Development of an Assessment for Entrustable Professional Activity (EPA) 10: Emergent Patient Management.
Medical schools in the United States are encouraged to prepare and certify the entrustment of medical students to perform 13 core entrustable professional activities (EPAs) prior to graduation. Entrustment is defined as the informed belief that the learner is qualified to autonomously perform specific patient-care activities. Core EPA-10 is the entrustment of a graduate to care for the emergent patient. The purpose of this project was to design a realistic performance assessment method for evaluating fourth-year medical students on EPA-10. First, we wrote five emergent patient case-scenarios that a medical trainee would likely confront in an acute care setting. Furthermore, we developed high-fidelity simulations to realistically portray these patient case scenarios. Finally, we designed a performance assessment instrument to evaluate the medical student's performance on executing critical actions related to EPA-10 competencies. Critical actions included the following: triage skills, mustering the medical team, identifying causes of patient decompensation, and initiating care. Up to four students were involved with each case scenario; however, only the team leader was evaluated using the assessment instruments developed for each case. A total of 114 students participated in the EPA-10 assessment during their final year of medical school. Most students demonstrated competence in recognizing unstable vital signs (97%), engaging the team (93%), and making appropriate dispositions (92%). Almost 87% of the students were rated as having reached entrustment to manage the care of an emergent patient (99 of 114). Inter-rater reliability varied by case scenario, ranging from moderate to near-perfect agreement. Three of five case-scenario assessment instruments contained items that were internally consistent at measuring student performance. Additionally, the individual item scores for these case scenarios were highly correlated with the global entrustment decision. High-fidelity simulation showed good potential for effective assessment of medical student entrustment of caring for the emergent patient. Preliminary evidence from this pilot project suggests content validity of most cases and associated checklist items. The assessments also demonstrated moderately strong faculty inter-rater reliability.


Non-V600 BRAF Mutations Define a Clinically Distinct Molecular Subtype of Metastatic Colorectal Cancer.
Purpose Molecular diagnostic testing has become an integral part of the evaluation of patients with metastatic colorectal cancer (CRC). Expanded mutational testing, such as next-generation sequencing (NGS), often identifies mutations with unclear clinical or prognostic implications. One such example is BRAF mutations that occur outside of codon 600 (non-V600 BRAF mutations). Methods We conducted this multicenter, retrospective cohort study to characterize the clinical, pathologic, and survival implications of non-V600 BRAF mutations in metastatic CRC. We pooled patients in whom non-V600 BRAF mutations were identified from NGS databases at three large molecular genetics reference laboratories. Results A total of 9,643 patients with metastatic CRC underwent NGS testing. We identified 208 patients with non-V600 BRAF mutations, which occurred in 2.2% of all patients tested and accounted for 22% of all BRAF mutations identified. Cancers with non-V600 BRAF mutations, compared with cancers with V600E BRAF (V600E BRAF) mutations, were found in patients who were significantly younger (58 v 68 years, respectively), fewer female patients (46% v 65%, respectively), and patients who had fewer high-grade tumors (13% v 64%, respectively) or right-sided primary tumors (36% v 81%, respectively). Median overall survival was significantly longer in patients with non-V600 BRAF-mutant metastatic CRC compared with those with both V600E BRAF-mutant and wild-type BRAF metastatic CRC (60.7 v 11.4 v 43.0 months, respectively; P < .001). In multivariable analysis, non-V600 BRAF mutation was independently associated with improved overall survival (hazard ratio, 0.18; P < .001). Conclusion Non-V600 BRAF mutations occur in approximately 2.2% of patients with metastatic CRC and define a clinically distinct subtype of CRC with an excellent prognosis.


Genotypic Characterization of Clinical Klebsiella spp. Isolates Collected From Patients With Suspected Community-Onset Sepsis, Sweden.
Klebsiella is a genus of Gram-negative bacteria known to be opportunistic pathogens that may cause a variety of infections in humans. Highly drug-resistant Klebsiella species, especially K. pneumoniae, have emerged rapidly and are becoming a major concern in clinical management. Although K. pneumoniae is considered the most important pathogen within the genus, the true clinical significance of the other species is likely underrecognized due to the inability of conventional microbiological methods to distinguish between the species leading to high rates of misidentification. Bacterial whole-genome sequencing (WGS) enables precise species identification and characterization that other technologies do not allow. Herein, we have characterized the diversity and traits of Klebsiella spp. in community-onset infections by WGS of clinical isolates (n = 105) collected during a prospective sepsis study in Sweden. The sequencing revealed that 32 of the 82 isolates (39.0%) initially identified as K. pneumoniae with routine microbiological methods based on cultures followed by matrix-assisted laser desorption-time of flight mass spectrometry (MALDI-TOF MS) had been misidentified. Of these, 23 were identified as Klebsiella variicola and nine as other members of the K. pneumoniae complex. Comparisons of the number of resistance genes showed that significantly fewer resistance genes were detected in Klebsiella oxytoca compared to K. pneumoniae and K. variicola (both values of p < 0.001). Moreover, a high proportion of the isolates within the K. pneumoniae complex were predicted to be genotypically multidrug-resistant (MDR; 79/84, 94.0%) in contrast to K. oxytoca (3/16, 18.8%) and Klebsiella michiganensis (0/4, 0.0%). All isolates predicted as genotypically MDR were found to harbor the combination of β-lactam, fosfomycin, and quinolone resistance markers. Multi-locus sequence typing (MLST) revealed a high diversity of sequence types among the Klebsiella spp. with ST14 (10.0%) and ST5429 (10.0%) as the most prevalent ones for K. pneumoniae, ST146 for K. variicola (12.0%), and ST176 for K. oxytoca (25.0%). In conclusion, the results from this study highlight the importance of using high-resolution genotypic methods for identification and characterization of clinical Klebsiella spp. isolates. Our findings indicate that infections caused by other members of the K. pneumoniae complex than K. pneumoniae are a more common clinical problem than previously described, mainly due to high rates of misidentifications.


Population Pharmacokinetic Modeling in the Presence of Missing Time-Dependent Covariates: Impact of Body Weight on Pharmacokinetics of Paracetamol in Neonates.
Body weight is the primary covariate in pharmacokinetics of many drugs and dramatically changes during the first weeks of life of neonates. The objective of this study is to determine if missing body weights in preterm and term neonates affect estimates of model parameters and which methods can be used to improve performance of a population pharmacokinetic model of paracetamol. Data for our analysis were obtained from previously published studies on the pharmacokinetics of intravenous paracetamol in neonates. We adopted a population model of body weight change in neonates to implement three previously introduced methods of handling missing covariates based on data imputation, likelihood function modification, and full random effects modeling. All models were implemented in NONMEM 7.4, and population parameters were estimated using the FOCE method. Our major finding was that missing body weights minimally affect population estimates of pharmacokinetic parameters but do affect the covariate relationship parameters, particularly the one describing dependence of clearance on body weight. None of the tested methods changed estimates of between-subject variability nor impacted the predictive performance of the model. Our analysis shows that a modeling approach towards handling missing covariates allows borrowing information gathered in various studies as long as they target the same population. This approach is particularly useful for handling time-dependent missing covariates.


Patterns and determinants of small-quantity LNS utilization in rural Malawi and Mozambique: considerations for interventions with specialized nutritious foods.
Small-quantity, lipid-based nutrient supplements (SQ-LNS) show promise to improve the quality of maternal and child diets, particularly during the first 1000 days of life. The potential of SQ-LNS to impact positively upon nutritional status relies on numerous factors, including complementary dietary intake, disease prevalence and dynamics of household utilization, including sharing practices. Therefore, this study sought to elucidate the patterns and determinants of SQ-LNS utilization among children 6-23 months and potential sharing practices of other household members prior to intervention development. In Ntchisi, Malawi and Cabo Delgado, Mozambique, both rural, agricultural settings, we conducted two home-feeding trials of 8 and 6 weeks, respectively, nested within a larger multi-phase, emergent formative research design. Multiple methods, including in-depth interviews (n = 38), direct meal observations (n = 80), full-day child observations (n = 38) and spot checks of SQ-LNS supply (n = 23), were conducted with households (n = 35 in Malawi; n = 24 in Mozambique). Overall, the SQ-LNS was utilized contrary to its recommended use, with 50% of households in Malawi reporting running out of stock too early and 87% of households in Mozambique either overusing or underusing the product. Utilization of SQ-LNS was manifested in four patterns of overuse and two of underuse and was determined by factors at multiple levels of influence. Maternal and child health efforts need to consider the reasons behind choices by households to overuse or underuse SQ-LNS and design intervention strategies to increase the likelihood of its appropriate utilization.


Alveolar ridge preservation with a collagen material: a randomized controlled trial.
Resorption of the alveolar bone is an unavoidable consequence of tooth extraction when appropriate alveolar ridge preservation (ARP) measures are not taken. The objective of this trial was to test the hypothesis that dimensional changes in the alveolar bone after tooth extraction would be reduced by inserting an equine collagen membrane and a collagen cone to fill and seal the alveolus (as ARP), in comparison to extraction with untreated alveoli. In this randomized clinical trial, 31 patients were directly treated with the collagen material after extraction of a tooth from the maxilla (the ARP group). Twenty-nine patients served as the control group. After extraction, no further treatment (i.e., no socket preservation measures) was performed in the control group. Changes in the alveolar process immediately after extraction and after an 8 (±1)-week healing period were evaluated 3-dimensionally. Blinded analyses were performed after superimposing the data from the digitalized impressions and surfaces generated by cone-beam computed tomography. Both the ARP and control groups showed a reduction of bone in the alveolar area after tooth extraction. However, significantly less bone resorption was detected in the clinically relevant buccal region in the ARP group. The median bone reduction was 1.18 mm in the ARP group and 5.06 mm in the control group (P=0.03). The proposed hypothesis that inserting a combination material comprising a collagen cone and membrane would lead to a difference in alveolar bone preservation can be accepted for the clinically relevant buccal distance. In this area, implantation of the collagen material led to significantly less alveolar bone resorption. German Clinical Trials Register at www.drks.de, DRKS00004769.


Contraceptive knowledge, attitudes, and use among adolescent mothers in the Cook Islands.
While the adverse health outcomes and broader economic and social factors associated with adolescent motherhood are well documented globally, limited research on unplanned pregnancy and birth among young women in Pacific Island nations exists. The study addresses this gap in the literature by examining the social and contextual factors that inform contraceptive knowledge, attitudes, and use among young women in the Cook Islands. Individual, in-depth interviews were conducted with ten women who became mothers before age twenty. Adolescents' contraceptive knowledge, attitudes, and behaviours were examined while taking into account the context in which they experienced an unplanned birth. Five participants were not using a contraceptive method when they became pregnant, believing they would not become pregnant. The remaining participants were using oral contraception but doing so inconsistently. Four participants had a sexual debut prior to age 15. The findings suggest a need to expand comprehensive approaches to sexual and reproductive health education, increase access to long-acting reversible contraceptive methods, and decrease the stigma associated with accessing family planning services in order to more effectively prevent unplanned pregnancy among adolescents in the Cook Islands. The findings provide insight into the factors contributing to high rates of adolescent pregnancy and birth in the Pacific region and suggest how public health advocates and health care providers might reduce reproductive health disparities in the Cook Islands and similar Pacific Island nations.


Long-lasting effects of land use history on soil fungal communities in second-growth tropical rain forests.
Our understanding of the long-lasting effects of human land use on soil fungal communities in tropical forests is limited. Yet, over 70% of all remaining tropical forests are growing in former agricultural or logged areas. We investigated the relationship among land use history, biotic and abiotic factors, and soil fungal community composition and diversity in a second-growth tropical forest in Puerto Rico. We coupled high-throughput DNA sequencing with tree community and environmental data to determine whether land use history had an effect on soil fungal community descriptors. We also investigated the biotic and abiotic factors that underlie such differences and asked whether the relative importance of biotic (tree diversity, basal tree area, and litterfall biomass) and abiotic (soil type, pH, iron, and total carbon, water flow, and canopy openness) factors in structuring soil fungal communities differed according to land use history. We demonstrated long-lasting effects of land use history on soil fungal communities. At our research site, most of the explained variation in soil fungal composition (R2 = 18.6%), richness (R2 = 11.4%), and evenness (R2 = 10%) was associated with edaphic factors. Areas previously subject to both logging and farming had a soil fungal community with lower beta diversity and greater evenness of fungal operational taxonomic units (OTUs) than areas subject to light logging. Yet, fungal richness was similar between the two areas of historical land use. Together, these results suggest that fungal communities in disturbed areas are more homogeneous and diverse than in areas subject to light logging. Edaphic factors were the most strongly correlated with soil fungal composition, especially in areas subject to light logging, where soils are more heterogenous. High functional tree diversity in areas subject to both logging and farming led to stronger correlations between biotic factors and fungal composition than in areas subject to light logging. In contrast, fungal richness and evenness were more strongly correlated with biotic factors in areas of light logging, suggesting that these metrics might reflect long-term associations in old-growth forests. The large amount of unexplained variance in fungal composition suggests that these communities are structured by both stochastic and niche assemblage processes.


The SARS-unique domain (SUD) of SARS coronavirus contains two macrodomains that bind G-quadruplexes.
Since the outbreak of severe acute respiratory syndrome (SARS) in 2003, the three-dimensional structures of several of the replicase/transcriptase components of SARS coronavirus (SARS-CoV), the non-structural proteins (Nsps), have been determined. However, within the large Nsp3 (1922 amino-acid residues), the structure and function of the so-called SARS-unique domain (SUD) have remained elusive. SUD occurs only in SARS-CoV and the highly related viruses found in certain bats, but is absent from all other coronaviruses. Therefore, it has been speculated that it may be involved in the extreme pathogenicity of SARS-CoV, compared to other coronaviruses, most of which cause only mild infections in humans. In order to help elucidate the function of the SUD, we have determined crystal structures of fragment 389-652 ("SUD(core)") of Nsp3, which comprises 264 of the 338 residues of the domain. Both the monoclinic and triclinic crystal forms (2.2 and 2.8 A resolution, respectively) revealed that SUD(core) forms a homodimer. Each monomer consists of two subdomains, SUD-N and SUD-M, with a macrodomain fold similar to the SARS-CoV X-domain. However, in contrast to the latter, SUD fails to bind ADP-ribose, as determined by zone-interference gel electrophoresis. Instead, the entire SUD(core) as well as its individual subdomains interact with oligonucleotides known to form G-quadruplexes. This includes oligodeoxy- as well as oligoribonucleotides. Mutations of selected lysine residues on the surface of the SUD-N subdomain lead to reduction of G-quadruplex binding, whereas mutations in the SUD-M subdomain abolish it. As there is no evidence for Nsp3 entering the nucleus of the host cell, the SARS-CoV genomic RNA or host-cell mRNA containing long G-stretches may be targets of SUD. The SARS-CoV genome is devoid of G-stretches longer than 5-6 nucleotides, but more extended G-stretches are found in the 3'-nontranslated regions of mRNAs coding for certain host-cell proteins involved in apoptosis or signal transduction, and have been shown to bind to SUD in vitro. Therefore, SUD may be involved in controlling the host cell's response to the viral infection. Possible interference with poly(ADP-ribose) polymerase-like domains is also discussed.


Genetic variants within the MAP kinase signalling network and anti-TNF treatment response in rheumatoid arthritis patients.
Rheumatoid arthritis (RA) does not always respond to available treatments, including tumour necrosis factor (TNF) antagonists. A study was undertaken to investigate whether genetic variation within genes, encoding proteins in the p38 signalling network, contributes to the variable response to TNF antagonists. 1102 UK Caucasian patients with RA receiving anti-TNF therapy (infliximab, adalimumab and etanercept) were genotyped for 38 pairwise-tagging single nucleotide polymorphisms (SNPs) spanning 12 candidate genes from the p38 network. Regression analyses were performed to test association between genotype and treatment response at 6 months using both absolute change in DAS28 (Disease Activity Score across 28 joints) and European League Against Rheumatism (EULAR) improvement criteria. Stratified analyses were performed to investigate association with individual therapies. Seven SNPs, in five genes, were associated with improvement in DAS28 at 6 months at a nominal 0.1 significance level, jointly explaining 3% of variance in outcome in a model adjusting for other predictors. These encoded proteins both upstream (MKK6) and downstream (MAPKAPK2, MSK1, MSK2) of p38, and MAPK14, the p38-α isoform of p38 MAPK. One SNP (rs2716191 in MAP2K6) was associated with EULAR response at the 0.1 level. SNPs generally showed greater correlation with response to infliximab and adalimumab, but not to etanercept. More SNPs than would be expected by chance, mapping to the p38 signalling network, showed association with the anti-TNF response as a whole, and particularly with the response to infliximab and adalimumab. Validation of these findings in independent cohorts is warranted.


Concept analysis: lack of anonymity.
To re-examine and expand understanding of the concept 'lack of anonymity' as a component of rural nursing theory. Early healthcare literature reports lack of anonymity as part of social and working environments, particularly rural nursing. Rural nursing theory included the first published concept analysis on lack of anonymity but lacked empirical referents. Workforce, societal and rural healthcare changes support an updated analysis. To further understand lack of anonymity, its present day use and applicability to diverse environments, research from multiple disciplines was reviewed. Concept analysis. A literature search using eight terms in eleven databases was conducted of literature published between 2008-2013. Walker and Avant's concept analysis methodology guided the analysis. The previous concept analysis is supported in part by current literature. The defining attributes, 'identifiable', 'establishing boundaries for public and private self and interconnectedness' in a community were updated. Updated antecedents include: (i) environmental context; (ii) opportunities to become visible; (iii) developing relationships and (iv) unconscious or limited awareness of public or personal privacy. Consequences are: (i) familiarity; (ii) visibility; (iii) awareness of privacy and (iv) manage or balance of lack of anonymity. Cases were constructed and empirical referents identified. The concept of lack of anonymity was updated; portions of the original definition remain unchanged. Empirical referents reveal the defining attributes in daily life and may guide future research on the effect of lack of anonymity on nursing practice. This analysis advances the conceptual understanding of rural nursing theory.


MiR223-3p promotes synthetic lethality in BRCA1-deficient cancers.
Defects in DNA repair give rise to genomic instability, leading to neoplasia. Cancer cells defective in one DNA repair pathway can become reliant on remaining repair pathways for survival and proliferation. This attribute of cancer cells can be exploited therapeutically, by inhibiting the remaining repair pathway, a process termed synthetic lethality. This process underlies the mechanism of the Poly-ADP ribose polymerase-1 (PARP1) inhibitors in clinical use, which target BRCA1 deficient cancers, which is indispensable for homologous recombination (HR) DNA repair. HR is the major repair pathway for stressed replication forks, but when BRCA1 is deficient, stressed forks are repaired by back-up pathways such as alternative nonhomologous end-joining (aNHEJ). Unlike HR, aNHEJ is nonconservative, and can mediate chromosomal translocations. In this study we have found that miR223-3p decreases expression of PARP1, CtIP, and Pso4, each of which are aNHEJ components. In most cells, high levels of microRNA (miR) 223-3p repress aNHEJ, decreasing the risk of chromosomal translocations. Deletion of the miR223 locus in mice increases PARP1 levels in hematopoietic cells and enhances their risk of unprovoked chromosomal translocations. We also discovered that cancer cells deficient in BRCA1 or its obligate partner BRCA1-Associated Protein-1 (BAP1) routinely repress miR223-3p to permit repair of stressed replication forks via aNHEJ. Reconstituting the expression of miR223-3p in BRCA1- and BAP1-deficient cancer cells results in reduced repair of stressed replication forks and synthetic lethality. Thus, miR223-3p is a negative regulator of the aNHEJ DNA repair and represents a therapeutic pathway for BRCA1- or BAP1-deficient cancers.


Platform-integrated mRNA isoform quantification.
Accurate estimation of transcript isoform abundance is critical for downstream transcriptome analyses and can lead to precise molecular mechanisms for understanding complex human diseases, like cancer. Simplex mRNA Sequencing (RNA-Seq) based isoform quantification approaches are facing the challenges of inherent sampling bias and unidentifiable read origins. A large-scale experiment shows that the consistency between RNA-Seq and other mRNA quantification platforms is relatively low at the isoform level compared to the gene level. In this project, we developed a platform-integrated model for transcript quantification (IntMTQ) to improve the performance of RNA-Seq on isoform expression estimation. IntMTQ, which benefits from the mRNA expressions reported by the other platforms, provides more precise RNA-Seq-based isoform quantification and leads to more accurate molecular signatures for disease phenotype prediction. In the experiments to assess the quality of isoform expression estimated by IntMTQ, we designed three tasks for clustering and classification of 46 cancer cell lines with four different mRNA quantification platforms, including newly developed NanoString's nCounter technology. The results demonstrate that the isoform expressions learned by IntMTQ consistently provide more and better molecular features for downstream analyses compared with five baseline algorithms which consider RNA-Seq data only. An independent RT-qPCR experiment on seven genes in twelve cancer cell lines showed that the IntMTQ improved overall transcript quantification. The platform-integrated algorithms could be applied to large-scale cancer studies, such as The Cancer Genome Atlas (TCGA), with both RNA-Seq and array-based platforms available. Source code is available at: https://github.com/CompbioLabUcf/IntMTQ. Supplementary data are available at Bioinformatics online.


The importance of H2 haplotype sharing in the induction of specific unresponsiveness by pretransplant blood transfusions.
The beneficial effect on graft survival achieved by pretransplant blood transfusions is well established. Previous studies have shown that the degree of major histocompatibility complex (MHC) (mis)-match between the transfusion donor and the recipient plays a determining role. However, other factors are also involved. In this study, we explored the hypothesis that, in addition to sharing of MHC antigens between the transfusion donor and the recipient, the MHC type of the organ donor is also of importance. To mimic the human situation, F1 mice, rather than inbred strains, were pretreated with haplotype-shared allogeneic whole blood transfusions and transplanted with hearts of organ donors with different matched or mismatched H2 haplotypes. When a heart was transplanted 1 week after donor-specific transfusion (DST; blood transfusion donor=organ donor), an excellent prolongation of graft survival was obtained (median survival time: 77 days vs. 9 days in untreated mice). However, this was only the case when a haplotype was shared with the recipient; a DST given with no match between organ donor (=BT donor) and recipient did not induce any prolongation. Furthermore, in order to obtain the optimal beneficial effect of a haplotype-shared blood transfusion, the other haplotype of the transfusion donor had to be mismatched with the recipient. The immunogenetic studies showed that haplotype-shared blood transfusions in combinations where the H2 type of the organ donor differed from that of the transfusion donor are less efficient in inducing prolongation of graft survival. These results demonstrate that haplotype-shared blood transfusions can induce a significantly prolonged survival of cardiac allografts in F1 mice. The immunogenetic studies suggest that presentation of alloantigen-derived peptides in the context of self MHC (the indirect pathway of allorecognition) is essential for the beneficial effect of haplotype-shared blood transfusions.


Flow-directed synthesis of spatially variant arrays of branched zinc oxide mesostructures.
The use of fluid flow to control crystal morphology during the liquid-phase synthesis of inorganic nanomaterials is a relatively under explored approach. Synthetic strategies that take advantage of flow effects present the opportunity to tune several parameters (e.g., flow velocity and direction) in addition to conventional growth parameters (e.g., time, temperature, chemistry, and concentration), and thus enable additional levels of control in the bottom-up synthesis of nanomaterials. The current work reports the application of microfluidics to the rational synthesis of spatially variant arrays of branched zinc oxide (ZnO) nanorods with predictable morphological and compositional characteristics. Specifically, the dislocation driven growth rates of branches within ZnO nanorod arrays was rationally controlled using dynamic, high-velocity precursor flow, yielding ZnO mesostructures with morphology that depended on the location within the arrays. This approach compliments current synthetic strategies and is generally applicable to a range of materials with a diverse set of functional properties (e.g., optical, magnetic, electronic) and applications.


Proteins interacting with nicotinic acetylcholine receptors: expanding functional and therapeutic horizons.
Nicotinic acetylcholine receptors (nAChRs) are ligand-gated ion channels that carry out the fast actions of the neurotransmitter acetylcholine (ACh). Over the past 30 years, it has become clear that the activity of nAChRs is dependent on their interaction with a host of proteins, and the number of these that have been identified has increased considerably with recent large-scale proteomic analyses. This review focuses on these interacting proteins, discussing how they regulate a wide range of functions including receptor assembly, and trafficking to and from the cell surface, as well as how they directly modulate functional characteristics such as sensitivity and the degree of response to ACh. Mutations giving rise to disease states highlight the importance of these interacting proteins. Here, we consider their potential as future therapeutic targets for treating diseases associated with altered nAChR function.


Update on toxic myopathies.
The toxic myopathies are a clinically and pathologically diverse group of disorders that can be caused by a variety of therapeutic agents used in clinical practice, as well as various venoms and other biological toxins. The most important iatrogenic causes are the statin and fibrate cholesterol-lowering agents that can cause a severe necrotizing myopathy and acute rhabdomyolysis and myoglobinuria. The current update focuses on the mechanisms of statin myotoxicity and the importance of genetic predisposing factors for statin myopathy, as well as the recently described form of necrotizing autoimmune myopathy, which is associated with antibodies to the 3-hydroxy-3-methylglutaryl-coenzyme A reductase enzyme and is responsive to aggressive immunotherapy. Mitochondrial myopathies associated with antiretroviral agents and the pyrimidine nucleoside analogue clevudine, and recent reports of myopathies caused by ingestion of red yeast rice and toxic species of mushrooms are also discussed.


Regulatory T cells: context matters.
Regulatory T cells are important for ensuring that the immune system does not attack self and does not overreact to external antigens. Understanding how these cells develop and maintain stable function provides general insights into cellular differentiation in general, as well as new opportunities for therapeutic manipulation.


Inhibition of Gli1 mobilizes endogenous neural stem cells for remyelination.
Enhancing repair of myelin is an important but still elusive therapeutic goal in many neurological disorders. In multiple sclerosis, an inflammatory demyelinating disease, endogenous remyelination does occur but is frequently insufficient to restore function. Both parenchymal oligodendrocyte progenitor cells and endogenous adult neural stem cells resident within the subventricular zone are known sources of remyelinating cells. Here we characterize the contribution to remyelination of a subset of adult neural stem cells, identified by their expression of Gli1, a transcriptional effector of the sonic hedgehog pathway. We show that these cells are recruited from the subventricular zone to populate demyelinated lesions in the forebrain but never enter healthy, white matter tracts. Unexpectedly, recruitment of this pool of neural stem cells, and their differentiation into oligodendrocytes, is significantly enhanced by genetic or pharmacological inhibition of Gli1. Importantly, complete inhibition of canonical hedgehog signalling was ineffective, indicating that the role of Gli1 both in augmenting hedgehog signalling and in retarding myelination is specialized. Indeed, inhibition of Gli1 improves the functional outcome in a relapsing/remitting model of experimental autoimmune encephalomyelitis and is neuroprotective. Thus, endogenous neural stem cells can be mobilized for the repair of demyelinated lesions by inhibiting Gli1, identifying a new therapeutic avenue for the treatment of demyelinating disorders.


Inhibitory effect of conjugated eicosapentaenoic acid on mammalian DNA polymerase and topoisomerase activities and human cancer cell proliferation.
Conjugated eicosapentaenoic acid (cEPA) selectively inhibited the activities of mammalian DNA polymerases (pols) and human DNA topoisomerases (topos) [Yonezawa Y, Tsuzuki T, Eitsuka T, Miyazawa T, Hada T, Uryu K, et al. Inhibitory effect of conjugated eicosapentaenoic acid on human DNA topoisomerases I and II. Arch Biochem Biophys 2005;435:197-206]. In this report, we investigated the inhibitory effect of cEPA on a human promyelocytic leukemia cell line, HL-60, to determine which enzymes influence cell proliferation. cEPA inhibited the proliferation of HL-60 cells (LD(50)=20.0 microM), and the inhibitory effect was stronger than that of non-conjugated EPA. cEPA arrested the cells at G1/S-phase, increased cyclin A and E protein levels, and prevented the incorporation of thymidine into the cells, indicating that it blocks the primary step of in vivo DNA replication by inhibiting the activity of replicative pols rather than topos. This compound also induced apoptosis of the cells. These results suggested the therapeutic potential of cEPA as a leading anti-cancer compound that poisons pols.


Management of heavy menstrual bleeding: is hysterectomy the radical mastectomy of gynecology?
Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.


Optogenetically induced low-frequency correlations impair perception.
Deployment of covert attention to a spatial location can cause large decreases in low-frequency correlated variability among neurons in macaque area V4 whose receptive-fields lie at the attended location. It has been estimated that this reduction accounts for a substantial fraction of the attention-mediated improvement in sensory processing. These estimates depend on assumptions about how population signals are decoded and the conclusion that correlated variability impairs perception, is purely hypothetical. Here we test this proposal directly by optogenetically inducing low-frequency fluctuations, to see if this interferes with performance in an attention-demanding task. We find that low-frequency optical stimulation of neurons in V4 elevates correlations among pairs of neurons and impairs the animal's ability to make fine sensory discriminations. Stimulation at higher frequencies does not impair performance, despite comparable modulation of neuronal responses. These results support the hypothesis that attention-dependent reductions in correlated variability contribute to improved perception of attended stimuli.


Alloreactive 2C T cells recognize a self peptide in the context of the mutant Kbm3 molecule.
Previous studies hav shown that 2C T cells have dual specificity for Ld and Kbm3 alloantigens and are positively selected in the context of Kb. Analysis of Kbm3-eluted peptides reveals a single HPLC fraction that is a central component of the Kbm3 allodeterminant. Peptides with biologic and biochemical properties indistinguishable from those of the Kbm3 allopeptide were also isolated from Kb and Kbm8, despite the fact that cells bearing these class I molecules are not efficient targets for 2C T cells. The allopeptide was isolated and compared with p2Ca, the Ld allopeptide recognized by 2C T cells in the context of Ld. The Kbm3 allopeptide was found to be biochemically and functionally different from p2Ca. Therefore, the 2C TCR has dual specificity for two different peptides presented in the context of two structurally distinct class I molecules. The possibility of a common peptide being bound by Kb, Kbm3, and Kbm8 suggests that the peptide defined as an allodeterminant in the context of Kbm3 may also function in the positive selection of 2C T cells when presented in the context of Kb and Kbm8 during thymic development. In support of this view, the allopeptide was also found in Kb and Kbm8 thymic peptide eluates.


Bioaccumulation assessment using predictive approaches.
Mandated efforts to assess chemicals for their potential to bioaccumulate within the environment are increasingly moving into the realm of data inadequacy. Consequently, there is an increasing reliance on predictive tools to complete regulatory requirements in a timely and cost-effective manner. The kinetic processes of absorption, distribution, metabolism, and elimination (ADME) determine the extent to which chemicals accumulate in fish and other biota. Current mathematical models of bioaccumulation implicitly or explicitly consider these ADME processes, but there is a lack of data needed to specify critical model input parameters. This is particularly true for compounds that are metabolized, exhibit restricted diffusion across biological membranes, or do not partition simply to tissue lipid. Here we discuss the potential of in vitro test systems to provide needed data for bioaccumulation modeling efforts. Recent studies demonstrate the utility of these systems and provide a "proof of concept" for the prediction models. Computational methods that predict ADME processes from an evaluation of chemical structure are also described. Most regulatory agencies perform bioaccumulation assessments using a weight-of-evidence approach. A strategy is presented for incorporating predictive methods into this approach. To implement this strategy it is important to understand the "domain of applicability" of both in vitro and structure-based approaches, and the context in which they are applied.


A third type of defensive behavior in the tenebrionid beetle Zophobas atratus pupae.
Pupae of the tenebrionid beetle Zophobas atratus Fabricius (Coleoptera: Tenebrionidae) exhibit two types of reflex abdominal motions in response to tactile stimulation: circular rotation and lateral bending to close pinching devices (gin-traps). In the present study, the pupa exhibited novel, sequential abdominal movements at 0.3-2.2 sec after the onset of mechanical stimulation. The most effective stimulation was gentle, double brushing on the ventral surface of an abdominal segment (sternite). The sequential abdominal movements consisted of the following three types of discrete elementary motions (100-350 ms in duration): rapid vibration of 30-40 Hz, circular rotation (or swing), and small wiggling movements. A sequence of abdominal movements generally started with a few bouts of vibration, but the number and order of subsequent motions varied considerably among different sessions and conditions. A restrained pupa often showed a prolonged sequence of many motions, including several rotations, whereas an unrestrained pupa often shortened the sequence by skipping a few rotations after the displacement of its whole body induced by the first abdominal rotation. Stimulation of two types of mechanosensitive sensilla, the hair sensilla (touch sensors) and campaniform sensilla (strain sensors), seemed to be necessary to initiate the defensive response. In natural environments, crawling of a small predator (or parasitoid) on the surface of the abdomen or repeated attacks of a large predator may induce this defensive response in the pupae.


Effects of Essential Newborn Care Training on Fresh Stillbirths and Early Neonatal Deaths by Maternal Education.
Infants of women with lower education levels are at higher risk for perinatal mortality. We explored the impact of training birth attendants and pregnant women in the Essential Newborn Care (ENC) Program on fresh stillbirths (FSBs) and early (7-day) neonatal deaths (END) by maternal education level in developing countries. A train-the-trainer model was used with local instructors in rural communities in six countries (Argentina, Democratic Republic of the Congo, Guatemala, India, Pakistan, and Zambia). Data were collected using a pre-/post-active baseline controlled study design. A total of 57,643 infants/mothers were enrolled. The follow-up rate at 7 days of age was 99.2%. The risk for FSB and END was higher for mothers with 0-7 years of education than for those with ≥8 years of education during both the pre- and post-ENC periods in unadjusted models and in models adjusted for confounding. The effect of ENC differed as a function of maternal education for FSB (interaction p = 0.041) without evidence that the effect of ENC differed as a function of maternal education for END. The model-based estimate of FSB risk was reduced among mothers with 0-7 years of education (19.7/1,000 live births pre-ENC, CI: 16.3, 23.0 vs. 12.2/1,000 live births post-ENC, CI: 16.3, 23.0, p < 0.001), but was not significantly different for mothers with ≥8 years of education, respectively. A low level of maternal education was associated with higher risk for FSB and END. ENC training was more effective in reducing FSB among mothers with low education levels.


Correlates and predictors of loneliness in older-adults: a review of quantitative results informed by qualitative insights.
Older persons are particularly vulnerable to loneliness because of common age-related changes and losses. This paper reviews predictors of loneliness in the older population as described in the current literature and a small qualitative study. Peer-reviewed journal articles were identified from psycINFO, MEDLINE, and Google Scholar from 2000-2012. Overall, 38 articles were reviewed. Two focus groups were conducted asking older participants about the causes of loneliness. Variables significantly associated with loneliness in older adults were: female gender, non-married status, older age, poor income, lower educational level, living alone, low quality of social relationships, poor self-reported health, and poor functional status. Psychological attributes associated with loneliness included poor mental health, low self-efficacy beliefs, negative life events, and cognitive deficits. These associations were mainly studied in cross-sectional studies. In the focus groups, participants mentioned environmental barriers, unsafe neighborhoods, migration patterns, inaccessible housing, and inadequate resources for socializing. Other issues raised in the focus groups were the relationship between loneliness and boredom and inactivity, the role of recent losses of family and friends, as well as mental health issues, such as shame and fear. Future quantitative studies are needed to examine the impact of physical and social environments on loneliness in this population. It is important to better map the multiple factors and ways by which they impact loneliness to develop better solutions for public policy, city, and environmental planning, and individually based interventions. This effort should be viewed as a public health priority.


High-level resistance to Bacillus thuringiensis toxin crylac and cadherin genotype in pink bollworm.
Resistance to transgenic cotton, Gossypium hirsutum L., producing Bacillus thuringiensis (Bt) toxin Cry1Ac is linked with three recessive alleles of a cadherin gene in laboratory-selected strains of pink bollworm, Pectinophora gossypiella (Saunders), a major cotton pest. Here, we analyzed a strain (MOV97-R) with a high frequency of cadherin resistance alleles, a high frequency of resistance to 10 microg of Cry1Ac per milliliter of diet, and an intermediate frequency of resistance to 1000 microg of Cry1Ac per ml of diet. We selected two strains for increased resistance by exposing larvae from MOV97-R to diet with 1000 microg of Cry1Ac per ml of diet. In both selected strains, two to three rounds of selection increased survival at 1000 microg of CrylAc per ml of diet to at least 76%, indicating genetic variation in survival at this high concentration and yielding >4300-fold resistance relative to a susceptible strain. Variation in cadherin genotype did not explain variation in survival at 1000 microg of Cry1Ac per ml of diet, implying that one or more other loci affected survival at this concentration. This conclusion was confirmed with results showing that when exposure to Cry1Ac stopped, survival at 1000 microg of Cry1Ac per ml of diet dropped substantially, but survival at 10 microg Cry1Ac per ml of diet remained close to 100% and all survivors had two cadherin resistance alleles. Although survival at 1000 microg of Cry1Ac per ml of diet is not required for resistance to Bt cotton, understanding how genes other than cadherin confer increased survival at this high concentration may reveal novel mechanisms of resistance.


Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey.
Many adolescent girls in low-income and middle-income countries lack appropriate facilities and support in school to manage menstruation. Little research has been conducted on how menstruation affects school absence. This study examines the association of menstrual hygiene management knowledge, facilities and practice with absence from school during menstruation among Bangladeshi schoolgirls. We conducted a nationally representative, cross-sectional study in Bangladeshi schools from March to June 2013 among girls 11 to 17 years old who reached menarche. We sampled 700 schools from 50 urban and 50 rural clusters using a probability proportional to size technique. We interviewed 2332 schoolgirls and conducted spot checks in each school for menstrual hygiene facilities. To assess factors associated with reported school absence, we estimated adjusted prevalence difference (APD) for controlling confounders' effect using generalised estimating equations to account for school-level clustering. Among schoolgirls who reached menarche, 41% (931) reported missing school, an average of 2.8 missed days per menstrual cycle. Students who felt uncomfortable at school during menstruation (99% vs 32%; APD=58%; CI 54 to 63) and who believed menstrual problems interfere with school performance (64% vs 30%; APD=27; CI 20 to 33) were more likely to miss school during menstruation than those who did not. School absence during menstruation was less common among girls attending schools with unlocked toilet for girls (35% vs 43%; APD=-5.4; CI -10 to -1.6). School absence was more common among girls who were forbidden from any activities during menstruation (41% vs 33%; APD=9.1; CI 3.3 to 14). Risk factors for school absence included girl's attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction. Enabling girls to manage menstruation at school by providing knowledge and management methods prior to menarche, privacy and a positive social environment around menstrual issues has the potential to benefit students by reducing school absence.


No benefit of ultrasound-guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double-blind randomized controlled trial.
Advances in laparoscopic techniques combined with enhanced recovery pathways have led to faster recuperation and discharge after colorectal surgery. Peripheral nerve blockade using transversus abdominis plane (TAP) blocks reduce opioid requirements and provide better analgesia for laparoscopic colectomies than do inactive controls. This double-blind randomized study was performed to compare TAP blocks using bupivacaine with standardized wound infiltration with local anaesthetic (LA). Seventy-one patients were randomized to receive either TAP block or wound infiltration. The TAP blocks were performed by experienced anaesthetists who used ultrasound guidance to deliver 40 ml of 0.25% bupivacaine post-induction into the transverse abdominis plane. In the control group, 40 ml of 0.25% bupivacaine was injected around the trocar and the extraction site by the surgeon. Both groups received patient-controlled analgesia (PCA) with intravenous morphine. Patients and nursing staff assessed pain scores 6, 12, 24 and 48 h after surgery. The primary outcome was overall morphine use in the first 48 h. Of the 71 patients, 20 underwent a right hemicolectomy and 51 a high anterior resection. The modified intention-to-treat analysis showed no significant differences in overall morphine use [47.3 (36.2-58.5) mg vs 46.7 (36.2-57.3) mg; mean (95% CI), P = 0.8663] in the first 48 h. Pain scores were similar at 6, 12, 24 and 48 h. No differences were found regarding time to mobilization, resumption of diet and length of hospital stay. In elective laparoscopic colectomies, standardized wound infiltration with LA has the same analgesic effect as TAP blocks post-induction using bupivacaine at 48 h.


Education in preventing HIV infection in Greek registered prostitutes.
From March 1984 to November 1985, 350 Greek registered prostitutes were screened for anti-HIV. Twelve of them (3.4%) were found to be positive. To monitor and control the further spread of HIV infection, an intensive educational campaign was established and screening every 3 months was implemented. Until October 1986, two new seroconversions were detected out of 270 examined (seroconversion rate of 0.74% per year). Further HIV infections have not been detected among the 282 prostitutes followed to 1988. This should be attributed to avoidance of clients from Central Africa and mainly to almost universal use of condoms as a result of the intensive educational campaign.


Eva1 Maintains the Stem-like Character of Glioblastoma-Initiating Cells by Activating the Noncanonical NF-κB Signaling Pathway.
Glioblastoma (GBM)-initiating cells (GIC) are a tumorigenic subpopulation that are resistant to radio- and chemotherapies and are the source of disease recurrence. Therefore, the identification and characterization of GIC-specific factors is critical toward the generation of effective GBM therapeutics. In this study, we investigated the role of epithelial V-like antigen 1 (Eva1, also known as myelin protein zero-like 2) in stemness and GBM tumorigenesis. Eva1 was prominently expressed in GICs in vitro and in stem cell marker (Sox2, CD15, CD49f)-expressing cells derived from human GBM tissues. Eva1 knockdown in GICs reduced their self-renewal and tumor-forming capabilities, whereas Eva1 overexpression enhanced these properties. Eva1 deficiency was also associated with decreased expression of stemness-related genes, indicating a requirement for Eva1 in maintaining GIC pluripotency. We further demonstrate that Eva1 induced GIC proliferation through the activation of the RelB-dependent noncanonical NF-κB pathway by recruiting TRAF2 to the cytoplasmic tail. Taken together, our findings highlight Eva1 as a novel regulator of GIC function and also provide new mechanistic insight into the role of noncanonical NF-κB activation in GIC, thus offering multiple potential therapeutic targets for preclinical investigation in GBM.


Distribution and biological activities of the flavonoid luteolin.
Epidemiological evidence suggests that flavonoids may play an important role in the decreased risk of chronic diseases associated with a diet rich in plant-derived foods. Flavonoids are also common constituents of plants used in traditional medicine to treat a wide range of diseases. The purpose of this article is to summarize the distribution and biological activities of one of the most common flavonoids: luteolin. This flavonoid and its glycosides are widely distributed in the plant kingdom; they are present in many plant families and have been identified in Bryophyta, Pteridophyta, Pinophyta and Magnoliophyta. Dietary sources of luteolin include, for instance, carrots, peppers, celery, olive oil, peppermint, thyme, rosemary and oregano. Preclinical studies have shown that this flavone possesses a variety of pharmacological activities, including antioxidant, anti-inflammatory, antimicrobial and anticancer activities. The ability of luteolin to inhibit angiogenesis, to induce apoptosis, to prevent carcinogenesis in animal models, to reduce tumor growth in vivo and to sensitize tumor cells to the cytotoxic effects of some anticancer drugs suggests that this flavonoid has cancer chemopreventive and chemotherapeutic potential. Modulation of ROS levels, inhibition of topoisomerases I and II, reduction of NF-kappaB and AP-1 activity, stabilization of p53, and inhibition of PI3K, STAT3, IGF1R and HER2 are possible mechanisms involved in the biological activities of luteolin.


Idiopathic interstitial pneumonias with connective tissue diseases features: A review.
A systematic approach is recommended to search for clinical and biological features of connective tissue disease (CTD) in any patient with interstitial lung disease (ILD). In the diagnostic approach to ILD, a diagnosis of CTD should be considered particularly in women and subjects younger than 50 years, and in those with an imaging and/or pathological pattern of non-specific interstitial pneumonia. However, the diagnosis of CTD may be difficult when ILD is the presenting or the dominant manifestation of CTD. A proportion of patients with ILD present symptoms that belong to the spectrum of CTD and/or biological autoimmune features, but do not fulfil diagnostic criteria for a given CTD. Some imaging and histopathological patterns may also suggest the presence of an underlying CTD. Although studies published to date used heterogeneous definitions and terminology for this condition, evidence is accumulating that even limited CTD features are relevant regarding symptoms, imaging features, pathological pattern and possibly evolution to overt CTD, whereas the impact on prognosis needs confirmation. Conversely, autoantibodies alone do not seem to impact the prognosis or management in patients with otherwise typical idiopathic pulmonary fibrosis and no extra-pulmonary manifestation. A collective international multidisciplinary effort has proposed a uniform definition and criteria for 'interstitial pneumonia with autoimmune features', a condition characterized by limited CTD features occurring in the setting of ILD, with the aim of fostering future clinical studies. Referral of ILD patients suspect to have CTD to a rheumatologist and possibly multidisciplinary discussion may contribute to a better management.


Iron, folate and vitamin B12 status of an elderly South African population.
To determine the prevalence of anaemia and the haemopoietic nutrient status of older mixed ancestry (coloured) South Africans. A cross-sectional analytic study. A random sample of 200 non-institutionalized subjects aged > or = 65 y of age, resident in urban Cape Town, was drawn using a two-stage cluster design. Trained fieldworkers interviewed subjects to obtain demographic and lifestyle data. Dietary intake was assessed using a validated food frequency questionnaire. Fasting blood samples were drawn for the determination of haematological parameters, serum vitamin B12, serum folate, RBC folate and a full blood count. The prevalence of anaemia was 13.9. Eight of the 26 cases of anaemia (31) were associated with suboptimal haemopoietic nutrient status; 2(25) and 3(38) cases of these 8 anaemic subjects had suboptimal vitamin B12 and folate status, respectively. Iron deficiency anaemia accounted for 5(63) of the subjects with nutrition-related anaemia. Ten men and two women (6.5 of subjects) had raised serum ferritin concentrations, half of whom had abnormal biochemical parameters indicative of alcohol abuse. Older coloured South Africans, particularly women, should be encouraged to eat diets with a high nutrient density and to consume adequate amounts of foods high in iron, folate and vitamin B12. Further investigation regarding the high prevalence of hyperferritinaemia found in the men in this population is indicated.


Donepezil delays progression to AD in MCI subjects with depressive symptoms.
To determine whether the presence of depression predicts higher rate of progression to Alzheimer disease (AD) in patients with amnestic mild cognitive impairment (aMCI) and whether donepezil treatment beneficially affect this relationship. The study sample was composed of 756 participants with aMCI from the 3-year, double-blind, placebo-controlled Alzheimer's Disease Cooperative Study drug trial of donepezil and vitamin E. Beck Depression Inventory (BDI) was used to assess depressive symptoms at baseline and participants were followed either to the end of study or to the primary endpoint of progression to probable or possible AD. Cox proportional hazards regression, adjusted for age at baseline, gender, apolipoprotein genotype, and NYU paragraph delayed recall score, showed that higher BDI scores were associated with progression to AD (p = 0.03). The sample was stratified into depressed (BDI score > or =10; n = 208) and nondepressed (BDI <10; n = 548) groups. Kaplan-Meier analysis showed that among the depressed subjects, the proportion progressing to AD was lower for the donepezil group than the combined vitamin E and placebo groups at 1.7 years (p = 0.023), at 2.2 years (p = 0.025), and remained marginally lower at 2.7 years (p = 0.070). The survival curves among the three treatment groups did not differ within the nondepressed participants. Results suggest that depression is predictive of progression from amnestic mild cognitive impairment (aMCI) to Alzheimer disease (AD) and treatment with donepezil delayed progression to AD among depressed subjects with aMCI. Donepezil appears to modulate the increased risk of AD conferred by the presence of depressive symptoms.


Brain MR: pathologic correlation with gross and histopathology. 2. Hyperintense white-matter foci in the elderly.
MR was performed on 23 formalin-fixed brain specimens of patients 60 years old or older at the time of death. In two of these subjects MR had also been performed in vivo prior to death. Fifteen hyperintense white-matter foci were found on long TR MR images in seven brains. These lesions were correlated with gross and microscopic pathology. Six lesions were infarctions, two were small foci of gliosis or noncavitated infarcts, two were plaques of demyelination, one was a minute brain cyst, and one was a congenital diverticulum of the lateral ventricle; in three foci the abnormality was not found. We identified no MR criteria to distinguish noncystic infarction from either gliosis or demyelination. However, MR was able to distinguish all these lesions from fluid-containing spaces-including cystic infarction, brain cyst, and ventricular diverticulum-since the lesions in the latter group may be isointense relative to CSF in vivo or to fluid in the subarachnoid space in the postmortem fixed state on all pulse sequences. The relationship of a ventricular diverticulum and a brain cyst to the ventricle or subarachnoid space serves as an additional differentiating feature on MR. In cases in which CT was also performed, it revealed corresponding hypodensities in two infarctions, but failed to reveal the foci of gliosis (or noncavital infarction), demyelination, or brain cyst. These data suggest that subtle changes of gliosis and demyelination, presumably from chronic vascular insufficiency, and/or frank infarction account for the majority of hyperintense white-matter lesions seen in MR in elderly patients. Distinguishing among the various lesions is difficult, but subtle differences are present when MR is correlated with histopathology.


Nucleotide sequence of kidney androgen-regulated protein mRNA and its cell-specific expression in Tfm/Y mice.
Kidney androgen-regulated protein (KAP) mRNA is an abundant renal mRNA that was originally identified by comparisons of the products of in vitro translation of poly(A) RNA from animals before and after androgen stimulation. KAP mRNA is 607 nucleotides long, excluding its poly(A) segment, and encodes a protein of 13,265 mol wt. A hydrophobic N-terminal domain forms a putative signal peptide of 18 amino acids, the cleavage of which results in a 103-amino acid mature protein with a molecular size of 11,297. The protein is highly negatively charged and contains regions of clustered Pro, Glu/Asp, Ser, and Thr residues that are associated with proteins with short half-lives. KAP mRNA is unusual in that it is expressed in two distinct regions of the kidney under different hormonal treatments. It is expressed throughout the cortex in the epithelial lining of the proximal tubules in response to androgen stimulation. After castration, only tubules in the outer stripe of the medulla express KAP mRNA. The androgen receptor-deficient Tfm/Y mutant strain exhibits KAP mRNA induction only in this juxtamedullary region after testosterone treatment. Expression of KAP mRNA in these cells is responsible for the relatively high basal levels of KAP mRNA in female and castrated male animals, and induction in these cells occurs by an androgen receptor (AR)-independent mechanism.


EVALUATION OF NUTRITIONAL STATUS IN PATIENTS WITH CYSTIC FIBROSIS ACCORDING TO AGE GROUP.
To evaluate the nutritional profile of the population assisted at a reference center for cystic fibrosis treatment. Cross-sectional study including patients with cystic fibrosis assisted at a pediatric reference center in São Paulo, Brazil, in 2014. All patients attending regular visits who agreed to participate in the study were included. A questionnaire on dietary habits (24-hour diet recall) and socioeconomic characteristics was applied. Anthropometric data (compared with the reference from the World Health Organization, 2006 and 2007) and pulmonary function data were collected from medical records. Patients were stratified into age groups for statistical analysis. A total of 101 patients were included in the study (59.4% male, 86.4% Caucasian), with median age of 10 years old. Most patients (n=77; 75%) were classified as eutrophic, but lower values of body mass index (BMI) Z scores were observed in schoolchildren and adolescents. The proportion of underweight patients was 10% (n=2) among preschoolers and 35% (n=6) of the school age group. Dietary intake was adequate, and the use of only two supplements (medium chain triglycerides and complete powdered supplement) was associated with adequacy of macronutrient intake. The socioeconomic characteristics did not show any statistical association with the nutritional state or nutritional consumption. Lung function was not significantly different between neither adolescents nor individuals with worse nutritional status in this sample. Most of the patients presented adequate nutritional status and adequate consumption of calories and macronutrients, indicating appropriate nutritional management. New studies focusing on preschool children should be performed to assess if it is possible to reduce the nutritional risk of patients with cystic fibrosis at older ages.


Activity of Thioallyl Compounds From Garlic Against Giardia duodenalis Trophozoites and in Experimental Giardiasis.
Fresh aqueous extracts (AGEs) and several thioallyl compounds (TACs) from garlic have an important antimicrobial activity that likely involves their interaction with exposed thiol groups at single aminoacids or target proteins. Since these groups are present in Giardia duodenalis trophozoites, in this work we evaluated the anti-giardial activity of AGE and several garlic's TACs. In vitro susceptibility assays showed that AGE affected trophozoite viability initially by a mechanism impairing cell integrity and oxidoreductase activities while diesterase activities were abrogated at higher AGE concentrations. The giardicidal activities of seven TACs were related to the molecular descriptor HOMO (Highest Occupied Molecular Orbital) energy and with their capacity to modify the -SH groups exposed in giardial proteins. Interestingly, the activity of several cysteine proteases in trophozoite lysates was inhibited by representative TACs as well as the cytopathic effect of the virulence factor giardipain-1. Of these, allicin showed the highest anti-giardial activity, the lower HOMO value, the highest thiol-modifying activity and the greatest inhibition of cysteine proteases. Allicin had a cytolytic mechanism in trophozoites with subsequent impairment of diesterase and oxidoreductase activities in a similar way to AGE. In addition, by electron microscopy a marked destruction of plasma membrane and endomembranes was observed in allicin-treated trophozoites while cytoskeletal elements were not affected. In further flow cytometry analyses pro-apoptotic effects of allicin concomitant to partial cell cycle arrest at G2 phase with the absence of oxidative stress were observed. In experimental infections of gerbils, the intragastric administration of AGE or allicin decreased parasite numbers and eliminated trophozoites in experimentally infected animals, respectively. These data suggest a potential use of TACs from garlic against G. duodenalis and in the treatment of giardiasis along with their additional benefits in the host's health.


Measuring Disability Inclusion: Feasibility of Using Existing Multidimensional Poverty Data in South Africa.
This paper presents a framework for measuring disability inclusion in order to examine the associations between disability severity and levels of inclusion, provides an example of its operationalization, and assesses the feasibility of using an existing dataset to measure disability inclusion using this framework. Inclusion here refers to the extent to which people with disabilities are accepted and recognized as individuals with authority, enjoy personal relationships, participate in recreation and social activities, have appropriate living conditions, are able to make productive contributions, and have required formal and informal support. Indicators for the operationalization were drawn from the Individual Deprivation Measure South Africa country study and were mapped on to the domains of inclusion (where relevant), and the Washington Group Short Set of questions were used to determine disability status (no, mild, or moderate/severe disability). The analysis indicates that individuals with disabilities experience generally worse outcomes and a comparative lack of inclusion compared to individuals without disabilities, and broadly that those with moderate or severe disabilities experience worse outcomes than those with mild disabilities. This analysis also provides insight into the limitations of using existing datasets for different purposes from their original design.


Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready-to-use therapeutic foods.
Outpatient therapeutic feeding protocols for the treatment of uncomplicated severe acute malnutrition in children were initially based on weight gain data from inpatient settings and expert knowledge of the physiological requirements during recovery. However, weight gain and energy requirements from historic inpatient settings may differ from modern outpatient settings and therefore may not be appropriate to guide current therapeutic feeding protocols. We calculated the weight gain and average estimated total daily energy requirement of children successfully treated for uncomplicated severe acute malnutrition as outpatients in Niger (n = 790). Mean energy provided by six therapeutic feeding protocols was calculated and compared with average estimated energy requirements in the study population. Overall weight gain was 5.5 g·kg-1 ·day-1 among recovered children. Average energy requirements ranged from 92 to 110 kcal·kg-1 ·day-1 depending on the estimation approach. Two current therapeutic feeding protocols were found to provide an excess of energy after the first week of treatment in our study population, whereas four research protocols tended to provide less energy than the estimated requirement after the first week of treatment. Alternative feeding protocols have the potential to simplify and lead to important savings for programmes but should be evaluated to show adequacy to meet the energy needs of children under treatment, as well as feasibility and cost efficiency. Our findings rely on theoretical calculations based on several assumptions and should be confirmed in field studies.


Immunogenicity and safety of the 10-valent pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) co-administered with DTPa vaccine in Japanese children: A randomized, controlled study.
This phase III, randomized, open-label, multicenter study (NCT01027845) conducted in Japan assessed the immunogenicity, safety, and reactogenicity of 10-valent pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV, given intramuscularly) co-administered with diphtheria-tetanus-acellular pertussis vaccine (DTPa, given subcutaneously). Infants (N=360 ) were randomized (2:1) to receive either PHiD-CV and DTPa (PHiD-CV group) or DTPa alone (control group) as 3-dose primary vaccination (3-4-5 months of age) and booster vaccination (17-19 months of age). Immune responses were measured before and one month after primary/booster vaccination and adverse events (AEs) were recorded. Post-primary immune responses were non-inferior to those in pivotal/efficacy European or Latin American pneumococcal protein D-conjugate vaccine studies. For each PHiD-CV serotype, at least 92.6% of infants post-primary vaccination and at least 97.7% of children post-booster had pneumococcal antibody concentrations ≥0.2 μg/ml, and at least 95.4% post-primary and at least 98.1% post-booster had opsonophagocytic activity (OPA) titers ≥8 . Geometric mean antibody concentrations and OPA titers (except OPA titer for 6B) were higher post-booster than post-priming for each serotype. All PHiD-CV-vaccinated children had anti-protein D antibody concentrations ≥100 EL.U/ml one month post-primary/booster vaccination and all were seroprotected/seropositive against each DTPa antigen. Redness and irritability were the most common solicited AEs in both groups. Incidences of unsolicited AEs were comparable between groups. Serious AEs were reported for 47 children (28 in PHiD-CV group); none were assessed as vaccine-related. In conclusion, PHiD-CV induced robust immune responses and was well tolerated when co-administered with DTPa in a 3-dose priming plus booster regimen to Japanese children.


Nuclear mRNA export requires specific FG nucleoporins for translocation through the nuclear pore complex.
Trafficking of nucleic acids and large proteins through nuclear pore complexes (NPCs) requires interactions with NPC proteins that harbor FG (phenylalanine-glycine) repeat domains. Specialized transport receptors that recognize cargo and bind FG domains facilitate these interactions. Whether different transport receptors utilize preferential FG domains in intact NPCs is not fully resolved. In this study, we use a large-scale deletion strategy in Saccharomyces cerevisiae to generate a new set of more minimal pore (mmp) mutants that lack specific FG domains. A comparison of messenger RNA (mRNA) export versus protein import reveals unique subsets of mmp mutants with functional defects in specific transport receptors. Thus, multiple functionally independent NPC translocation routes exist for different transport receptors. Our global analysis of the FG domain requirements in mRNA export also finds a requirement for two NPC substructures-one on the nuclear NPC face and one in the NPC central core. These results pinpoint distinct steps in the mRNA export mechanism that regulate NPC translocation efficiency.


Areas with High Hazard Potential for Autochthonous Transmission of Aedes albopictus-Associated Arboviruses in Germany.
The intensity and extent of transmission of arboviruses such as dengue, chikungunya, and Zika virus have increased markedly over the last decades. Autochthonous transmission of dengue and chikungunya by Aedes albopictus has been recorded in Southern Europe where the invasive mosquito was already established and viraemic travelers had imported the virus. Ae. albopictus populations are spreading northward into Germany. Here, we model the current and future climatically suitable regions for Ae. albopictus establishment in Germany, using climate data of spatially high resolution. To highlight areas where vectors and viraemic travellers are most likely to come into contact, reported dengue and chikungunya incidences are integrated at the county level. German cities with the highest likelihood of autochthonous transmission of Aedes albopictus-borne arboviruses are currently located in the western parts of the country: Freiburg im Breisgau, Speyer, and Karlsruhe, affecting about 0.5 million people. In addition, 8.8 million people live in regions considered to show elevated hazard potential assuming further spread of the mosquito: Baden-Württemberg (Upper Rhine, Lake Constance regions), southern parts of Hesse, and North Rhine-Westphalia (Lower Rhine). Overall, a more targeted and thus cost-efficient implementation of vector control measures and health surveillance will be supported by the detailed maps provided here.


Consequences of the matrix effect on recovery of dinotefuran and its metabolites in green tea during tandem mass spectrometry analysis.
Determining the residues of dinotefuran and its metabolites (MNG, UF, and DN) is highly problematic because of their polar characteristics. Additionally, tea contains many compounds that can interfere with residue analysis. Thus, the aim of the present study was to refine the extraction method that assures good recoveries for dinotefuran and its metabolites and removes most of the matrix components in green tea using liquid chromatography-tandem mass spectrometry (LC/MS/MS). We attempted to increase the extraction efficiency of the QuEChERS method by selecting the appropriate solvents among ethyl acetate, acetone, isopropanol, 25% methanol in acetonitrile, and methanol. We found that methanol was the best extraction solvent for dinotefuran and its polar metabolites in dry green tea samples; however, due to a limitation of an appropriate partitioning salt, acetonitrile was used as the extraction solvent. Matrix enhancement and suppression effects were observed for all analytes, which made the recovery rates variable. DN recovery was <70% when compared with matrix-matched calibration, whereas it was within the acceptable range (70-120%) when compared with solvent calibration. The opposite was observed for MNG and dinotefuran due to a matrix suppression effect. UF recovery was consistent in both matrix-matched and solvent calibrations despite having little suppressive effect. The method was successfully applied and dinotefuran and its metabolite residues were found in field-incurred green tea samples. The current findings suggest that using methanol as an appropriate QuEChERS solvent for problematic polar pesticides and investigating a suitable partitioning salt would considerably strengthen the practical impact of such data.


Virus-Induced Cancers of the Skin and Mucosa: Are We Dealing with "Smoking Guns" or "Smoke and Mirrors" in the Operating Theatre?
Human papillomavirus (HPV) alone is thought to cause ~610,000 cases of cancer per year, and is the dominant aetiological agent for ano-genital (esp. cervical) and head and neck cancers (esp. oropharyngeal). Merkel cell polyomavirus (MCV) is a more recently discovered virus which causes Merkel cell carcinoma, a rare but highly aggressive skin malignancy. We explored the available published evidence to see if transmission of live HPV or MCV virus in smoke generated by laser or diathermy was feasible, and would pose an infection risk. Long-term infection with such carcinogenic viruses would then pose an increased risk for the development of virus-induced cancers in medical personnel. The morphological structures of both HPV and MCV are very similar, and the size, external capsids and genomic structures show striking similarity. Both viruses have a non-enveloped external protein capsid consisting of 72 capsomeres, and a double-stranded DNA core. Sizes of both viruses range from 50 to 60 nm. There are now recent data demonstrating live and infectious HPV in smoke, and that these viruses can be used to infect cells in vitro. Further, anecdotal reports of virus transmission leading to disease causation in the production of respiratory airway viral warts (benign disease), and, finally, reports of HPV-induced oropharyngeal carcinoma (malignant disease) in two gynaecological surgeons as an occupational health hazard have been published recently. There is now sufficient evidence to support the hypotheses that live infectious carcinogenic viruses can be transmitted via smoke generated from surgical procedures, and, in rare instances, actually cause significant disease. Protective measures such as smoke extraction and airway protection should be instituted for all healthcare personnel, particularly those with multiple repeated exposures such as gynaecological surgeons.


Nitrogen-corrected apparent metabolizable energy value of crude glycerol for laying hens.
An experiment was conducted with laying hens to determine the AME(n) value of crude glycerol, a coproduct of biodiesel production. Crude glycerol (87% glycerol, 9% water, 0.03% methanol, 1.26% Na, and 3,625 kcal/kg of gross energy) was obtained from a commercial biodiesel production facility (Ag Processing Inc., Sergeant Bluff, IA). A total of forty-eight 40-wk-old laying hens (Hy-Line W-36) were placed in metabolic cages (2 hens/ cage) and given free access to the experimental diets. A corn and soybean meal-based basal diet (18% CP, 2,875 kcal/kg of AME(n), 4.51% Ca, 0.51% nonphytate P) was formulated with 15% glucose.H(2)O and 1% Celite. Four dietary treatments were created by substituting 0, 5, 10, or 15% crude glycerol for glucose.H(2)O (3,640 kcal/kg of AME(n)). After 7 d of dietary adaptation, excreta were collected twice daily for 3 d, freeze-dried, and analyzed for contents of DM, Kjeldahl N, acid-insoluble ash, and gross energy. Egg production was recorded daily, and eggs were collected on d 7 and 8 of the experiment for calculation of egg mass (egg production x egg weight). Feed consumption was measured over the 10-d experimental period. Egg-production data were analyzed by ANOVA with 4 treatments and 6 replications in a completely randomized experimental design. The AME(n) value of crude glycerol was estimated as the slope of the linear relationship between the inclusion rate of dietary crude glycerol and the glucose-corrected AME(n) value of the experimental diets. No significant treatment effects (P > 0.1) were apparent for egg-production rate (93.0%), egg weight (56.1 g), egg mass (52.2 g/d), or feed consumption (104 g/d). Linear regression analysis (P < 0.001, r(2) = 0.92, n = 24) revealed that the AME(n) value of the crude glycerol used in this study was 3,805 +/- 238 kcal/kg (mean +/- SEM; as-is basis) for laying hens.


COVID-19 policy analysis: labour structure dictates lockdown mobility behaviour.
Countries and cities around the world have resorted to unprecedented mobility restrictions to combat COVID-19 transmission. Here we exploit a natural experiment whereby Colombian cities implemented varied lockdown policies based on ID number and gender to analyse the impact of these policies on urban mobility. Using mobile phone data, we find that the restrictiveness of cities' mobility quotas (the share of residents allowed out daily according to policy advice) does not correlate with mobility reduction. Instead, we find that larger, wealthier cities with more formalized and complex industrial structure experienced greater reductions in mobility. Within cities, wealthier residents are more likely to reduce mobility, and commuters are especially more likely to stay at home when their work is located in wealthy or commercially/industrially formalized neighbourhoods. Hence, our results indicate that cities' employment characteristics and work-from-home capabilities are the primary determinants of mobility reduction. This finding underscores the need for mitigations aimed at lower income/informal workers, and sheds light on critical dependencies between socio-economic classes in Latin American cities.


Holistic acupuncture approach to idiopathic refractory nausea, abdominal pain and bloating.
To evaluate the effectiveness of a holistic acupuncture approach on nausea, pain, bloating and electrogastrogram (EGG) parameters in patients with intractable symptoms. Twelve patients with no or mild nausea (those without nausea had bloating or pain) and 10 with a history of moderate to severe nausea were referred for acupuncture. All underwent an EGG and were treated at acupuncture points PC6, SP4 and DU20. Visual analog scales (VAS) assessing severity of nausea, pain and bloating were obtained before and after acupuncture treatment. Nineteen patients received three and three patients received two treatments. VAS scores for nausea reflected the clinical assessment and differed significantly between mild and moderate/severe nausea groups. Acupuncture significantly improved severity of nausea in both groups with improved pre-treatment nausea between the first and third treatments in the moderate/severe nausea group. Pain scores improved with acupuncture in the mild nausea group only and bloating improved only with the first treatment in this group. Patients with bloating with VAS scores greater than 35 pre-treatment improved with acupuncture and over all VAS scores for pain improved with treatment. Acupuncture increased the power in the 2.7 to 3.5 cpm range in the EGG. In this uncontrolled clinical study, a holistic acupuncture approach significantly improved nausea in patients with refractory symptoms and increased the power in the 2.7-3.5 cpm component of the electrogastrogram. Bloating and pain VAS scores improved acutely with treatment. This study suggests that acupuncture may be effective in this refractory group of patients and further study using appropriate controls is warranted.


WE-E-217BCD-01: Digital Breast Tomosynthesis: Basic Principles and the QMP's Role.
Digital breast tomosynthesis is a form of limited angle tomography, in which section (slice) images are produced from a series of discrete projection images acquired at different angles. Tomosynthesis can be useful in breast imaging by providing potentially better visibility of lesions over conventional mammography, especially in patients with dense breasts. This talk will cover the various physics aspects of DBT, including reconstruction algorithms, the importance of deblurring, and optimizing image acquisition parameters. Remaining important research questions in DBT will be presented and discussed. The presentation will also discuss MQSA Certificate extension process for currently approved digital breast tomosynthesis (DBT) systems. Training requirements, manufacturer required tests for Mammography Equipment Evaluation (MEE) as acceptance tests, and phantom imaging for the purpose of approval of certificate extension will be described. The talk will emphasize the specific tests where special attention must be given and will discuss how the techs should be advised to perform these tests. 1. To understand the fundamentals of tomosynthesis reconstruction, including deblurring, algorithm choice, and optimization 2. To understand FDA's certificate extension process for DBT 3. To understand the requirements for MEE 4. To understand the required AEC tracking data Research sponsored in part by NIH, Siemens, and GE Healthcare.


Validation of a urine test and characterization of the putative genetic mutation for hyperuricosuria in Bulldogs and Black Russian Terriers.
To determine whether hyperuricosuria was a predisposing factor for urate urolithiasis in Bulldogs and Black Russian Terriers (BRTs) and to estimate the allele frequency of the Cys181Phe genetic mutation in urate transporter SLC2A9 in these breeds. 192 Bulldogs, 101 BRTs, 10 Dalmatians, and 9 dogs of other breeds. Uric acid (UA) and creatinine (Cr) concentrations were quantified in urine samples collected from all dogs via midstream catch during natural voiding. Buccal swab or blood samples were also obtained, and DNA was extracted and used to genotype SLC2A9 sequence variants by use of pyrosequencing assays. A urine test for hyperuricosuria was validated in adult dogs by comparing urinary UA:Cr ratios between known hyperuricosuric and nonhyperuricosuric dogs. Significantly higher UA:Cr ratios were found in some Bulldogs and BRTs, compared with ratios in other dogs from these breeds. These dogs were also homozygous for the SLC2A9 Cys181Phe mutation. The allele frequency of the Cys181Phe mutation was 0.16 in Bulldogs and 0.51 in BRTs. On the basis of these allele frequencies, 3% of the Bulldog population and 27% of the BRT population were estimated to be hyperuricosuric. Results suggested the genetic mutation associated with hyperuricosuria, first identified in Dalmatians, also appears to cause hyperuricosuria in Bulldogs and BRTs, indicating that similar management strategies for urate urolithiasis can be used in these breeds. The allele frequency of the mutation was high in both breeds, and DNA testing can be used to select against the mutation.


Early angiogenic proteins associated with high risk for bronchopulmonary dysplasia and pulmonary hypertension in preterm infants.
Early pulmonary vascular disease in preterm infants is associated with the subsequent development of bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH); however, mechanisms that contribute to or identify infants with increased susceptibility for BPD and/or PH are incompletely understood. Therefore, we tested if changes in circulating angiogenic peptides during the first week of life are associated with the later development of BPD and/or PH. We further sought to determine alternate peptides and related signaling pathways with the risk for BPD or PH. We prospectively enrolled infants with gestational age <34 wk and collected blood samples during their first week of life. BPD and PH were assessed at 36 wk postmenstrual age. Samples were assayed for each of the 1,121 peptides included in the SOMAscan scan technology, with subsequent pathway analysis. Of 102 infants in the study, 82 had BPD, and 13 had PH. Multiple angiogenic proteins (PF-4, VEGF121, ANG-1, bone morphogenetic protein 10 [BMP10], hepatocyte growth factor (HGF), ANG-2) were associated with the subsequent diagnosis of BPD; and FGF-19, PF-4, connective tissue activating peptide (CTAP)-III, and PDGF-AA levels were associated with BPD severity. Early increases in BMP10 was strongly associated with the late risk for BPD and PH. We found that early alterations of circulating angiogenic peptides and others were associated with the subsequent development of BPD. We further identified peptides that were associated with BPD severity and BPD-associated PH, including BMP10. We speculate that proteomic biomarkers during the first week of life may identify infants at risk for BPD and/or PH to enhance care and research.


Prevention of unintentional childhood injuries.
Injuries are the leading cause of death in children and teenagers in the United States. The leading causes of unintentional injury vary by age and include drowning, poisoning, suffocation, fires, burns, falls, and motor vehicle, bicycle, and pedestrian-related crashes. Most injuries are preventable by modifying the child's environment (e.g., use of stair gates) and having parents engage in safety practices (e.g., keeping matches or lighters out of reach of children). Effective injury prevention methods include the use of childproof caps on medications and household poisons, age-appropriate restraints in motor vehicles (i.e., car seats, booster seats, seat belts), bicycle helmets, and a four-sided fence with a locked gate around residential swimming pools.


Correlates of sleep irregularity in schizophrenia.
Circadian rhythm disruption, manifested as circadian misalignment, difficulty initiating sleep, and sleep-wake irregularity, is often left unrecognized in patients with schizophrenia. Studies have shown multiple adverse consequences of sleep irregularity, but limited data is available on schizophrenia. This is a secondary analysis of a case-control study of 66 schizophrenia patients with delayed sleep-wake phase (with or without meeting criteria for the disorder) and normal sleep-wake phase (mean age = 44.08 years; 45.45% males). Potential correlates included sleep quality, daytime sleepiness, social rhythms, chronotype, psychiatric symptoms, psychosocial functioning, metabolic index, cognitive function, and sociodemographic, lifestyle and pharmacological factors. Square successive difference (SSD) scores, derived from 1-week sleep diary and actigraphy, were indexes of sleep irregularity. Multilevel modeling analysis, with SSD scores as level-1 measures and the hypothesized correlates as level-2 measures, was performed. Statistical significance was Bonferroni-adjusted. Higher SSD scores of sleep diary and actigraphy variables were significantly associated with positive and depressive symptoms, poor sleep quality, daytime sleepiness, irregular social rhythm, evening chronotype, delayed sleep-wake phase disorder, later caffeine use and dinner time, greater cigarette use, and lower dosages of hypnotics and antipsychotics. Our findings highlight the implications of sleep irregularity in schizophrenia and the need for a multimodal intervention.


Oral, ultra-long-lasting drug delivery: Application toward malaria elimination goals.
Efforts at elimination of scourges, such as malaria, are limited by the logistic challenges of reaching large rural populations and ensuring patient adherence to adequate pharmacologic treatment. We have developed an oral, ultra-long-acting capsule that dissolves in the stomach and deploys a star-shaped dosage form that releases drug while assuming a geometry that prevents passage through the pylorus yet allows passage of food, enabling prolonged gastric residence. This gastric-resident, drug delivery dosage form releases small-molecule drugs for days to weeks and potentially longer. Upon dissolution of the macrostructure, the components can safely pass through the gastrointestinal tract. Clinical, radiographic, and endoscopic evaluation of a swine large-animal model that received these dosage forms showed no evidence of gastrointestinal obstruction or mucosal injury. We generated long-acting formulations for controlled release of ivermectin, a drug that targets malaria-transmitting mosquitoes, in the gastric environment and incorporated these into our dosage form, which then delivered a sustained therapeutic dose of ivermectin for up to 14 days in our swine model. Further, by using mathematical models of malaria transmission that incorporate the lethal effect of ivermectin against malaria-transmitting mosquitoes, we demonstrated that this system will boost the efficacy of mass drug administration toward malaria elimination goals. Encapsulated, gastric-resident dosage forms for ultra-long-acting drug delivery have the potential to revolutionize treatment options for malaria and other diseases that affect large populations around the globe for which treatment adherence is essential for efficacy.


Serum folate and homocysteine levels are associated with colon tumorigenesis in end-stage renal disease patients.
The aim of this study was to evaluate the effect of folate and homocysteine on colon tumorigenesis by performing colonoscopy and examining serum folate and homocysteine levels in end-stage renal disease (ESRD) patients. We performed colonoscopy in 72 ESRD patients who were undergoing hemodialysis and also measured their serum folate and homocysteine levels. Serum folate and homocysteine concentrations of the 72 ESRD patients were 6.0±3.9 μg/l and 37.3±25.5 μmol/l, respectively. Colorectal neoplasia was detected in 47 (65%) of the patients. Compared to a control group, ESRD patients had significantly more and larger neoplasia (P=0.002 and 0.001, respectively). Multivariate analysis revealed that ESRD patients with lower levels of serum homocysteine had significantly more and larger neoplasia than those with higher levels (P=0.02 and 0.03, respectively). In addition, patients with a shorter duration of hemodialysis were likely to have larger neoplasia. ESRD patients had higher than normal serum homocysteine levels. Interestingly, patients with lower homocysteine levels were likely to carry more and larger colorectal neoplasia. These results suggest that suppression of folate metabolism and an elevated serum homocysteine concentration are inversely associated with colon tumorigenesis in ESRD patients.


Trust and informed consent: insights from community members on the Kenyan coast.
Trust is an important theme running through the literature on the ethics of biomedical research, but it is rarely given centre stage. In this paper, we present data gathered from a study aimed at exploring community views regarding the informed consent processes carried out by a large research centre on the Kenyan Coast. The findings point to the centrality of trust and elements of mistrust in general community views, in parents' (mis)understanding of studies they consent their children to be involved in, in refusals and concerns, and in community members' views about whether informed consent is a relevant and practical model to follow. Tentative ideas on how trust and a healthy mistrust might be balanced highlight the importance of strengthening communication surrounding basic health care as well as research, and of fostering 'an inner generated ethic of service'. The latter is particularly fundamental, but cannot be built and regulated through the laws, policies and guidelines that currently govern biomedical research practice.


Targeting TNF alpha for the therapy of rheumatoid arthritis.
Our pre-clinical studies have demonstrated a pathogenic role for TNF alpha in RA. Firstly, TNF alpha and its receptors are upregulated and co-expressed in the synovium and cartilage-pannus junction of RA joints. Secondly, mononuclear cells from RA joints maintained in culture produce many cytokines with pro-inflammatory activity, including TNF alpha. Neutralizing TNF alpha antibodies in vitro reduces the production of these pro-inflammatory cytokines, including IL-1, IL-8, and GM-CSF. Thirdly, when injected into arthritic DBA/l mice with collagen-induced arthritis, monoclonal anti-TNF antibodies decrease inflammatory damage of joints. Clinical trials employing cA2, a monoclonal chimeric anti-TNF alpha antibody, in open-label and randomized placebo-controlled studies have demonstrated a dose-dependent efficacy with impressive improvement in disease activity and acute phase responses lasting several weeks. We conclude that TNF alpha is a critical mediator of inflammation in RA and is an important therapeutic target in this disease.


Toward a novel membrane process for organic carbon removal-fate of slowly biodegradable substrate in super fast membrane bioreactor.
The study tested the performance of super fast membrane bioreactor (SFMBR) using starch as a slowly biodegradable substrate, exploring the fate of starch, and the response of the microbial community. SFMBR was operated at extremely low sludge ages of 0.5-2.0 days, with a hydraulic retention time of 1.0 h. Average values for permeate chemical oxygen demand (COD) always remained in the narrow range between 14 and 18 mg/L, regardless of the selected mode of MBR operation at different sludge ages. Soluble COD levels in the reactor were consistently higher than the corresponding permeate COD. Parameters defining process kinetics, determined by model calibration of oxygen uptake rate (OUR) profiles, varied as a function of sludge age. Model simulation of SFMBR performance indicated total removal of hydrolysis products so that permeate COD consisted of residual microbial products. PCR-DGGE experiments revealed significant shifts in the composition of the microbial community imposed by variations in the sludge age, reflecting on corresponding process kinetics.