Enhanced platelet adherence and aggregation in Chagas' disease: a potential pathogenic mechanism for cardiomyopathy.
Spasm and thrombosis of the coronary microcirculation has been implicated in the pathogenesis of the cardiomyopathy of Chagas' disease. We demonstrate that increases in platelet adherence and aggregation accompany Trypanosoma cruzi infection and may contribute to the observed microvascular pathology. Scanning electron microscopy and radiolabeled platelets studies revealed that platelet adherence to T. cruzi-infected human endothelial cells was significantly increased when compared to controls (P = 0.024). In in vitro experiments, we determined the influence of infection on prostacyclin production, a marker of endothelial cell perturbation. The basal levels of 6-keto-prostaglandin F1 alpha was significantly greater in the supernatant of infected endothelial cells than in those of uninfected endothelial cells (P less than 0.05). The influence of infection was assessed on platelet aggregation at days 5 and 12 post-infection in A/J mice. Platelets from T. cruzi-infected mice were 2-6-fold more sensitive to aggregation induced by adenosine diphosphate and sodium arachidonate than controls. Thromboxane B2 levels in the plasma of infected mice were greater than controls. These data support the hypothesis that heightened platelet reactivity and endothelial cell dysfunction are associated with acute Chagas' disease and may cause coronary microvascular spasm and/or occlusion.


Integration of Novel Agents into the Care of Patients with Multiple Myeloma.
The pace of therapeutic drug development in multiple myeloma has reached unprecedented levels, with five regulatory approvals for relapsed and/or refractory disease of either new drugs or new drug regimens in 2015, one already in 2016, and still others anticipated. This has provided a wide array of options to be considered by patients and their health care providers in the event of relapse after or progression on front-line therapy. Most of these agents are currently being evaluated in earlier patient populations, including as parts of induction, consolidation, and maintenance therapy approaches, where their benefits may be even greater. Moreover, additional randomized studies have been completed with our previous stable of novel agents that inform their use in these settings as well. In the current contribution to this CCR Focus on multiple myeloma, we will present an overview of some of the key recent data that have supported the addition of these new therapeutics to our armamentarium against multiple myeloma. Also, we will provide some guidelines about possible best practices in applying these regimens and attempt to extrapolate how they will be used as parts of our future standards of care. Clin Cancer Res; 22(22); 5443-52. ©2016 AACR SEE ALL ARTICLES IN THIS CCR FOCUS SECTION, "MULTIPLE MYELOMA MULTIPLYING THERAPIES".


Phloretin reduces cell injury and inflammation mediated by Staphylococcus aureus via targeting sortase B and the molecular mechanism.
Sortase B (SrtB) is a vital virulence factor that plays a critical role in Staphylococcus aureus (S. aureus) infections, indicating that it could be a latent target for S. aureus infections. In this study, phloretin, a natural compound that primarily exists in the pericarp and velamen of apples and pears, shows little anti-S. aureus activity, but significantly inhibited SrtB activity in vitro. The results of lactate dehydrogenase release and live/dead cell assays suggested that phloretin reduced human alveolar epithelial cell damage caused by S. aureus. Additionally, an adhesion assay confirmed that phloretin lowered the colony count of S. aureus in human alveolar cells. Phloretin treatment significantly attenuated the inflammatory response in macrophage cells (J774) co-cultured with S. aureus as determined by an enzyme-linked immune-sorbent assay. Furthermore, the results of molecular dynamics simulation, site-directed mutagenesis, and fluorescence spectroscopy quenching indicated that phloretin was directly located in the active pocket of SrtB and blocked substrate binding, leading to the loss of SrtB activity. These results indicate that phloretin is a possible candidate for treatment of S. aureus infections.


Exploring structural variants in environmentally sensitive gene families.
Environmentally sensitive plant gene families like NBS-LRRs, receptor kinases, defensins and others, are known to be highly variable. However, most existing strategies for discovering and describing structural variation in complex gene families provide incomplete and imperfect results. The move to de novo genome assemblies for multiple accessions or individuals within a species is enabling more comprehensive and accurate insights about gene family variation. Earlier array-based genome hybridization and sequence-based read mapping methods were limited by their reliance on a reference genome and by misplacement of paralogous sequences. Variant discovery based on de novo genome assemblies overcome the problems arising from a reference genome and reduce sequence misplacement. As de novo genome sequencing moves to the use of longer reads, artifacts will be minimized, intact tandem gene clusters will be constructed accurately, and insights into rapid evolution will become feasible.


Biosynthesis of milk fat, protein, and lactose: roles of transcriptional and posttranscriptional regulation.
The demand for high-quality milk is increasing worldwide. The efficiency of milk synthesis can be improved by taking advantage of the accumulated knowledge of the transcriptional and posttranscriptional regulation of genes coding for proteins involved in the synthesis of fat, protein, and lactose in the mammary gland. Research in this area is relatively new, but data accumulated in the last 10 years provide a relatively clear picture. Milk fat synthesis appears to be regulated, at least in bovines, by an interactive network between SREBP1, PPARγ, and LXRα, with a potential role for other transcription factors, such as Spot14, ChREBP, and Sp1. Milk protein synthesis is highly regulated by insulin, amino acids, and amino acid transporters via transcriptional and posttranscriptional routes, with the insulin-mTOR pathway playing a central role. The transcriptional regulation of lactose synthesis is still poorly understood, but it is clear that glucose transporters play an important role. They can also cooperatively interact with amino acid transporters and the mTOR pathway. Recent data indicate the possibility of nutrigenomic interventions to increase milk fat synthesis by feeding long-chain fatty acids and milk protein synthesis by feeding amino acids. We propose a transcriptional network model to account for all available findings. This model encompasses a complex network of proteins that control milk synthesis with a cross talk between milk fat, protein, and lactose regulation, with mTOR functioning as a central hub.


Identification of trans-golgi network proteins in Arabidopsis thaliana root tissue.
Knowledge of protein subcellular localization assists in the elucidation of protein function and understanding of different biological mechanisms that occur at discrete subcellular niches. Organelle-centric proteomics enables localization of thousands of proteins simultaneously. Although such techniques have successfully allowed organelle protein catalogues to be achieved, they rely on the purification or significant enrichment of the organelle of interest, which is not achievable for many organelles. Incomplete separation of organelles leads to false discoveries, with erroneous assignments. Proteomics methods that measure the distribution patterns of specific organelle markers along density gradients are able to assign proteins of unknown localization based on comigration with known organelle markers, without the need for organelle purification. These methods are greatly enhanced when coupled to sophisticated computational tools. Here we apply and compare multiple approaches to establish a high-confidence data set of Arabidopsis root tissue trans-Golgi network (TGN) proteins. The method employed involves immunoisolations of the TGN, coupled to probability-based organelle proteomics techniques. Specifically, the technique known as LOPIT (localization of organelle protein by isotope tagging), couples density centrifugation with quantitative mass-spectometry-based proteomics using isobaric labeling and targeted methods with semisupervised machine learning methods. We demonstrate that while the immunoisolation method gives rise to a significant data set, the approach is unable to distinguish cargo proteins and persistent contaminants from full-time residents of the TGN. The LOPIT approach, however, returns information about many subcellular niches simultaneously and the steady-state location of proteins. Importantly, therefore, it is able to dissect proteins present in more than one organelle and cargo proteins en route to other cellular destinations from proteins whose steady-state location favors the TGN. Using this approach, we present a robust list of Arabidopsis TGN proteins.


Clear cell colorectal carcinoma: Time to clarify diagnosis.
Primary clear cell colorectal carcinoma (CCC) is a very rare entity accounting for only 35 cases reported in the Literature. CCC is neither classified as a distinct entity nor is it defined as a CRC variant because its ontogeny remains unclear. Most of the reported CCC were found in the distal colon in patients with a mean age of 56 years. Histologically, clear cell change is the main morphologic feature and may present in a "pure" form, composed exclusively of clear cells, or in a "composite" form, admixed with other morphologically different components. It is possible to distinguish two biologically different types of CCC, with different clinical-pathologic features, therapeutic management and diagnostic criteria: a) Intestinal CCC consisting of an aggressive neoplasm, affecting mainly adult men, characterized by an intestinal-type immunoprofile (CK20+, CK7-, CEA+, CDX-2+) and b) Müllerian CCC consisting of an indolent carcinoma of the sigmoid-rectum, affecting young women, characterized by a different (CK7+, CK20-, CEA-, CA125 +) immunoprofile. Considerable diagnostic difficulties can arise in distinguishing CCC and primary or secondary clear cell neoplasms, such as metastases from renal carcinoma, lower urinary tract, female genital tract, adrenal gland, mesothelioma, melanoma and primary intestinal PEComa. In this paper we review the Literature with two additional cases in order to define the diagnostic criteria of CCC.


Clustering of food and activity preferences in primary school children.
This study examined clustering of food and activity preferences in Dutch primary school children. It also explored whether the preference clusters are associated with child and parental background characteristics and with parenting practices. Data were used from 1480 parent-child dyads participating in the IVO Nutrition and Physical Activity Child cohort (INPACT). Children aged 8-11years reported their preferences for food (e.g. fruit and sweet snacks) and activities (e.g. biking and watching television) at school with a newly-developed, visual instrument designed for primary school children. Parents completed a questionnaire at home. Principal component analysis was used to identify preference clusters. Backward regression analyses were used to examine the relationship between child and parental characteristics with cluster scores. We found (1) a clustering of preferences for unhealthy foods and unhealthy drinks, (2) a clustering of preferences for various physical activity behaviours, and (3) a clustering of preferences for unhealthy drinks and sedentary behaviour. Boys had a higher cluster score than girls on all three preference clusters. In addition, physical activity-related parenting practices were negatively related to unhealthy preference clusters and positively to the physical-activity-preference cluster. The next step is to relate our preference clusters to child dietary and activity behaviours, with special attention to gender differences. This may help in the development of interventions aimed at improving children's food and activity preferences.


Gender and role models in the education of medical doctors: a qualitative exploration of gendered ways of thinking.
To examine how 'gendered ways of thinking' relate to role models in medical education. This study employed an explorative, qualitative, and cross-sectional design. A total of 57 interviews were held with medical students (28 interviews) and with faculty members (29 interviews) at a Swedish medical school. Participants were asked to describe their role models and the attributes that made certain individuals role models. Data were analysed using an inductive approach in three separate steps that explored the relationship between role models and gender. Males do not generally consider female doctors as role models, and male role models are generally viewed as more admirable than female role models. This was shown in all steps of the analysis and most prominently in how male role models were described as qualitatively more admirable than female role models. Male role models are thus more common (for male and female students) and described as more admirable. The results point to the persistence of 'gendered ways of thinking' that subtly shape medical students. Gendering role models is disadvantageous to female doctors in several ways, so the results have implications for women's career paths and opportunities. The results can thus form a basis for discussing and teaching the importance of gender in role modelling and in medical education in general.


Conservation physiology of marine fishes: state of the art and prospects for policy.
The state of the art of research on the environmental physiology of marine fishes is reviewed from the perspective of how it can contribute to conservation of biodiversity and fishery resources. A major constraint to application of physiological knowledge for conservation of marine fishes is the limited knowledge base; international collaboration is needed to study the environmental physiology of a wider range of species. Multifactorial field and laboratory studies on biomarkers hold promise to relate ecophysiology directly to habitat quality and population status. The 'Fry paradigm' could have broad applications for conservation physiology research if it provides a universal mechanism to link physiological function with ecological performance and population dynamics of fishes, through effects of abiotic conditions on aerobic metabolic scope. The available data indicate, however, that the paradigm is not universal, so further research is required on a wide diversity of species. Fish physiologists should interact closely with researchers developing ecological models, in order to investigate how integrating physiological information improves confidence in projecting effects of global change; for example, with mechanistic models that define habitat suitability based upon potential for aerobic scope or outputs of a dynamic energy budget. One major challenge to upscaling from physiology of individuals to the level of species and communities is incorporating intraspecific variation, which could be a crucial component of species' resilience to global change. Understanding what fishes do in the wild is also a challenge, but techniques of biotelemetry and biologging are providing novel information towards effective conservation. Overall, fish physiologists must strive to render research outputs more applicable to management and decision-making. There are various potential avenues for information flow, in the shorter term directly through biomarker studies and in the longer term by collaborating with modellers and fishery biologists.


Effects of N-acetoxy-2-acetylaminofluorene and N'-nitro-N-nitrosoguanidine on nuclear DNA synthesis in rat liver.
A system for the study of DNA synthesis in isolated nuclei is described for sham and regenerating rat liver. The system has been characterized with respect to nuclear purity, conditions for optimum incorporation of [5-methyl-3H]thymidine triphosphate, time course of incorporation, product analysis by neutral and alkaline sucrose gradients, and the effect of exogenously added DNA. No difference in the basal level of activity was detected between nuclei prepared from normal or regenerating liver when isolated 24 hr after operation. However, exogenous activated DNA preferentially stimulated [5-methyl-3H]thymidine triphosphate incorporation in nuclei from regenerating liver. Activated DNA caused to react with the carcinogen N-acetoxy-2-acetylaminofluorene was a less effective primer-template in this system and decreased in a dose-dependent fashion the incorporation of [5-methyl-3H]thymidine triphosphate to below basal levels in nuclei from both normal and regenerating liver. The carcinogen N-methyl-N'-nitro-N-nitrosoguanidine had no inhibitory effect when assayed in this fashion.


Clinical significance of nephrotoxicity in patients treated with amphotericin B for suspected or proven aspergillosis.
The records of 239 immunosuppressed patients receiving amphotericin B for suspected or proven aspergillosis were reviewed to determine rates of nephrotoxicity, dialysis, and fatality. The mean and median durations of treatment were 20.4 and 15.0 days, respectively. The creatinine level doubled in 53% of patients and exceeded 2.5 mg/dL in 29%; 14.5% underwent dialysis; and 60% died. A multivariate Cox proportional hazards analysis showed that patients whose creatinine level exceeded 2.5 mg/dL (hazard ratio [HR], 42.02; P<.001), allogeneic bone marrow transplantation (BMT) patients (HR, 6.34; P<. 001), and autologous BMT patients (HR, 5.06; P=.024) were at greatest risk for requiring hemodialysis. Use of hemodialysis (HR, 3. 089; P<.001), duration of amphotericin B use (HR, 1.03 per day; P=. 015), and use of nephrotoxic agents (HR, 1.96; P=.017) were associated with greater risk of death, whereas patients undergoing solid organ transplantation were at lowest risk (HR, 0.46; P=.002). These data indicate that elevated creatinine levels during amphotericin B treatment are associated with a substantial risk for hemodialysis and a higher mortality rate, but the risks vary in different patient groups.


Inside Honeybee Hives: Impact of Natural Propolis on the Ectoparasitic Mite Varroa destructor and Viruses.
Social immunity is a key factor for honeybee health, including behavioral defense strategies such as the collective use of antimicrobial plant resins (propolis). While laboratory data repeatedly show significant propolis effects, field data are scarce, especially at the colony level. Here, we investigated whether propolis, as naturally deposited in the nests, can protect honeybees against ectoparasitic mites Varroa destructor and associated viruses, which are currently considered the most serious biological threat to European honeybee subspecies, Apis mellifera, globally. Propolis intake of 10 field colonies was manipulated by either reducing or adding freshly collected propolis. Mite infestations, titers of deformed wing virus (DWV) and sacbrood virus (SBV), resin intake, as well as colony strength were recorded monthly from July to September 2013. We additionally examined the effect of raw propolis volatiles on mite survival in laboratory assays. Our results showed no significant effects of adding or removing propolis on mite survival and infestation levels. However, in relation to V. destructor, DWV titers increased significantly less in colonies with added propolis than in propolis-removed colonies, whereas SBV titers were similar. Colonies with added propolis were also significantly stronger than propolis-removed colonies. These findings indicate that propolis may interfere with the dynamics of V. destructor-transmitted viruses, thereby further emphasizing the importance of propolis for honeybee health.


Community-oriented medical education: bringing perspectives to curriculum planners in Damascus University.
The varying health needs in Syria because of the trend of increasing communicable and noncommunicable diseases necessitate new curricula for all health professions schools in which community health needs, socio-cultural aspects of health and disease can be emphasized. There is a need to produce more primary level healthcare professionals who are trained to apply the principles, policies and strategies of the World Health Organization and achieve better health for all. A new perspective in the Faculty of Dentistry in Damascus University has been suggested and is presented here. Graduates generally are not well prepared to provide primary level healthcare in the community. Community-oriented medical education (COME) can produce health-oriented professionals who are equipped with broad skills and able to work for health promotion, disease prevention, and cure. Health orientation is one of the most radical features of COME, wherein the curriculum is appropriate to learners' future practice in the community. Community orientation enables students to become more people focused so that they can work towards people's self-empowerment, change people's attitudes and behaviors, and improve their self-awareness and esteem. This viewpoint addresses the importance of redesigning the dental curriculum and the need to implement COME in Damascus University. It is proposed as an example of changes needed in all health professions schools in Syria. The call to redesign the curricula to serve the health needs of the Syrian population will be difficult to achieve but is vital. Improving our understanding of the concept of COME and having all sectors of government and society commit to it will make the transition possible and will make the COME a reality.


An ecological framework to understand the efficacy of fecal microbiota transplantation.
Human gut microbiota plays critical roles in physiology and disease. Our understanding of ecological principles that govern the dynamics and resilience of this highly complex ecosystem remains rudimentary. This knowledge gap becomes more problematic as new approaches to modifying this ecosystem, such as fecal microbiota transplantation (FMT), are being developed as therapeutic interventions. Here we present an ecological framework to understand the efficacy of FMT in treating conditions associated with a disrupted gut microbiota, using the recurrent Clostridioides difficile infection as a prototype disease. This framework predicts several key factors that determine the efficacy of FMT. Moreover, it offers an efficient algorithm for the rational design of personalized probiotic cocktails to decolonize pathogens. We analyze data from both preclinical mouse experiments and a clinical trial of FMT to validate our theoretical framework. The presented results significantly improve our understanding of the ecological principles of FMT and have a positive translational impact on the rational design of general microbiota-based therapeutics.


Cluster perturbation theory. II. Excitation energies for a coupled cluster target state.
In cluster perturbation (CP) theory, we consider a target excitation space relative to a Hartree-Fock state and partition the target excitation space into a parent excitation space and an auxiliary excitation space. The zeroth-order state is in CP theory a coupled cluster (CC) state in the parent excitation space, and the target state is a CC state in the target excitation space. In this paper, we derive CP series for excitation energies in orders of the CC parent-state similarity-transformed fluctuation potential where the zeroth-order term in the series is an excitation energy for the CC parent state response eigenvalue equation and where the series formally converge to an excitation energy for the CC target state response eigenvalue equation. We give explicit expressions for the lowest-order excitation energy corrections. We also report calculations for CP excitation energy series for various parent and target excitation spaces and examine how well the lower-order corrections can reproduce the total excitation energies. Considering the fast local convergence we have observed for the CP excitation energy series, it becomes computationally attractive to use low-order corrections in CP series to obtain excitation energies of CC target state quality. For the CPS(D-n) series, the first-order correction vanishes, the second-order correction becomes the CIS(D) model, and for the CPS(D-3) model, our calculations suggest that excitation energies of CCSD quality are obtained. The numerical results also suggest that a similar behavior can be seen for the low-order excitation energy corrections for CP series where the parent state contains more than a singles excitation space, e.g., for the CPSD(T) model. We therefore expect the low-order excitation energy corrections in CP series soon to become state-of-the-art models for determining excitation energies of CC target state quality.


The effect of fluid and carbohydrate feedings during intermittent cycling exercise.
The purpose of this study was to determine the effect of ingesting water or carbohydrates solutions on physiologic function and performance during 1.6 h of intermittent cycling exercise in the heat (dry bulb temperature = 33 degrees C). Thirteen male subjects (24 to 35 yr) completed four separate rides. Each ride consisted of intermittent steady-state cycling (at 55 and 65% VO2max) interspersed with five rest periods. A timed 480 revolution cycling task completed each experimental session. During each rest period, subjects consumed 2 ml.kg-1 body weight of water placebo or solutions of 5% glucose polymer, 6% sucrose/glucose, or 7% glucose polymer/fructose. Beverages were administered in double-blind, counter-balanced order. No differences were observed among subjects in response to beverage treatments for changes in plasma concentrations of total proteins, sodium, potassium, lactate, or in osmolality, percent change in plasma volume, heart rate, oxygen uptake, respiratory exchange ratio, rating of perceived exertion, sweat rate, rectal temperature, or mean skin temperature. Compared to water placebo, the carbohydrate treatments produced higher plasma glucose values following 1 h cycling (P less than 0.01). Mean (SD) times for the 480 revolution cycling task: water placebo = 432 (43) s; glucose polymer = 401 (52) s; *sucrose/glucose = 384 (39) s; and *glucose polymer/fructose = 375 (30) s, where = P less than 0.001 compared to water placebo. Physiologic function was similarly maintained during exercise by all beverage treatments, while ingestion of sucrose/glucose and glucose polymer/fructose resulted in improved end-exercise cycling performance.


Enhanced T-Cell Maturation and Monocyte Aggregation Are Features of Cellular Inflammation in Human T-Lymphotropic Virus Type 1-Associated Myelopathy.
Human T-lymphotropic virus type 1 (HTLV-1)-associated myelopathy (HAM) is an inflammatory condition characterized by severe disability and high levels of infected white blood cells. The circulating cellular inflammatory changes that distinguish this condition from asymptomatic infection are not well understood. To investigate the immune characteristics of individuals with low or high HTLV-1 proviral load (pVL), symptomatic disease, and the impact of immunosuppressive therapy, 38 women living with HTLV-1 infection, at a median age of 59 (52-68) years, were studied. Nineteen were asymptomatic carriers with low or high pVL; 19 were diagnosed with HAM, with 10 receiving anti-inflammatory therapy. Peripheral blood mononuclear cells were stained and analyzed for frequency distribution and activation of innate and adaptive immune cell subsets using multiparameter flow cytometry. Inflation of the CD4:CD8 ratio (>2) was observed among all groups irrespective of pVL. The frequency of naive CD4+ T cells correlated inversely with HTLV-1 pVL (rs = -0.344, P = .026). Mature T effector memory TEM CD4+ T cells were expanded in patients with untreated HAM compared with asymptomatic carriers (P < .001) but less so in those on therapy. High levels of exhausted (PD-1+) and senescent (CD28null) CD4+ and CD8+ T cells were observed in all individuals, particularly in those with HAM, while monocytes showed increased aggregation and CD14+CD56- monocytes were less frequent. CD4:CD8 ratio inflation is a feature of HTLV-1 infection, whereas enhanced CD4+ T cell maturation and monocyte aggregation are features of HAM, reflecting widespread inflammatory change, which may be detectable presymptomatically and be amenable to anti-inflammatory treatment.


Decreased cesarean birth rates and improved perinatal outcome: a seven-year study.
This study examined the decrease in cesarean section rates in relation to perinatal mortality between 1987 and 1993 at the primary referral hospital in north Jordan. Most of the population is at high risk and of low socioeconomic status. The cesarean section rate decreased from 15.5 percent in 1987 to 8.7 percent in 1993, and has remained at this low rate. During the same period the perinatal mortality dropped from 52 to 20.9 deaths per 1000 live births. These results do not include perinatal morbidity. The successful reduction of the cesarean section rate is attributed to active management of labor, trial of labor for women with a previous cesarean birth, and vaginal breech delivery in selected women. We conclude that the rate of cesarean delivery can be safely reduced in a developing country without adverse effects on birth outcomes.


Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study.
Although transcranial magnetic stimulation (TMS) can be an effective acute antidepressant treatment, few studies systematically examine persistence of benefit. We assessed the durability of antidepressant effect after acute response to TMS in patients with major depressive disorder (MDD) using protocol-specified maintenance antidepressant monotherapy. Three hundred one patients were randomly assigned to active or sham TMS in a 6-week, controlled trial. Nonresponders could enroll in a second, 6-week, open-label study. Patients who met criteria for partial response (i.e., >25% decrease from the baseline HAMD 17) during either the sham-controlled or open-label study (n = 142) were tapered off TMS over 3 weeks, while simultaneously starting maintenance antidepressant monotherapy. Patients were then followed for 24 weeks in a naturalistic follow-up study examining the long-term durability of TMS. During this durability study, TMS was readministered if patients met prespecified criteria for symptom worsening (i.e., a change of at least one point on the CGI-S scale for 2 consecutive weeks). Relapse was the primary outcome measure. Ten of 99 (10%; Kaplan-Meier survival estimate = 12.9%) patients relapsed. Thirty-eight (38.4%) patients met criteria for symptom worsening and 32/38 (84.2%) reachieved symptomatic benefit with adjunctive TMS. Safety and tolerability were similar to acute TMS monotherapy. These initial data suggest that the therapeutic effects of TMS are durable and that TMS may be successfully used as an intermittent rescue strategy to preclude impending relapse.


Long-term echocardiographic changes in left ventricular size and function following surgery for severe mitral regurgitation.
Chronic mitral regurgitation (MR) results in a state of chronic left ventricular (LV) volume overload, resulting in compensatory dilatation. Mitral valve (MV) surgery for regurgitation reduces LV preload but increases LV afterload. Few data are available documenting subsequent changes in LV size and function over time following MV surgery for severe regurgitation in unselected populations. Pre- and postoperative echocardiograms (n=454) acquired from 108 consecutive patients with chronic MR who underwent MV surgery were analyzed. LV diastolic diameter was 4 mm smaller on postoperative compared to preoperative exams, whereas LV fractional shortening (FS) was unchanged. Linear regression analysis showed no change in LV diastolic diameter over time postoperatively, whereas LV FS increased over time following surgery. Improvement in LV FS occurred at an average rate of 1.6% per year (95% CI, 0.2-2.9). Subgroups were small, but the same secular trends were generally noted in groups with or without coronary artery bypass graft surgery (CABGS) and in those with or without mitral leaflet disease. Following MV surgery for MR, LV diastolic diameter reduces by 2 mm at the time of surgery, but then remains stable over time. Improvement in LV function over time postoperatively was only seen in those without concomitant CABGS, possibly related to less baseline myocardial scarring in this group.


AGDF-Net: Learning Domain Generalizable Depth Features with Adaptive Guidance Fusion.
Cross-domain generalizable depth estimation aims to estimate the depth of target domains (i.e., real-world) using models trained on the source domains (i.e., synthetic). Previous methods mainly use additional real-world domain datasets to extract depth specific information for cross-domain generalizable depth estimation. Unfortunately, due to the large domain gap, adequate depth specific information is hard to obtain and interference is difficult to remove, which limits the performance. To relieve these problems, we propose a domain generalizable feature extraction network with adaptive guidance fusion (AGDF-Net) to fully acquire essential features for depth estimation at multi-scale feature levels. Specifically, our AGDF-Net first separates the image into initial depth and weak-related depth components with reconstruction and contrary losses. Subsequently, an adaptive guidance fusion module is designed to sufficiently intensify the initial depth features for domain generalizable intensified depth features acquisition. Finally, taking intensified depth features as input, an arbitrary depth estimation network can be used for real-world depth estimation. Using only synthetic datasets, our AGDF-Net can be applied to various real-world datasets (i.e., KITTI, NYUDv2, NuScenes, DrivingStereo and CityScapes) with state-of-the-art performances. Furthermore, experiments with a small amount of real-world data in a semi-supervised setting also demonstrate the superiority of AGDF-Net over state-of-the-art approaches.


MALT1 Is a Targetable Driver of Epithelial-to-Mesenchymal Transition in Claudin-Low, Triple-Negative Breast Cancer.
MALT1 is the effector protein of the CARMA/Bcl10/MALT1 (CBM) signalosome, a multiprotein complex that drives pro-inflammatory signaling pathways downstream of a diverse set of receptors. Although CBM activity is best known for its role in immune cells, emerging evidence suggests that it plays a key role in the pathogenesis of solid tumors, where it can be activated by selected G protein-coupled receptors (GPCR). Here, we demonstrated that overexpression of GPCRs implicated in breast cancer pathogenesis, specifically the receptors for Angiotensin II and thrombin (AT1R and PAR1), drove a strong epithelial-to-mesenchymal transition (EMT) program in breast cancer cells that is characteristic of claudin-low, triple-negative breast cancer (TNBC). In concert, MALT1 was activated in these cells and contributed to the dramatic EMT phenotypic changes through regulation of master EMT transcription factors including Snail and ZEB1. Importantly, blocking MALT1 signaling, through either siRNA-mediated depletion of MALT1 protein or pharmacologic inhibition of its activity, was effective at partially reversing the molecular and phenotypic indicators of EMT. Treatment of mice with mepazine, a pharmacologic MALT1 inhibitor, reduced growth of PAR1+, MDA-MB-231 xenografts and had an even more dramatic effect in reducing the burden of metastatic disease. These findings highlight MALT1 as an attractive therapeutic target for claudin-low TNBCs harboring overexpression of one or more selected GPCRs. This study nominates a GPCR/MALT1 signaling axis as a pathway that can be pharmaceutically targeted to abrogate EMT and metastatic progression in TNBC, an aggressive form of breast cancer that currently lacks targeted therapies.


Long-term passive acoustic recordings track the changing distribution of North Atlantic right whales (Eubalaena glacialis) from 2004 to 2014.
Given new distribution patterns of the endangered North Atlantic right whale (NARW; Eubalaena glacialis) population in recent years, an improved understanding of spatio-temporal movements are imperative for the conservation of this species. While so far visual data have provided most information on NARW movements, passive acoustic monitoring (PAM) was used in this study in order to better capture year-round NARW presence. This project used PAM data from 2004 to 2014 collected by 19 organizations throughout the western North Atlantic Ocean. Overall, data from 324 recorders (35,600 days) were processed and analyzed using a classification and detection system. Results highlight almost year-round habitat use of the western North Atlantic Ocean, with a decrease in detections in waters off Cape Hatteras, North Carolina in summer and fall. Data collected post 2010 showed an increased NARW presence in the mid-Atlantic region and a simultaneous decrease in the northern Gulf of Maine. In addition, NARWs were widely distributed across most regions throughout winter months. This study demonstrates that a large-scale analysis of PAM data provides significant value to understanding and tracking shifts in large whale movements over long time scales.


Integrins can collaborate with growth factors for phosphorylation of receptor tyrosine kinases and MAP kinase activation: roles of integrin aggregation and occupancy of receptors.
Integrins mediate cell adhesion, migration, and a variety of signal transduction events. These integrin actions can overlap or even synergize with those of growth factors. We examined for mechanisms of collaboration or synergy between integrins and growth factors involving MAP kinases, which regulate many cellular functions. In cooperation with integrins, the growth factors EGF, PDGF-BB, and basic FGF each produced a marked, transient activation of the ERK (extracellular signal-regulated kinase) class of MAP kinase, but only if the integrins were both aggregated and occupied by ligand. Transmembrane accumulation of total tyrosine-phosphorylated proteins, as well as nonsynergistic MAP kinase activation, could be induced by simple integrin aggregation, whereas enhanced transient accumulation of the EGF-receptor substrate eps8 required integrin aggregation and occupancy, as well as EGF treatment. Each type of growth factor receptor was itself induced to aggregate transiently by integrin ligand-coated beads in a process requiring both aggregation and occupancy of integrin receptors, but not the presence of growth factor ligand. Synergism was also observed between integrins and growth factors for triggering tyrosine phosphorylation of EGF, PDGF, and FGF receptors. This collaborative response also required both integrin aggregation and occupancy. These studies identify mechanisms in the signal transduction response to integrins and growth factors that require various combinations of integrin aggregation and ligands for integrin or growth factor receptors, providing opportunities for collaboration between these major regulatory systems.


Real-time electron-holographic interference microscopy with a liquid-crystal spatial light modulator.
An electron-holographic interference microscope that produces a time-sequential interference micrograph at a TV rate is developed. In this system, the electron off-axis hologram detected with a TV camera is transferred to a liquid-crystal spatial light modulator as a video signal. The liquid-crystal spatial light modulator can function as a thin amplitude hologram or a thin phase hologram. Time-sequential interference micrograph is obtained at a TV rate by superimposition of a plane reference wave onto the reconstructed object wave. Experimental results for observing a dynamic domain-wall motion in thin Permalloy film are demonstrated.


A time series approach for evaluating intra-city heat-related mortality.
Extreme heat is a leading cause of weather-related mortality. Most research has considered the aggregate response of the populations of large metropolitan areas, but the focus of heat-related mortality and morbidity investigations is shifting towards a more fine-scale approach in which impacts are measured in smaller units such as postal codes. However, most existing statistical techniques to model the relationship between temperature and mortality cannot be directly applied to the intra-city scale because small sample sizes inhibit proper modelling of seasonality and long-term trends. Here we propose a time series technique based on local-scale mortality observations that can provide more reliable information about vulnerability within metropolitan areas. The method combines a generalised additive model with direct standardisation to account for changing death rates in intra-city zones. We apply the method to a 26-year time series of postal code-referenced mortality data from Philadelphia County, USA, where we find that heat-related mortality is unevenly spatially distributed. Fifteen of 46 postal codes are associated with significantly increased mortality on extreme heat days, most of which are located in the central and western portions of the county. In some cases the local death rate is more than double the county average. Identification of high-risk areas can enable targeted public health intervention and mitigation strategies.


Efficacy of the Marquette Method of natural family planning.
To determine the effectiveness of the Marquette Method (MM) of natural family planning (NFP) as a method of avoiding pregnancy. This was a 12-month retrospective evaluation of the MM system of NFP. Two hundred and four women (mean age, 28.6 years) and their male partners (mean age, 30.3 years) who sought to learn a method for avoiding pregnancy with the MM from four clinical sites were taught to track their fertility by self-observation of cervical mucus, by use of an electronic monitor that measures urinary levels of estrone-3-glucuronide and luteinizing hormone, and by use of basal body temperature. All unintended pregnancies were evaluated by professional nurses as to whether they were intended or not. Pregnancy rates over 12 months of use were determined by survival analysis. There were a total of 12 unintended pregnancies, only 1 with correct use. The 12-month "correct use" pregnancy rate was 0.6 (i.e., 99.4% effective) and the "typical use" (total pregnancy rate) was 10.6 (i.e., 89.4% effective) per 100 users. When used correctly, the MM system of NFP is an effective means of avoiding pregnancy. The efficacy of the MM system includes proper preparation of the professional nurse NFP teachers.


Glycosylation of procathepsin L does not account for species molecular-mass differences and is not required for proteolytic activity.
Cathepsin L is a major lysosomal cysteine proteinase in mouse and human cells. Despite similar predicted molecular masses, procathepsin L in these two species migrates on SDS/polyacrylamide gels with apparent molecular masses of 39 kDa and 42 kDa respectively. To determine if glycosylation differences account for this discrepancy, and to ascertain whether glycosylation is essential for enzymic activity, mouse and human procathepsins L were expressed at high concentrations in mouse NIH 3T3 cells or in human A431 cells after DNA-mediated transfection of cloned DNAs for these enzymes. In pulse-chase studies, human procathepsin L transfectants synthesized and secreted large amounts of enzymically active 42 kDa proenzyme and processed it into 34 kDa and 26 kDa intracellular peptides, a pattern of secretion and processing similar to that seen with endogenous or transfected mouse procathepsin L. Both translation of cloned procathepsin L cDNAs in vitro and Endoglycosidase H treatment of 39 kDa mouse and 42 kDa human procathepsin L resulted in non-glycosylated proteins 2 kDa lower in molecular mass than the untreated proteins for both species. This suggests that glycosylation differences are not responsible for the molecular-mass disparity between the two species. Moreover, Endoglycosidase H-treated mouse enzyme retained full proteolytic activity, indicating that glycosylation of cathepsin L is not essential for enzymic function.


Psychosocial functioning among regular cannabis users with and without cannabis use disorder.
In the United States, cannabis accessibility has continued to rise as the perception of its harmfulness has decreased. Only about 30% of regular cannabis users develop cannabis use disorder (CUD), but it is unclear if individuals who use cannabis regularly without ever developing CUD experience notable psychosocial impairment across the lifespan. Therefore, psychosocial functioning was compared across regular cannabis users with or without CUD and a non-user control group during adolescence (age 17; early risk) and young adulthood (ages 18-25; peak CUD prevalence). Weekly cannabis users with CUD (n = 311), weekly users without CUD (n = 111), and non-users (n = 996) were identified in the Minnesota Twin Family Study. Groups were compared on alcohol and illicit drug use, psychiatric problems, personality, and social functioning at age 17 and from ages 18 to 25. Self-reported cannabis use and problem use were independently verified using co-twin informant report. In both adolescence and young adulthood, non-CUD users reported significantly higher levels of substance use problems and externalizing behaviors than non-users, but lower levels than CUD users. High agreement between self- and co-twin informant reports confirmed the validity of self-reported cannabis use problems. Even in the absence of CUD, regular cannabis use was associated with psychosocial impairment in adolescence and young adulthood. However, regular users with CUD endorsed especially high psychiatric comorbidity and psychosocial impairment. The need for early prevention and intervention - regardless of CUD status - was highlighted by the presence of these patterns in adolescence.


Association of Lbc Rho guanine nucleotide exchange factor with alpha-catenin-related protein, alpha-catulin/CTNNAL1, supports serum response factor activation.
The Rho GTPase signaling pathway is required for actin cytoskeletal organization and serum response factor-dependent gene transcription. Lbc is a Rho-specific guanine nucleotide exchange factor that contains a modulatory C-terminal region. To elucidate Lbc regulatory mechanism(s), a yeast two-hybrid screen for proteins that interact with the Lbc C-terminal region was carried out, resulting in multiple isolation of cDNAs encoding the same 734-amino acid Lbc interacting protein. The Lbc interacting protein has homology with the alpha-catenin cell adhesion component and is identical to the alpha-catenin-like alpha-catulin protein of unknown function. The human alpha-catulin gene (CTNNAL1) maps to 9q31-32. Here we identify the predicted endogenous alpha-catulin product, document alpha-catulin and Lbc co-expression in multiple human cell lines, and show alpha-catulin and Lbc subcellular co-fractionation and intracellular localization. The required regions for Lbc and alpha-catulin interaction were mapped, and complex formation between Lbc and alpha-catulin in mammalian cells was detected. Functionally, alpha-catulin co-expression leads to increased Lbc-induced serum response factor activation in vivo as measured by a transcriptional reporter assay. Furthermore, alpha-catulin co-expression enhances Lbc-induced GTP-Rho formation in vivo. These results support the concept that the recently identified alpha-catulin protein may modulate Rho pathway signaling in vivo by providing a scaffold for the Lbc Rho guanine nucleotide exchange factor.


Medicare and Medicaid programs: hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; Hospital Value-Based Purchasing Program; organ procurement organizations; quality improvement organizations; Electronic Health Records (EHR) Incentive Program; provider reimbursement determinations and appeals. Final rule with comment period and final rules.
: This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2014 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Hospital Value-Based Purchasing (VBP) Program. In the final rules in this document, we are finalizing changes to the conditions for coverage (CfCs) for organ procurement organizations (OPOs); revisions to the Quality Improvement Organization (QIO) regulations; changes to the Medicare fee-for-service Electronic Health Record (EHR) Incentive Program; and changes relating to provider reimbursement determinations and appeals.


Fluoxetine efficacy in social phobia.
To determine the efficacy of fluoxetine in the treatment of social phobia, fluoxetine was administered to 16 patients with a primary DSM-III-R diagnosis of social phobia in a 12-week, open, clinical trial. Treatment began at 20 mg of fluoxetine daily and was increased according to clinical response and side effects every 4 weeks. Patients completed self-report measures of anxiety and depression at baseline and at Weeks 4, 8, and 12. These included the Beck Depression Inventory, the Social Avoidance and Distress Scale, the Fear of Negative Evaluation Scale, the State-Trait Anxiety Inventory, the Fear Questionnaire, the Social Anxiety Thoughts Questionnaire, and the Social Adjustment Scale-Self-Report. Clinicians completed a Clinical Global Improvement Scale. Thirteen of the 16 patients completed the trial. Three patients (18.8%) were unable to complete the trial due to adverse side effects. Of the 13 (81.2%) remaining patients, 10 were considered to be responders and 3 were considered to be nonresponders. Measures of social anxiety and phobic avoidance showed a significant improvement from baseline to endpoint, achieving a significance of p < .005. Responders to fluoxetine were more likely to have been older at onset of the social phobic symptoms and had a shorter duration of illness. These findings suggest that fluoxetine may be effective in the treatment of social phobia. Double-blind studies will be required to further investigate these findings.


Potential for Monitoring Gut Microbiota for Diagnosing Infections and Graft-versus-Host Disease in Cancer and Stem Cell Transplant Patients.
Gut microbiota, the collective community of microorganisms inhabiting the intestine, have been shown to provide many beneficial functions for the host. Recent advances in next-generation sequencing and advanced molecular biology approaches have allowed researchers to identify gut microbiota signatures associated with disease processes and, in some cases, establish causality and elucidate underlying mechanisms. This report reviews 3 commonly used methods for studying the gut microbiota and microbiome (the collective genomes of the gut microorganisms): 16S rRNA gene sequencing, bacterial group or species-specific quantitative polymerase chain reaction (qPCR), and metagenomic shotgun sequencing (MSS). The technical approaches and resources needed for each approach are outlined, and advantages and disadvantages for each approach are summarized. The findings regarding the role of the gut microbiota in the health of patients with cancer and stem cell transplant (SCT) patients (specifically in modulating the development of gut-derived bacterial infections and a posttransplant immune-mediated complication known as graft-vs-host-disease) are reviewed. Finally, there is discussion of the potential viability of these approaches in the actual clinical treatment of cancer and SCT patients. Advances in next-generation sequencing have revolutionized our understanding of the importance of the gut microbiome to human health. Both 16S rRNA gene sequencing and MSS are currently too labor-intensive or computationally burdensome to incorporate into real-time clinical monitoring of gut microbiomes. Yet, the lessons learned from these technologies could be adapted to currently used methods (e.g., qPCR) that could then be rigorously tested in the clinical care of these patients.


Influence of prostaglandins E2 and F2 alpha on passage pressure across the uterotubal junction and isthmus in the rat.
The influence of prostaglandins E2 and F2 alpha on passage pressure across the uterotubal junction (UTJ) and isthmus were studied in rats that were either in the pro-oestrus, oestrus, metoestrus or dioestrus phases. Effects of these prostaglandins were also investigated in rats that had been either ovariectomized and treated with oestradiol or medroxiprogesterone acetate, or only ovariectomized. In each rat, the left UTJ was surgically resected and the isthmus anastomosed to the uterine horn, whereas the right UTJ was left untouched. The passage pressures across the left isthmus and the right UTJ were measured before and after prostaglandin treatment. The pressures obtained in the UTJ in the oestrus phase and oestrogen-treated ovariectomized animals were lower than those registered in the remaining groups. Prostaglandin E2 decreased the pressures when compared with pre-treatment measures in all groups. Significantly higher pressures were registered across the UTJ in prostaglandin F2 alpha than in E2 treatment, with these higher pressures being similar to pre-treatment pressures. Both hormonal changes throughout the oestrous cycle and prostaglandin E2 treatment had a similar influence on the passage pressure across the isthmus, as that described for UTJ, but with lower values. The results indicate that prostaglandin E2 decreases the passage pressure across both UTJ and isthmus and can have an influence on the regulation of transport across these 2 areas.


Contraceptive Challenges in Women With Common Medical Conditions.
Women have the opportunity to meet personal contraceptive goals with convenient, highly reliable, and easily reversible methods. Long-acting reversible contraception represents an increasingly popular option for most women throughout the reproductive lifespan. Nonetheless, many women and their health care providers are challenged by coexisting medical issues. We aim to help clinicians individualize contraception and use shared decision-making to enhance patient satisfaction and continuation with their method.


Vertebrate DNA in fecal samples from bonobos and gorillas: evidence for meat consumption or artefact?
Deciphering the behavioral repertoire of great apes is a challenge for several reasons. First, due to their elusive behavior in dense forest environments, great ape populations are often difficult to observe. Second, members of the genus Pan are known to display a great variety in their behavioral repertoire; thus, observations from one population are not necessarily representative for other populations. For example, bonobos (Pan paniscus) are generally believed to consume almost no vertebrate prey. However, recent observations show that at least some bonobo populations may consume vertebrate prey more commonly than previously believed. We investigated the extent of their meat consumption using PCR amplification of vertebrate mitochondrial DNA (mtDNA) segments from DNA extracted from bonobo feces. As a control we also attempted PCR amplifications from gorilla feces, a species assumed to be strictly herbivorous. We found evidence for consumption of a variety of mammalian species in about 16% of the samples investigated. Moreover, 40% of the positive DNA amplifications originated from arboreal monkeys. However, we also found duiker and monkey mtDNA in the gorilla feces, albeit in somewhat lower percentages. Notably, the DNA sequences isolated from the two ape species fit best to the species living in the respective regions. This result suggests that the sequences are of regional origin and do not represent laboratory contaminants. Our results allow at least three possible and mutually not exclusive conclusions. First, all results may represent contamination of the feces by vertebrate DNA from the local environment. Thus, studies investigating a species' diet from feces DNA may be unreliable due to the low copy number of DNA originating from diet items. Second, there is some inherent difference between the bonobo and gorilla feces, with only the later ones being contaminated. Third, similar to bonobos, for which the consumption of monkeys has only recently been documented, the gorilla population investigated (for which very little observational data are as yet available) may occasionally consume small vertebrates. Although the last explanation is speculative, it should not be discarded a-priori given that observational studies continue to unravel new behaviors in great ape species.


Different types of retinal inhibition have distinct neurotransmitter release properties.
Neurotransmitter release varies between neurons due to differences in presynaptic mechanisms such as Ca(2+) sensitivity and timing. Retinal rod bipolar cells respond to brief dim illumination with prolonged glutamate release that is tuned by the differential release of GABA and glycine from amacrine cells in the inner retina. To test if differences among types of GABA and glycine release are due to inherent amacrine cell release properties, we directly activated amacrine cell neurotransmitter release by electrical stimulation. We found that the timing of electrically evoked inhibitory currents was inherently slow and that the timecourse of inhibition from slowest to fastest was GABAC receptors > glycine receptors > GABAA receptors. Deconvolution analysis showed that the distinct timing was due to differences in prolonged GABA and glycine release from amacrine cells. The timecourses of slow glycine release and GABA release onto GABAC receptors were reduced by Ca(2+) buffering with EGTA-AM and BAPTA-AM, but faster GABA release on GABAA receptors was not, suggesting that release onto GABAA receptors is tightly coupled to Ca(2+). The differential timing of GABA release was detected from spiking amacrine cells and not nonspiking A17 amacrine cells that form a reciprocal synapse with rod bipolar cells. Our results indicate that release from amacrine cells is inherently asynchronous and that the source of nonreciprocal rod bipolar cell inhibition differs between GABA receptors. The slow, differential timecourse of inhibition may be a mechanism to match the prolonged rod bipolar cell glutamate release and provide a way to temporally tune information across retinal pathways.


Hypothesis generative head-to-head study comparing efficacy of afatinib and osimertinib based on immunological biomarkers in Japanese NSCLC patients with EGFR mutations (Heat on Beat study).
In the FLAURA trial, superiority of osimertinib over the standard of care (SOC) was not demonstrated in Asian patients; SOC seemed favorable among Japanese patients (hazard ratio 1.39, 95% confidence interval 0.82-2.33). Three reasons are suggested: since rechallenge with epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) is covered by health insurance in Japan, EGFR-TKI rechallenge rate was higher in SOC than in the osimertinib group, which resulted in a long-term sequential administration of EGFR-TKIs; treatment discontinuation rate was high in the osimertinib group due to adverse events such as interstitial pneumonia among Japanese patients. EGFR-TKIs enhance tumor antigen-specific cytotoxicity of T cells, especially first- and second-generation EGFR-TKIs, which are more active against various cells with wild-type EGFR, including regulatory T cells. Consequently, subsequent immune checkpoint inhibitor therapy seemed more promising in the SOC group. Therefore, optimal first-line EGFR-TKI for EGFR-mutant advanced lung cancer may not have been identified in Japanese patients. The Heat on Beat study is a randomized, open-label, multicenter, phase II study to compare OS between initial treatment with afatinib and osimertinib in treatment-naïve patients with advanced or recurrent EGFR-mutant NSCLC. Exploration of immunomonitoring through peripheral blood mononuclear cells will also be performed, before, during, and after treatment. Treatment-naïve EGFR mutation-positive non-small cell lung cancer (NSCLC) patients (N = 100) will be randomized to two groups in a 1:1 ratio. The co-primary endpoints are 3-year survival rate and characterization of immune environment associated with response to afatinib, osimertinib, or immune checkpoint inhibitors. Enrollment will start in May 2020 at 28 sites in Japan and continue for 1 year, with 3-year follow-up. Because there is no clinical trial comparing second- with third-generation EGFR-TKI for advanced EGFR-mutant NSCLC, our study would provide a major impact on clinical practice. Trial registration Japan Registry of Clinical Trials, jRCTs031190221, registered date: 25 February 2020, https://jrct.niph.go.jp/en-latest-detail/jRCTs031190221.


Spatial physical activity patterns among primary school children living in neighbourhoods of varying socioeconomic status: a cross-sectional study using accelerometry and Global Positioning System.
Neighbourhood socioeconomic status (SES) has been shown to be related to health status and overweight independent of individual SES. However, results about the association between neighbourhood SES and physical activity among children are ambiguous. Particularly, it is unknown how socioeconomic factors influence the spatial context of children's moderate-vigorous physical activity (MVPA) and sedentary behaviour (SB). This study aimed to investigate by means of Global Positioning System (GPS) and accelerometry whether locations where children engage in MVPA and SB differ by neighbourhood SES. Participants included 83 children aged 7-9 from nine public schools located in a low- and high-SES area in Zurich, Switzerland. Children wore an accelerometer and GPS sensor for seven consecutive days. Time-matched accelerometer and GPS data was mapped with a geographic information system and each data point assigned to one of eight activity settings. The amount and proportion of MVPA and SB were calculated for every setting. To investigate differences between the two SES groups, multilevel analyses accounting for the hierarchical structure of the data were conducted. Both SES groups achieved most minutes in MVPA at own school, on streets and at home and recorded the highest proportions of MVPA in recreational facilities, streets and other schools. The highest amounts and proportions of SB were found at home and own school. High-SES children accumulated significantly more minutes in MVPA and SB in parks, sport facilities, other schools and streets, while the low-SES group spent more time in both activities in other places. When taking the total time spent in a setting into account and using the proportion of MVPA or SB, the only differences between the two groups were found at other schools and outside, where the high-SES children showed a significantly higher activity level (p-values <0.001). Several differences in the spatial activity pattern between children from low- and high-SES neighbourhoods were found, independent of their individual SES. The findings seem to highlight the importance of providing safe streets and access to appropriate types of recreational facilities to reach recommended PA levels. Further policies to reduce SB within home and school environment are needed.


Inferring the serotype associated with dengue virus infections on the basis of pre- and postinfection neutralizing antibody titers.
Currently, the only tests capable of determining the serotype associated with dengue virus (DENV) infection require sampling during the period of acute viremia. No test can accurately detect the serotype associated with past DENV infections. The standard assay for determination of serotype-specific antibody against DENV is the plaque reduction neutralization test (PRNT), although performance of this test continues to be evaluated. From a cohort study among schoolchildren in Thailand, PRNT values were determined in serum samples collected before and after infection. A multinomial logistic regression model was used to infer the serotype associated with intercurrent DENV infections. Models were validated based on polymerase chain reaction identification of DENV serotypes. The serotype associated with DENV infection inferred by the model corresponded with polymerase chain reaction in 67.6% of cases, and the kappa statistic was 0.479. A model for 35 cases with primary seroconversion correctly identified the DENV serotypes causing infection in 77.1% of cases, compared with 66.9%, using a model for 169 cases with secondary seroconversion. The best model using only postinfection PRNT values correctly inferred the DENV serotype causing infection in 60.3% of cases. A statistical model based on both pre- and postinfection PRNT values can be used to infer the serotype associated with DENV infections in prospective studies and vaccine trials.


Free-Living Physical Activity Measured With a Wearable Device Is Associated With Larger Hippocampus Volume and Greater Functional Connectivity in Healthy Older Adults: An Observational, Cross-Sectional Study in Northern Portugal.
Several studies using neuroimaging techniques have established a positive relationship between physical activity (PA) and brain structure and function in older populations. However, the use of subjective measures of PA and the lack of multimodal neuroimaging approaches have limited the understanding of this association. This study aims to explore the associations between PA and brain structure and function by objectively evaluating PA. Community-dwelling cognitively healthy older adults (without diagnosed cognitive, neurological or degenerative disease) were recruited from local health centers and local gyms. In a cross-sectional design, participants were evaluated regarding cognitive, clinical, anthropometric, physical performance, and lifestyle characteristics. A 3 T magnetic resonance imaging (MRI) was performed for structural and functional brain measures. PA time and level was assessed via a Xiaomi Mi Band 2® worn for 15 consecutive days. Participants (n = 110, after inclusion/exclusion criteria and completion of all evaluations) were 58 females (56%), with an average age of 68.42 years old (SD = 3.12), most were active. Multiple regression analysis revealed that higher time spent in vigorous PA associated with larger left parahippocampal gyrus and right hippocampus volumes. Furthermore, the analysis of the functional connectome indicated a greater functional connectivity (FC) between the frontal gyrus, cingulate gyrus, occipital inferior lobe for light, moderate, and total PA time, and sedentary time associated with lower FC in the same networks. Overall, the structural and functional findings may provide evidence on the relevant association between PA and brain health in aging.


Gene-expression analysis of early- and late-maturation-stage rat enamel organ.
Enamel maturation is a dynamic process that involves high rates of mineral acquisition, associated fluctuations in extracellular pH, and resorption of extracellular enamel proteins. During maturation, ameloblasts change from having a tall, thin, and highly polarized organization, characteristic of the secretory stage, to having a low columnar and widened morphology in the maturation stage. To identify potential differences in gene expression throughout maturation, we obtained enamel organ epithelial cells derived from the early- and late-maturation stages of rat incisor and analyzed the global gene-expression profiles at each stage. Sixty-three candidate genes were identified as having potential roles in the maturation process. Quantitative PCR was used to confirm the results of this genome-wide analysis in a subset of genes. Transcripts enriched during late maturation (n = 38) included those associated with lysosomal activity, solute carrier transport, and calcium signaling. Also up-regulated were transcripts involved in cellular responses to oxidative stress, proton transport, cell death, and the immune system. Transcripts down-regulated during the late maturation stage (n =25) included those with functions related to cell adhesion, cell signaling, and T-cell activation. These results indicate that ameloblasts undergo widespread molecular changes during the maturation stage of amelogenesis and hence provide a basis for future functional investigations into the mechanistic basis of enamel mineralization.


Climatic effects in Central Europe on the frequency of medical treatments of dairy cows.
In the present study, the relationship between the temperature-humidity index (THI) and the incidence of medical treatments in lactating dairy cows in Lower Saxony, Germany, was investigated. Records of all veterinary-treated cases over 2 years (2003 and 2005) from eight Holstein-Friesian dairy herds raised in loose-housing systems (55 to 170 cows per herd) were evaluated. After exclusion of management-dependent and climate-independent cases, a total of 5547 treatments were analyzed. Treatments were clustered into the following groups: metabolism, fertility, udder and foot/leg. Meteorological data were compiled from the nearest weather station (average distance ± s.d. 39 ± 13 km). Hourly temperatures and relative humidity values were used to calculate the THI, which was divided into classes. Out of the total number of treatments, 37.4%, 32.9%, 21.6% and 8.1% belonged to metabolism, udder, fertility and foot/leg, respectively. Data were analyzed with a mixed model that included THI class, season and year as fixed effects and farm as random effect. In general, incidences were neither affected by the year (P > 0.05) and season (P > 0.05) nor by THI classes (P > 0.05). In tendency, incidences of metabolic treatments increased with increasing THI and incidences of udder treatments increased with decreasing THI. In conclusion, indications of moderate heat stress during summer months in Central Europe were found in the present study, although THI and season did not affect the different disease complexes significantly.


Multiplexing free-space optical signals using superimposed collinear orbital angular momentum states.
As a proof of concept, we experimentally demonstrate multiplexing of free-space optical signals in multiple channels labeled with different states of orbital angular momentum. The multiplexing process is carried out by a dynamic liquid-crystal spatial light modulator, while the phase function is calculated by an iterative algorithm. A binary amplitude computer-generated hologram serves as a demultiplexer.


Zygomaticomaxillary "lateral swing" osteotomy for augmentation of midface deficiency.
Various surgical modalities have been proposed for the augmentation of midface deficiency without correction of the occlusal component. They include autogenous bone and cartilage grafts, alloplastic materials, and osteotomies. We propose an innovative osteotomy technique for augmentation of the midface including the infraorbital rims, the zygoma, the anterior maxillae, and the paranasal areas without advancing the dental-bearing segment. This procedure was carried out on a 21-year-old male patient who had a deficiency of the anterior maxillae including the infraorbital rims. His occlusion was in Class I molar relation. The surgical exposure was carried out through a midface degloving approach. This bilateral osteotomy encompasses the anterior maxillae and the zygoma; the osteotomy line running superiorly from the medial aspect of the infra-orbital rim to the root of the frontal process of maxilla. Inferiorly, the line runs above the apices of the maxillary teeth laterally underneath the zygomatic buttress, separating part of the zygomaticomaxillary suture posteriorly. Medially, the osteotomy line runs parallel to the piriform aperture. The osteotomy is pedicled on the zygomaticotemporal suture. A greenstick fracture at the zygomatic arch pedicled the osteotomized segment to the zygomatic process of the temporal bone. The entire segment was swung laterally outward, effectively separating part of the zygomaticomaxillary suture posteriorly. Fixation was achieved with a single 2-mm L-shaped, 4-hole plate with gap at the zygomatic buttress region. This osteotomy technique resulted in fullness of the anterior maxillae and infraorbital rims, with increased anterior and lateral projection of the zygoma. The zygomaticomaxillary "lateral swing" osteotomy is a reliable and stable technique for total midface augmentation not requiring occlusion correction.


Active and passive smoking are associated with increased carotid wall thickness. The Atherosclerosis Risk in Communities Study.
Active cigarette smoking has been established as a potent risk factor for carotid atherosclerosis in clinical populations; however, neither the role of active smoking in general populations nor the impact of environmental tobacco smoke has been well described. The association between carotid artery wall thickness and cigarette smoking was studied in 12,953 black and white men and women, aged 45 to 65 years, examined in the Atherosclerosis Risk in Communities Study. Participants were classified as current smokers (n = 3525), past smokers (n = 4315), never smokers reporting weekly exposure to environmental tobacco smoke (ETS or "passive smoking") of at least 1 hour (n = 3339), or never smokers reporting no weekly exposure to ETS (n = 1774). Carotid artery intimal-medial thickness (IMT) was measured by B-mode ultrasound. Increased IMT was observed in each category, in order from smallest to greatest increase: never smokers not exposed to ETS, never smokers exposed to ETS, past smokers, and current smokers. The larger IMT observed in the nonsmoking group exposed to ETS compared with the nonsmokers not exposed persisted after control for diet, physical activity, body mass index, alcohol intake, education, and major cardiovascular risk factors. Among past and current smokers, increased pack-years of exposure was associated with increased IMT. Among nonsmoking men exposed to ETS, there was a significant increase in IMT with increasing number of hours per week of ETS exposure. These data confirm the strong relationship between active smoking and carotid artery IMT and provide initial evidence that passive smoking exposure is related to greater IMT. Increasing exposure to cigarette smoke (either pack-years of active smoking or hours of ETS) was significantly related to increased IMT.


The aims of systems biology: between molecules and organisms.
The systems approach to biology has a long history. Its recent rapid resurgence at the turn of the century reflects the problems encountered in interpreting the sequencing of the genome and the failure of that immense achievement to provide rapid and direct solutions to major multi-factorial diseases. This paper argues that systems biology is necessarily multilevel and that there is no privileged level of causality in biological systems. It is an approach rather than a separate discipline. Functionality arises from biological networks that interact with the genome, the environment and the phenotype. This view of biology is very different from the gene-centred views of neo-Darwinism and molecular biology. In neuroscience, the systems approach leads naturally to 2 important conclusions: first, that the idea of 'programs' in the brain is confusing, and second, that the self is better interpreted as a process than as an object.


Dynamics of a scrapie outbreak in a flock of Romanov sheep--estimation of transmission parameters.
Knowledge of epidemiological mechanisms and parameters underlying scrapie transmission in sheep flocks remains very limited at present. Here we introduce a method for fitting stochastic transmission models to outbreak data to estimate bounds on key transmission parameters. We apply this method to data describing an outbreak of scrapie in a closed flock of Romanov sheep. The main findings are that the relative infectiousness of infected animals in this outbreak becomes appreciable early into disease incubation and that the mean incubation period is less than 1.5 years. We also find that the data are consistent with a broad range of values for the basic reproduction number R0 and describe how the boundaries of this range depend on assumptions about the mean incubation period and the contribution to transmission of a long-lived environmental reservoir of infectivity.


Use of the synthetic peptide neurogranin(28-43) as a selective protein kinase C substrate in assays of tissue homogenates.
The synthetic peptide neurogranin(28-43), the sequence of which is homologous to the phosphorylation site of the brain specific protein kinase C (PKC) substrates neurogranin and neuromodulin, was tested for its utility as a PKC substrate in crude tissue homogenates. The phosphorylation of neurogranin(28-43) shows time- and protein concentration-dependency. In prolonged incubations, the addition of the protein phosphatase inhibitor sodium pyrophosphate results in increased phosphorylation of neurogranin(28-43). The phosphorylation of neurogranin(28-43) was compared to that of another widely used PKC substrate, S6(229-249). Neurogranin(28-43) is as potent as S6(229-249) and more selective than S6(229-249) as a PKC substrate. Greater than 95% of phosphate incorporation into neurogranin(28-43) can be inhibited by a selective PKC inhibitor, PKC(19-36). Kinetic analysis of neurogranin(28-43) phosphorylation in hippocampal homogenate revealed an apparent Km of 147 nM, virtually identical to previously published Km observed for phosphorylation of the substrate by purified PKC. In addition, we assayed several neuronal and nonneuronal tissues using neurogranin(28-43) as substrate in the presence or absence of detergent. We show that the relative PKC activity assayed with neurogranin(28-43) correlates well to the relative amount of PKC known to be present in various neuronal and nonneuronal tissues. Overall, this report shows that neurogranin(28-43) can be used to selectively assay PKC, even in tissue containing low PKC activity.


Arbuscular mycorrhizal fungi influence water relations, gas exchange, abscisic acid and growth of micropropagated chile ancho pepper (Capsicum annuum) plantlets during acclimatization and post-acclimatization.
Little is known about the role of arbuscular mycorrhiza fungi (AMF) on physiological changes of micropropagated plantlets during acclimatization and post-acclimatization. Using chile ancho pepper (Capsicum annuum L. cv. San Luis), measurements were made of water relations, gas exchange, abscisic acid (ABA), plantlet growth and AMF development. Plantlets had low photosynthetic rates (A) and poor initial growth during acclimatization. Relative water content (RWC) decreased during the first days after transfer from tissue culture containers to ex vitro conditions. Consequently, transpiration rates (E) and stomatal conductance (gs) declined, confirming that in vitro formed stomata were functional and able to respond ex vitro to partial desiccation--thus avoiding excessive leaf dehydration and plant death. Colonization by AMF occurred within 3 days after inoculation. Colonized plantlets had lower leaf ABA and higher RWC than noncolonized (NonAMF) plantlets during peak plant dehydration (6 days after plant transfer)--and a higher A and gs as early as days 5 and 7. During post-acclimatization [after day 8, when RWC increased and stabilized], A increased in all plantlets; however, more dramatic changes occurred with AMF plantlets. Within 48 days, 45% of the roots sampled of inoculated plantlets were colonized and had extensive arbuscule development. At this time, AMF plantlets also had greater E, A, leaf chlorophyll, leaf elemental N, P and K, leaf dry biomass and leaf area, fruit production and differences in carbon partitioning [lower root/shoot ratio and higher leaf area ratio] compared with NonAMF plantlets. Rapid AMF colonization enhanced physiological adjustments, which helped plantlets recover rapidly during acclimatization and obtain greater growth during post-acclimatization.


Protective effects of pentoxifylline in retinal ischemia/reperfusion injury.
We studied the effect of pentoxifylline on retinal lipid peroxidation and histopathologic changes due to ischemia/reperfusion (I/R). A total of 15 pigmented male guinea pigs were divided into 3 equal groups as control, sham and treatment groups. After application of high intraocular pressure for 90 min for the induction of retinal ischemia, 24-hour reperfusion was established in the sham and treatment groups. In the treatment and sham groups, either 45 mg/kg of pentoxifylline or saline was given 3 times at 8-hour intervals. Biochemical assay and histopathologic evaluation were performed on one randomly selected eye of each animal which was enucleated at the end of the reperfusion period, and retinal malondialdehyde (MDA) levels and thickness of the retinal tissue were determined for each group. The mean MDA level of the sham group was significantly higher versus the control and treatment groups (p < 0.001). When compared with the control group, the mean MDA level of the treatment group was slightly higher, but the difference was not statistically significant (p > 0.05). In comparison with the control group there was a significant increase in the thickness of the retina in the sham group (p < 0.0001), and no significant difference was found in the retinal thickness of the treatment group (p > 0.05). Pentoxifylline might have a preventive effect on the I/R injury of the retina.


A Conceptual Model for Understanding Academic Physicians' Performances of Identity: Findings From the University of Utah.
To explore how academic physicians perform social and professional identities and how their personal experiences inform professional identity formation. Semistructured interviews and observations were conducted with 25 academic physicians of diverse gender and racial/ethnic backgrounds at the University of Utah School of Medicine from 2015 to 2016. Interviews explored the domains of social identity, professional identity, and relationships with patients and colleagues. Patient interactions were observed. Interviews and observations were audio-recorded, transcribed, and analyzed using grounded theory. Three major themes emerged: Physicians' descriptions of identity differed based on social identities, as women and racially/ethnically minoritized participants linked their gender and racial/ethnic identities, respectively, to their professional roles more than men and white, non-Latino/a participants; physicians' descriptions of professional practice differed based on social identities, as participants who associated professional practices with personal experiences often drew from events connected to their minoritized identities; and physicians' interactions with patients corresponded to their self-described actions. Professional identity formation is an ongoing process, and the negotiation of personal experiences is integral to this process. This negotiation may be more complex for physicians with minoritized identities. Implications for medical education include providing students, trainees, and practicing physicians with intentional opportunities for reflection and instruction on connecting personal experiences and professional practice.


Thinking like a trader selectively reduces individuals' loss aversion.
Research on emotion regulation has focused upon observers' ability to regulate their emotional reaction to stimuli such as affective pictures, but many other aspects of our affective experience are also potentially amenable to intentional cognitive regulation. In the domain of decision-making, recent work has demonstrated a role for emotions in choice, although such work has generally remained agnostic about the specific role of emotion. Combining psychologically-derived cognitive strategies, physiological measurements of arousal, and an economic model of behavior, this study examined changes in choices (specifically, loss aversion) and physiological correlates of behavior as the result of an intentional cognitive regulation strategy. Participants were on average more aroused per dollar to losses relative to gains, as measured with skin conductance response, and the difference in arousal to losses versus gains correlated with behavioral loss aversion across subjects. These results suggest a specific role for arousal responses in loss aversion. Most importantly, the intentional cognitive regulation strategy, which emphasized "perspective-taking," uniquely reduced both behavioral loss aversion and arousal to losses relative to gains, largely by influencing arousal to losses. Our results confirm previous research demonstrating loss aversion while providing new evidence characterizing individual differences and arousal correlates and illustrating the effectiveness of intentional regulation strategies in reducing loss aversion both behaviorally and physiologically.


Cancer chemoprevention by resveratrol: in vitro and in vivo studies and the underlying mechanisms (review).
Cancer, next only to heart diseases, is the second leading cause of deaths in the United States of America and many other nations in the world. The prognosis for a patient with metastatic carcinoma of the lung, colon, breast, or prostate (four of the most common and lethal forms of cancer, which together account for more than half of all deaths from cancer in the USA), remains dismal. Conventional therapeutic and surgical approaches have not been able to control the incidence of most of the cancer types. Therefore, there is an urgent need to develop mechanism-based approaches for the management of cancer. Chemoprevention via non-toxic agents could be one such approach. Many naturally occurring agents have shown cancer chemopreventive potential in a variety of bioassay systems and animal models, having relevance to human disease. It is appreciated that an effective and acceptable chemopreventive agent should have certain properties: (a), little or no toxic effects in normal and healthy cells; (b), high efficacy against multiple sites; (c), capability of oral consumption; (d), known mechanism of action; (e), low cost; and (f), acceptance by human population. Resveratrol is one such agent. A naturally occurring polyphenolic antioxidant compound present in grapes, berries, peanuts and red wine. In some bioassay systems resveratrol has been shown to afford protection against several cancer types. The mechanisms of resveratrol's broad cancer chemopreventive effects are not completely understood. In this review, we present the cancer chemopreventive effects of resveratrol in an organ-specific manner. The mechanisms of the antiproliferative/cancer chemopreventive effects of resveratrol are also presented. We believe that continued efforts are needed, especially well-designed pre-clinical studies in the animal models that closely mimic/represent human disease, to establish the usefulness of resveratrol as cancer chemopreventive agent. This should be followed by human clinical trials in appropriate cancer types in suitable populations.


Low-grade inflammation, metabolic syndrome and the risk of chronic kidney disease: the 2005 Korean National Health and Nutrition Examination Survey.
Either chronic inflammation or metabolic syndrome (MetS) is associated with renal impairment. This cross-sectional study was designed to investigate the relationship between elevated white blood cell (WBC) counts and chronic kidney disease (CKD) stage 3 or more according to the presence of MetS in adult Koreans. In total, 5,291 subjects (≥ 20 yr-old) participating in the 2005 Korean National Health and Nutrition Examination were included. CKD stage 3 or more was defined as having an estimated glomerular filtration rate below 60 mL/min/1.73 m(2), as calculated using the formula from the Modification of Diet in Renal Disease study. The odds ratio (95% confidence interval) for CKD stage 3 or more in the highest WBC quartile (≥ 7,200 cells/µL) was 1.70 (1.17-2.39) after adjusting for MetS and other covariates, compared with the lowest WBC quartile (< 5,100 cells/µL). In subjects with MetS, the prevalence risk for CKD stage 3 or more in the highest WBC quartile was 2.25 (1.28-3.95) even after fully adjusting for confounding variables. In contrast, this positive association between WBC quartile and CKD stage 3 or more disappeared in subjects without MetS. Low-grade inflammation is significantly associated with CKD stage 3 or more in subjects with MetS but not in those without MetS.


SOX4 can redirect TGF-β-mediated SMAD3-transcriptional output in a context-dependent manner to promote tumorigenesis.
Expression of the transcription factor SOX4 is often elevated in human cancers, where it generally correlates with tumor-progression and poor-disease outcome. Reduction of SOX4 expression results in both diminished tumor-incidence and metastasis. In breast cancer, TGF-β-mediated induction of SOX4 has been shown to contribute to epithelial-to-mesenchymal transition (EMT), which controls pro-metastatic events. Here, we identify SMAD3 as a novel, functionally relevant SOX4 interaction partner. Genome-wide analysis showed that SOX4 and SMAD3 co-occupy a large number of genomic loci in a cell-type specific manner. Moreover, SOX4 expression was required for TGF-β-mediated induction of a subset of SMAD3/SOX4-co-bound genes regulating migration and extracellular matrix-associated processes, and correlating with poor-prognosis. These findings identify SOX4 as an important SMAD3 co-factor controlling transcription of pro-metastatic genes and context-dependent shaping of the cellular response to TGF-β. Targeted disruption of the interaction between these factors may have the potential to disrupt pro-oncogenic TGF-β signaling, thereby impairing tumorigenesis.


Structure-based moloney murine leukemia virus reverse transcriptase mutants with altered intracellular direct-repeat deletion frequencies.
Template switching rates of Moloney murine leukemia virus reverse transcriptase mutants were tested using a retroviral vector-based direct-repeat deletion assay. The reverse transcriptase mutants contained alterations in residues that modeling of substrates into the catalytic core had suggested might affect interactions with primer and/or template strands. As assessed by the frequency of functional lacZ gene generation from vectors in which lacZ was disrupted by insertion of a sequence duplication, the frequency of template switching varied more than threefold among fully replication-competent mutants. Some mutants displayed deletion rates that were lower and others displayed rates that were higher than that of wild-type virus. Replication for the mutants with the most significant alterations in template switching frequencies was similar to that of the wild type. These data suggest that reverse transcriptase template switching rates can be altered significantly without destroying normal replication functions.


Roles of rapsyn and agrin in interaction of postsynaptic proteins with acetylcholine receptors.
At the neuromuscular junction, aggregates of acetylcholine receptors (AChRs) are anchored in the muscle membrane by association with rapsyn and other postsynaptic proteins. We have investigated the interactions between the AChR and these proteins in cultured C2 myotubes before and after treatment with agrin, a nerve-derived protein that induces AChRs to cluster. When AChRs were isolated from detergent extracts of untreated C2 myotubes, they were associated with rapsyn and, to a lesser degree, with utrophin, beta-dystroglycan, MuSK, and src-related kinases, but not with syntrophin. Treatment with agrin increased the association of AChRs with MuSK, a receptor tyrosine kinase that forms part of the agrin receptor complex, without affecting other interactions. Analysis of rapsyn-deficient myotubes, which do not form protein clusters in response to agrin, revealed that rapsyn is required for association of the AChR with utrophin and beta-dystroglycan, and for the agrin-induced increase in association with MuSK, but not for constitutive interactions with MuSK and src-related kinases. In rapsyn -/- myotubes, agrin caused normal tyrosine phosphorylation of AChR-associated and total MuSK, whereas phosphorylation of the AChR beta subunit, both constitutive and agrin-induced, was strongly reduced. These results show first that aneural myotubes contain preassembled AChR protein complexes that may function in the assembly of the postsynaptic apparatus, and second that rapsyn, in addition to its role in AChR phosphorylation, mediates selected protein interactions with the AChR and serves as a link between the AChR and the dystrophin/utrophin glycoprotein complex.


Experience with 100 consecutive simultaneous kidney-pancreas transplants with bladder drainage.
From December 1985 to December 1989, 100 consecutive simultaneous pancreas-kidney (SPK) transplants were performed at the University of Wisconsin Hospital and Clinics. Bladder drainage technique was used for all grafts. One- and three-year patient survival was 93% and 90%; kidney survival, 90% and 85%; and pancreas survival, 86% and 84%. Quadruple immunosuppressive therapy was used in all patients and consisted of either MALG or OKT3 induction, and cyclosporine, prednisone, and azathioprine maintenance therapy. OKT3 induction therapy was used in 42 patients and Minnesota antilymphocyte globule in 58 patients, with equivalent results except for more opportunistic infection with OKT3. The duodenal button technique was used in the first 17 patients with systemic anticoagulation and was associated with significantly more postoperative bleeding and infection compared with the duodenal segment technique. The most common surgical complication of the duodenal segment technique was urine leak (13%), which usually occurred from the distal duodenal segment. The most common urologic complication of bladder drainage was hematuria (13%), which was usually self-limited. Within 6 months of transplantation, 84% of patients developed urinary tract infections, and 25% of patients had opportunistic infections. The surgical techniques and immunosuppressive methods used in this series are reviewed, and strategies for preventing medical and surgical complications are outlined.


Application of "less is more" to low back pain.
An initiative of the National Physicians Alliance, the project titled "Promoting Good Stewardship in Clinical Practice," developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was "Don't do imaging for low back pain within the first 6 weeks unless red flags are present." This article presents data that support this recommendation. We selectively reviewed the literature, including recent reviews, guidelines, and commentaries, on the benefits and risks of routine imaging in low back pain. In particular, we searched PubMed for systematic reviews or meta-analyses published in the past 5 years. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality systematic review and meta-analysis focused on clinical outcomes in patients with low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care. Published data also document harms associated with early imaging for low back pain, including patient "labeling," unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.


Selection for resistance to oseltamivir in seasonal and pandemic H1N1 influenza and widespread co-circulation of the lineages.
In Spring 2009, a novel reassortant strain of H1N1 influenza A emerged as a lineage distinct from seasonal H1N1. On June 11, the World Heath Organization declared a pandemic - the first since 1968. There are currently two main branches of H1N1 circulating in humans, a seasonal branch and a pandemic branch. The primary treatment method for pandemic and seasonal H1N1 is the antiviral drug Tamiflu (oseltamivir). Although many seasonal H1N1 strains around the world are resistant to oseltamivir, initially, pandemic H1N1 strains have been susceptible to oseltamivir. As of February 3, 2010, there have been reports of resistance to oseltamivir in 225 cases of H1N1 pandemic influenza. The evolution of resistance to oseltamivir in pandemic H1N1 could be due to point mutations in the neuraminidase or a reassortment event between seasonal H1N1 and pandemic H1N1 viruses that provide a neuraminidase carrying an oseltamivir-resistant genotype to pandemic H1N1. Using phylogenetic analysis of neuraminidase sequences, we show that both seasonal and pandemic lineages of H1N1 are evolving to direct selective pressure for resistance to oseltamivir. Moreover, seasonal lineages of H1N1 that are resistant to oseltamivir co-circulate with pandemic H1N1 throughout the globe. By combining phylogenetic and geographic data we have thus far identified 53 areas of co-circulation where reassortment can occur. At our website POINTMAP, http://pointmap.osu.edu we make available a visualization and an application for updating these results as more data are released. As oseltamivir is a keystone of preparedness and treatment for pandemic H1N1, the potential for resistance to oseltamivir is an ongoing concern. Reassortment and, more likely, point mutation have the potential to create a strain of pandemic H1N1 against which we have a reduced number of treatment options.