dynamic CT angiography derived from perfusion CT. The stroke etiologies were defined by the international Trial of Org 10172 in Acute Stroke Treatment criteria. Poisson regression analyses and diagnostic testing were used to investigate the relationship between the multisegment clot sign and stroke etiologies.

RESULTS:

Finally, 194 patients with intracranial large-artery occlusion were enrolled. According to the Trial of Org 10172 in Acute Stroke Treatment criteria, 110 (56.7%) patients were diagnosed with cardioembolism; 43 (22.2%), with large-artery atherosclerosis; and 41 (21.1%), with undetermined etiology. The multisegment clot sign was found in 74 (38%) patients. Poisson regression analysis showed that the presence of the multisegment clot sign was significantly higher in patients with cardioembolism than in those with large-artery atherosclerosis (52.7% versus 9.3%; prevalence ratio, 1.53; 95% confidence interval, 1.03–2.90; P = .037). For determined etiologies, the sensitivity, specificity, and positive and negative predictive values of the multisegment clot sign for predicting cardioembolism were 52.7%, 90.7%, 93.5%, and 42.9%, respectively.

CONCLUSIONS:

The presence of the multisegment clot sign on dynamic CTA specifically indicates intracranial large-artery occlusion caused by an embolism from a cardiac source, which may be useful for acute management and secondary prevention of stroke.



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A Patient Dose-Reduction Technique for Neuroendovascular Image-Guided Interventions: Image-Quality Comparison Study [PATIENT SAFETY]

BACKGROUND AND PURPOSE:

The ROI–dose-reduced intervention technique represents an extension of ROI fluoroscopy combining x-ray entrance skin dose reduction with spatially different recursive temporal filtering to reduce excessive image noise in the dose-reduced periphery in real-time. The aim of our study was to compare the image quality of simulated neurointerventions with regular and reduced radiation doses using a standard flat panel detector system.

MATERIALS AND METHODS:

Ten 3D-printed intracranial aneurysm models were generated on the basis of a single patient vasculature derived from intracranial DSA and CTA. The incident dose to each model was reduced using a 0.7-mm-thick copper attenuator with a circular ROI hole (10-mm diameter) in the middle mounted inside the Infinix C-arm. Each model was treated twice with a primary coiling intervention using ROI-dose-reduced intervention and regular-dose intervention protocols. Eighty images acquired at various intervention stages were shown twice to 2 neurointerventionalists who independently scored imaging qualities (visibility of aneurysm-parent vessel morphology, associated vessels, and/or devices used). Dose-reduction measurements were performed using an ionization chamber.

RESULTS:

A total integral dose reduction of 62% per frame was achieved. The mean scores for regular-dose intervention and ROI dose-reduced intervention images did not differ significantly, suggesting similar image quality. Overall intrarater agreement for all scored criteria was substantial (Kendall = 0.62887; P < .001). Overall interrater agreement for all criteria was fair ( = 0.2816; 95% CI, 0.2060–0.3571).

CONCLUSIONS:

Substantial dose reduction (62%) with a live peripheral image was achieved without compromising feature visibility during neuroendovascular interventions.



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7T Brain MRS in HIV Infection: Correlation with Cognitive Impairment and Performance on Neuropsychological Tests [ADULT BRAIN]

BACKGROUND AND PURPOSE:

Validated neuroimaging markers of HIV-associated neurocognitive disorder in patients on antiretroviral therapy are urgently needed for clinical trials. The purpose of this study was to explore the relationship between cognitive impairment and brain metabolism in older subjects with HIV infection. It was hypothesized that MR spectroscopy measurements related to neuronal health and function (particularly N-acetylaspartate and glutamate) would be lower in HIV-positive subjects with worse cognitive performance.

MATERIALS AND METHODS:

Forty-five HIV-positive patients (mean age, 58.9 ± 5.3 years; 33 men) underwent detailed neuropsychological testing and brain MR spectroscopy at 7T. Twenty-four subjects were classified as having asymptomatic cognitive impairment, and 21 were classified as having symptomatic cognitive impairment. Single-voxel proton MR spectra were acquired from 5 brain regions and quantified using LCModel software. Brain metabolites and neuropsychological test results were compared using nonparametric statistics and Pearson correlation coefficients.

RESULTS:

Differences in brain metabolites were found between symptomatic and asymptomatic subjects, with the main findings being lower measures of N-acetylaspartate in the frontal white matter, posterior cingulate cortex, and precuneus. In the precuneus, glutamate was also lower in the symptomatic group. In the frontal white matter, precuneus, and posterior cingulate cortex, NAA and glutamate measurements showed significant positive correlation with better performance on neuropsychological tests.

CONCLUSIONS:

Compared with asymptomatic subjects, symptomatic HIV-positive subjects had lower levels of NAA and glutamate, most notably in the frontal white matter, which also correlated with performance on neuropsychological tests. High-field MR spectroscopy offers insight into the pathophysiology associated with cognitive impairment in HIV and may be useful as a quantitative outcome measure in future treatment trials.



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MRI Features of Aquaporin-4 Antibody-Positive Longitudinally Extensive Transverse Myelitis: Insights into the Diagnosis of Neuromyelitis Optica Spectrum Disorders [SPINE]

BACKGROUND AND PURPOSE:

Longitudinally extensive transverse myelitis is a well-documented spinal manifestation of neuromyelitis optica spectrum disorders, however, other forms of nontumorous myelopathy can also manifest as longitudinally extensive transverse myelitis. Our aim was to evaluate the MR imaging features of aquaporin-4 antibody–positive longitudinally extensive transverse myelitis, which is strongly associated with neuromyelitis optica spectrum disorders.

MATERIALS AND METHODS:

We evaluated cervicomedullary junction involvement, cord expansion ratios, bright spotty lesions, the number of involved segments, skipped lesions, enhancement patterns, and axial distribution patterns using spinal MR imaging of 41 patients with longitudinally extensive transverse myelitis who underwent aquaporin-4 antibody testing. Univariate logistic regression analysis was performed to identify factors associated with aquaporin-4 antibody seropositivity, which were then used to develop a scoring system for diagnosing aquaporin-4 antibody–positive longitudinally extensive transverse myelitis. Interrater reliability for cord expansion ratio measurement and bright spotty lesions was determined using intraclass correlation coefficients and values, respectively.

RESULTS:

Fifteen patients with longitudinally extensive transverse myelitis were aquaporin-4 antibody–positive. Sex (female), cervicomedullary junction involvement, a cord expansion ratio of >1.4, and bright spotty lesions were significantly associated with aquaporin-4 antibody seropositivity. The sensitivity and specificity of the scoring system were 73.3% and 96.2%, respectively. The interclass correlation value for the cord expansion ratio was 0.78, and the value for bright spotty lesions was 0.61.

CONCLUSIONS:

Our scoring system, based on cervicomedullary junction involvement, higher cord expansion ratio, bright spotty lesions, and female sex, can facilitate the timely diagnosis of neuromyelitis optica spectrum disorders.



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Usefulness of perfusion- and diffusion-weighted imaging to differentiate between pilocytic astrocytomas and high-grade gliomas: a multicenter study in Japan

Abstract

Purpose

Imaging findings of pilocytic astrocytoma (PA) vary widely, sometimes resembling those of high-grade glioma (HGG). This study aimed to identify the imaging parameters that can be used to differentiate PA from HGG.

Methods

Altogether, 60 patients with PAs and 138 patients with HGGs were included in the study. Tumor properties and the presence of hydrocephalus, peritumoral edema, and dissemination were evaluated. We also measured the maximum relative cerebral blood flow (rCBFmax) and volume (rCBVmax) and determined the minimum apparent diffusion coefficient (ADCmin) in the tumor's solid components. The relative T1 (rT1), T2 (rT2), and contrast-enhanced T1 (rCE-T1) intensity values were evaluated. Parameters were compared between PAs and HGGs using the Mann–Whitney U test. Receiver operating characteristic (ROC) curve analysis was also used to evaluate these imaging parameters. A value of P < .05 was considered to indicate significance.

Results

Intratumoral hemorrhage and calcification were observed in 10.0% and 21.7% of PAs, respectively. The rCBFmax and rCBVmax values were significantly lower in PAs (0.50 ± 0.35, 1.82 ± 1.21) than those in HGGs (2.98 ± 1.80, 9.54 ± 6.88) (P < .0001, P = .0002, respectively). The ADCmin values were significantly higher in PAs (1.36 ± 0.56 × 10−3 mm2/s) than those in HGGs (0.86 ± 0.37 × 10−3 mm2/s) (P < .0001). ROC analysis showed that the best diagnostic performance was achieved with rCBFmax.

Conclusion

The rCBFmax, rCBVmax, and ADCmin can differentiate PAs from HGGs.



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GEC-ESTRO ACROP recommendations in skin brachytherapy

The aim of this publication is to compile available literature data and expert experience regarding skin brachytherapy (BT) in order to produce general recommendations on behalf of the GEC-ESTRO Group.

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Oral manifestations of lipoid proteinosis in a 10-year-old female: a case report and literature update

Publication date: Available online 14 February 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Kevin C. Lee, Scott M. Peters, Yen Chen Kevin Ko, Timothy C. Kunkle, Michael A. Perrino, Angela J. Yoon, Elizabeth M. Philipone
Lipoid proteinosis (LP) is a rare autosomal recessive disorder characterized by the deposition of amorphous hyaline material in the dermis and submucosal connective tissue. Herein, we present a case of LP with significant oral, dermatological, and neurological manifestations occurring in a 10 year-old Asian female. In addition to the more typical oral findings of restricted tongue movement and labial and buccal mucosal involvement, this case highlights an unusual pattern of gingival enlargement infrequently reported in the literature. As LP almost always involves the oral cavity, often before the onset of cutaneous lesions, it is important for dental providers to be familiar with the oral manifestations of this disease. Early detection and diagnosis of LP by the dental practitioner can help expedite proper multidisciplinary care and lead to significant reductions in patient morbidity and mortality.



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Rapidly expanding mixed lesion of the maxilla in a 17-month-old boy

Publication date: Available online 14 February 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Ho-Hyun (Brian) Sun, Chan M. Park, Jeffrey A. Elo




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Pentoxifylline, Tocopherol and Clodronate for the treatment of mandibular osteoradionecrosis: A systematic review

Publication date: Available online 14 February 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Author(s): Miriam Martos-Fernández, Manel Saez-Barba, Jose López-López, Albert Estrugo-Devesa, Jose María Balibrea-del-Castillo, Coro Bescós-Atín
ObjetiveThe purpose of this article is to evaluate the healing benefit of provided by combining Pentoxifylline-Tocopherol or Pentoxifylline-Tocopherol-Clodronate for treating osteoradionecrosis due to their antioxidant and antifibritic properties.Study designWe searched for relevant literature in PubMed using a combination of "osteoradionecrosis" and the following keywords: "pentoxifillyne", "tocopherol", "vitamin E" or "clodronate". We considered articles in English or Spanish, with no limitations on the publication date.ResultsThe combination of Pentoxifylline plus Tocopherol +/- Clodronate was found to be effective for the treatment of mandibular osteoradionecrosis although data was generally scarce and mostly consisted of retrospective case series.ConclusionThis drug therapy is well tolerated and could be promising for the treatment of mandibular osteoradionecrosis although prospective randomized controlled clinical trials are needed.



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Unperturbed, high spatial resolution measurement of Radon-222 in soil-gas depth profile

Publication date: Available online 15 February 2018
Source:Journal of Environmental Radioactivity
Author(s): K. Mitev, Ch. Dutsov, S. Georgiev, T. Boshkova, D. Pressyanov
This work presents a method for measuring the depth distribution of 222Rn activity in soil gas. The method is based on the capacity of polycarbonates to absorb 222Rn and on the possibility of performing sensitive measurements of 222Rn absorbed by the polycarbonates via liquid scintillation counting (LSC). The method is the following: cylindrical holes are drilled along a metal rod and Makrofol® N polycarbonate foils enclosed in polyethylene envelopes are placed in each hole. The rod is driven into the soil and kept for a certain time. As long as the rod is in the soil, the polycarbonate foils are exposed to the 222Rn concentration at their depth. At the end of the exposure the rod is pulled out and the foils are transferred to liquid scintillation (LS) vials filled with liquid scintillator. The 222Rn absorbed in the foils is then measured with a LS analyzer. The rod with the polycarbonate foils acts as a passive probe which senses the 222Rn concentration at different depths beneath the ground surface. The achievable minimum detectable 222Rn activity concentration with the equipment and conditions used in this study is around 12.5 kBq/m3. It can easily be lowered below 1 kBq/m3 if larger foils and low-background LS analyzers are used. Since the method does not require air sampling the depth distribution of 222Rn in the soil is unperturbed by the sampling. The spatial distribution and the maximum measurement depth are set by the distance between the holes and the depth to which the rod can be fixed into the ground. Results from in situ applications of the method in terrains with high 222Rn in soil-gas are reported, which demonstrate the feasibility and the usefulness of the proposed approach.



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Imaging and Pathologic findings of Hepatic Small Vessel Hemangioma

Publication date: Available online 14 February 2018
Source:Current Problems in Diagnostic Radiology
Author(s): Balasubramanya Rangaswamy, Marta Minervini, Mitchell Tublin, Biatta Sholosh, Anil K Dasyam
Hepatic small vessel hemangioma represents a distinct yet very rare pathologic entity of the liver. The entity has also been in the past referred to as adult capillary hemangioma of the liver and congenital noninvoluting hemangioma. Imaging findings are not definitive and biopsy or resection is ultimately necessary. Pathologically these represent vasoformative abnormalities with infiltrative margins that can potentially mimic hepatic angiosarcoma. Immunohistochemistry can help differentiate hepatic small vessel hemangioma from angiosarcoma. Given the infiltrative growth pattern and unknown outcomes, resection and or close follow up has been recommended. Recently the term hepatic small vessel neoplasm has been coined in view of the unknown outcomes and some concerning findings on molecular analysis. We report two cases of this unusual entity and describe its imaging, gross pathologic, histopathologic and immunohistochemical features.



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Radiographic markers for measuring tibial rotation based on CT-reconstructed radiographs: an accuracy and feasibility study

Abstract

Objectives

Malreduction in the axial plane (malrotation) following tibial fracture surgery is often undiagnosed. A few clinical and radiographic methods have been proposed for measuring tibial rotation intraoperatively, yet have failed to match the accuracy of computed tomography (CT). The aim of this study was to develop radiographic tools for future intraoperative assessment of the tibial shaft rotation profile.

Methods

The setting was a laboratory computerized analysis. Twenty lower limb CT scans were used to construct a three-dimensional (3D) model using AMIRA© software. A virtual 3D cylinder was implanted in the posterior condylar line and in the transmalleolar axis. The 3D models were used to simulate four standard knee and ankle plain radiographs. On each radiograph, four landmarks were depicted by two observers and their relation with the cylinder was measured and analyzed for accuracy and reproducibility. A cadaveric lower leg was implanted with two Kirschner wires. A CT scan was performed in addition to 2D fluoroscopy. The simulated radiographs and the fluoroscopy were compared for accuracy.

Results

Measurement of the landmarks showed reliability in most of the knee anteroposterior and ankle mortise radiographs (coefficients of variation < 0.01 and = 0.01) respectively. Cadaveric measurement of the landmarks using real fluoroscopy and simulated radiographs were similar.

Conclusions

To date, no reliable and common methods have been reported for the evaluation of tibial axial rotation. We propose a model in which simple radiographic landmarks can be used to calculate a 3D coordinate system that accurately assesses the axial rotation angle of the tibial shaft.



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Middle-aged female with palpable swelling over the abdominal wall



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Correction to: Voriconazole-induced periostitis deformans: serial imaging in a patient with ANCA vasculitis

Abstract

The original version of this paper unfortunately contained mistakes in the affiliations for all authors.



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Not all sagittal band tears come with extensor instability: a case report with radiological and operative correlation

Abstract

The sagittal bands are a component of the extensor hood. They serve an important role in stabilizing the extensor tendon by forming a "check-rein" to radial–ulnar translation of the tendon over the metacarpal head, and extending the metacarpophalangeal (MCP) joint by virtue of attaching the extensor tendon to the palmar plate. Injury to the sagittal band is thought to cause extensor instability and subluxation to the contralateral side by disruption of this "check-rein" function, although recent evidence from cadaver studies suggests that ulnar sagittal band tear may be spared of extensor instability. As a case in point, we encountered a patient with surgically proven ulnar sagittal band tear, who did not have any extensor tendon subluxation or any limitation in motion. Intraoperative findings demonstrated a chronic-appearing ulnar sagittal band tear, indicating that chronic injury with fibrosis may stabilize the central band. Therefore, in patients with metacarpophalangeal pain without central tendon subluxation or limitation of motion, it remains important to raise the concern of sagittal band tear for appropriate treatment. We present the clinical course of this case, with radiological and operative findings, followed by a review of the relevant literature.



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A child with painless left wrist swelling



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The posterior–anterior flexed view is better than the anterior–posterior view for assessing osteoarthritis of the knee

Abstract

Objective

The aim of this study is to determine whether the posterior–anterior (PA)-flexed view improves the radiographic assessment of patients with knee pain compared with the standard standing anterior–posterior radiograph.

Materials and methods

Three hundred and sixty-five patients with knee pain underwent anterior–posterior (AP), PA flexed, lateral, and Merchant radiographs of the knee. Knees were grouped as mild (Kellgren and Lawrence [K-L] 1–2) or severe (K-L 3–4) osteoarthritis (OA) and either varus (medial compartment), valgus (lateral compartment), or patellofemoral OA.

Results

In knees with mild valgus OA on AP view (K–L 1–2), the PA flexed view was more sensitive than the AP view. The measured lateral minimal joint space width (minJSW) decreased more than 2 mm in 68% of the patients, resulting in an increase in K–L grade (3 or 4). In patients with severe valgus OA and in all patients with varus and patellofemoral OA, there was no difference between AP and PA flexed view with regard to radiographic measurements or KL grade. Based on the Medicare reimbursement rate using the PA flexed view alone instead of both views reduced imaging costs by 47%.

Conclusion

The PA flexed view better classifies the severity of lateral compartment disease in patients with mild valgus OA and provides comparable diagnostic sensitivity for joint space narrowing in varus- and patellofemoral OA. Using the PA flexed view alone was more cost effective than using the combination of AP and PA flexed imaging.



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Middle-aged female with palpable swelling over the abdominal wall



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Parosteal extra-axial chordoma of the second metacarpal bone: a case report with literature review

Abstract

Extra-axial chordoma is a chordoma that occurs in non-axial locations. It is a very rare tumor, with 20 cases reported to date; 14 in bone and six in soft tissue. Of the 14 skeletal extra-axial chordomas, ten were intramedullary and four were intracortical. We report the first case of parosteal extra-axial chordoma arising in the second metacarpal bone, expressing brachyury on immunohistochemical analysis, and describe the pathologic and radiologic findings. We suggest that extra-axial chordoma can occur in parosteal bone lesions or the hand, without features of bone distribution or bone-specific sites.



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Thank you to our reviewers of 2017



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A child with painless left wrist swelling



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Browser’s notes



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Lipoma arborescens of the bicipitoradial bursa

Abstract

Lipoma arborescens (LA) is a rare, benign articular lesion that is most commonly found within the suprapatellar recess of the knee. An extremely rare case of LA involving unilateral bicipitoradial bursa is described in this study. A 58-year-old male presented with a superficial soft mass on the volar aspect of the left forearm. The magnetic resonance imaging (MRI) examination demonstrated a lobulated complex mass containing multiple frond-like fatty nodules, along the distal biceps tendon in the bicipitoradial bursa. Ultrasound-guided biopsy of the lesion confirmed the diagnosis of LA and patient was scheduled for surgical excision. Recognizing the characteristic imaging of LA, particularly on MRI, is essential for accurate pre-procedural diagnosis.



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Uncommon observation of bifocal giant subchondral cysts in the hip: diagnostic role of CT arthrography and MRI, with pathological correlation

Abstract

Subchondral cysts (or geodes) are common in osteoarthritis (OA), usually in association with other typical signs, i.e., joint space narrowing, subchondral bone sclerosis, and osteophytosis. However, large lesions without the typical signs of OA or lesions located outside the weight-bearing areas are unusual and may be confused for other conditions, in particular, those of tumoral origin. We report the findings in a 48-year-old man who had been complaining of left buttock pain for 3 years, getting worse over the last year, and an evolutive limited range of motion of the hip. The pain was increased by weight-bearing and was not relieved by nonsteroidal anti-inflammatory drugs. Radiographs and CT showed a large multilocular lytic lesion within the femoral head and a large lytic lesion in the left ilio-ischiatic ramus, raising the question of bifocal tumoral involvement. On MRI, the lesions had low signal intensity on T1- and high signal intensity on T2-weighted MR images, with subtle peripheral enhancement on post-contrast T1-weighted images. CT arthrography, by demonstrating a communication between the femoral head and ischiatic cysts and the joint space allowed us to definitively rule out malignant conditions and to make the diagnosis of subchondral bone cysts. Total hip arthroplasty was performed. Pathological analysis of the resected femoral head and of material obtained at curettage of the ischiatic lesion confirmed the diagnosis of degenerative geodes. This case illustrates an atypical bifocal location of giant subchondral cysts in the hip joint mimicking lytic tumors, in the absence of osteoarthritis or rheumatoid arthritis, and highlights the role of CT arthrography in identifying this condition.



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Symptomatic os talus secundarius: a case report and review of the literature

Abstract

Os talus secundarius is an extremely rare accessory ossicle located at the lateral aspect of the talus just anterior to the fibula. Although rarely seen, it may cause lateral-sided chronic ankle pain. Only a few cases of symptomatic os talus secundarius have been reported to date. Herein, a 42-year-old male patient with symptomatic os talus secundarius is presented, and its imaging findings, differential diagnosis, and treatment are discussed.

Level of evidence: Level IV.



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The predictive value of MRI in the syndesmotic instability of ankle fracture

Abstract

Objective

Although many types of ankle fracture can be combined with syndesmosis injury, preoperative imaging studies rarely reveal instability of the syndesmosis. This study assessed the use of magnetic resonance imaging (MRI) for syndesmotic instability in patients with unstable ankle fracture.

Methods

A total of 74 patients who were treated for Lauge-Hansen supination external rotation/Weber B type fracture or pronation external rotation/Weber C type fracture and who underwent MRI for preoperative assessment were enrolled. The MRI findings of the syndesmotic ligament and the results of an intraoperative stress test were evaluated.

Results

Twenty-six patients had a positive result on the intraoperative stress test for syndesmotic instability. The MRI findings of the syndesmotic ligaments revealed that complete tear of the posterior inferior tibiofibular ligament (PITFL) was the most reliable predictor of syndesmotic instability (sensitivity, 74%; specificity, 78%; positive predictive value, 54%). Interobserver agreement for the intraoperative stress test and MRI assessment was excellent, except for the MRI findings of the interosseous ligament (62% agreement; kappa, 0.3).

Conclusions

Complete tear of the PITFL on MRI has additional diagnostic value for syndesmotic instability in ankle fracture. However, because the sensitivity might not be sufficient to justify the costs associated with MRI, cost-effectiveness should be considered.



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Triple elastofibromas located in the supra- and infrascapular regions—a case report

Abstract

We report a case of triple elastofibromas located in the supra- and infrascapular regions. A 61-year-old female with a history of bilateral elastofibroma in the typical subscapular region (6 years before) was admitted for the evaluation of a left-sided suprascapular mass that she had first noted 3 months before. On physical examination, a firm, painless, mobile mass was palpated in the subcutaneous tissue. The patient had not observed any changes of the two known lesions over the past 6 years. The patient denied a family history of elastofibroma. The signal characteristic on T1- and T2-weighted images as well as contrast enhancement curves on dynamic study was identical in all three masses. Ultrasound-guided biopsy performed before surgical intervention confirmed the diagnosis of elastofibroma. This case report has a teaching value as, to our knowledge, it is the only one in the literature with images of synchronous elastofibromas documented by dynamic contrast-enhanced MRI. In cases of elastofibroma with diagnostic difficulties, particularly in uncommon sites, a dynamic contrast-enhanced MRI may help to establish the proper diagnosis. This case report gives an example of rare multiple elastofibromas, presents current diagnostic imaging methods, and reminds us that elastofibroma is not exclusive to the posterior thoracic region.



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Gastric cancer metastatic to neck lipoma: a case report with imaging consideration

Abstract

A 71-year-old man visited our hospital for examination of a soft neck mass. Computed tomography and magnetic resonance imaging scans showed a well-circumscribed large lipomatous tumor with multiple nodules inside. Atypical lipomatous tumor or lipoma involving the lymph nodes was considered. Pathological examination of the surgical specimen suggested typical lipoma including multiple metastatic foci from gastric cancer. Subsequent endoscopy revealed a gastric tumor, which was histologically proven to be signet-ring cell carcinoma. Considering these findings, this case was diagnosed as tumor-to-tumor metastasis to lipoma. We present the first such case with imaging and clinical characteristics.



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Percutaneous CT-guided sacroiliac joint sampling for infection: aspiration, biopsy, and technique

Abstract

Objective

To evaluate methods of CT-guided sacroiliac joint sampling in patients with suspected infection.

Materials and methods

All CT-guided sacroiliac joint sampling procedures for suspected infection were reviewed for sampling type (aspiration, lavage aspiration, biopsy), microbiology results, and clinical and imaging follow-up. The primary gold standard was anatomic pathology. If pathology was not available, then positive blood culture with the same organism as SIJ sampling, imaging and clinical follow-up, or clinical follow-up only were used. Anterior and posterior joint distention was evaluated by MRI within 7 days of the procedure.

Results

A total of 34 patients (age 39 ± 20 (range, 6–75) years; 21 F, 13 M) were included. Aspiration samples only were obtained in 13/34 (38%) cases, biopsy samples only in 9/34 (26%) cases, and both samples in 12/34 (35%) cases. There was an overall 54% sensitivity and 86% specificity. For the aspiration samples, sensitivity and specificity were 60 and 81%, respectively, compared to 45 and 90% for the biopsy samples. In cases with both samples, biopsy did not add additional microbial information. Seventeen (17/34, 50%) patients had an MRI. The anterior joint was more distended than the posterior joint in 15/17 (88%) of patients, and this difference was significant (P = 0.0003). All of these 17 patients had an attempted aspiration by a posterior approach; 6/17 (35%) resulted in a successful aspiration.

Conclusions

Aspiration of the sacroiliac joint has a higher sensitivity than biopsy and should always be attempted first. MRI may be helpful for procedure planning.



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Complete resolution and remodeling of chronic recurrent multifocal osteomyelitis on MRI and radiographs

Abstract

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition thought to be under-diagnosed, with a true prevalence of more than the 1 in 10,000 estimated. It is a condition that is classically described as polyostotic with a relapsing and remitting course, preferentially affecting the metaphyses of tubular bones in the pediatric population. Lesions have characteristic appearances of cortical hyperostosis and mixed lytic/sclerotic medullary appearances radiographically, with active osteitis and periostitis best seen with fluid-sensitive sequences on magnetic resonance imaging (MRI). There are reports of lesions resolving on follow-up radiographs and MRI scans, but no supporting images. In particular, although the marrow appearances and degree of osteitis have been shown to improve on MRI, complete resolution and remodeling back to normal has never been demonstrated. We present a case of a lesion that has completely healed and remodeled back to normal appearances on both radiographs and MRI, and consider this the standard for the often loosely used terms "normalization" and "resolution". We discuss the implications of this for our understanding of the natural history of CRMO, and how this adds weight to the condition being significantly under-diagnosed. It provides a "gold standard" to be aimed for when assessing treatments for CRMO, and the optimal outcomes that are possible. It also provides further insight into the potential of pediatric bone to recover and remodel when affected by inflammatory conditions.



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Concomitant hook of hamate fractures in patients with scaphoid fracture: more common than you might think

Abstract

Objective

The scaphoid is the most commonly fractured carpal bone. The presence of a concomitant hook of hamate fracture is of particular relevance given that it is often occult on routine wrist/scaphoid radiographs and that hook of hamate fractures are prone to symptomatic non-union, resulting in chronic ulnar wrist pain. Prompt diagnosis and immobilisation/fixation may minimise such complications. Our study is aimed at assessing the frequency of concomitant hook of hamate fractures in patients with scaphoid fractures.

Methods

Hook of hamate fracture is often occult on wrist/scaphoid radiographs. Hence, we identified all 2,568 CT and MRI studies performed to investigate scaphoid fracture at our institution from April 2005 to March 2016. Three hundred and twelve out of 2,568 cases were confirmed to have a scaphoid fracture. Images were then retrospectively reviewed by a Consultant Musculoskeletal Radiologist and Musculoskeletal Radiologist Trainee to assess for the presence of concomitant hook of hamate fracture and, if present, whether this was identified on initial reporting.

Results

Concomitant hook of hamate fracture was identified in 10.3% of cases (32 out of 312, 30 on CT, 2 on MRI); most were minimally/non-displaced. Sixty percent of fractures identified on CT were missed on the initial review (18 out of 30). Both cases identified on MRI had been initially reported.

Conclusion

Scaphoid fracture is associated with higher than expected rates of concomitant hook of hamate fracture. Given the potential morbidity associated with hook of hamate fracture, this should be considered a review area when investigating scaphoid injury. These fractures are often minimally displaced, hence easily overlooked on CT. MRI may therefore be superior when investigating radiographically occult scaphoid fractures.



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Implantation of computed tomography-guided Iodine-125 seeds in combination with chemotherapy for the treatment of stage III non-small cell lung cancer.

Related Articles

Implantation of computed tomography-guided Iodine-125 seeds in combination with chemotherapy for the treatment of stage III non-small cell lung cancer.

J Contemp Brachytherapy. 2017 Dec;9(6):527-534

Authors: Huo X, Huo B, Wang H, Wang L, Cao Q, Zheng G, Wang J, Chai S, Zhang Z, Yang K, Niu Y, Wang H

Abstract
Purpose: We investigated the role of computed tomography (CT)-guided Iodine-125 (125I) seed implantation in combination with chemotherapy for the treatment of stage III non-small cell lung carcinoma (NSCLC).
Material and methods: The data from 182 patients with stage III NSCLC who were treated with radioactive 125I seed implantation between June 2002 and June 2009, and who received sequential platinum-based combination chemotherapy using the most common combination of platinum and gemcitabine, were retrospectively reviewed. The 182 patients received a prescribed dose of 110.0 Gy, with a median radioactivity of 0.70 mCi (range, 0.64-0.78 mCi, 2.37-3.26 × 107 Bq). The median number of 125I seeds was 38 pellets (range, 6-105 pellets). The median post-operation dose covering 100% of the target volume (D100) was 94.5 Gy (range, 54.6-125.5 Gy). The median D90 was 143.0 Gy (range, 121.6-184.0).
Results: The 1-, 3-, and 5-year overall survival rates were 83.35%, 25.57%, and 11.34%, respectively; the median survival time was 24.76 months. At 1, 3, and 5 years, the local control rates were 92.01%, 86.51%, and 76.45%, respectively; the median local control time was 25.28 months. For patients with stage IIIA and IIIB NSCLC, the median survival times were 26.67 and 24.59 months, respectively (p = 0.2). Pre-treatment hemoglobin level, tumor volume, and postoperative D100 were significantly associated with survival. A total of 24 patients experienced pneumothorax (incidence rate, 13.20%), and 17 patients experienced hemothorax (incidence rate, 5.0%).
Conclusions: CT-guided 125I seed implantation combined with chemotherapy is an effective, minimally invasive method for the treatment of stage III NSCLC. Furthermore, hemoglobin levels before treatment, D100, and the maximum diameter of the tumor may be prognostic factors in patients with NSCLC treated sequentially with radiotherapy and chemotherapy.

PMID: 29441096 [PubMed]



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Happy birthday SRA!

Happy birthday SRA!

Surg Radiol Anat. 2018 Feb 13;:

Authors: Duparc F

PMID: 29442135 [PubMed - as supplied by publisher]



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Seven days in medicine: 7-13 February 2018

GP accessParents are urged to use pharmacies to relieve pressureNHS England launched a campaign on 12 February to promote the use of pharmacies for minor health problems in children, saying that...
recent?d=yIl2AUoC8zA recent?d=dnMXMwOfBR0 recent?i=NKNO4fL3i_M:neyojhVrzZg:V_sGLiP recent?d=qj6IDK7rITs recent?i=NKNO4fL3i_M:neyojhVrzZg:gIN9vFw recent?d=l6gmwiTKsz0 recent?d=7Q72WNTAKBA recent?i=NKNO4fL3i_M:neyojhVrzZg:F7zBnMy recent?i=NKNO4fL3i_M:neyojhVrzZg:-BTjWOF


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Production, milk and plasma fatty acid profile, and nutrient utilization in Jersey cows fed flaxseed oil and corn grain with different particle size

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): V. Brossillon, S.F. Reis, D.C. Moura, J.G.B. Galvão, A.S. Oliveira, C. Côrtes, A.F. Brito
ABSTRACTWe aimed to compare the effects of ground (GC) or cracked corn (CC), with or without flaxseed oil (FSO), on milk yield, milk and plasma fatty acid (FA) profile, and nutrient digestibility in Jersey cows fed diets formulated to contain similar starch concentrations. Twelve multiparous organic-certified Jersey cows averaging (mean ± standard deviation) 455 ± 41.9 kg of body weight and 152 ± 34 d in milk and 4 primiparous organic-certified Jersey cows averaging (mean ± standard deviation) 356 ± 2.41 kg of body weight and 174 ± 30 d in milk in the beginning of the experiment were used. Cows were randomly assigned to treatment sequences in a replicated 4 × 4 Latin square design with a 2 × 2 factorial arrangement of treatments. Each period lasted 24 d with 18 d for diet adaptation and 6 d for data and sample collection. Treatments were fed as total mixed rations consisting of (dry matter basis): (1) 0% FSO + 27.1% GC, (2) 0% FSO + 28.3% CC, (3) 3% FSO + 27.1% GC, and (4) 3% FSO + 28.3% CC. All cows were offered 55% of the total diet dry matter as mixed grass-legume baleage and treatments averaged 20% starch. Significant FSO × corn grain particle size interactions were observed for some variables including milk concentration of lactose and proportions of cis-9,cis-12,cis-15 18:3 in milk and plasma. The proportion of cis-9,cis-12,cis-15 18:3 in milk and plasma decreased slightly when comparing GC versus CC in 0% FSO cows, but a larger reduction was observed in 3% FSO cows. Dry matter intake did not differ and averaged 16.1 kg/d across diets. Feeding 3% FSO increased yields of milk and milk fat and lactose and feed and milk N efficiencies, but decreased fat, true protein, and MUN concentrations and apparent total-tract digestibility of fiber. The Σ branched-chain, Σ<16C, Σ16C, and Σn-6 FA decreased, whereas Σ18C, Σcis-18:1, and Σtrans-18:1 FA increased in 3% versus 0% FSO cows. No effect of corn particle size was observed for production and milk components. However, the apparent total-tract digestibility of starch was greater in GC than CC cows. Compared with CC, GC increased Σ branched-chain, Σ<16C, Σ16C, Σn-6 FA, and decreased Σ18C and Σ cis-18:1 FA in milk fat. Overall, results of this study are more directly applicable to dairy cows fed low starch, mixed grass-legume baleage-based diets.



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Does clinical mastitis in the first 100 days of lactation 1 predict increased mastitis occurrence and shorter herd life in dairy cows?

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): J.A. Hertl, Y.H. Schukken, L.W. Tauer, F.L. Welcome, Y.T. Gröhn
ABSTRACTThe objectives of this study were to estimate the direct effects of clinical mastitis (CM) occurring in early productive life (defined as the first 100 d of the first lactation) of Holstein dairy cows on the future rate of CM occurrence and on the length of total productive lifetime. Information on CM cases and other data occurring in 55,144 lactations in 24,831 cows in 5 New York State Holstein herds was collected from January 2004 until February 2014. For the first objective, a generalized linear mixed model with a Poisson distribution was used to study the effects of CM cases occurring in the first 100 d of a cow's first lactation, as well as farm indicator and number of days in the cow's lifetime, on the future lifetime rate of CM. Only cows that had completed their productive life [i.e., all had been culled (or sold) or had died; n = 14,440 cows] were included in this analysis. For the second objective, a Cox proportional hazards model was used to study the effects of CM cases occurring in the first 100 d of a cow's first lactation on the length of total productive lifetime. The model was stratified by farm. All 24,831 cows were included in this analysis with right censoring. Cows experienced between 0 and 4 CM cases in the first 100 d of lactation 1. Over their lifetime, cows experienced between 0 and 25 CM cases. During the study period, 10% of all cows died and nearly half of all cows were culled. The average length of productive life, including censored observations, was 2.0 yr after first calving. Compared with cows having no CM cases in the first 100 d of lactation 1, cows with 1 CM case in that time period had a 1.5 times higher rate of total number of CM cases over their lifetime. Cows with 2 (or 3 or more) CM cases in the first 100 d of lactation 1 had a 1.7 times (or 2.6 times) higher rate of total number of CM cases over their lifetime. For each additional CM case occurring in the first 100 d of lactation 1, the hazard rate of culling increased by 34%. Given economic conditions for preferentially culling mastitic cows, the study findings may help farmers make optimal decisions with regard to culling of such cows.



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NEWS AND ANNOUNCEMENTS

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3





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Influence of feeding supplements of almond hulls and ensiled citrus pulp on the milk production, milk composition, and methane emissions of dairy cows

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): S.R.O. Williams, A.V. Chaves, M.H. Deighton, J.L. Jacobs, M.C. Hannah, B.E. Ribaux, G.L. Morris, W.J. Wales, P.J. Moate
ABSTRACTAlmond hulls and citrus pulp have been fed to dairy cows with variable responses for milk production, but no information exists on their effect on enteric methane emissions. This experiment examined the effects of dietary supplementation with either almond hulls or ensiled citrus pulp on the milk yield, milk composition, and enteric methane emissions of dairy cows. Thirty-two Holstein dairy cows in mid lactation were offered 1 of 3 diets over a 28-d experiment. Twelve cows received a control (CON) diet, 10 cows a diet containing almond hulls (ALH), and 10 cows a diet containing ensiled citrus pulp (CIT). All cows were offered 6.0 kg of dry matter (DM)/d of crushed corn, 2.0 kg of DM/d of cold-pressed canola, and 0.2 kg of DM/d of a mineral mix. In addition, cows fed the CON diet were offered 14.5 kg of DM/d of alfalfa cubes; cows fed the ALH diet were offered 10.5 kg of DM/d of alfalfa cubes and 4.0 kg of DM/d of almond hulls; and cows on the CIT diet were offered 11.5 kg of DM/d of alfalfa cubes and 3.0 kg of DM/d of ensiled citrus pulp. Milk yield was measured daily and milk composition was measured on 4 d of each week. Individual cow methane emissions were measured by a sulfur hexafluoride tracer technique on d 24 to 28 of the experiment. The mean milk yield of cows fed the CON diet (27.4 kg/d) was greater than the mean milk yield of cows fed the ALH diet (24.6 kg/cow per day), whereas the mean milk yield of cows fed the CIT diet (26.2 kg/cow per day) was not different from the mean milk yield from cows fed the other 2 diets. Dietary treatment did not influence the concentrations of milk fat, protein, and lactose or fat yields, but the mean protein yield from cows fed the CON diet (0.87 kg/d) was greater than that from cows fed the ALH diet (0.78 kg/d) but not different to those fed the CIT diet (0.85 kg/d). In general, we found no differences in the proportion of individual fatty acids in milk. The mean pH of ruminal fluid from cows offered the CON diet was not different to the pH in the ruminal fluids of cows offered the ALH or the CIT diets. The mean methane emissions (g/d) and yields (g/kg of DM intake) were not influenced by dietary treatment. These findings indicate that, although almond hulls and ensiled citrus pulp can be used as a low-cost feed supplement, almond hulls did negatively affect milk production and neither inhibited enteric methane emissions.



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Effect of bovine lactoferrin and human lactoferrin on the proliferative activity of the osteoblast cell line MC3T3-E1 in vitro

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): J.L. Zhang, X. Han, Y.J. Shan, L.W. Zhang, M. Du, M. Liu, H.X. Yi, Y. Ma
ABSTRACTWe conducted a comparative in vitro study on the proliferative effects of natural human lactoferrin (nhLF) and bovine lactoferrin (bLF) on osteoblasts. We investigated cell proliferation, cell survival, cell cycle, and mRNA and protein expression of proliferating cell nuclear antigen. Results indicated that treatment with 100 μg/mL of bLF or nhLF promoted the proliferation and sustenance of osteoblasts, and increased the length of the G2/M and S phases compared with the untreated osteoblasts. Results of real-time quantitative PCR and Western blot showed that mRNA and protein expression of proliferating cell nuclear antigen by osteoblasts treated with bLF or nhLF were greater than those of the untreated control. At the same concentration, bLF demonstrated a greater effect on osteoblast proliferation than did nhLF. This study provides insights of significance in the utlization of bLF in healthy food formulas.



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Milk from cows fed a diet with a high forage:concentrate ratio improves inflammatory state, oxidative stress, and mitochondrial function in rats

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Gina Cavaliere, Giovanna Trinchese, Nadia Musco, Federico Infascelli, Chiara De Filippo, Vincenzo Mastellone, Valeria Maria Morittu, Pietro Lombardi, Raffaella Tudisco, Micaela Grossi, Vincenzo Monda, Monica I. Cutrignelli, Antonietta Messina, Serena Calabrò, Heleena B. Moni, Luigi Stradella, Giovanni Messina, Marcellino Monda, Marianna Crispino, Maria Pina Mollica
ABSTRACTExcessive energy intake may evoke complex biochemical processes characterized by inflammation, oxidative stress, and impairment of mitochondrial function that represent the main factors underlying noncommunicable diseases. Because cow milk is widely used for human nutrition and in food industry processing, the nutritional quality of milk is of special interest with respect to human health. In our study, we analyzed milk produced by dairy cows fed a diet characterized by a high forage:concentrate ratio (high forage milk, HFM). In view of the low n-6:n-3 ratio and high content of conjugated linoleic acid of HFM, we studied the effects of this milk on lipid metabolism, inflammation, mitochondrial function, and oxidative stress in a rat model. To this end, we supplemented for 4 wk the diet of male Wistar rats with HFM and with an isocaloric amount (82 kJ, 22 mL/d) of milk obtained from cows fed a diet with low forage:concentrate ratio, and analyzed the metabolic parameters of the animals. Our results indicate that HFM may positively affect lipid metabolism, leptin:adiponectin ratio, inflammation, mitochondrial function, and oxidative stress, providing the first evidence of the beneficial effects of HFM on rat metabolism.



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INTERPRETIVE SUMMARIES, MARCH 2018

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3





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Milk basic protein supplementation exerts an anti-inflammatory effect in a food-allergic enteropathy model mouse

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Aiko Ono-Ohmachi, Haruyo Nakajima-Adachi, Yoshikazu Morita, Ken Kato, Satoshi Hachimura
ABSTRACTTo examine novel functions of milk basic protein (MBP) in T-cell-related inflammatory diseases, such as autoimmune diseases and allergies, we evaluated the effects of MBP on the causative responses of ovalbumin (OVA)-specific T cells in a food-allergic enteropathy model, OVA23–3 mice, which express an OVA-specific T-cell receptor gene. The OVA-specific CD4+ T cells of the mesenteric lymph nodes (MLN) from OVA23–3 mice were cultured with CD11c+ dendritic cells of MLN from BALB/cA mice in the absence or presence of MBP following stimulation with OVA; then the levels of CD69 expression and the levels of cytokine production by CD4+ T cells were measured to evaluate activation. The effects of MBP supplementation of OVA 23–3 mice were assessed by feeding a diet containing OVA (OVA diet) with or without MBP for 28 d. Intestinal inflammation, together with activation and cytokine production of CD4+ T cells by MLN, as well as femoral bone mineral density, were measured. In in vitro culture, MBP inhibited excess activation and IL-4 production by CD4+ T cells. The supplementation of MBP to the OVA diet attenuated OVA-specific IgE production in OVA-diet-fed OVA23–3 mice and slightly resolved developing enteropathy caused by excess IL-4 production by CD4+ T cells. Feeding OVA diet to OVA23–3 mice exhibited bone loss accompanied with enteropathy, whereas MBP supplementation prevented bone loss and increased osteoprotegerin, an osteoclastogenesis inhibitory factor, in the mice. The inhibition of T-cell-activation in both MLN and bone marrow by MBP supplementation may help prevent increased IgE levels caused by excessive IL-4 production and bone loss accompanied by enteropathy. Our findings show that MBP may help attenuate both T-cell-related inflammation and bone loss.



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Replacing ground corn with incremental amounts of liquid molasses does not change milk enterolactone but decreases production in dairy cows fed flaxseed meal

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): C.P. Ghedini, D.C. Moura, R.A.V. Santana, A.S. Oliveira, A.F. Brito
ABSTRACTWe investigated the effects of replacing ground corn (GRC) with incremental amounts of liquid molasses (LM) on milk enterolactone concentration, antioxidant enzymes activity in plasma, production, milk fatty acid (FA) profile, and nutrient utilization in Jersey cows fed flaxseed meal and low-starch diets. Sixteen multiparous organically certified Jersey cows averaging (mean ± standard deviation) 101 ± 45 d in milk, 462 ± 38 kg of body weight, and 19.8 ± 3.90 kg/d of milk in the beginning of the study were randomly assigned to treatment sequences in a replicated 4 × 4 Latin square design, with 14 d for diet adaptation and 7 d for data and sample collection. Diets were fed as total mixed rations consisting (dry matter basis) of 52% grass-legume baleage, 8% grass hay, 8.5% soyhulls, 2.5% roasted soybean, 15% flaxseed meal, and 2% minerals-vitamins premix. The GRC-to-LM dietary ratios (dry matter basis) were 12:0, 8:4, 4:8, and 0:12. Orthogonal polynomials were used to test linear, quadratic, and cubic effects using the MIXED procedure of SAS (SAS Institute Inc., Cary, NC). The milk concentration of enterolactone tended to respond cubically, thus suggesting that replacing GRC with LM did not affect this lignan in milk. The plasma activities of the antioxidant enzymes glutathione peroxidase and catalase did not differ, but superoxide dismutase activity tended to respond cubically with feeding increasing amounts of LM. Dry matter intake and yields of milk and milk fat, true protein, and lactose decreased linearly with substituting GRC for LM. Whereas the concentrations of milk fat and milk true protein did not differ across treatments, milk lactose content decreased linearly. Feeding incremental levels of LM reduced linearly the milk concentration of urea N and the amount of N excreted in urine, and tended to decrease linearly the concentration of plasma urea N. Apparent total-tract digestibilities of dry matter, organic matter, and neutral and acid detergent fiber did not differ across treatments, whereas digestibility of crude protein decreased linearly. Digestibility of starch responded linearly and quadratically, but the actual differences between treatments were too small to be biologically significant. Milk FA profile was substantially changed most notably by linear increases in cis-9,trans-11 18:2, cis-9,cis-12,cis-15 18:3, Σ odd-chain FA, and the trans-11-to-trans-10 ratio, and linear decreases in cis-9 18:1 and cis-9,cis-12 18:2 when replacing GRC by incremental amounts of LM.



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Construction of an enzymatic route using a food-grade recombinant Bacillus subtilis for the production and purification of epilactose from lactose

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Qiuming Chen, Weiwei He, Xin Yan, Tao Zhang, Bo Jiang, Timo Stressler, Lutz Fischer, Wanmeng Mu
ABSTRACTLactose is a main by-product in the cheese industry. Many attempts have been made to convert the lactose to high value-added products, including epilactose. Epilactose is a valuable prebiotic and can be epimerized from lactose with cellobiose 2-epimerase (CEase). The objective of the present work was to construct a food-grade recombinant Bacillus subtilis that produces CEase from Thermoanaerobacterium saccharolyticum. The CEase was expressed in B. subtilis without antibiotic resistance genes. After fermentation, the maximum volumetric activity of the fermented broth was more than 7 U/mL. The activity of the recombinant B. subtilis was increased by up to 3.7 fold after ethanol permeabilization. Then, 66.9 ± 0.7 g/L of epilactose was produced from 300 g/L of whey powder solution in 1 h with 13.3 U/mL of permeabilized biocatalyst. In addition, an enzymatic route including degradation of the lactose, yeast fermentation, and cation exchange chromatography was described to further purify the produced epilactose from lactose. Finally, epilactose with a purity >98% was produced from 300 g/L of lactose with a yield of 24.0%. In conclusion, neither antibiotics nor pathogenic bacteria were used throughout the epilactose production and purification procedure.



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Association analysis for udder index and milking speed with imputed whole-genome sequence variants in Nordic Holstein cattle

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Júlia Gazzoni Jardim, Bernt Guldbrandtsen, Mogens Sandø Lund, Goutam Sahana
ABSTRACTGenome-wide association testing facilitates the identification of genetic variants associated with complex traits. Mapping genes that promote genetic resistance to mastitis could reduce the cost of antibiotic use and enhance animal welfare and milk production by improving outcomes of breeding for udder health. Using imputed whole-genome sequence variants, we carried out association studies for 2 traits related to udder health, udder index, and milking speed in Nordic Holstein cattle. A total of 4,921 bulls genotyped with the BovineSNP50 BeadChip array were imputed to high-density genotypes (Illumina BovineHD BeadChip, Illumina, San Diego, CA) and, subsequently, to whole-genome sequence variants. An association analysis was carried out using a linear mixed model. Phenotypes used in the association analyses were deregressed breeding values. Multitrait meta-analysis was carried out for these 2 traits. We identified 10 and 8 chromosomes harboring markers that were significantly associated with udder index and milking speed, respectively. Strongest association signals were observed on chromosome 20 for udder index and chromosome 19 for milking speed. Multitrait meta-analysis identified 13 chromosomes harboring associated markers for the combination of udder index and milking speed. The associated region on chromosome 20 overlapped with earlier reported quantitative trait loci for similar traits in other cattle populations. Moreover, this region was located close to the FYB gene, which is involved in platelet activation and controls IL-2 expression; FYB is a strong candidate gene for udder health and worthy of further investigation.



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Technical note: Development and validation of a new method for the quantification of soluble and micellar calcium, magnesium, and potassium in milk

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): M. Franzoi, G. Niero, M. Penasa, M. Cassandro, M. De Marchi
ABSTRACTMilk mineral content is a key trait for its role in dairy processes such as cheese-making, its use as source of minerals for newborns, and for all traits involving salt-protein interactions. This study investigated a new method for measuring mineral partition between soluble and micellar fractions in bovine milk after rennet coagulation. A new whey dilution step was added to correct the quantification bias due to whey trapped in curd and excluded volume. Moreover, the proposed method allowed the quantification of the diffusible volume after milk coagulation. Milk mineral content and concentration in whey, and diluted whey were quantified by acid digestion and inductively coupled plasma optical emission spectrometry. The repeatability of the method for micellar Ca, Mg, and K was between 2.07 and 8.96%, whereas reproducibility ranged from 4.01 to 9.44%. Recovery of total milk minerals over 3 spiking levels ranged from 92 to 97%. The proposed method provided an accurate estimation of micellar and soluble minerals in milk, and curd diffusible volume.



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Control of Listeria monocytogenes in whole milk using antimicrobials applied individually and in combination

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Sarah M. Kozak, Stephanie R.B. Brown, Yustyna Bobak, Dennis J. D'Amico
ABSTRACTDairy product recalls and dairy-related illnesses are often the result of contamination with Listeria monocytogenes, which can occur throughout the dairy production and supply chains. The use of antimicrobial compounds is one practical approach for controlling pathogen survival and growth in foods. The goal of this study was to use fluid milk as a model system to identify listeristatic or listericidal treatments that show promise for application in fluid milk and for further evaluation in other dairy products (e.g., cheese). Caprylic acid (CA), ε-polylysine (EPL), hydrogen peroxide, lauric arginate (LAE), and sodium caprylate (SC) were added individually or in combination to whole milk inoculated with L. monocytogenes at ˜4 log10 cfu/mL. Samples were stored at 7°C for 21 d, and L. monocytogenes counts were determined weekly. Inhibitory concentrations of LAE (800 mg/L) and EPL (100–400 mg/L), as well as SC and CA (3,200 mg/L each), were identified. The addition of EPL at 800 mg/L reduced L. monocytogenes counts by >3 log10 cfu/mL from initial inoculation levels after 21 d. Addition of hydrogen peroxide to milk reduced counts by >3 log10 cfu/mL from initial inoculation within 24 h (400 and 800 mg/L) or by d 7 (200 mg/L). Although the combinatory treatments of EPL + CA, EPL + LAE, and LAE + SC were characterized as indifferent, EPL + SC worked synergistically to reduce L. monocytogenes populations in milk over 21 d. Overall, these data identify potential antimicrobial treatments to control L. monocytogenes in milk and serve as a foundation for the continued development of antimicrobial controls for L. monocytogenes in dairy products.



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Short communication: Signs of host genetic regulation in the microbiome composition in 2 dairy breeds: Holstein and Brown Swiss

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): O. Gonzalez-Recio, I. Zubiria, A. García-Rodríguez, A. Hurtado, R. Atxaerandio
ABSTRACTThis study aimed to evaluate whether the host genotype exerts any genetic control on the microbiome composition of the rumen in cattle. Microbial DNA was extracted from 18 samples of ruminal content from 2 breeds (Holstein and Brown Swiss). Reads were processed using mothur (https://www.mothur.org/) in 16S and 18S rRNA gene-based analyses. Then, reads were classified at the genus clade, resulting in 3,579 operational taxonomic units (OTU) aligned against the 16S database and 184 OTU aligned against the 18S database. After filtering on relative abundance (>0.1%) and penetrance (95%), 25 OTU were selected for the analyses (17 bacteria, 1 archaea, and 7 ciliates). Association with the genetic background of the host animal based on the principal components of a genomic relationship matrix based on single nucleotide polymorphism markers was analyzed using Bayesian methods. Fifty percent of the bacteria and archaea genera were associated with the host genetic background, including Butyrivibrio, Prevotella, Paraprevotella, and Methanobrevibacter as main genera. Forty-three percent of the ciliates analyzed were also associated with the genetic background of the host. In total, 48% of microbes were associated with the host genetic background. The results in this study support the hypothesis and provide some evidence that there exists a host genetic component in cattle that can partially regulate the composition of the microbiome.



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Phenotypic, fermentation characterization, and resistance mechanism analysis of bacteriophage-resistant mutants of Lactobacillus delbrueckii ssp. bulgaricus isolated from traditional Chinese dairy products

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Kaibo Deng, Wei Fang, Baodong Zheng, Song Miao, Guicheng Huo
ABSTRACTBacteriophage infection is a large factor in dairy industrial production failure on the basis of pure inoculation fermentation, and developing good commercial starter cultures from wild dairy products and improving the environmental vigor of starter cultures by enhancing their phage resistance are still the most effective solutions. Here we used a spontaneous isolation method to obtain bacteriophage-resistant mutants of Lactobacillus delbrueckii ssp. bulgaricus strains that are used in traditional Chinese fermented dairy products. We analyzed their phenotypes, fermentation characteristics, and resistance mechanisms. The results showed that bacteriophage-insensitive mutants (BIM) BIM8 and BIM12 had high bacteriophage resistance while exhibiting fermentation and coagulation attributes that were as satisfying as those of their respective parent strains KLDS1.1016 and KLDS1.1028. According to the attachment receptor detection, mutants BIM8 and BIM12 exhibited reduced absorption to bacteriophage phiLdb compared with their respective bacteriophage-sensitive parent strains because of changes to the polysaccharides or teichoic acids connected to their peptidoglycan layer. Additionally, genes, including HSDR, HSDM, and HSDS, encoding 3 subunits of a type I restriction-modification system were identified in their respective parent strains. We also discovered that HSDR and HSDM were highly conserved but that HSDS was variable because it is responsible for the DNA specificity of the complex. The late lysis that occurred only in strain KLDS1.1016 and not in strain KLDS1.1028 suggests that the former and its mutant BIM8 also may have an activatable restriction-modification mechanism. We conclude that the L. bulgaricus BIM8 and BIM12 mutants have great potential in the dairy industry as starter cultures, and their phage-resistance mechanism was effective mainly due to the adsorption interference and restriction-modification system.



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Relative bioavailability of carnitine delivered by ruminal or abomasal infusion or by encapsulation in dairy cattle

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): K.E. Olagaray, J.E. Shaffer, C.K. Armendariz, A. Bellamine, S. Jacobs, E.C. Titgemeyer, B.J. Bradford
ABSTRACTTwo studies were designed to evaluate the relative bioavailability of l-carnitine delivered by different methods in dairy cattle. In experiment 1, 4 Holstein heifers were used in a split-plot design to compare ruminally or abomasally infused l-carnitine. The study included 2 main-plot periods, with infusion routes allocated in a crossover design. Within main-plot periods, each of 3 subplot periods consisted of 4-d infusions separated with 4-d rest periods. Subplot treatments were infusion of 1, 3, and 6 g of l-carnitine/d in conjunction with 6 g/d of arabinogalactan given in consideration of eventual product manufacturing. Doses increased within a period to minimize carryover risk. Treatments were solubilized in 4 L of water and delivered in two 10-h infusions daily. Blood was collected before the start of infusion period and on d 4 of each infusion period to obtain baseline and treatment l-carnitine concentrations. There was a dose × route interaction and route effect for increases in plasma carnitine above baseline, with increases above baseline being greater across all dose levels when infused abomasally compared with ruminally. Results demonstrated superior relative bioavailability of l-carnitine when ruminal exposure was physically bypassed. In experiment 2, 56 lactating Holstein cows (143 ± 72 d in milk) were used in 2 cohorts in randomized complete block designs (blocked by parity and milk production) to evaluate 2 rumen-protected products compared with crystalline l-carnitine. Treatments were (1) control, (2) 3 g/d of crystalline l-carnitine (crystalline), (3) 6 g/d of crystalline, (4) 5 g/d of 40COAT (40% coating, 60% l-carnitine), (5) 10 g/d of 40COAT, (6) 7.5 g/d of 60COAT (60% coating, 40% l-carnitine), and (7) 15 g/d of 60COAT. Treatments were top-dressed to diets twice daily. Each cohort used 14-d and included a 6-d baseline measurement period with the final 2 d used for data and sample collection, and an 8-d treatment period with the final 2 d used for data and sample collection. Plasma, urine, and milk samples were analyzed for l-carnitine. Crystalline and 40COAT linearly increased plasma l-carnitine, and 60COAT tended to linearly increase plasma l-carnitine. Total excretion (milk + urine) of l-carnitine averaged 1.52 ± 0.04 g/d in controls, increased linearly with crystalline and 40COAT, and increased quadratically with 60COAT. Crystalline increased plasma l-carnitine and l-carnitine excretion more than 40COAT and 60COAT. In conclusion, preventing ruminal degradation of l-carnitine increased delivery of bioavailable carnitine to cattle, but effective ruminal protection and postruminal bioavailability is challenging.



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Lactation response to soybean meal and rumen-protected methionine supplementation of corn silage-based diets

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): H. Nursoy, M. Gonzalez Ronquillo, A.P. Faciola, G.A. Broderick
ABSTRACTCorn silage, an important forage fed to dairy cows in the United States, is energy rich but protein poor. The objectives of this experiment were to investigate the effects on production of milk and milk components of feeding corn silage-based diets with 4 levels of dietary crude protein (CP) plus rumen-protected methionine (RPM). Thirty-six cows were blocked by days in milk into 9 squares and randomly assigned to 9 balanced 4 × 4 Latin squares with four 4-wk periods. All diets were formulated to contain, as a percent of dry matter (DM), 50% corn silage, 10% alfalfa silage, 4% soyhulls, 2.4% mineral-vitamin supplement, and 30% neutral detergent fiber. Supplemental RPM (Mepron, Evonik Corp., Kennesaw, GA) was added to all diets to maintain a Lys:Met ratio of 3.1 in digested AA. Ground high-moisture corn was reduced and soybean meal (SBM) plus RPM increased to give diets containing, on average, 11% CP (28% corn, 31% starch, 6% SBM, 4 g of RPM/d), 13% CP (23% corn, 29% starch, 10% SBM, 8 g of RPM/d), 15% CP (19% corn, 26% starch, 15% SBM, 10 g of RPM/d), and 17% CP (14% corn, 24% starch, 19% SBM, 12 g of RPM/d). Data from the last 14 d of each period were analyzed using the mixed procedures in SAS (SAS Institute Inc., Cary, NC). With the exception of milk fat and milk lactose content, we found no significant effects of diet on all production traits. We did note linear responses to dietary CP concentration for intake, production of milk and milk components, and MUN. Cows fed the 11% CP diet had reduced DM intake, lost weight, and yielded less milk and milk components. Mean separation indicated that only true protein yield was lower on 13% CP than on 17% dietary CP, but not different between 15 and 17% CP. This indicated no improvement in production of milk and milk components above 15% CP. Quadratic trends for yield of milk, energy-corrected milk, and true protein suggested that a dietary CP concentration greater than 15% may be necessary to maximize production or, alternately, that a plateau was reached and no further CP was required. Although diet influenced apparent digestibility of DM, organic matter, and neutral detergent fiber, digestibility did not increase linearly with dietary CP. However, we observed linear and quadratic effects of dietary CP on acid detergent fiber digestibility. As expected, we found a linear effect of dietary CP on apparent N digestibility and on fecal and urinary N excretion, but no effect of diet on estimated true N digestibility. Ruminal concentrations of ammonia, total AA, peptides, and branched-chain volatile fatty acids also increased linearly with dietary CP. Quadratic responses indicated that 14.0 to 14.8% CP was necessary to optimize digestion and energy utilization. Overall results indicated that, when RPM was added to increase Lys:Met to 3.1, 15% CP was adequate for lactating dairy cows fed corn silage diets supplemented with SBM and secreting about 40 kg of milk/d; N excretion was lower than at 17% CP but with no reduction in yield of milk and milk components.



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Antibacterial activity of selenium-enriched lactic acid bacteria against common food-borne pathogens in vitro

Publication date: March 2018
Source:Journal of Dairy Science, Volume 101, Issue 3
Author(s): Jingpeng Yang, Jing Wang, Kun Yang, Miaomiao Liu, Yiman Qi, Tingjing Zhang, Mingtao Fan, Xinyuan Wei
ABSTRACTSelenium (Se) is an essential trace element for human health and animal nutrition. The aim of this study was to evaluate the inhibitory activities of Se-enriched lactic acid bacteria (LAB), Lactobacillus delbrueckii ssp. bulgaricus and Streptococcus thermophilus, against pathogenic Salmonella typhimurium, Escherichia coli, Staphylococcus aureus, and Listeria monocytogenes in vitro. The results indicated that the accumulation amount of Se by Lactobacillus delbrueckii ssp. bulgaricus and Streptococcus thermophilus reached 12.05 ± 0.43 µg/mL and 11.56 ± 0.25 µg/mL, respectively, accompanied by the relative maximum living cells when sodium selenite was 80 µg/mL. Oxford cup double plate assay showed that bacterial culture solution and cell-free culture supernatant (CFCS) from Se-enriched LAB exerted stronger antibacterial activity than those from the non-Se strains. The growth of pathogenic bacterial culture with CFCS at any growth stages was worse than that without CFCS; moreover, the inhibiting effect of CFCS of Se-enriched LAB was more significant than that of non-Se strains. Results from a scanning electron microscope equipped with energy dispersion X-ray spectrometry showed that elemental Se nanoparticles, which characteristically energy peak around 1.42 keV, were deposited on the cell surfaces of Lactobacillus delbrueckii ssp. bulgaricus. In addition, CFCS of Se-enriched LAB induced more serious cell structure damage of pathogenic bacteria than did non-Se LAB.



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Cover Image

Thumbnail image of graphical abstract

The cover image, by Vinidh Paleri et al., is based on the Original Article Transoral robotic surgery for residual and recurrent oropharyngeal cancers: Exploratory study of surgical innovation using the IDEAL framework for early-phase surgical studies, DOI: 10.1002/hed.25032



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Issue Information



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A Traveler From Africa With Fever and Aggravated Chronic Back Pain

(See page 805 for the Photo Quiz.)

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News



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A Traveler from Africa with Fever and Aggravated Chronic Back Pain

(See pages 806–7 for the Answer to the Photo Quiz.)

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In the Literature



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Cover



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Artemisinin Therapy for Malaria in Hemoglobinopathies: A Systematic Review

Abstract
Artemisinin derivatives are widely used antimalarial drugs. There is some evidence from in vitro, animal and clinical studies that hemoglobinopathies may alter their disposition and antimalarial activity. This review assesses relevant data in α-thalassemia, sickle cell disease (SCD), β-thalassemia and hemoglobin E. There is no convincing evidence that the disposition of artemisinin drugs is affected by hemoglobinopathies. Although in vitro studies indicate that Plasmodium falciparum cultured in thalassemic erythrocytes is relatively resistant to the artemisinin derivatives, mean 50% inhibitory concentrations (IC50s) are much lower than in vivo plasma concentrations after recommended treatment doses. Since IC50s are not increased in P. falciparum cultures using SCD erythrocytes, delayed post-treatment parasite clearance in SCD may reflect hyposplenism. As there have been no clinical studies suggesting that hemoglobinopathies significantly attenuate the efficacy of artemisinin combination therapy (ACT) in uncomplicated malaria, recommended artemisinin doses as part of ACT remain appropriate in this patient group.

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Reply to Magréault et al

To the Editor—We thank Magréault and colleagues for their comments [1] that allow us to better specify our approach to colistin plasma determination.

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Colistin Pharmacokinetics in Pediatrics

To the Editor—Mesini et al have recently published an article relying on colistin area under the time-concentration curve (AUC) in children, leading to dosing regimen recommendations [1]. Measured colistin concentrations are surprisingly high and uncontrolled degradation of the infused prodrug (colistin methanesulfonate [CMS]) may be suspected, but this is impossible to assess as CMS concentrations are not reported. Yet there is no doubt that AUC estimate based on 2 concentrations is inappropriate.

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Dose Suggestions for Intravenous Colistin in Pediatric Patients: Caution Required

To the Editor—Mesini et al reported plasma concentrations of colistin in 7 pediatric patients (aged 46 days to 13 years) who were receiving intravenously the inactive prodrug colistimethate; across all patients, plasma colistin concentrations were measured on 13 occasions [1]. That report has been the subject of critical appraisal by Magréault et al [2], who expressed substantial concerns about the magnitude of the plasma colistin concentrations reported and the pharmacokinetic analysis conducted by Mesini and coworkers. I agree with Magréault et al and amplify their comments. I have very substantial concerns about the dosing recommendations implicitly presented in the report of Mesini and coworkers.

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Breast Implant Q Fever as a Source of In-Hospital Transmission

Abstract
Herein, we describe the first case of mammary implant infection caused by Coxiella burnetii, resulting in delayed diagnosis and treatment and an in-hospital cross-transmission of Q fever to medical personnel.

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Immediate Antiretroviral Therapy Decreases Mortality Among Patients With High CD4 Counts in China: A Nationwide, Retrospective Cohort Study

Abstract
Background
Clinical trials have demonstrated that immediate initiation of antiretroviral therapy (ART) reduces AIDS-related morbidity and mortality. We tested the hypothesis that initiating ART ≤30 days after human immunodeficiency virus (HIV) diagnosis would be associated with reduced mortality among people living with HIV (PLWH) with CD4 counts >500 cells/μL.
Methods
PLWH enrolled in the Chinese National HIV Information System between January 2012 and June 2014 with CD4 counts >500 cells/μL were followed for 12 months. Cox proportional hazards model was used to determine hazard ratios (HRs) for PLWH who initiated ART after HIV diagnosis. ART initiation was treated as a time-dependent variable.
Results
We enrolled 34581 PLWH with CD4 >500 cells/μL; 1838 (5.3%) initiated ART ≤30 days after diagnosis (immediate ART group), and 19 deaths were observed with a mortality rate of 1.04 per 100 person-years (PY). Fifty-eight deaths were documented among the 5640 PLWH in the delayed ART group with a mortality rate of 2.25 per 100 PY. There were 713 deaths among the 27103 PLWH in the no ART group with a mortality rate of 2.39 per 100 PY. After controlling for potential confounding factors, ART initiation at ≤30 days (adjusted HR, 0.37 [95% confidence interval, .23–.58]) was a statistically significant protective factor.
Conclusions
We found that immediate ART is associated with a 63% reduction in overall mortality among PLWH with CD4 counts >500 cells/μL in China, supporting the recommendation to initiate ART immediately following HIV diagnosis.

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Reply to Kenyon

To the Editor—We thank Chris Kenyon for his comments [1] on our recent article [2], which showed that increased syphilis testing is associated with a relative increase in detection of asymptomatic early latent syphilis and a fall in secondary syphilis. Kenyon has hypothesized that the increase in proportion of early latent syphilis may be explained by an increasing proportion of repeated syphilis infections, which in turn are more likely to be asymptomatic [1]. However, we believe this is unlikely to explain our observations. In response, we undertook a further analysis of repeated syphilis infections among men who have sex with men (MSM) attending the Melbourne Sexual Health Centre (MSHC), where 32% of syphilis cases (1215 of 3831) in our study were diagnosed. Repeated syphilis infections were identified based on patient self-reported past history of syphilis using computer-assisted self-interview (CASI) at the MSHC from mid-2008 to ensure complete capture of diagnoses if patients had tested elsewhere outside the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood-borne Viruses (ACCESS) network.

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Increases in Asymptomatic Early Syphilis May Reflect Increases in Repeated Episodes of Syphilis and Not Enhanced Screening

To the Editor—In their analysis of men who have sex with men (MSM) attending a national sentinel network of 46 sexual health clinics in Australia between 2007 and 2014, Chow et al [1] found a decline in the proportion of syphilis cases that were secondary syphilis and a corresponding increase in early latent syphilis. These changes occurred during a period of increased coverage and frequency of syphilis testing in MSM. The authors interpret this association as representing an “interruption of syphilis progression” and thereby a reduction in the infectiousness of syphilis.

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Increases in Neisseria gonorrhoeae With Reduced Susceptibility to Azithromycin Among Men Who Have Sex With Men in Seattle, King County, Washington, 2012–2016

Abstract
Background
Antimicrobial-resistant Neisseria gonorrhoeae is a major public health threat. The Centers for Disease Control and Prevention (CDC) recommends ceftriaxone 250 mg plus azithromycin (AZM) 1 g for gonorrhea treatment. Resistance to AZM could affect gonorrhea control efforts.
Methods
Using gonococcal isolates collected at the Public Health–Seattle & King County (PHSKC) Sexually Transmitted Disease (STD) Clinic from 2012 to 2016, focusing on 2014–2016, we compared cases with the CDC AZM alert value minimum inhibitory concentration (MIC) (≥2 µg/mL) to those with AZM MIC ≤1 µg/mL, antimicrobial susceptibility profiles and clinical outcomes.
Results
In 2012 and 2013, none of the 263 patients from whom we isolated N. gonorrhoeae from the urethra were infected with organisms with an AZM MIC ≥2 µg/mL. Between 2014 and 2016, 4.4% of 926 gonorrhea cases demonstrated reduced susceptibility to AZM; 93% of these cases occurred among men who have sex with men (MSM). Among MSM, 5.0% of 2014–2016 cases demonstrated reduced susceptibility to AZM. No AZM alert value isolates had concomitant cephalosporin resistance. There were 2 potential treatment failures: 1 pharyngeal infection treated with AZM 2 g alone, and 1 pharyngeal infection that persisted after study drug.
Conclusions
Among MSM with gonorrhea in Seattle, 5% have gonorrhea with reduced susceptibility to AZM. The World Health Organization recommends changing treatment guidelines when >5% of isolates are resistant to a recommended drug. The emergence of resistant AZM gonorrhea should prompt reconsideration of current treatment recommendations, and highlights the need for new therapies for gonorrhea.

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Impact of Public Safety Policies on Human Immunodeficiency Virus Transmission Dynamics in Tijuana, Mexico

Abstract
Background
North Tijuana, Mexico is home to many individuals at high risk for transmitting and acquiring human immunodeficiency virus (HIV). Recently, policy shifts by local government impacted how these individuals were handled by authorities. Here we examined how this affected regional HIV transmission dynamics.
Methods
HIV pol sequences and associated demographic information were collected from 8 research studies enrolling persons in Tijuana and were used to infer viral transmission patterns. To evaluate the impact of recent policy changes on HIV transmission dynamics, qualitative interviews were performed on a subset of recently infected individuals.
Results
Between 2004 and 2016, 288 unique HIV pol sequences were obtained from individuals in Tijuana, including 46.4% from men who have sex with men, 42.1% from individuals reporting transactional sex, and 27.8% from persons who inject drugs (some individuals had >1 risk factor). Forty-two percent of sequences linked to at least 1 other sequence, forming 37 transmission clusters. Thirty-two individuals seroconverted during the observation period, including 8 between April and July 2016. Three of these individuals were putatively linked together. Qualitative interviews suggested changes in policing led individuals to shift locations of residence and injection drug use, leading to increased risk taking (eg, sharing needles).
Conclusions
Near real-time molecular epidemiologic analyses identified a cluster of linked transmissions temporally associated with policy shifts. Interviews suggested these shifts may have led to increased risk taking among individuals at high risk for HIV acquisition. With all public policy shifts, downstream impacts need to be carefully considered, as even well-intentioned policies can have major public health consequences.

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Understanding the Promises and Hurdles of Metagenomic Next-Generation Sequencing as a Diagnostic Tool for Infectious Diseases

Abstract
Agnostic metagenomic next-generation sequencing (mNGS) has emerged as a promising single, universal pathogen detection method for infectious disease diagnostics. This methodology allows for identification and genomic characterization of bacteria, fungi, parasites, and viruses without the need for a priori knowledge of a specific pathogen directly from clinical specimens. Although there are increasing reports of mNGS successes, several hurdles need to be addressed, such as differentiation of colonization from infection, extraneous sources of nucleic acid, method standardization, and data storage, protection, analysis, and interpretation. As more commercial and clinical microbiology laboratories develop mNGS assays, it is important for treating practitioners to understand both the power and limitations of this method as a diagnostic tool for infectious diseases.

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