Ultrastructural analysis of ectopic synaptic boutons arising from peripherally regenerated primary afferent fibers.
The central axons of peripherally regenerated Abeta primary sensory neurons were impaled in the dorsal columns of alpha-chloralose-anesthetized cats 9-12 mo after axotomy. The adequate peripheral stimulus was determined, and the afferent fibers intracellularly stimulated while simultaneously recording the resulting cord dorsum potentials (CDPs). Fibers that successfully had reinnervated the skin responded to light tactile stimulation, and evoked CDPs that suggested dorsally located boutons were stained intracellularly with horseradish peroxidase (HRP). Two HRP-stained regenerated Abeta afferent fibers were recovered that supported large numbers of axon collaterals and swellings in laminae I, IIo, and IIi. Sections containing the ectopic collateral fibers and terminals in the superficial dorsal horn were embedded in plastic. Analyses of serial ultrathin sections revealed that ectopic projections from both regenerated fibers supported numerous synaptic boutons filled with clear round vesicles, a few large dense core vesicles (LDCVs) and several mitochondria (>3). All profiles examined in serial sections (19) formed one to three asymmetric axo-dendritic contacts. Unmyelinated portions of ectopic fibers giving rise to en passant and terminal boutons often contained numerous clear round vesicles. Several boutons (47%) received asymmetric contacts from axon terminals containing pleomorphic vesicles. These results strongly suggest that regenerated Abeta fibers activated by light tactile stimuli support functional connections in the superficial dorsal horn that have distinct ultrastructural features. In addition, the appearance of LDCVs suggests that primary sensory neurons are capable of changing their neurochemical phenotype.


Protein synthesis in rabbit reticulocytes: characteristics of a postribosomal supernatant factor that reverses inhibition of protein synthesis in heme-deficient lysates and inhibition of ternary complex (Met-tRNAfMet.eIF-2.GTP) formation by heme-regulated inhibitor.
During heme deficiency in reticulocyte lysates, a translational inhibitor (heme-regulated inhibitor, HRI) that blocks polypeptide chain initiation is activated. HRI is a protein kinase that specifically phosphorylates the 38,000-dalton subunit of the Met-tRNAfMet binding factor, eIF-2. Phosphorylation of eIF-2 by HRI prevents its interaction with at least two additional factors, resulting in a net reduction in formation of ternary complex (Met-tRNAfMet.eIF-2.GTP) and AUG-dependent transfer of Met-tRNAfMet to 40S ribosomal subunits. A factor (sRF) that reverses protein synthesis inhibition in heme-deficient lysates has been purified from reticulocyte postribosomal supernatant. sRF also reverses the inhibition of ternary complex formation by HRI in a fractionated system. The ternary complex inhibition reversal activity and the protein synthesis inhibition reversal activity cosediment at 12.5 S upon glycerol density gradient centrifugation, and both activities are sensitive to heat or N-ethylmaleimide. Purified sRF does not dephosphorylate eIF-2 whose phosphorylation has been catalyzed by HRI, nor does the sRF prevent the phosphorylation of eIF-2 by HRI in a fractionated system. sRF stimulates ternary complex formation by both phosphorylated and nonphosphorylated eIF-2. These observations suggest that the sensitivity of protein synthesis to phosphorylation of eIF-2 by HRI may be modulated by the concentration and activity of sRF.


Barriers to health service access among female migrant Ugandan sex workers in Guangzhou, China.
Increased trade between China and Uganda has fueled trafficking of female Ugandans into China. These women may face challenges accessing health services. This study focused on examining barriers to health care access among female Ugandan sex workers in China. In 2014, we undertook in-depth interviews with 19 female Ugandan sex workers in Guangzhou, China. Interviews focused on barriers to health service access and were analyzed using an a priori coding framework followed by open-coding to capture emergent themes. Out of 19 women, 12 women reported a history of being trafficked into China. None of the women had a valid Chinese visa. Fear of being arrested for lack of documentation discouraged women in this sample from accessing hospital services. Low pay, housing exploitation, and remittances contributed to participants' lack of financial resources, which further inhibited their ability to access health services. Participants expressed feeling social isolation from the local community and reported mistrust of local individuals and organizations, including hospitals. Ugandan sex workers in China faced substantial structural barriers that limited health service access. Policy changes and the development of new programs are urgently needed to ensure these women have improved access to health services.


Parental longevity and survival in elderly patients with Hodgkin's lymphoma.
In general, elderly patients with Hodgkin's lymphoma (HL) have a less favorable prognosis than younger patients. Factors such as inadequate therapy often due to decreased tolerance to treatment, presence of intercurrent diseases and accumulation of certain clinical and biological risk factors contribute to the poor outcome. Established predictors of prognosis in HL are less appropriate in the elderly population. Consequently, there is a need for additional markers to guide treatment decisions and to improve prediction of outcome. In the general population, the expected length of life of an individual is intimately associated with that of his/her parents. In a small cohort of elderly HL patients, we had previously observed high familial life-span of two previous generations predicts superior survival. The aim of this study was to test the hypothesis that parental longevity alone--an easily accessible and non-disease associated variable--is also associated with improved outcome using an enlarged series of elderly HL patients. One hundred and twenty-one patients with HL >60 years at diagnosis were included. The median follow-up time was 67 (range 37-175) months. Data regarding age at death and reported cause of death were available through parish offices for 228 (94%) parents. The effect of parental lifespan on HL survival included the use of Kaplan-Meier curves and Cox' proportional hazards regression analysis. Maternal as well as paternal lifespan correlated poorly with HL survival, both with regard to overall and disease-specific survival. There was, however, a tendency towards a decreased risk of dying among patients with low maternal lifespan (all-cause mortality: RR=0.7, 95% CI 0.5-1.0). Parental longevity does not predict superior survival in elderly patients with HL.


Precise nucleosome positioning and the TATA box dictate requirements for the histone H4 tail and the bromodomain factor Bdf1.
Acetylation of histone tails plays a key role in chromatin dynamics and is associated with the potential for gene expression. We show here that a 2-3 bp mispositioning of the nucleosome covering the TATA box at PHO5 induces a dependency on the acetylatable lysine residues of the histone H4 N-terminal region and on the TFIID-associated bromodomain factor Bdf1. This dependency arises either through fusion of the PHO5 promoter to a lacZ reporter or by mutation of the TATA box in the natural gene. The results suggest that promoters in which the TATA box is either absent or poorly accessible on the surface of a nucleosome may compensate by using Bdf1 bromodomains and acetylated H4 tails to anchor TFIID to the promoter during the initial stages of transcription activation. We propose that nucleosome positioning at the nucleotide level provides a subtle, but highly effective, mechanism for gene regulation.


Persistent generation of thrombin after acute myocardial infarction.
During the acute phase of myocardial infarction, the generation of thrombin is reflected in the sudden rise of fibrinopeptide A (FPA) and the thrombin-antithrombin III (TAT) complex in blood. We have systematically determined the FPA and TAT plasma concentrations over a period of 14 days after acute myocardial infarction in 100 patients. Mean levels of both thrombin markers were the highest on admission, remained elevated over the following few days, and then gradually declined after day 5. Still, by the end of the first week two thirds of the patients had distinctly elevated TAT and FPA levels, and by the end of the second week such an abnormality was present in half of them. Continuous intravenous heparin infusion at a dose of 20,000 units/day, administered for 1 week to patients who had either received (n = 21) or not received (n = 17) streptokinase, led to a significant depression (p less than 0.05) of thrombin markers over the first 48 hours, an effect that did not persist over the subsequent days of treatment. In patients not assigned to heparin treatment, those in heart failure had significantly (p less than 0.05) higher mean TAT and FPA values on days 3, 5, and 7 compared with patients in whom heart failure was absent. Infarct extension, pulmonary embolism, and death were also associated with a rise in one or both thrombin markers, often preceding the onset of clinical symptoms. Thrombinogenesis was not accompanied by changes in mean plasma concentrations of prothrombin, antithrombin III, or alpha 2-macroglobulin.(ABSTRACT TRUNCATED AT 250 WORDS)


Predictive and prognostic values of BubR1 and synuclein-gamma expression in breast cancer.
The aim of this study is to determine the expression level of spindle assembly checkpoint (SAC) proteins-BubR1 and synuclein-gamma (SNCG) in human breast cancer tissues and to test whether there is a relationship between their expression levels and clinicopathologic parameters including respons to taxanes, tumor grade, estrogen receptor (ER) pozitivity, HER2 status, and overall survival (OS). We analyzed retrospectively paraffin-embedded tissue sections from 55 breast cancer patients whose clinical outcomes had been tracked after taxane treatment in neoadjuvan and metastatic setting. The expression status of BubR1 and SNCG was defined by immunohistochemistry (IHC) using the anti-BubR1 and anti-SNCG antibody. The BubR1 and SNCG was overexpressed in 38% and 62% of the study group, respectively. There was borderline significant correlation between low BubR1 expression and increased taxane sensitivity (P=0.05). In contrast, high SNCG expression was significantly associated with decreased taxane sensitivity (P=0.01). There was no association between the clinicopathologic parameters including histologic grade, ER positivity and HER2 status and the level of these proteins. However, triple negative tumors showed significantly more high BubR1 expression than those other molecular subtypes (P=0.04). Kaplan-Meier survival analysis failed to show a significant correlation between expression levels of BubR1 and SNCG and overall survival although patients with low levels of both proteins had a marginally longer survival time compared to those with high levels. In summary, our data suggest that both BubR1 and SNCG may be promising predictive marker rather than prognostic marker in patients with breast cancer.


Computational multi-focus imaging combining sparse model with color dependent phase mask.
A method for extended depth of field imaging based on image acquisition through a thin binary phase plate followed by fast automatic computational post-processing is presented. By placing a wavelength dependent optical mask inside the pupil of a conventional camera lens, one acquires a unique response for each of the three main color channels, which adds valuable information that allows blind reconstruction of blurred images without the need of an iterative search process for estimating the blurring kernel. The presented simulation as well as capture of a real life scene show how acquiring a one-shot image focused at a single plane, enable generating a de-blurred scene over an extended range in space.


Diamond Light Source: contributions to SARS-CoV-2 biology and therapeutics.
The impact of COVID-19 on public health and the global economy has led to an unprecedented research response, with a major emphasis on the development of safe vaccines and drugs. However, effective, safe treatments typically take over a decade to develop and there are still no clinically approved therapies to treat highly pathogenic coronaviruses. Repurposing of known drugs can speed up development and this strategy, along with the use of biologicals (notably monoclonal antibody therapy) and vaccine development programmes remain the principal routes to dealing with the immediate impact of COVID-19. Nevertheless, the development of broadly-effective highly potent antivirals should be a major longer term goal. Structural biology has been applied with enormous effect, with key proteins structurally characterised only weeks after the SARS-CoV-2 sequence was released. Open-access to advanced infrastructure for structural biology techniques at synchrotrons and high-end cryo-EM and NMR centres has brought these technologies centre-stage in drug discovery. We summarise the role of Diamond Light Source in responses to the pandemic and note the impact of the immediate release of results in fuelling an open-science approach to early-stage drug discovery.


Proteomics of effector-triggered immunity (ETI) in plants.
Effector-triggered immunity (ETI) was originally termed gene-for-gene resistance and dates back to fundamental observations of flax resistance to rust fungi by Harold Henry Flor in the 1940s. Since then, genetic and biochemical approaches have defined our current understanding of how plant "resistance" proteins recognize microbial effectors. More recently, proteomic approaches have expanded our view of the protein landscape during ETI and contributed significant advances to our mechanistic understanding of ETI signaling. Here we provide an overview of proteomic techniques that have been used to study plant ETI including both global and targeted approaches. We discuss the challenges associated with ETI proteomics and highlight specific examples from the literature, which demonstrate how proteomics is advancing the ETI research field.


Genetic diversity and networks of exchange: a combined approach to assess intra-breed diversity.
Cryopreservation of three endangered Belgian sheep breeds required to characterize their intra-breed genetic diversity. It is assumed that the genetic structure of a livestock breed depends mostly on gene flow due to exchanges between herds. To quantify this relation, molecular data and analyses of the exchanges were combined for three endangered Belgian breeds. For each breed, between 91 and 225 sheep were genotyped with 19 microsatellites. Genetic differentiations between breeds and among herds within a breed were evaluated and the genetic structure of the breeds was described using Bayesian clustering (Structure). Exchanges of animals between 20, 46 and 95 herds according to breed were identified via semi-directed interviews and were analyzed using the concepts of the network theory to calculate average degrees and shortest path lengths between herds. Correlation between the Reynolds' genetic distances and the shortest path lengths between each pair of herds was assessed by a Mantel test approach. Genetic differentiation between breeds was high (0.16). Overall Fst values among herds were high in each breed (0.17, 0.11 and 0.10). Use of the Bayesian approach made it possible to identify genetic groups of herds within a breed. Significant correlations between the shortest path lengths and the Reynolds' genetic distances were found in each breed (0.87, 0.33 and 0.41), which demonstrate the influence of exchanges between herds on the genetic diversity. Correlation differences between breeds could be explained by differences in the average degree of the animal exchange networks, which is a measure of the number of exchanges per herd. The two breeds with the highest average degree showed the lowest correlation. Information from the exchange networks was used to assign individuals to the genetic groups when molecular information was incomplete or missing to identify donors for a cryobank. A fine-scale picture of the population genetic structure at the herd level was obtained for the three breeds. Network analysis made it possible to highlight the influence of exchanges on genetic structure and to complete or replace molecular information in establishing a conservation program.


Nasomaxillary Expansion by Endoscopically-Assisted Surgical Expansion (EASE): An airway centric approach
The aim of this study was to analyze the skeletal, dental and airway changes with endoscopically assisted surgical expansion (EASE) to widen the nasomaxillary complex for the treatment of sleep apnea in adults. One hundred and five consecutive patients underwent EASE. Cone beam computed tomography (CBCT) was conducted preoperatively and within four weeks after the completion of the expansion process. Computational fluid dynamic (CFD) analysis was performed on 20 randomly selected patients to assess airway flow changes. One hundred patients (67 males) with the mean age of 35.0±13.5 years (17-64 years) had completed pre- and post-expansion imaging. Ninety-six patients (96%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal cavity expansion was 3.12±1.11 mm at ANS, 3.64±1.06 mm at first molar and 2.39±1.15 mm at PNS. The zygoma expansion was 2.17±1.11 mm. The ratio of dental expansion to skeletal expansion was 1.23:1 (3.83 mm:3.12 mm) at canine and 1.31:1 (4.77 mm:3.64 mm) at first molar. CFD airway simulation showed a dynamic change following expansion throughout the airway. The mean negative pressure improved in the nasal airway (from -395.5±721.0 to -32.7±19.2 Pa), nasopharyngal airway (from -394.2±719.4 to -33.6±18.5 Pa), oropharyngeal airway (from -405.9±710.8 to -39.4±19.3 Pa) and hypopharyngeal airway (from -422.6±704.9 to -55.1±33.7 Pa). The mean airflow velocity within the nasal airway decreased from 18.8±15.9 to 7.6±2.0 m/s and the oropharyngeal airway decreased from 4.2±2.9 to 3.2±1.2 m/s. The velocity did not change significantly in the nasopharyngeal and hypopharyngeal regions. EASE results in expansion of the midpalatal suture from the ANS to PNS with a nearly pure skeletal movement of minimal dental effect. The expansion of the nasomaxillary complex resulted in the widening of the nasal sidewall throughout the nasal cavity. The improved air flow dynamics was demonstrated by CFD simulation.


Symptomatic gastric sarcoidosis in a patient with pulmonary sarcoidosis in remission.
Sarcoidosis is a multisystem, non-infectious, granulomatous disease of unknown cause, characterised by histological evidence of non-caseating granulomas. Gastrointestinal (GI) involvement is uncommon, reported in <1% of patients with the disease. Herein, we present a rare case of isolated gastric sarcoidosis in a patient with latent pulmonary sarcoidosis and unexplained manifestations of GI disease, illustrating that clinical disease expression is variable; may be organ-specific; and, known disease latency confined to one organ does not exclude the possibility of active disease in another organ system. In patients with organ-specific sarcoidosis, whether active or in remission, presenting with GI symptoms, the possibility of gastric sarcoidosis should be considered. Oesophagogastroduodenoscopy and biopsy, when indicated, should be considered for definitive diagnosis.


Effects of phencyclidine, amphetamine and related compounds on dopamine release from and uptake into striatal synaptosomes.
The ability of phencyclidine (PCP), amphetamine and other substances to stimulate dopamine release from and inhibit dopamine uptake into rat striatal synaptosomes was examined in a continuous superfusion system. Inhibition of uptake was measured by determining inhibition of [3H]dopamine displacement by unlabeled dopamine ([1H]dopamine). The displacement of [3H]dopamine by 10(-7) M [1H]dopamine was temperature- and sodium-sensitive and calcium-independent. [1H]Dopamine was an order of magnitude more potent than serotonin or norepinephrine in displacing [3H]dopamine. The concentrations of reserpine required to inhibit [3H]dopamine uptake and [3H]dopamine displacement by [1H]dopamine were similar. Nomifensine, benztropine, PCP and amphetamine also inhibited the displacement of [3H]dopamine by [1H]dopamine at concentrations which have been shown previously to inhibit the uptake of [3H]dopamine, suggesting that the mechanism behind displacement and uptake are very similar. PCP, at 10(-7) to 10(-5) M, significantly inhibited [3H]dopamine displacement by 10(-7) M [1H]dopamine, PCP was less potent than nomifensine or benztropine in inhibiting [3H]-dopamine displacement by 10(-7) M [1H]dopamine, but was equipotent to amphetamine. Superfusion of the synaptosomes for 6 min with PCP, 10(-6)M, induced increases in the spontaneous release of dopamine. In this regard, PCP was less potent than amphetamine, reserpine, flupenthixol, or benztropine. Upon initial exposure of the synaptosomes to amphetamine at 10(-7) to 10(-5) M, a substantial calcium-dependent release of dopamine was induced. In contrast, PCP did not stimulate the early calcium-dependent release of dopamine. These results indicate that PCP is less potent than amphetamine at releasing dopamine and may affect dopamine metabolism in the striatum primarily by inhibiting the reuptake of this catecholamine.


On the ouabain-sensitive potassium activated p-nitrophenyl phosphatase activity of vascular muscle plasma membranes.
Sodium-pump ATPase is known to be a cell membrane enzyme being responsible for vectorial transport of Na+ against electrochemical gradient across the plasma membranes of most cell types. In smooth muscles, this Na+-pump ATPase activity is notoriously low and its measurement is complicated by remarkably high level of the basal ATPase activities. In this communication, the properties of ouabain-sensitive, potassium-activated p-nitrophenyl phosphatase (pNPPase) activity which is a partial reaction of the Na+-pump are reported and compared in plasma membrane enriched fractions of mesenteric arteries from hypertensive and normotensive rats. The pNPPase activity of isolated plasma membrane vesicles from this vascular muscle is optimally stimulated by low concentrations of KCl (5-25 mM) at pH 7.8. Ouabain at 1.0 mM inhibits up to 75% of the K+-activated pNPPase activity under the optimal assay condition. Osmotic shock of the plasma membrane vesicles resulted in about 30% enhancement of the ouabain-sensitive K+-pNPPase activity compared to the control values. Although apparent difference was observed in this enzyme activity using similar preparations obtained from rats of different strains, the relative enhancement of such ouabain-sensitive K+-pNPPase activities by osmotic shock was not significantly different between vascular membrane fractions from the spontaneously hypertensive rats and the Wistar-Kyoto normotensive rats. Our results suggest that the intrinsic Na+-pump activity of small blood vessels in genetic hypertension in rats is not altered and the isolation procedure does not have differential effect on the orientation of plasma membrane vesicles in fractions obtained from hypertensive and normotensive rats.


Endoplasmic reticulum stress induces the expression of fetuin-A to develop insulin resistance.
Fetuin-A is a biomarker reported to be important in many metabolic disorders, including obesity, diabetes, and hepatic steatosis. Although it is well known that fetuin-A is increased in diabetes and nonalcoholic fatty liver disease (NAFLD), the levels of fetuin-A in diabetic patients with NAFLD are unknown. Furthermore, the regulation of fetuin-A expression is still obscure. In this study, a total of 180 age- and sex-matched subjects with normal glucose tolerance, NAFLD, newly diagnosed diabetes (NDD), and NDD with NAFLD were recruited. We found that the levels of fetuin-A were significantly increased in NDD with NAFLD as compared with NDD or NAFLD subjects. We further used HepG2 cells to investigate the regulation of fetuin-A. Treatment with endoplasmic reticulum (ER) stress activator, thapsigargin, increased the expression of fetuin-A mRNA and protein in a time- and dose-dependent manner. Pretreatment with ER stress inhibitor, 4-phenylbutyrate, reversed high glucose or palmitate-induced fetuin-A expression. Moreover, treatment with 4-phenylbutyrate in both streptozotocin-induced and high-fat diet-induced diabetic mice not only decreased hepatic fetuin-A levels but also improved hyperglycemia. Taken together, we found that fetuin-A levels were increased in diabetes patients with NAFLD. Moreover, ER stress induced by high glucose and palmitate increased the expression of fetuin-A and further contributed to the development of insulin resistance.


Hepatitis C Screening in Commercially Insured U.S. Birth-cohort Patients: Factors Associated with Testing and Effect of an EMR-based Screening Alert.
Hepatitis C virus (HCV) testing rates among U.S. birth-cohort patients have been studied extensively, limited data exists to differentiate birth-cohort screening from risk- or liver disease-based testing. This study aims to identify factors associated with HCV antibody (HCV-Ab) testing in a group of insured birth cohort patients, to determine true birth cohort testing rates, and to determine whether an electronic medical record (EMR)-driven Best Practice Alert (BPA) would improve birth cohort testing rates. All birth-cohort outpatients between 2010 and 2015 were identified. HCV-Ab test results, clinical, and demographic variables were extracted from the EMR, and factors associated with testing were analyzed by logistic regression. True birth-cohort HCV screening rates were determined by detailed chart review for all outpatient visits during one calendar month. An automated Best Practice Alert was used to identify unscreened patients at the point of care, and to prompt HCV testing. Screening rates before and after system-wide implementation of the BPA were compared. The historic HCV-Ab testing rate was 11.2% (11,976/106,753). Younger age, female gender, and African American, Asian, or Hispanic ethnicity, and medical comorbidities such as chronic hemodialysis, HIV infection, and rheumatologic and psychiatric comorbidities were associated with higher testing rates. However, during the one-month sampling period, true age cohort-based testing was performed in only 69/10,089 patients (0.68%). Following the system-wide implementation of the HCV BPA, testing rates increased from 0.68% to 10.76% (P<0.0001). We documented low HCV-Ab testing rates in our baby boomers population. HCV testing was typically performed in the presence of known risk factors or established liver disease. The implementation of an EMR-based HCV BPA resulted in a marked increase in testing rates. Our study highlights current HCV screening gaps, and the utility of the EMR to improve screening rates and population health.


Regional variation in mercury and stable isotopes of red snapper (Lutjanus campechanus) in the northern Gulf of Mexico, USA.
The presence of total mercury (Hg) in fish tissue and the potential associated health risks has become a global concern in marine ecosystems. Few studies have examined basin-scale variation in Hg accumulation in marine ecosystems, and determining if Hg concentrations in fish tissue vary across marine ecosystems is a key monitoring question. The present study evaluated Hg concentrations in red snapper (Lutjanus campechanus) tissue across three regions of the northern Gulf of Mexico (Alabama, Louisiana, and Texas, USA) and between two habitat types (oil and gas platforms and nonplatforms) within each region. Nitrogen (δ(15)N), carbon (δ(13)C), and sulfur (δ(34)S) stable isotopes were used to investigate ecological differences that may affect Hg concentrations among regions and between habitats. Mercury concentrations in red snapper tissue were positively correlated with fish total length. Regional differences in Hg concentrations were significant, with fish collected from Alabama having the highest concentrations and fish collected from Louisiana having the lowest. No significant difference existed in Hg concentrations between habitats, suggesting that association with platforms may not be a significant factor contributing to red snapper Hg concentrations. While δ(15)N did not differ significantly among the three regions, Texas red snapper were more enriched in δ(34)S and depleted in δ(13)C compared with Alabama and Louisiana red snapper. Although the majority of red snapper collected in the present study had Hg concentrations below safe consumption guidelines, regional differences suggest that spatially explicit monitoring programs may be important for basin-wide assessments.


Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation.
Post-craniotomy intracranial air can be present in patients scheduled for air ambulance transport to their home hospital. We aimed to assess risk for in-flight intracranial pressure (ICP) increases related to observed intracranial air volumes, hypothetical sea level pre-transport ICP, and different potential flight levels and cabin pressures. A cohort of consecutive subdural hematoma evacuation patients from one University Medical Centre was assessed with post-operative intracranial air volume measurements by computed tomography. Intracranial pressure changes related to estimated intracranial air volume effects of changing atmospheric pressure (simulating flight and cabin pressure changes up to 8000 ft) were simulated using an established model for intracranial pressure and volume relations. Approximately one third of the cohort had post-operative intracranial air. Of these, approximately one third had intracranial air volumes less than 11 ml. The simulation estimated that the expected changes in intracranial pressure during 'flight' would not result in intracranial hypertension. For intracranial air volumes above 11 ml, the simulation suggested that it was possible that intracranial hypertension could develop 'inflight' related to cabin pressure drop. Depending on the pre-flight intracranial pressure and air volume, this could occur quite early during the assent phase in the flight profile. DISCUSSION: These findings support the idea that there should be radiographic verification of the presence or absence of intracranial air after craniotomy for patients planned for long distance air transport. Very small amounts of air are clinically inconsequential. Otherwise, air transport with maintained ground-level cabin pressure should be a priority for these patients.


Azithromycin during Acute Chronic Obstructive Pulmonary Disease Exacerbations Requiring Hospitalization (BACE). A Multicenter, Randomized, Double-Blind, Placebo-controlled Trial.
Rationale: Azithromycin prevents acute exacerbations of chronic obstructive pulmonary disease (AECOPDs); however, its value in the treatment of an AECOPD requiring hospitalization remains to be defined.Objectives: We investigated whether a 3-month intervention with low-dose azithromycin could decrease treatment failure (TF) when initiated at hospital admission and added to standard care.Methods: In an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled trial, patients who had been hospitalized for an AECOPD and had a smoking history of ≥10 pack-years and one or more exacerbations in the previous year were randomized (1:1) within 48 hours of hospital admission to azithromycin or placebo. The study drug (500 mg/d for 3 d) was administered on top of a standardized acute treatment of systemic corticosteroids and antibiotics, and subsequently continued for 3 months (250 mg/2 d). The patients were followed for 6 months thereafter. Time-to-first-event analyses evaluated the TF rate within 3 months as a novel primary endpoint in the intention-to-treat population, with TF defined as the composite of treatment intensification with systemic corticosteroids and/or antibiotics, a step-up in hospital care or readmission for respiratory reasons, or all-cause mortality.Measurements and Main Results: A total of 301 patients were randomized to azithromycin (n = 147) or placebo (n = 154). The TF rate within 3 months was 49% in the azithromycin group and 60% in the placebo group (hazard ratio, 0.73; 95% confidence interval, 0.53-1.01; P = 0.0526). Treatment intensification, step-up in hospital care, and mortality rates within 3 months were 47% versus 60% (P = 0.0272), 13% versus 28% (P = 0.0024), and 2% versus 4% (P = 0.5075) in the azithromycin and placebo groups, respectively. Clinical benefits were lost 6 months after withdrawal.Conclusions: Three months of azithromycin for an infectious AECOPD requiring hospitalization may significantly reduce TF during the highest-risk period. Prolonged treatment seems to be necessary to maintain clinical benefits.


Preterm labour--is Mycoplasma hominis involved?
To assess whether Mycoplasma hominis is associated with preterm labour in primigravidae and multigravidae with previous midtrimester abortion or preterm labour. Cohort analytical study. Tygerberg Hospital, a tertiary academic hospital in the Western Cape. Gram's stains were done on smears taken from the posterior vaginal fornix, at the first antenatal visit, between 16 and 26 weeks' gestation, in primigravidae and multigravidae at risk for preterm labour. Cultures for M. hominis and other commonly occurring organisms were done from endocervical swabs taken at the same visit. The outcome of pregnancy in mothers with positive cultures for M. hominis was then compared with outcome in women with negative cultures. Prevalence of Chlamydia trachomatis, Ureaplasma urealyticum, bacterial vaginosis and preterm delivery, birth weight and perinatal deaths. Cultures for M. hominis were positive in 83 patients (21%) and negative in 312 (79%). Significantly more mothers in the positive group (40%) delivered before 37 weeks' gestation than in the negative group (28%, P = 0.0313). Their babies weighed significantly less (2,669 g v. 2,864 g, P = 0.0141). The positive group was also associated with more alcohol use in pregnancy and fewer of them were married. C. trachomatis was found in 18% of mothers in the positive group but in 8% of the negative group (P = 0.0082). U. urealyticum was cultured in 96% of mothers in the positive group in contrast to 81% in the negative group (P = 0.001). Bacterial vaginosis was observed on 75% of mothers with positive cultures for M. hominis but in 22% with negative cultures (P = 0.00001, odds ratio 10.21, 95% confidence interval: 5.63-18.65). Positive culture for M. hominis was associated with more preterm deliveries and also with a higher frequency of C. trachomatis, U. urealyticum and bacterial vaginosis.


A multicenter, 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face.
Each soft tissue filler product has its own unique profile in terms of adverse events. In this large-scale study, we investigated the safety profile of Radiesse, an injectable calcium hydroxylapatite (CaHA) implant, in treatment of nasolabial folds and other areas of the face. We also investigated the efficacy in a subset of the larger patient group. After obtaining informed consent from the subjects, researchers injected CaHA at two treatment centers into 113 patients (100 women and 13 men, ranging in age from 26 to 78 years) for a variety of facial aesthetic applications over a period of 47 months. Seventy-five patients had a single injection session; 38 had multiple sessions. Most patients (102) received 1.0 mL of CaHA per session; 12 received 2.0 mL per session. Typically, CaHA was administered with a 27-gauge 0.5- or 1 1/4-in. needle. Safety. Of 113 patients, only 7 reported minor adverse events that were short-term and resolved within 1 month: transient ecchymosis (3), nongranulatomous submucosal nodules of the lip (2), and inflammation and edema (2). Efficacy. Efficacy ratings were performed for a subset of patients (n=41). On a scale of 1 to 5 (1=unsatisfactory; 5=excellent), the mean patient evaluation score for look and feel of the implant was 4.6; the mean physician scores for the look and feel of the implant were 4.5 and 4.6, respectively. During the 6-month follow-up visit, patients' mean ratings of the look and feel of the implant were 4.8 and 4.9, respectively. The physician's mean ratings for the look and feel of the implant were 4.5 and 4.9, respectively. In our study, CaHA performed well, with a favorable safety profile, high patient satisfaction (90% of patients reported very good or excellent results), and good durability. We are especially pleased with the low incidence of adverse events coupled with the favorable responses from the patients themselves due to longevity of correction.


Development of a questionnaire to collect public health data for school entrants in London: Child Health Assessment at School Entry (CHASE) project.
To develop a multiprofessional consensus about the relative contributions of the components of children's health and well-being and to develop a questionnaire that can be used to assess these in London's children. Semi-structured interviews with health, education and social services professionals were used to identify areas to include in the questionnaire. These ideas were used as the basis for a wider Delphi consultation, with 79 experts in the area of child health. Round 1 of the Delphi asked panelists to rate 54 items as to whether they should be included in the questionnaire or not. Responses were divided into four categories: item to be included measurement method agreed, item to be included measurement method not agreed, no consensus, or excluded. In round 2, consensus was sought for the categories where there was none following round 1. Themes identified by the interviews were: economic factors, ethnicity, environment, nutrition, hygiene and physical activity, growth, suffers from chronic/serious illness, development, disability and learning, accidents and hospital attendances, self-regulation, psychological well-being, significant life events. After Delphi round 1, items included, where quality measurement method was agreed, were: deprivation index (from postcode), child's ethnicity, temporary accommodation, care status, registered with general practitioner, dental visits, height, weight, special educational needs status, baseline educational assessment result, immunization status, visual and hearing function. Following round 2, items relating to chronic illness, mental health, physical functioning, general health, self-esteem, family cohesion and accident status were agreed for inclusion with a measurement method also agreed. The questionnaire was acceptable to parents. The validity, reliability and feasibility of this questionnaire must now be examined. This data set, if collected across London, would substantially increase the public health data available and allow trends in health to be monitored.


Highly constrained intergenic Drosophila ultraconserved elements are candidate ncRNAs.
Eukaryotes contain short (∼80-200 bp) regions that have few or no substitutions among species that represent hundreds of millions of years of evolutionary divergence. These ultraconserved elements (UCEs) are candidates for containing essential functions, but their biological roles remain largely unknown. Here, we report the discovery and characterization of UCEs from 12 sequenced Drosophila species. We identified 98 elements ≥80 bp long with very high conservation across the Drosophila phylogeny. Population genetic analyses reveal that these UCEs are not present in mutational cold spots. Instead we infer that they experience a level of selective constraint almost 10-fold higher compared with missense mutations in protein-coding sequences, which is substantially higher than that observed previously for human UCEs. About one-half of these Drosophila UCEs overlap the transcribed portion of genes, with many of those that are within coding sequences likely to correspond to sites of ADAR-dependent RNA editing. For the remaining UCEs that are in nongenic regions, we find that many are potentially capable of forming RNA secondary structures. Among ten chosen for further analysis, we discovered that the majority are transcribed in multiple tissues of Drosophila melanogaster. We conclude that Drosophila species are rich with UCEs and that many of them may correspond to novel noncoding RNAs.


[Reasons for sick leave certifications: a case-control study of the Israeli Family Medicine Research Network (RAMBAM)].
Sick-leave certification (SLC) is a legal document that provides official work exemption. In Israel, all SLCs are issued by primary care physicians. When providing a SLC, physicians are influenced by medical as well as nonmedical issues, such as the patients' psychosocial state and their workplace characteristics. To evaluate the explicit and implicit reasons for a SLC in Israeli primary care practices. A case-control prospective study was conducted in 47 urban primary care clinics in Israel. Patients of working age who received a SLC and a control group of consecutive patients without a SLC were included. Patients were interviewed by phone using a structured questionnaire, regarding their socio-demographic background, the duration of the SLC, their workplace characteristics, and their self-rated health status. The doctors completed a consent form, signed by the patients, incLuding the explicit and the implicit reason for providing a SLC. Data was obtained from 918 patients; of these patients, 560 received a SLC and 358 were controls. The average duration of the SLC was 5.49 +/- 8.22 days, with a median of 3 days. The main explicit reasons for a SLC were: an acute medical problem (50%), and the patient's request (40%). The physicians' implicit reason was mainly the patient's request (84%). Self-employed workers and workers who do not receive payment for a full months work had significantly fewer SLCs. A Logistic regression model found younger age, salaried workers, entitlement for sick leave, special payment for a full months work, visiting for an acute illness or a request for SLC were the main factors significant in SLC provision. Providing SLCs is a common task of primary physicians in Israel Most SLCs are for a short time, up to 3 days. Family physicians usually accept their patients' request for a SLC. Workplace regulations influence patients' and physicians' behaviors related to SLCs.


Novel bisnaphthalimidopropyl (BNIPs) derivatives as anticancer compounds targeting DNA in human breast cancer cells.
Bisnaphthalimidopropyl (BNIP) derivatives are a family of compounds that exert anti-cancer activities in vitro and, according to previous studies, variations in the linker sequence have increased their DNA binding and cytotoxic activities. By modifying the linker sequence of bisnaphthalimidopropyl diaminodicyclohexylmethane (BNIPDaCHM), a previously synthesised BNIP derivative with anti-cancer properties, three novel BNIP derivatives were designed. Bisnaphthalimidopropyl-piperidylpropane (BNIPPiProp), a structural isomer of BNIPDaCHM, bisnaphthalimidopropyl ethylenedipiperidine dihydrobromide (BNIPPiEth), an isoform of BNIPDaCHM with a shorter linker chain, and (trans(trans))-bisnaphthalimidopropyl diaminodicyclohexylmethane (trans,trans-BNIPDaCHM), a stereoisomer of BNIPDaCHM, were successfully synthesised (72.3-29.5% yield) and characterised by nuclear magnetic resonance spectroscopy (NMR) and mass spectrometry (MS). Competitive displacement of ethidium bromide (EtBr) and UV binding studies were used to study the interactions of BNIP derivatives with Calf Thymus DNA. The cytotoxicity of these derivatives was assessed against human breast cancer MDA-MB-231 and SKBR-3 cells by MTT assay. Propidium iodide (PI) flow cytometry was conducted in order to evaluate the cellular DNA content in both breast cancer cell lines before and after treatment with BNIPs. The results showed that all novel BNIPs exhibit strong DNA binding properties in vitro, and strong cytotoxicity, with IC50 values in the range of 0.2-3.3 μM after 24 hours drug treatment. Two of the novel BNIP derivatives, BNIPPiEth and trans,trans-BNIPDaCHM, exhibited greater cytotoxicity against the two breast cancer cell lines studied, compared to BNIPDaCHM. By synthesising enantiopures and reducing the length of the linker sequence, the cytotoxicity of the BNIP derivatives was significantly improved compared to BNIPDaCHM, while maintaining DNA binding and bis-intercalating properties. In addition, cell cycle studies indicated that trans,trans-BNIPDaCHM, the most cytotoxic BNIP derivative, induced sub-G1 cell cycle arrest, indicative of apoptotic cell death. Based on these findings, further investigation is under way to assess the potential efficacy of trans,trans-BNIPDaCHM and BNIPPiEth in treating human breast cancer.


Estrogen Hormone Is an Essential Sex Factor Inhibiting Inflammation and Immune Response in COVID-19.
Although vaccines have been evaluated and approved for SARS-CoV-2 infection prevention, there remains a lack of effective treatments to reduce the mortality of COVID-19 patients already infected with SARS-CoV-2. The global data of COVID-19 showed that men have a higher mortality rate than women. We further observed that the proportion of mortality of female increases starting from around the age of 55 significantly. Thus, sex is an essential factor associated with COVID-19 mortality, and sex related genetic factors could be interesting mechanisms and targets for COVID-19 treatment. However, the associated sex factors and signaling pathways remain unclear. Here, we propose to uncover the potential sex associated factors using systematic and integrative network analysis. The unique results indicated that estrogen hormones (ER), e.g., estrone and estriol, 1) interacting with ESR1/2 receptors, 2) can inhibit SARS-CoV-2 caused inflammation and immune response signaling in host cells; and 3) estrogen hormone is associated with the distinct fatality rates between male and female COVID-19 patients. Specifically, a high level of estradiol protecting young female COVID-19 patients, and estrogen loss to an extremely low level in females after about 55 years of age causing the increased fatality rate of women. In conclusion, estrogen hormone, interacting with ESR1/2 receptors, is an essential sex factor that protects COVID-19 patients by inhibiting inflammation and immune response caused by SARS-CoV-2 infection. Medications perturb the down-stream of ESR1/ESR2 to inhibit the inflammation and immune response can be effective or synergistic combined with other existing drugs for COVID-19 treatment.


Medicine in a multi-cultural society: the effect of cultural background on beliefs about medications.
This exploratory, cross-sectional study examined the effect of self-reported cultural background on beliefs about medicines (modern pharmaceuticals) and perceptions of personal sensitivity to the adverse effects of taking medication. Using a validated questionnaire, beliefs about pharmaceutical medication were compared between 500 UK undergraduate students who identified themselves as having an Asian or European cultural background. There was a significant association between cultural background and beliefs about the benefits and dangers of medicines. Students who self-reported to have an Asian cultural background expressed more negative views about medication than those who reported a European cultural background. Students with an Asian cultural background were significantly more likely to perceive medicines as being intrinsically harmful, addictive substances that should be avoided. They were significantly less likely to endorse the benefits of modern medication. There was no significant relationship between cultural background and perceptions of personal sensitivity to medication effects or belief about how doctors use medication. In the total sample, past and present experience of taking medication was associated with a more positive orientation to medicines in general. Students who considered themselves to have a European cultural background had significantly more experience with prescribed medication than those who selected an Asian cultural background. The relationship between cultural background and beliefs about medicines in general was maintained after controlling for potential confounding variables, including chosen degree course, experience of taking prescribed medication, age, and gender. The identification of differences in beliefs about medication, between two specific cultural groups, suggests the need for a greater understanding of the effects of cultural background on medicine-usage with potential implications for the conduct of prescribing-related consultations and for the provision of patient information on medication.


Learning Implicit Brain MRI Manifolds with Deep Learning.
An important task in image processing and neuroimaging is to extract quantitative information from the acquired images in order to make observations about the presence of disease or markers of development in populations. Having a low-dimensional manifold of an image allows for easier statistical comparisons between groups and the synthesis of group representatives. Previous studies have sought to identify the best mapping of brain MRI to a low-dimensional manifold, but have been limited by assumptions of explicit similarity measures. In this work, we use deep learning techniques to investigate implicit manifolds of normal brains and generate new, high-quality images. We explore implicit manifolds by addressing the problems of image synthesis and image denoising as important tools in manifold learning. First, we propose the unsupervised synthesis of T1-weighted brain MRI using a Generative Adversarial Network (GAN) by learning from 528 examples of 2D axial slices of brain MRI. Synthesized images were first shown to be unique by performing a cross-correlation with the training set. Real and synthesized images were then assessed in a blinded manner by two imaging experts providing an image quality score of 1-5. The quality score of the synthetic image showed substantial overlap with that of the real images. Moreover, we use an autoencoder with skip connections for image denoising, showing that the proposed method results in higher PSNR than FSL SUSAN after denoising. This work shows the power of artificial networks to synthesize realistic imaging data, which can be used to improve image processing techniques and provide a quantitative framework to structural changes in the brain.


Longitudinal effect of CD4 by cotrimoxazole use on malaria incidence among HIV-infected Ugandan adults on antiretroviral therapy: a randomized controlled study.
The effect of CD4 count on malaria incidence in HIV infected adults on antiretroviral therapy (ART) was assessed in the context of a randomized controlled trial on the effect of stopping cotrimoxazole (CTX). This study presents a sub-analysis of the COSTOP trial (ISRCTN44723643) which was carried out among HIV-infected Ugandan adults stable on ART with CD4 counts ≥250 cells/µl. Participants were randomized (1:1) to continue CTX or stop CTX and receive matching placebo, and were followed up for a minimum of 1 year (median 2.5 years). CD4 counts were measured at baseline, 3 months and then every 6 months. Clinical malaria was defined as fever and a positive blood slide. First, the relationship between current CD4 count during follow-up and malaria among participants on placebo was examined; using random effects Poisson regression to account for repeated episodes. Second, the effect of CD4 count at enrolment, CD4 count at ART initiation, and CD4 count during follow-up on malaria, was assessed within each trial arm; to examine whether the effect of CD4 count differed by CTX use. 2180 participants were enrolled into the COSTOP trial. The incidence of clinical malaria was approximately four episodes/100 person years in the CTX arm and 14 episodes/100 person years in the placebo arm. There was no evidence of an association of current CD4 and clinical malaria incidence (P = 0.56), or parasitaemia levels (P = 0.24), in the placebo arm. Malaria incidence did not differ by CD4 count at ART initiation, enrolment or during follow up, irrespective of CTX use. When compared with participants in the lowest CD4 stratum, rate ratios within each trial arm were all close to 1, and P values were all above P = 0.30. The immune status of HIV infected participants who are stable on ART as measured by CD4 count was not associated with malaria incidence and did not modify the effect of stopping CTX on malaria. The decision of whether to stop or continue CTX prophylaxis for malaria in HIV infected individuals who are stable on ART should not be based on CD4 counts alone. COSTOP trial registration number ISRCTN44723643.


Serum biomarkers reveal long-term cardiac injury in isoproterenol-treated African green monkeys.
The assessment of cardiac toxicity is a major challenge in both drug development and clinical trials, and numerous marketed pharmaceuticals have been removed from the market due to unpredicted cardiac effects. Serum troponins are widely used indicators of cardiac injury; however, they are short-lived and have not been validated in preclinical animal models. In this study, we have used filter-aided sample preparation (FASP) and tandem mass tag (TMT) labeling to investigate serum protein alterations in isoproterenol-treated African green monkeys. Our results showed that the combination of FASP and TMT labeling provided highly reproducible and efficient sample preparation, which enables us to identify and quantify serum proteins with high confidence. We focused on the proteins that exhibit long-term alteration upon isoproterenol injection and discovered nine proteins exhibiting significant changes at 48 and 72 h postdosing. We further chose three proteins, serum amyloid A (SAA), frutose biphosphate aldolase A (FBAA), and fetuin A, for validation using enzyme-linked immunosorbent assay (ELISA). The serum concentration of SAA showed a ∼ 50 fold increase, while concentration of FBAA and fetuin A exhibited a significant decrease accompanying isoproterenol-induced cardiotoxicity. This work provides valuable insights for multimarker evaluation of long-term cardiac injury.


A machine learning approach for quantifying age-related histological changes in the mouse kidney.
The ability to quantify aging-related changes in histological samples is important, as it allows for evaluation of interventions intended to effect health span. We used a machine learning architecture that can be trained to detect and quantify these changes in the mouse kidney. Using additional held out data, we show validation of our model, correlation with scores given by pathologists using the Geropathology Research Network aging grading scheme, and its application in providing reproducible and quantifiable age scores for histological samples. Aging quantification also provides the insights into possible changes in image appearance that are independent of specific geropathology-specified lesions. Furthermore, we provide trained classifiers for H&E-stained slides, as well as tutorials on how to use these and how to create additional classifiers for other histological stains and tissues using our architecture.This architecture and combined resources allow for the high throughput quantification of mouse aging studies in general and specifically applicable to kidney tissues.


Indomethacin decreases optic nerve oxygen tension by a mechanism other than cyclo-oxygenase inhibition.
We investigated the effect of several Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), on the preoptic nerve oxygen tension (ONPO2), as indomethacin previously has demonstrated a strong decreasing effect on ONPO2. We tested whether these NSAIDs, like indomethacin, also reduce the increasing effect of dorzolamide on ONPO2. ONPO2 was measured 0.5 mm above the optic disc in 23 domestic pigs (26-36 kg) with a polarographic oxygen-sensitive electrode. One of the following NSAIDs was administered intravenously as increasing doses or as one large dose: indomethacin, ibuprofen, diclofenac, ketoprofen, parecyclo-oxygenase-2 inhibitor and lornoxicam. Indomethacin was both tested alone and after preceding administration of the other NSAIDs. Dorzolamide was also tested after preceding administration of NSAIDs different from indomethacin. Indomethacin decreased ONPO2 significantly in a dose-dependent manner. None of the other NSAIDs produced any effect on the ONPO2 (p>>0.05; n = 17). No difference was found between the effect of indomethacin injected alone, and after preceding administration of the other NSAIDs. Intravenous dorzolamide (500 mg) increased ONPO2 by 32 (7)% (n = 7; p<0.001) after preceding administration of several NSAIDs different from indomethacin. Indomethacin decreased ONPO2, while the other NSAIDs showed no effect on ONPO2, and they did not affect the effect of indomethacin. The hypoxic effect of indomethacin must be due to another mechanism than cyclo-oxygenase inhibition. The effect of dorzolamide on ONPO2 is not related to prostaglandin production.


Health facility committees and facility management - exploring the nature and depth of their roles in Coast Province, Kenya.
Community participation has been emphasized internationally as a way of enhancing accountability, as well as a means to enhance health goals in terms of coverage, access and effective utilization. In rural health facilities in Kenya, initiatives to increase community accountability have focused on Health Facility Committees (HFCs). In Coast Province the role of HFCs has been expanded with the introduction of direct funding of rural facilities. We explored the nature and depth of managerial engagement of HFCs at the facility level in two rural districts in this Coastal setting, and how this has contributed to community accountability We conducted structured interviews with the health worker in-charge and with patients in 30 health centres and dispensaries. These data were supplemented with in-depth interviews with district managers, and with health workers and HFC members in 12 health centres and dispensaries. In-depth interviews with health workers and HFC members included a participatory exercise to stimulate discussion of the nature and depth of their roles in facility management. HFCs were generally functioning well and played an important role in facility operations. The breadth and depth of engagement had reportedly increased after the introduction of direct funding of health facilities which allowed HFCs to manage their own budgets. Although relations with facility staff were generally good, some mistrust was expressed between HFC members and health workers, and between HFC members and the broader community, partially reflecting a lack of clarity in HFC roles. Moreover, over half of exit interviewees were not aware of the HFC's existence. Women and less well-educated respondents were particularly unlikely to know about the HFC. There is potential for HFCs to play an active and important role in health facility management, particularly where they have control over some facility level resources. However, to optimise their contribution, efforts are needed to improve their training, clarify their roles, and improve engagement with the wider community.


Understanding Care Integration from the Ground Up: Five Organizing Constructs that Shape Integrated Practices.
To provide empirical evidence on key organizing constructs shaping practical, real-world integration of behavior health and primary care to comprehensively address patients' medical, emotional, and behavioral health needs. In a comparative case study using an immersion-crystallization approach, a multidisciplinary team analyzed data from observations of practice operations, interviews, and surveys of practice members, and implementation diaries. Practices were drawn from 2 studies of practices attempting to integrate behavioral health and primary care: Advancing Care Together, a demonstration project of 11 practices located in Colorado, and the Integration Workforce Study, a study of 8 practices across the United States. We identified 5 key organizing constructs influencing integration of primary care and behavioral health: 1) Integration REACH (the extent to which the integration program was delivered to the identified target population), 2) establishment of continuum of care pathways addressing the location of care across the range of patient's severity of illness, 3) approach to patient transitions: referrals or warm handoffs, 4) location of the integration workforce, and 5) participants' mental model for integration. These constructs intertwine within an organization's historic and social context to produce locally adapted approaches to integrating care. Contextual factors, particularly practice type, influenced whether specialty mental health and substance use services were colocated within an organization. Interaction among 5 organizing constructs and practice context produces diverse expressions of integrated care. These constructs provide a framework for understanding how primary care and behavioral health services can be integrated in routine practice.


Supervised enzyme network inference from the integration of genomic data and chemical information.
The metabolic network is an important biological network which relates enzyme proteins and chemical compounds. A large number of metabolic pathways remain unknown nowadays, and many enzymes are missing even in known metabolic pathways. There is, therefore, an incentive to develop methods to reconstruct the unknown parts of the metabolic network and to identify genes coding for missing enzymes. This paper presents new methods to infer enzyme networks from the integration of multiple genomic data and chemical information, in the framework of supervised graph inference. The originality of the methods is the introduction of chemical compatibility as a constraint for refining the network predicted by the network inference engine. The chemical compatibility between two enzymes is obtained automatically from the information encoded by their Enzyme Commission (EC) numbers. The proposed methods are tested and compared on their ability to infer the enzyme network of the yeast Saccharomyces cerevisiae from four datasets for enzymes with assigned EC numbers: gene expression data, protein localization data, phylogenetic profiles and chemical compatibility information. It is shown that the prediction accuracy of the network reconstruction consistently improves owing to the introduction of chemical constraints, the use of a supervised approach and the weighted integration of multiple datasets. Finally, we conduct a comprehensive prediction of a global enzyme network consisting of all enzyme candidate proteins of the yeast to obtain new biological findings. Softwares are available upon request.


A hole-conductor-free, fully printable mesoscopic perovskite solar cell with high stability.
We fabricated a perovskite solar cell that uses a double layer of mesoporous TiO2 and ZrO2 as a scaffold infiltrated with perovskite and does not require a hole-conducting layer. The perovskite was produced by drop-casting a solution of PbI2, methylammonium (MA) iodide, and 5-ammoniumvaleric acid (5-AVA) iodide through a porous carbon film. The 5-AVA templating created mixed-cation perovskite (5-AVA)x(MA)1- xPbI3 crystals with lower defect concentration and better pore filling as well as more complete contact with the TiO2 scaffold, resulting in a longer exciton lifetime and a higher quantum yield for photoinduced charge separation as compared to MAPbI3. The cell achieved a certified power conversion efficiency of 12.8% and was stable for >1000 hours in ambient air under full sunlight.


Biological evaluation of paclitaxel-peptide conjugates as a model for MMP2-targeted drug delivery.
Paclitaxel (PTX) is a highly effective cytotoxic agent widely used for the treatment of several solid tumors. However, PTX shows dose-limiting cytotoxicity and in most cases induces drug resistance followed by failure in treatment. To enhance the therapeutic index of a given drug, various drug delivery methods have been explored to systemically deliver sufficient amount of the drug to the desired site. In the present study, we designed and synthesized two PTX prodrugs by conjugating PTX at different sites with an octapeptide (AcGPLGIAGQ) that can be cleaved by MMP2 at tumor sites. As a result, PTX is expected to be released at the tumor sites, absorbed by the tumor cells, and thereby inhibit the tumor growth. We evaluated the in vitro activities of the two drugs in a panel of drug-sensitive and -resistant cancer cell lines and their in vivo efficacies in a HT1080 fibrosarcoma mouse xenograft model that overexpresses MMP2. Our in vitro results showed that the PTX-AcGPLGIAGQ conjugates inhibited cancer cell proliferation with higher activity compared to that observed for free PTX, both of which were mediated by an arrest of G(2)/M-phase of the cell cycle. Consistent with the in vitro results, treatment with PTX-octapeptide conjugate resulted in extensive areas of necrosis and a lower percentage of proliferating cells in xenograft tumor sections. Together, our results indicate the potential of the tumor-targeted delivery of PTX to exploit the specific recognition of MMP2, reduce toxicity, and selectively kill tumor cells.


Family-oriented interventions for adults with acquired brain injury and their families: a scoping review.
This scoping review sought to describe the literature on the different types of interventions to support families of patients with acquired brain injuries (ABIs) and their outcomes. Acquired brain injuries are among the leading causes of disability in adults worldwide and have physical, cognitive or/and behavioral consequences not only for the patient, but also for the family. Several support interventions have been proposed in different contexts at different phases of recovery with various levels of evidence, yet no synthesis is available to date. We included studies that focused on family members of patients suffering from ABI. The concept under review included any type of intervention or action oriented to support families of patients with ABI, in any care setting. We included all published qualitative and quantitative designs, including those in the gray literature. A three-step search strategy was performed. Searches were conducted in eight major databases, MEDLINE, PubMed, Embase, CINAHL, PsycINFO, Cochrane, JBI Database of Systematic Reviews and Implementation Reports, Web of Science in April 2017, and seven databases for unpublished studies in November 2017. This review was limited to studies published in English and French since January 2007. Additional studies were searched amongst reference lists of all included articles. We included 89 studies, 19 secondary studies (systematic reviews n = 13, other type of reviews n = 6) and 70 primary studies (experimental studies n = 20, quasi-experimental studies n = 33, other designs n = 17). Even if heterogeneity was found in the characteristics of the 64 selected interventions, emotional support and education were highlighted as the main core components for family-oriented interventions. Mental health and burden were the two most prevalent outcomes found in this scoping review. Interventions targeted families and patients together in 56% of the cases or families alone. This scoping review provides an actual state of the current evidence available for families of patients with ABI. Extended and heterogeneous literature was found, showing the growing interest for considering ABI as a family issue in recent years. However, the overall level of evidence found indicates that more research is still needed to determine key components to intervene within this specific population.


Emotional reactivity, regulation and childhood stuttering: a behavioral and electrophysiological study.
The purpose of this preliminary study was to assess whether behavioral and psychophysiological correlates of emotional reactivity and regulation are associated with developmental stuttering, as well as determine the feasibility of these methods in preschool-age children. Nine preschool-age children who stutter (CWS) and nine preschool-age children who do not stutter (CWNS) listened to brief background conversations conveying happy, neutral, and angry emotions (a resolution conversation followed the angry conversation), then produced narratives based on a text-free storybook. Electroencephalograms (EEG) recorded during listening examined cortical correlates of emotional reactivity and regulation. Speech disfluencies and observed emotion regulation were measured during a narrative immediately after each background conversation. Results indicated that decreased use of regulatory strategies is related to more stuttering in children who stutter. However, no significant differences were found in EEG measurements of emotional reactivity and regulation between CWS and CWNS or between emotion elicitation conditions. Findings were taken to suggest that use of regulatory strategies may relate to the fluency of preschool-age children's speech-language output. The reader will be able to (1) describe emotional reactivity and regulation processes, (2) discuss evidence for or against the relations of emotional reactivity, regulation and stuttering, (3) understand how multiple measures can be used to measure emotional reactivity and regulation.


First identification of PODXL nonsense mutations in autosomal dominant focal segmental glomerulosclerosis.
Recently, a novel heterozygous missense mutation c.T1421G (p. L474R) in the PODXL gene encoding podocalyxin was identified in an autosomal dominant focal segmental glomerulosclerosis (AD-FSGS) pedigree. However, this PODXL mutation appeared not to impair podocalyxin function, and it is necessary to identify new PODXL mutations and determine their causative role for FSGS. In the present study, we report the identification of a heterozygous nonsense PODXL mutation (c.C976T; p. Arg326X) in a Chinese pedigree featured by proteinuria and renal insufficiency with AD inheritance by whole exome sequencing (WES). Total mRNA and PODXL protein abundance were decreased in available peripheral blood cell samples of two affected patients undergoing hemodialysis, compared with those in healthy controls and hemodialysis controls without PODXL mutation. We identified another novel PODXL heterozygous nonsense mutation (c.C1133G; p.Ser378X) in a British-Indian pedigree of AD-FSGS by WES. In vitro study showed that, human embryonic kidney 293T cells transfected with the pEGFP-PODXL-Arg326X or pEGFP-PODXL-Ser378X plasmid expressed significantly lower mRNA and PODXL protein compared with cells transfected with the wild-type plasmid. Blocking nonsense-mediated mRNA decay (NMD) significantly restored the amount of mutant mRNA and PODXL proteins, which indicated that the pathogenic effect of PODXL nonsense mutations is likely due to NMD, resulting in podocalyxin deficiency. Functional consequences caused by the PODXL nonsense mutations were inferred by siRNA knockdown in cultured podocytes and podocalyxin down-regulation by siRNA resulted in decreased RhoA and ezrin activities, cell migration and stress fiber formation. Our results provided new data implicating heterozygous PODXL nonsense mutations in the development of FSGS.


Integrated treatment of comorbid depression and substance use disorders.
The goals of this 6-month prospective study were to evaluate the effect of a current diagnosis of depression on the course and outcome of addiction treatment and to determine whether patients with depression received or required additional treatment compared with those without depression. On entering addiction treatment, 75 men and 45 women with substance use disorders were assessed by clinical and semistructured interviews, Global Assessment Scale, Hamilton Rating Scale for Depression, Beck Depression Inventory, and revised 90-item Symptom Checklist. Forty-three patients (35.8%) met DSM-IV criteria for a current depressive disorder at intake into addiction treatment. The depressed patients had significantly (p < .0001) higher levels of psychopathology at intake. However, contrary to previous studies, they fared as well as the nondepressed patients in terms of all addiction outcome measures and all indicators of psychiatric status at 6 months. During the 6-month follow-up period, the depressed patients received more treatment than the nondepressed patients. Specifically, they had more psychiatric appointments, and they were more likely to require inpatient detoxification and to be prescribed new antidepressant medication regimens. Depression comorbidity may not have had a negative impact on the course and outcome of addiction treatment because the dual disorder was identified at the initial assessment, and integrated psychiatric care was available. It may be that additional treatment compensated for greater psychopathology among dual-disorder patients.


Newborn and childhood differential DNA methylation and liver fat in school-age children.
Non-alcoholic fatty liver disease is the most common chronic liver disease in children in western countries. Adverse early-life exposures are associated with higher liver fat percentages in children. Differential DNA methylation may underlie these associations. We aimed to identify differential DNA methylation in newborns and children associated with liver fat accumulation in childhood. We also examined whether DNA methylation at 22 cytosine-phosphate-guanine sites (CpGs) associated with adult non-alcoholic fatty liver disease is associated with liver fat in children. Within a population-based prospective cohort study, we analyzed epigenome-wide DNA methylation data of 785 newborns and 344 10-year-old children in relation to liver fat fraction at 10 years. DNA methylation was measured using the Infinium HumanMethylation450 BeadChip (Illumina). We measured liver fat fraction by Magnetic Resonance Imaging. Associations of single CpG DNA methylation at the two-time points with liver fat accumulation were analyzed using robust linear regression models. We also analyzed differentially methylation regions using the dmrff package. We looked-up associations of 22 known adult CpGs at both ages with liver fat at 10 years. The median liver fat fraction was 2.0% (95% range 1.3, 5.1). No single CpGs and no differentially methylated regions were associated with liver fat accumulation. None of the 22 known adult CpGs were associated with liver fat in children. DNA methylation at birth and in childhood was not associated with liver fat accumulation in 10-year-old children in this study. This may be due to modest sample sizes or DNA methylation changes being a consequence rather than a determinant of liver fat.


Influence of laser parameters and staining on femtosecond laser-based intracellular nanosurgery.
Femtosecond (fs) laser-based intracellular nanosurgery has become an important tool in cell biology, albeit the mechanisms in the so-called low-density plasma regime are largely unknown. Previous calculations of free-electron densities for intracellular surgery used water as a model substance for biological media and neglected the presence of dye and biomolecules. In addition, it is still unclear on which time scales free-electron and free-radical induced chemical effects take place in a cellular environment. Here, we present our experimental study on the influence of laser parameters and staining on the intracellular ablation threshold in the low-density plasma regime. We found that the ablation effect of fs laser pulse trains resulted from the accumulation of single-shot multiphoton-induced photochemical effects finished within a few nanoseconds. At the threshold, the number of applied pulses was inversely proportional to a higher order of the irradiance, depending on the laser repetition rate and wavelength. Furthermore, fluorescence staining of subcellular structures before surgery significantly decreased the ablation threshold. Based on our findings, we propose that dye molecules are the major source for providing seed electrons for the ionization cascade. Consequently, future calculations of free-electron densities for intracellular nanosurgery have to take them into account, especially in the calculations of multiphoton ionization rates.


Exenatide reduces reperfusion injury in patients with ST-segment elevation myocardial infarction.
Exenatide, a glucagon-like-peptide-1 analogue, increases myocardial salvage in experimental settings with coronary occlusion and subsequent reperfusion. We evaluated the cardioprotective effect of exenatide at the time of reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). A total of 172 patients with STEMI and Thrombolysis in Myocardial Infarction flow 0/1 were randomly assigned to exenatide or placebo (saline) intravenously. Study treatment was commenced 15 min before intervention and maintained for 6 h after the procedure. The primary endpoint was salvage index calculated from myocardial area at risk (AAR), measured in the acute phase, and final infarct size measured 90 ± 21 days after pPCI by cardiac magnetic resonance (CMR). In 105 patients evaluated with CMR, a significantly larger salvage index was found in the exenatide group than in the placebo group (0.71 ± 0.13 vs. 0.62 ± 0.16; P= 0.003). Infarct size in relation to AAR was also smaller in the exenatide group (0.30 ± 0.15 vs. 0.39 ± 0.15; P= 0.003). In a regression analysis, there was a significant correlation between the infarct size and the AAR for both treatment groups and an analysis of covariance showed that datapoints in the exenatide group lay significantly lower than for the placebo group (P= 0.011). There was a trend towards smaller absolute infarct size in the exenatide group (13 ± 9 vs. 17 ± 14 g; P= 0.11). No difference was observed in left ventricular function or 30-day clinical events. No adverse effects of exenatide were observed. In patients with STEMI undergoing pPCI, administration of exenatide at the time of reperfusion increases myocardial salvage.


State-level infrastructure and economic effects of switchgrass cofiring with coal in existing power plants for carbon mitigation.
This paper presents a linear programming (LP) methodology for estimating the cost of reducing a state's coal-fired power plant carbon dioxide emissions by cofiring switchgrass and coal. LP modeling allows interplay between regionally specific switchgrass production forecasts, coal plant locations, and individual coal plant historic performance data to determine an allocation of switchgrass minimizing cost or maximizing carbon reduction. The LP methodology is applied to two states, Pennsylvania (PA) and Iowa (IA), and results are presented with a discussion of modeling assumptions, techniques, and carbon mitigation policy implications. The LP methodology estimates that, in PA, 4.9 million tons of CO2/year could be mitigated at an average cost of less than $34/ton of CO2 and that, in IA, 7 million tons of CO2/year could be mitigated at an average Cost of Mitigation of $27/ton of CO2. Because the factors determining the cofiring costs vary so much between the two states, results suggest that cofiring costs will also vary considerably between different U.S. regions. A national level analysis could suggest a lowest-cost cofiring region. This paper presents techniques and assumptions that can simplify biomass energy policy analysis with little effect on analysis conclusions.


Resistance to paclitaxel is proportional to cellular total antioxidant capacity.
Paclitaxel, one of the most commonly prescribed chemotherapeutic agents, is active against a wide spectrum of human cancer. The mechanism of its cytotoxicity, however, remains controversial. Our results indicate that paclitaxel treatment increases levels of superoxide, hydrogen peroxide, nitric oxide (NO), oxidative DNA adducts, G2-M arrest, and cells with fragmented nuclei. Antioxidants pyruvate and selenium, the NO synthase inhibitor N(omega)-nitro-L-arginine methyl ester, and the NO scavenger manganese (III) 2-(4-carboxyphenyl)-4,4,5,5-tetramethyl-imidazoline-1-oxyl-3-oxide all decreased paclitaxel-mediated DNA damage and sub-G1 cells. In contrast, the glutamylcysteine synthase inhibitor buthionine sulfoximine (BSO) and the superoxide dismutase (SOD) inhibitor 2-methoxyestradiol (2-ME) increased the sub-G1 fraction in paclitaxel-treated cells. These results suggest that reactive oxygen and nitrogen species are involved in paclitaxel cytotoxicity. This notion is further supported with the observation that concentrations of paclitaxel required to inhibit cell growth by 50% correlate with total antioxidant capacity. Moreover, agents such as arsenic trioxide (As2O3), BSO, 2-ME, PD98059, U0126 [mitogen-activated protein/extracellular signal-regulated kinase inhibitors], and LY294002 (phosphatidylinositol 3-kinase/Akt inhibitor), all of which decrease clonogenic survival, also decrease the total antioxidant capacity of paclitaxel-treated cells, regardless whether they are paclitaxel sensitive or paclitaxel resistant. These results suggest that paclitaxel chemosensitivity may be predicted by taking total antioxidant capacity measurements from clinical tumor samples. This, in turn, may then improve treatment outcomes by selecting out potentially responsive patients.


[In vitro activity of arbekacin against clinical isolates of Staphylococcus species and gram-negative bacilli].
Methicillin-resistant Staphylococcus aureus (MRSA) and some gram-negative bacilli are very prevalent nosocomial pathogens, commonly causing mixed infections, and are often resistant to multiple drugs. Arbekacin is an aminoglycoside used for the treatment of MRSA infections, but is also active against some gram-negative bacilli. The aim of this study was to determine in vitro activity of arbekacin against recent clinical isolates of staphylococci and gram-negative bacilli. The strains were isolated from clinical specimens of patients at Severance Hospital in 2003. Antimicrobial susceptibility was tested by the Clinical and Laboratory Standards Institute agar dilution method. The following arbekacin breakpoints were used: susceptible, </=4 microg/mL; and resistant, >/=16 microg/mL . All isolates of staphylococci tested were inhibited by </=4 microg/mL of arbekacin, regardless of their methicillin susceptibility. The MIC90s of arbekacin, 1-4 microg/mL, were 8->32-fold and >32-128-fold lower than those of amikacin and gentamicin, respectively. The resistance rates of MRSA, methicillin-susceptible S. aureus, methicillin-resistant coagulase-negative staphylococci (CNS) and methicillin-susceptible CNS were 0% to arbekacin, 0-54% to amikacin, and 24-79% to gentamicin. The MIC90s of arbekacin for Escherichia coli and Citrobacter freundii, 1 microg/mL and 16 microg/mL, were 2-4-fold and 8-16-fold lower than those of amikacin and gentamicin, respectively. However, The MIC90s of arbekacin for other species of gram-negative bacilli, 64->128 microg/mL, were similar to those of other aminoglycosides. Arbekacin may be a useful alternative to glycopeptides for the treatment of monomicrobial methicillin-resistant staphylococcal infections, as well as mixed infections with gram-negative bacilli, as most isolates of E. coli, C. freundii and some other gram-negative bacilli were also susceptible to arbekacin.


The Crystal Structure of Calmodulin Bound to the Cardiac Ryanodine Receptor (RyR2) at Residues Phe4246-Val4271 Reveals a Fifth Calcium Binding Site.
Calmodulin (CaM) regulates the activity of a Ca2+ channel known as the cardiac ryanodine receptor (RyR2), which facilitates the release of Ca2+ from the sarcoplasmic reticulum during excitation-contraction coupling in cardiomyocytes. Mutations that disrupt this CaM-dependent channel inactivation result in cardiac arrhythmias. RyR2 contains three different CaM binding sites: CaMBD1 (residues 1940-1965), CaMBD2 (residues 3580-3611), and CaMBD3 (residues 4246-4275). Here, we report a crystal structure of Ca2+-bound CaM bound to RyR2 CaMBD3. The structure reveals Ca2+ bound to the four EF-hands of CaM as well as a fifth Ca2+ bound to CaM in the interdomain linker region involving Asp81 and Glu85. The CaM mutant E85A abolishes the binding of the fifth Ca2+ and weakens the binding of CaMBD3 to Ca2+-bound CaM. Thus, the binding of the fifth Ca2+ is important for stabilizing the complex in solution and is not a crystalline artifact. The CaMBD3 peptide in the complex adopts an α-helix (between Phe4246 and Val4271) that interacts with both lobes of CaM. Hydrophobic residues in the CaMBD3 helix (Leu4255 and Leu4259) form intermolecular contacts with the CaM N-lobe, and the CaMBD3 mutations (L4255A and L4259A) each weaken the binding of CaM to RyR2. Aromatic residues on the opposite side of the CaMBD3 helix (Phe4246 and Tyr4250) interact with the CaM C-lobe, but the mutants (F4246A and Y4250A) have no detectable effect on CaM binding in solution. We suggest that the binding of CaM to CaMBD3 and the binding of a fifth Ca2+ to CaM may contribute to the regulation of RyR2 channel function.


Targeting cancer using fragment based drug discovery.
Over the past decade, fragment-based drug discovery has developed significantly and has gained increasing popularity in the pharmaceutical industry as a powerful alternative and complement to traditional high-throughput screening approaches for hit identification. Fragment-based methods are capable of rapidly identifying starting points for structure-based drug design from relatively small libraries of low molecular weight compounds. The main constraints are the need for sensitive methods that can reliably detect the typically weak interactions between fragments and the target protein, and strategies for transforming fragments into higher molecular weight drug candidates. This approach has recently been validated as series of compounds from various programs have entered clinical trials.


The globally distributed genus Alexandrium: multifaceted roles in marine ecosystems and impacts on human health.
The dinoflagellate genus Alexandrium is one of the major harmful algal bloom (HAB) genera with respect to the diversity, magnitude and consequences of blooms. The ability of Alexandrium to colonize multiple habitats and to persist over large regions through time is testimony to the adaptability and resilience of this group of species. Three different families of toxins, as well as an as yet incompletely characterized suite of allelochemicals are produced among Alexandrium species. Nutritional strategies are equally diverse, including the ability to utilize a range of inorganic and organic nutrient sources, and feeding by ingestion of other organisms. Many Alexandrium species have complex life histories that include sexuality and often, but not always, cyst formation, which is characteristic of a meroplanktonic life strategy and offers considerable ecological advantages. Due to the public health and ecosystem impacts of Alexandrium blooms, the genus has been extensively studied, and there exists a broad knowledge base that ranges from taxonomy and phylogeny through genomics and toxin biosynthesis to bloom dynamics and modeling. Here we present a review of the genus Alexandrium, focusing on the major toxic and otherwise harmful species.


Maternal environmental contribution to adult sensitivity and resistance to obesity in Long Evans rats.
The OLETF rat is an animal model of early onset hyperphagia induced obesity, presenting multiple pre-obese characteristics during the suckling period. In the present study, we used a cross-fostering strategy to assess whether interactions with obese dams in the postnatal environment contributed to the development of obesity. On postnatal Day (PND)-1 OLETF and control LETO pups were cross-fostered to same or opposite strain dams. An independent ingestion test was performed on PND11 and a nursing test on PND18. Rats were sacrificed at weaning or on PND90, and plasma leptin, insulin, cholesterol, triglycerides and alanine aminotransferase (ALT) were assayed. Fat pads were collected and weighed and adipocyte size and number were estimated. Body weight and intake, as well as the estrous cycle of the female offspring were monitored. During the suckling period, the pups' phenotype was almost completely determined by the strain of the mother. However, pups independently ingested food according to their genotype, regardless of their actual phenotype. At adulthood, cross fostered males of both strains and LETO females were affected in regard of their adiposity levels in the direction of the foster dam. On the other hand, OLETF females showed almost no alterations in adiposity but were affected by the strain of the dams in parameters related to the metabolic syndrome. Thus, OLETF females showed reduced liver adiposity and circulating levels of ALT, while LETO females presented a disrupted estrous cycle and increased cholesterol and triglycerides in the long term. The present study provides further support for the early postnatal environment playing a sex-divergent role in programming later life phenotype. In addition, it plays a more central role in determining the functioning of mechanisms involved in energy balance that may provide protection from or sensitivity to later life obesity and pathologies related to the metabolic syndrome.


Ratios of proteins in cerebrospinal fluid in Parkinson's disease cognitive decline: prospective study.
There is a need for biomarkers of dementia in PD. To determine if the levels of the main CSF proteins and their ratios are associated with deterioration in cognition and progression to dementia in the short to mid term. The Parkinson's Progression Markers Initiative database was used as an exploratory cohort, and a center-based cohort was used as a replication cohort. Amyloid ß1-42, total tau, threonine-181 phosphorylated tau, and α-synuclein in the CSF and the ratios of these proteins were assessed. In the Parkinson's Progression Markers Initiative cohort (n = 281), the total tau/amyloid ß1-42, total tau/α-synuclein, total tau/amyloid ß1-42+α-synuclein, and amyloid ß1-42/total tau ratios were associated with a risk of progression to dementia over a 3-year follow-up. In the replication cohort (n = 40), the total tau/α-synuclein and total tau/amyloid ß1-42+α-synuclein ratios were associated with progression to dementia over a 41-month follow-up. Ratios of the main proteins found in PD patient brain inclusions that can be measured in the CSF appear to have value as short- to mid-term predictors of dementia. © 2018 International Parkinson and Movement Disorder Society.


Apical versus Non-Apical Lead: Is ICD Lead Position Important for Successful Defibrillation?
We aim to compare the acute and long-term success of defibrillation between non-apical and apical ICD lead position. The position of the ventricular lead was recorded by the implanting physician for 2,475 of 2,500 subjects in the Shockless IMPLant Evaluation (SIMPLE) trial, and subjects were grouped accordingly as non-apical or apical. The success of intra-operative defibrillation testing and of subsequent clinical shocks were compared. Propensity scoring was used to adjust for the impact of differences in baseline variables between these groups. There were 541 leads that were implanted at a non-apical position (21.9%). Patients implanted with a non-apical lead had a higher rate of secondary prevention indication. Non-apical location resulted in a lower mean R-wave amplitude (14.0 vs. 15.2, P < 0.001), lower mean pacing impedance (662 ohm vs. 728 ohm, P < 0.001), and higher mean pacing threshold (0.70 V vs. 0.66 V, P = 0.01). Single-coil leads and cardiac resynchronization devices were used more often in non-apical implants. The success of intra-operative defibrillation was similar between propensity score matched groups (89%). Over a mean follow-up of 3 years, there were no significant differences in the yearly rates of appropriate shock (5.5% vs. 5.4%, P = 0.98), failed appropriate first shock (0.9% vs. 1.0%, P = 0.66), or the composite of failed shock or arrhythmic death (2.8% vs. 2.3% P = 0.35) according to lead location. We did not detect any reduction in the ICD efficacy at the time of implant or during follow-up in patients receiving a non-apical RV lead.


What are the Optimal Cutoff Values for ESR and CRP to Diagnose Osteomyelitis in Patients with Diabetes-related Foot Infections?
Distinguishing osteomyelitis from soft-tissue infection of the foot is important because osteomyelitis is associated with more operations, amputation, and prolonged antibiotic exposure. Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are routinely ordered inflammatory biomarkers for evaluating foot infection. When initial evaluation is inconclusive, advanced imaging is indicated, and high clinical or radiographic suspicion of osteomyelitis may indicate bone biopsy to identify organisms and antibiotic sensitivity. Although ESR and CRP levels are helpful for distinguishing osteomyelitis from soft-tissue infections in patients with diabetes-related foot infections, parameters regarding optimal cutoff values for those tests have not, to our knowledge, been defined. (1) What are the optimal cutoff values for ESR and CRP to differentiate osteomyelitis from soft-tissue infection in patients with diabetes-related foot infection? (2) Can a diagnostic algorithm be derived to guide interpretation of ESR and CRP to improve recognition of osteomyelitis in the setting of diabetic foot infection? The medical records of 1842 patients between 18 and 89 years of age treated at our institution between January 1, 2010 and February 6, 2017 for foot infection were reviewed. For inclusion, patients must have had a diagnosis of diabetes mellitus, moderate or severe infection, ESR and CRP values within 72 hours of admission, either advanced imaging (MRI or single-positron emission computed tomography/computed tomography [SPECT/CT]) or bone biopsy during admission and must not have had comorbidities that could affect ESR and CRP, such as autoimmune disorders. As such, 1489 patients were excluded, and 353 patients were included in the study. Osteomyelitis was diagnosed by positive bone culture or histopathology. Osteomyelitis was considered to be absent if there was a negative MRI or SPECT/CT result, or negative bone culture and histology findings if imaging was inconclusive. We identified 176 patients with osteomyelitis and 177 with soft-tissue infection. A blinded investigator performed the statistics. Optimal cutoffs of ESR and CRP were determined using receiver operative characteristic (ROC) analysis. A diagnostic algorithm was determined using epidemiologic principles of screening evaluations. An ESR of 60 mm/h and a CRP level of 7.9 mg/dL were determined to be the optimal cutoff points for predicting osteomyelitis based on results of the ROC analysis. The ESR threshold of 60 mm/h demonstrated a sensitivity of 74% (95% confidence interval [CI], 67-80) and specificity of 56% (95% CI, 48-63) for osteomyelitis, whereas the CRP threshold of 7.9 mg/dL had a sensitivity of 49% (95% CI, 41-57) and specificity of 80% (95% CI, 74-86). If the ESR is < 30 mm/h, the likelihood of osteomyelitis is low. However, if ESR is > 60 mm/h and CRP level is > 7.9 mg/dL, the likelihood of osteomyelitis is high, and treatment of suspected osteomyelitis should be strongly considered. While ESR is better for ruling out osteomyelitis initially, CRP helps distinguish osteomyelitis from soft-tissue infection in patients with high ESR values. Further prospective studies addressing the prognostic value of ESR and CRP are needed, and a more comprehensive diagnostic algorithm should be developed to include other diagnostic tests such as probe-to-bone and imaging. Level III, diagnostic study.


TNF blockade in rheumatoid arthritis: implications for therapy and pathogenesis.
The role of the immune response in rheumatoid arthritis (RA) is a subject of debate, although it is widely believed to be a T-cell-driven disease. Progress is being hindered by lack of convincing evidence of a defined specific antigen initiating or perpetuating the response. Clinical trials using monoclonal antibodies directed against T-cell surface molecules such as CD4. CD5, and CD7 have thus far not provided evidence of efficacy. The negative data may reflect inadequate dosing or could suggest that indiscriminate depletion of T cells is insufficient by itself as a therapeutic strategy. Blocking proinflammatory cytokines (e.g. TNF alpha, IL-1) or augmenting anti-inflammatory cytokines (e.g. IL-10) offers an alternative approach to therapy. Clinical trials using monoclonal anti-TNF alpha have been particularly successful in controlling inflammation and markedly reducing acute phase proteins and cellular ingress. However, because disease invariably relapses, repeated therapy is necessary. Preliminary experience suggests that this is possible. Anti-TNF therapy for RA has defined a molecular target and new approach for treating immuno-inflammatory disorders.