Time-varying respiratory system elastance: a physiological model for patients who are spontaneously breathing.
Respiratory mechanics models can aid in optimising patient-specific mechanical ventilation (MV), but the applications are limited to fully sedated MV patients who have little or no spontaneously breathing efforts. This research presents a time-varying elastance (E(drs)) model that can be used in spontaneously breathing patients to determine their respiratory mechanics. A time-varying respiratory elastance model is developed with a negative elastic component (E(demand)), to describe the driving pressure generated during a patient initiated breathing cycle. Data from 22 patients who are partially mechanically ventilated using Pressure Support (PS) and Neurally Adjusted Ventilatory Assist (NAVA) are used to investigate the physiology relevance of the time-varying elastance model and its clinical potential. E(drs) of every breathing cycle for each patient at different ventilation modes are presented for comparison. At the start of every breathing cycle initiated by patient, E(drs) is < 0. This negativity is attributed from the E(demand) due to a positive lung volume intake at through negative pressure in the lung compartment. The mapping of E(drs) trajectories was able to give unique information to patients' breathing variability under different ventilation modes. The area under the curve of E(drs) (AUCE(drs)) for most patients is > 25 cmH2Os/l and thus can be used as an acute respiratory distress syndrome (ARDS) severity indicator. The E(drs) model captures unique dynamic respiratory mechanics for spontaneously breathing patients with respiratory failure. The model is fully general and is applicable to both fully controlled and partially assisted MV modes.


Aggregation and Stability of Reduced Graphene Oxide: Complex Roles of Divalent Cations, pH, and Natural Organic Matter.
The aggregation and stability of graphene oxide (GO) and three successively reduced GO (rGO) nanomaterials were investigated. Reduced GO species were partially reduced GO (rGO-1h), intermediately reduced GO (rGO-2h), and fully reduced GO (rGO-5h). Specifically, influence of pH, ionic strength, ion valence, and presence of natural organic matter (NOM) were studied. Results show that stability of GO in water decreases with successive reduction of functional groups, with pH having the greatest influence on rGO stability. Stability is also dependent on ion valence and the concentration of surface functional groups. While pH did not noticeably affect stability of GO in the presence of 10 mM NaCl, adding 0.1 mM CaCl2 reduced stability of GO with increased pH. This is due to adsorption of Ca(2+) ions on the surface functional groups of GO which reduces the surface charge of GO. As the concentration of rGO functional groups decreased, so did the influence of Ca(2+) ions on rGO stability. Critical coagulation concentrations (CCC) of GO, rGO-1h, and rGO-2h were determined to be ∼ 200 mM, 35 mM, and 30 mM NaCl, respectively. In the presence of CaCl2, CCC values of GO and rGO are quite similar, however. Long-term studies show that a significant amount of rGO-1h and rGO-2h remain stable in Call's Creek surface water, while effluent wastewater readily destabilizes rGO. In the presence NOM and divalent cations (Ca(2+), Mg(2+)), GO aggregates settle from suspension due to GO functional group bridging with NOM and divalent ions. However, rGO-1h and rGO-2h remain suspended due to their lower functional group concentration and resultant reduced NOM-divalent cation bridging. Overall, pH, divalent cations, and NOM can play complex roles in the fate of rGO and GO.


Cocaine sensitization of coronary artery contractions: mechanism of drug-induced spasm.
Illicit cocaine use has been associated with a high incidence of cardiovascular complications including coronary spasm, arrhythmias, myocardial infarction and sudden death. Adverse effects of cocaine have been attributed routinely to the consequences of increased concentrations of the adrenergic transmitter at its sites of action including the coronary vasculature. The present study examined non-neurogenic postsynaptic sites of cocaine action in cattle coronary arteries that could account for its clinical profile. It was found that cocaine (3.3 x 10(-5) M) greatly increased responses to potassium chloride (by 98.4 +/- 13.8%) that are totally dependent on extracellular calcium. However, contractions to a thromboxane A2 analog, which are much less dependent on extracellular calcium influx, were not increased significantly by cocaine. Cocaine (3.3 x 10(-5) M) more than doubled the magnitude of non-neurogenic responses to field stimulation, but these responses were not enhanced in the presence of a calcium channel antagonist. Spontaneously generated tone was magnified significantly by cocaine (3.3 x 10(-5) M) (by 127.5 +/- 45.2%), and this enhancement also was selectively antagonized by nifedipine. Subthreshold concentrations of the calcium channel opener, Bay K 8644, also were increased greatly by cocaine, and this magnification was antagonized by nifedipine. Cocaine did not magnify responses to norepinephrine that are inhibitory in cattle coronary arteries, and desmethylimipramine, a potent inhibitor of catecholamine uptake, had no sensitizing effects on responses to potassium chloride, norepinephrine or field stimulation. It is concluded that cocaine has a potent action on the calcium L channels, magnifying the effects of stimuli that make use of these channels in contractions.(ABSTRACT TRUNCATED AT 250 WORDS)


Microenvironment-dependent growth of preneoplastic and malignant plasma cells in humanized mice.
Most human cancers, including myeloma, are preceded by a precursor state. There is an unmet need for in vivo models to study the interaction of human preneoplastic cells in the bone marrow microenvironment with non-malignant cells. Here, we genetically humanized mice to permit the growth of primary human preneoplastic and malignant plasma cells together with non-malignant cells in vivo. Growth was largely restricted to the bone marrow, mirroring the pattern in patients with myeloma. Xenografts captured the genomic complexity of parental tumors and revealed additional somatic changes. Moreover, xenografts from patients with preneoplastic gammopathy showed progressive growth, suggesting that the clinical stability of these lesions may in part be due to growth controls extrinsic to tumor cells. These data demonstrate a new approach to investigate the entire spectrum of human plasma cell neoplasia and illustrate the utility of humanized models for understanding the functional diversity of human tumors.


Position paper on tuberculosis screening in patients with immune mediated inflammatory diseases candidates for biological therapy.
Chronic immunosuppression is a known risk factor for tuberculosis. Our aim was to reach a consensus on screening and prevention of tuberculosis in patients with immune mediated inflammatory diseases candidates to biologic therapy. Critical appraisal of the literature and expert opinion on immunosuppressive therapies and risk of tuberculosis. The currently recommended method for screening is the tuberculin skin test and the interferon gamma assay, after exclusion of active tuberculosis. Positively screened patients should be treated for latent tuberculosis infection. Patients may start biological therapy after 1 to 2 months, as long as they are strictly adhering to and tolerating their preventive regimen.


Simultaneous detection of HFE C282Y, H63D and S65C mutations associated with type 1 haemochromatosis using a multiplex luminex bead assay.
Type 1 hereditary haemochromatosis (HH) is a common genetic disorder in Caucasoids resulting from mutations in the HFE gene. Routine diagnostic testing for type 1 HH involves genotyping for two of these described HFE mutations, C282Y and H63D. In some cases typing of a third mutation, S65C is also performed. Several techniques have been reported for HFE genotyping and these include polymerase chain reaction (PCR)-sequence-specific primers (SSP), PCR-restriction fragment length polymorphism (RFLP), PCR-sequence-specific oligonucleotide probe (SSOP), real-time PCR followed by melting curve analysis and TaqMan assay. The aim of this study was to develop an alternative method to both conventional PCR and real-time PCR/TaqMan assay to detect all three HFE mutations in a single assay using Luminex technology. DNA controls of known genotypes (n = 109) were used to evaluate this approach. These controls were selected to represent the three possible genotypes (wild type, mutant, heterozygous) for each mutation. Subsequently, blind DNA samples (n = 100) were used to validate this method. This new assay was then compared with current techniques (in-house PCR-SSP and TaqMan assay). Comparison of genotypes obtained with the Luminex method with those previously reported by both in-house PCR-SSP and TaqMan assay showed 100% concordance for both DNA controls and blind DNA samples and no discrepancies were observed. Allelic frequency for C282Y, H63D and S65C mutations were 22%, 16% and 2%, respectively. We report here a high-throughput, accurate and robust multiplex luminex bead assay for routine clinical testing of C282Y, H63D and S65C mutations in the HFE gene.


S100A6 is increased in a stepwise manner during pancreatic carcinogenesis: clinical value of expression analysis in 98 pancreatic juice samples.
There are few reports describing the diagnostic significance of S100A6 expression in clinical samples obtained from patients with pancreatic disease. In the present study, we measured S100A6 expression in pancreatic tissues and juice to evaluate its involvement in pancreatic carcinogenesis. We did quantitative real-time reverse transcription-PCR to measure mRNA expression in microdissected cells and pancreatic juice samples. Microdissected invasive ductal carcinoma and intraductal papillary mucinous neoplasm (IPMN) cells expressed significantly higher levels of S100A6 than did microdissected pancreatitis-affected epithelial and normal cells (all comparison; P < 0.008). Median levels of S100A6 in invasive ductal carcinoma were higher than those in IPMN, and those in pancreatitis-affected epithelial cells tended to be higher than those in normal cells, although these differences were not statistically significant. In analyses of pancreatic juice, IPMN and pancreatic cancer samples expressed significantly higher levels of S100A6 than did chronic pancreatitis samples (both; P < 0.017), but levels in pancreatic cancer and IPMN samples did not differ form each other. Receiver operating characteristic (ROC) curve analysis revealed that measurement of S100A6 was useful for discriminating cancer (area under the ROC curve, 0.864) or IPMN (area under the ROC curve, 0.749) from chronic pancreatitis. The present data suggest that expression of S100A6 is increased in a stepwise manner during pancreatic carcinogenesis and may be a biomarker for evaluating malignant potential. Measurement of S100A6 in pancreatic juice may be useful to detect early pancreatic cancer or identify individuals with high-risk lesions that may progress to pancreatic cancer.


Surgical treatment of retroiliac ectopic ureters with secondary hydronephrosis and hydroureter in a dog.
An 8-month-old 41.2-kg (90.6-lb) sexually intact male Dogue de Bordeaux with urinary incontinence and signs of nausea was referred for further evaluation and treatment of bilateral hydronephrosis, hydroureter, and ectopic ureters. Clinicopathologic analyses revealed urine specific gravity and serum concentrations of urea nitrogen and creatinine within reference limits. Abdominal ultrasonography and CT revealed unilateral abdominal cryptorchidism, ureters that bilaterally passed dorsal to and appeared compressed by the external iliac arteries (retroiliac ureters), and bilateral hydronephrosis, hydroureter, and ectopic ureters. On CT, minimal uptake of contrast medium by the right kidney indicated either a lack of renal function or ureteral obstruction. The dog underwent exploratory laparotomy, right ureteronephrectomy, left neoureterocystostomy, bilateral castration, and incisional gastropexy without complication and was discharged 2 days postoperatively. Eleven days after surgery, the dog had improved but continued urinary incontinence, improved left hydronephrosis and hydroureter, and serum concentrations of urea nitrogen and creatinine within reference limits. At 24 months after surgery, the dog was reportedly clinically normal, other than having persistent urinary incontinence. To our knowledge, this was the first report of a dog with retroiliac ureters and compression-induced ureteral obstruction with secondary hydroureter and hydronephrosis. Retroiliac ureters should be considered as a differential diagnosis in young dogs with ureteral obstruction. Our findings indicated that a good outcome was possible for a dog with retroiliac ureters treated surgically; however, the presence of additional congenital anomalies should be considered and may alter the prognosis in dogs with retroiliac ureters.


The Korean National Burden of Disease Study: from Evidence to Policy.
Following the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), disability-adjusted life years (DALYs) have been widely used as a summary measure of population health. The DALY metric is a comprehensive measurement of population health, enabling comparison among groups. However, the available data and reliance on estimates to supplement the data gap require contextualization at the national level, and the outcomes of which are more appropriate for national policymakers. The Korean National Burden of Disease (KNBD) study was initiated by the Research and Development Project of the Ministry of Health and Welfare, funded by a 5-year grant from 2013, to contextualize the GBD method to the Korean population. Here, we provide a comprehensive overview of the KNBD study with its achievements and challenges and discuss the implications for public health policies.


Effect of hyperosmolar sodium lactate infusion on haemodynamic status and fluid balance compared with hydroxyethyl starch 6% during the cardiac surgery.
No solution has been determined ideal for fluid therapy during cardiac surgery. Previous studies have shown that hyperosmolar sodium lactate (HSL) infusion has improved cardiac performance with smaller volume infusion, which resulted in negative fluid balance. This study compared the effects between a patent-protected HSL infusion and hydroxyethyl starch (HES) 6% on haemodynamic status of the patients undergoing cardiac surgery. In this open-label prospective controlled randomized study, patients were randomly assigned to receive loading dose of either HSL or HES 6%, at 3 mL/kgBW within 15 min, at the beginning of surgery. Haemodynamic parameters and fluid balance were evaluated, while biochemical parameters and any adverse effect were also recorded. Haemodynamic and laboratory parameters were analyzed through repeated measures analysis of variance. Statistical assessment of fluid management was carried out through Student t-test. All statistical analyses were performed using the statistical package for the social sciences(®) version 15, 2006 (SPSS Inc., Chicago, IL). Out of 100 enrolled patients in this study (50 patients in each arm), 98 patients were included in analysis (50 in HSL group; 48 in HES group). Cardiac index increased higher in HSL group (P = 0.01), whereas systemic vascular resistance index decreased more in HSL than HES group (P = 0.002). Other haemodynamic parameters were comparable between HSL and HES group. Fluid balance was negative in HSL group, but it was positive in HES group (-445.94 ± 815.30 mL vs. +108.479 ± 1219.91 mL, P < 0.009). Administration of HSL solution during the cardiac surgery improved cardiac performance and haemodynamic status better than HES did.


Spatially distributed effects of mental exhaustion on resting-state FMRI networks.
Brain activity during rest is spatially coherent over functional connectivity networks called resting-state networks. In resting-state functional magnetic resonance imaging, independent component analysis yields spatially distributed network representations reflecting distinct mental processes, such as intrinsic (default) or extrinsic (executive) attention, and sensory inhibition or excitation. These aspects can be related to different treatments or subjective experiences. Among these, exhaustion is a common psychological state induced by prolonged mental performance. Using repeated functional magnetic resonance imaging sessions and spatial independent component analysis, we explored the effect of several hours of sustained cognitive performances on the resting human brain. Resting-state functional magnetic resonance imaging was performed on the same healthy volunteers in two days, with and without, and before, during and after, an intensive psychological treatment (skill training and sustained practice with a flight simulator). After each scan, subjects rated their level of exhaustion and performed an N-back task to evaluate eventual decrease in cognitive performance. Spatial maps of selected resting-state network components were statistically evaluated across time points to detect possible changes induced by the sustained mental performance. The intensive treatment had a significant effect on exhaustion and effort ratings, but no effects on N-back performances. Significant changes in the most exhausted state were observed in the early visual processing and the anterior default mode networks (enhancement) and in the fronto-parietal executive networks (suppression), suggesting that mental exhaustion is associated with a more idling brain state and that internal attention processes are facilitated to the detriment of more extrinsic processes. The described application may inspire future indicators of the level of fatigue in the neural attention system.


Juror stress: identification and intervention.
The impact of stressful life events has been studied extensively in the psychiatric literature. Crisis debriefing techniques have been shown to be effective in decreasing psychiatric morbidity following exposure to these stressful situations. Stress reactions and crisis debriefing have been reported in many groups including combat veterans, survivors of natural disasters and accidents, victims of violence, and law enforcement and emergency personnel who respond to such events. One group that has not been studied extensively is jurors who are exposed to potentially disturbing material introduced as evidence in trials. Stress reactions in jurors and the value of debriefing of juries have been described by us in an earlier work. This paper describes debriefing sessions with three juries exposed to emotionally distressing material during murder trials. In comparing our experiences with these sets of jurors a number of common reactions were identified. These are discussed and a model for jury debriefing is presented.


B-Raf inhibitors induce epithelial differentiation in BRAF-mutant colorectal cancer cells.
BRAF mutations are associated with aggressive, less-differentiated and therapy-resistant colorectal carcinoma. However, the underlying mechanisms for these correlations remain unknown. To understand how oncogenic B-Raf contributes to carcinogenesis, in particular to aspects other than cellular proliferation and survival, we generated three isogenic human colorectal carcinoma cell line models in which we can dynamically modulate the expression of the B-Raf(V600E) oncoprotein. Doxycyclin-inducible knockdown of endogenous B-Raf(V600E) decreases cellular motility and invasion in conventional and three-dimensional (3D) culture, whereas it promotes cell-cell contacts and induces various hallmarks of differentiated epithelia. Importantly, all these effects are recapitulated by B-Raf (PLX4720, vemurafenib, and dabrafenib) or MEK inhibitors (trametinib). Surprisingly, loss of B-Raf(V600E) in HT29 xenografts does not only stall tumor growth, but also induces glandular structures with marked expression of CDX2, a tumor-suppressor and master transcription factor of intestinal differentiation. By performing the first transcriptome profiles of PLX4720-treated 3D cultures of HT29 and Colo-205 cells, we identify several upregulated genes linked to epithelial differentiation and effector functions, such as claudin-1, a Cdx-2 target gene encoding a critical tight junction component. Thereby, we provide a mechanism for the clinically observed correlation between mutant BRAF and the loss of Cdx-2 and claudin-1. PLX4720 also suppressed several metastasis-associated transcripts that have not been implicated as targets, effectors or potential biomarkers of oncogenic B-Raf signaling so far. Together, we identify a novel facet of clinically applied B-Raf or MEK inhibitors by showing that they promote cellular adhesion and differentiation of colorectal carcinoma cells.


Sex differences in corticotropin-releasing factor receptor signaling and trafficking: potential role in female vulnerability to stress-related psychopathology.
Although the higher incidence of stress-related psychiatric disorders in females is well documented, its basis is unknown. Here, we show that the receptor for corticotropin-releasing factor (CRF), the neuropeptide that orchestrates the stress response, signals and is trafficked differently in female rats in a manner that could result in a greater response and decreased adaptation to stressors. Most cellular responses to CRF in the brain are mediated by CRF receptor (CRFr) association with the GTP-binding protein, G(s). Receptor immunoprecipitation studies revealed enhanced CRFr-G(s) coupling in cortical tissue of unstressed female rats. Previous stressor exposure abolished this sex difference by increasing CRFr-G(s) coupling selectively in males. These molecular results mirrored the effects of sex and stress on sensitivity of locus ceruleus (LC)-norepinephrine neurons to CRF. Differences in CRFr trafficking were also identified that could compromise stress adaptation in females. Specifically, stress-induced CRFr association with beta-arrestin2, an integral step in receptor internalization, occurred only in male rats. Immunoelectron microscopy confirmed that stress elicited CRFr internalization in LC neurons of male rats exclusively, consistent with reported electrophysiological evidence for stress-induced desensitization to CRF in males. Together, these studies identified two aspects of CRFr function, increased cellular signaling and compromised internalization, which render CRF-receptive neurons of females more sensitive to low levels of CRF and less adaptable to high levels of CRF. CRFr dysfunction in females may underlie their increased vulnerability to develop stress-related pathology, particularly that related to increased activity of the LC-norepinephrine system, such as depression or post-traumatic stress disorder.


Molecular targets of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) within the zebrafish ovary: insights into TCDD-induced endocrine disruption and reproductive toxicity.
TCDD is a reproductive toxicant and endocrine disruptor, yet the mechanisms by which it causes these reproductive alterations are not fully understood. In order to provide additional insight into the molecular mechanisms that underlie TCDD's reproductive toxicity, we assessed TCDD-induced transcriptional changes in the ovary as they relate to previously described impacts on serum estradiol concentrations and altered follicular development in zebrafish. In silico computational approaches were used to correlate candidate regulatory motifs with observed changes in gene expression. Our data suggest that TCDD inhibits follicle maturation via attenuated gonadotropin responsiveness and/or depressed estradiol biosynthesis, and that interference of estrogen-regulated signal transduction may also contribute to TCDD's impacts on follicular development. TCDD may also alter ovarian function by disrupting various signaling pathways such as glucose and lipid metabolism, and regulation of transcription. Furthermore, events downstream from initial TCDD molecular-targets likely contribute to ovarian toxicity following chronic exposure to TCDD. Data presented here provide further insight into the mechanisms by which TCDD disrupts follicular development and reproduction in fish, and can be used to formulate new hypotheses regarding previously documented ovarian toxicity.


Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study.
To investigate the feasibility and safety of a combined intravenous (IV) and intra-arterial (IA) approach to recanalization in patients with ischemic stroke. Subjects ages 18 to 80 with an NIH Stroke Scale (NIHSS) > or =10 at baseline had IV recombinant tissue plasminogen activator (rt-PA) started (0.6 mg/kg, 60 mg maximum over 30 minutes) within 3 hours of onset. Additional rt-PA was then administered via microcatheter at the site of the thrombus up to a total dose of 22 mg over 2 hours of infusion or until thrombolysis. Primary comparisons were with similar subsets of placebo and rt-PA-treated subjects from the NINDS rt-PA Stroke Trial. The 80 subjects had a median baseline NIHSS score of 18. The median time to initiation of IV rt-PA was 140 minutes as compared with 108 minutes for placebo and 90 minutes for rt-PA-treated subjects in the NINDS rt-PA Stroke Trial. The 3-month mortality in Interventional Management Study (IMS) subjects (16%) was numerically lower but not statistically different than the mortality of placebo (24%) and rt-PA-treated subjects (21%) in the NINDS rt-PA Stroke Trial. The rate of symptomatic intracerebral hemorrhage (6.3%) in IMS subjects was similar to that of rt-PA-treated subjects (6.6%) but higher than the rate in placebo-treated subjects (1.0%, P=0.018) in the NINDS rt-PA Stroke Trial. IMS subjects had a significantly better outcome at 3 months than NINDS placebo-treated subjects for all outcome measures (odds ratios > or =2). A randomized trial of standard IV rt-PA as compared with a combined IV and IA approach is needed.


A randomized, double-blind, phase III trial of personalized peptide vaccination for recurrent glioblastoma.
We conducted a phase III trial of personalized peptide vaccination (PPV) for human leukocyte antigen (HLA)-A24+ recurrent glioblastoma to develop a new treatment modality. We randomly assigned 88 recurrent glioblastoma patients to receive PPV (n = 58) or the placebo (n = 30) at a 2-to-1 ratio. Four of 12 warehouse peptides selected based on preexisting peptide-specific immunoglobulin G levels or the corresponding placebos were injected 1×/week for 12 weeks. Our trial met neither the primary (overall survival [OS]) nor secondary endpoints. Unfavorable factors for OS of 58 PPV patients compared with 30 placebo patients were SART2-93 peptide selection (n = 13 vs 8, hazard ratio [HR]: 15.9), ≥70 years old (4 vs 4, 7.87), >70 kg body weight (10 vs 7, 4.11), and performance status (PS)3 (8 vs 2, 2.82), respectively. Consequently, the median OS for PPV patients without SART2-93 selection plus one of these 3 favorable factors (<70 y old, ≤70 kg, or PS0-2) was significantly longer than that for the corresponding placebo patients (HR: 0.49, 0.44, and 0.51), respectively. Preexisting immunity against both all 12 warehouse peptides besides SART2-93 and the other cytotoxic T lymphocyte epitope peptides was significantly depressed in the patients with SART2-93 selection (n = 21) compared with that of the patients without SART2-93 selection (n = 67). Biomarkers correlative for favorable OS of the PPV patients were a lower percentage of CD11b+CD14+HLA-DRlow immunosuppressive monocytes and a higher percentage of CD4+CD45RA- activated T cells, the intermediate levels of chemokine C-C ligand 2 (CCL2), vascular endothelial growth factor, interleukin (IL)-6, IL-17, or haptoglobin, respectively. This phase III trial met neither the primary nor secondary endpoints.


Sinusoidal immunity: macrophages at the lymphohematopoietic interface.
Macrophages are widely distributed throughout the body, performing vital homeostatic and defense functions after local and systemic perturbation within tissues. In concert with closely related dendritic cells and other myeloid and lymphoid cells, which mediate the innate and adaptive immune response, macrophages determine the outcome of the inflammatory and repair processes that accompany sterile and infectious injury and microbial invasion. This article will describe and compare the role of specialized macrophage populations at two critical interfaces between the resident host lymphohematopoietic system and circulating blood and lymph, the carriers of cells, humoral components, microorganisms, and their products. Sinusoidal macrophages in the marginal zone of the spleen and subcapsular sinus and medulla of secondary lymph nodes contribute to the innate and adaptive responses of the host in health and disease. Although historically recognized as major constituents of the reticuloendothelial system, it has only recently become apparent that these specialized macrophages in close proximity to B and T lymphocytes play an indispensable role in recognition and responses to exogenous and endogenous ligands, thus shaping the nature and quality of immunity and inflammation. We review current understanding of these macrophages and identify gaps in our knowledge for further investigation.


Can an antimicrobial stewardship program reduce length of stay of immune-competent adult patients admitted to hospital with diagnosis of community-acquired pneumonia? Study protocol for pragmatic controlled non-randomized clinical study.
Pneumonia is responsible for a large proportion of hospital admissions and antibiotic utilization. Physician adherence to evidence-based pneumonia management guidelines is poor. Antimicrobial stewardship programs (ASPs) are an effective intervention to mitigate against unwarranted variation from these guidelines. Despite this benefit, ASPs have not been shown to reduce the length of stay of hospitalized patients with pneumonia. In immune-competent adult patients admitted to a hospital ward with a diagnosis of community-acquired pneumonia, does a multi-faceted ASP utilizing prospective chart audit and feedback reduce the length of stay, compared with usual care, without increasing the risk of death or readmission 30 days after discharge from hospital? Starting on 1 April 2013, all consecutive immune-competent adult patients (>18 years old) admitted to a hospital ward with a positive febrile respiratory illness screening questionnaire and a diagnosis of pneumonia by the attending physician will be eligible for inclusion in this non-randomized study. All eligible patients who fulfill the ASP review criteria will undergo a prospective chart audit, followed by an ASP recommendation provided to the attending physician. The attending physician is responsible for implementing or rejecting the ASP recommendation. This is a modified stepped-wedge design with a baseline data collection period of 3 months, followed by non-random sequential introduction of the ASP intervention on each of four hospital wards in a single community-based, academic-affiliated 339-bed acute-care hospital in Barrie, ON, Canada. The primary outcome measure is hospital length of stay; secondary outcome measures include days and duration of antibiotic therapy, and inadvertent adverse outcomes of 30 day post-discharge mortality and hospital readmission rates. Differences in outcome measures will be assessed using extended Cox regression analysis. Time to ASP intervention is included as a time-dependent covariate in the final model, to account for time-dependent bias. By designing a pragmatic clinical trial with unique design and analytic features, we not only expect to demonstrate the effectiveness of a real-world ASP, but also provide a model for program evaluation that can be used more broadly to improve patient safety and quality of care. ClinicalTrials.gov NCT02264756 .


Functional polymorphism of the CK2alpha intronless gene plays oncogenic roles in lung cancer.
Protein kinase CK2 is frequently up-regulated in human cancers, although the mechanism of CK2 activation in cancer remains unknown. In this study, we investigated the role of the CK2alpha intronless gene (CSNK2A1P, a presumed CK2alpha pseudogene) in the pathogenesis of human cancers. We found evidence of amplification and over-expression of the CSNK2A1P gene in non-small cell lung cancer and leukemia cell lines and 25% of the lung cancer tissues studied. The mRNA expression levels correlated with the copy numbers of the CSNK2A1P gene. We also identified a novel polymorphic variant (398T/C, I133T) of the CSNK2A1P gene and showed that the 398T allele is selectively amplified over the 398C allele in 101 non-small cell lung cancer tissue samples compared to those in 48 normal controls (p = 0.013<0.05). We show for the first time CSNK2A1P protein expression in transfected human embryonic kidney 293T and mouse embryonic fibroblast NIH-3T3 cell lines. Both alleles are transforming in these cell lines, and the 398T allele appears to be more transforming than the 398C allele. Moreover, the 398T allele degrades PML tumor suppressor protein more efficiently than the 398C allele and shows a relatively stronger binding to PML. Knockdown of the CSNK2A1P gene expression with specific siRNA increased the PML protein level in lung cancer cells. We report, for the first time, that the CSNK2A1P gene is a functional proto-oncogene in human cancers and its functional polymorphism appears to degrade PML differentially in cancer cells. These results are consistent with an important role for the 398T allele of the CSNK2A1P in human lung cancer susceptibility.


Identification of Small Molecule Compounds for Pharmacological Chaperone Therapy of Aspartylglucosaminuria.
Aspartylglucosaminuria (AGU) is a lysosomal storage disorder that is caused by genetic deficiency of the enzyme aspartylglucosaminidase (AGA) which is involved in glycoprotein degradation. AGU is a progressive disorder that results in severe mental retardation in early adulthood. No curative therapy is currently available for AGU. We have here characterized the consequences of a novel AGU mutation that results in Thr122Lys exchange in AGA, and compared this mutant form to one carrying the worldwide most common AGU mutation, AGU-Fin. We show that T122K mutated AGA is expressed in normal amounts and localized in lysosomes, but exhibits low AGA activity due to impaired processing of the precursor molecule into subunits. Coexpression of T122K with wildtype AGA results in processing of the precursor into subunits, implicating that the mutation causes a local misfolding that prevents the precursor from becoming processed. Similar data were obtained for the AGU-Fin mutant polypeptide. We have here also identified small chemical compounds that function as chemical or pharmacological chaperones for the mutant AGA. Treatment of patient fibroblasts with these compounds results in increased AGA activity and processing, implicating that these substances may be suitable for chaperone mediated therapy for AGU.


An Electrochromic Tristable Molecular Switch.
A tristable [2]catenane, composed of a macrocyclic polyether incorporating 1,5-dioxynaphthalene (DNP) and tetrathiafulvalene (TTF) units along with a 4,4'-bipyridinium (BIPY(•+)) radical cation as three very different potential recognition sites, interlocked mechanically with the tetracationic cyclophane, cyclobis(paraquat-p-phenylene) (CBPQT(4+)), was synthesized by donor-acceptor templation, employing a "threading-followed-by-cyclization" approach. In this catenane, movement of the CBPQT(4+) ring in its different redox states among these three potential recognition sites, with corresponding color changes, is achieved by tuning external redox potentials. In the starting state, where no external potential is applied, the ring encircles the TTF unit and displays a green color. Upon oxidation of the TTF unit, the CBPQT(4+) ring moves to the DNP unit, producing a red color. Finally, if all the BIPY(2+) units are reduced to BIPY(•+) radical cations, the resulting CBPQT(2(•+)) diradical dication will migrate to the BIPY(•+) unit, resulting in a purple color. These readily switchable electrochromic properties render the [2]catenane attractive for use in electro-optical devices.


Somatic mosaicism and disease.
The large number of cell divisions required to make a human body inevitably leads to the accumulation of somatic mutations. Such mutations cause individuals to be somatic mosaics. Recent advances in genomic technology now allow measurement of somatic diversity. Initial studies confirmed the expected high levels of somatic mutations within individuals. Going forward, the big questions concern the degree to which those somatic mutations influence disease. Theory predicts that the frequency of mutant cells should vary greatly between individuals. Such somatic mutational variability between individuals could explain much of the diversity in the risk of disease. But how variable is mosaicism between individuals in reality? What is the relation between the fraction of cells carrying a predisposing mutation and the risk of disease? What kinds of heritable somatic change lead to disease besides classical DNA mutations? What molecular processes connect a predisposing somatic change to disease? We know that predisposing somatic mutations strongly influence the onset of cancer. Likewise, neurodegenerative diseases may often begin from somatically mutated cells. If so, both neurodegeneration and cancer may be diseases of later life for which much of the risk may be set by early life somatic mutations.


Vitamin D and energy homeostasis: of mice and men.
The vitamin D endocrine system has many extraskeletal targets, including adipose tissue. 1,25-Dihydroxyvitamin D₃, the active form of vitamin D, not only increases adipogenesis and the expression of typical adipocyte genes but also decreases the expression of uncoupling proteins. Mice with disrupted vitamin D action--owing to gene deletion of the nuclear receptor vitamin D receptor (Vdr) or the gene encoding 1α-hydroxylase (Cyp27b1)--lose fat mass over time owing to an increase in energy expenditure, whereas mice with increased Vdr-mediated signalling in adipose tissue become obese. The resistance to diet-induced obesity in mice with disrupted Vdr signalling is caused at least partially by increased expression of uncoupling proteins in white adipose tissue. However, the bile acid pool is also increased in these animals, and bile acids are known to be potent inducers of energy expenditure through activation of several nuclear receptors, including Vdr, and G-protein-coupled receptors, such as GPBAR1 (also known as TGR5). By contrast, in humans, obesity is strongly associated with poor vitamin D status. A causal link has not been firmly proven, but most intervention studies have failed to demonstrate a beneficial effect of vitamin D supplementation on body weight. The reasons for the major discrepancy between mouse and human data are unclear, but understanding the link between vitamin D status and energy homeostasis could potentially be very important for the human epidemic of obesity and the metabolic syndrome.


Biologising parenting: neuroscience discourse, English social and public health policy and understandings of the child.
In recent years, claims about children's developing brains have become central to the formation of child health and welfare policies in England. While these policies assert that they are based on neuro-scientific discoveries, their relationship to neuroscience itself has been debated. However, what is clear is that they portray a particular understanding of children and childhood, one that is marked by a lack of acknowledgment of child personhood. Using an analysis of key government-commissioned reports and additional advocacy documents, this article illustrates the ways that the mind of the child is reduced to the brain, and this brain comes to represent the child. It is argued that a highly reductionist and limiting construction of the child is produced, alongside the idea that parenting is the main factor in child development. It is concluded that this focus on children's brains, with its accompanying deterministic perspective on parenting, overlooks children's embodied lives and this has implications for the design of children's health and welfare services.


Expression of the mediators of dioxin toxicity, aryl hydrocarbon receptor (AHR) and the AHR nuclear translocator (ARNT), is developmentally regulated in mouse teeth.
Dioxins are persistent and ubiquitous environmental poisons that become enriched in the food chain. Besides being acutely lethal, the most toxic dioxin congener, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), is developmentally toxic to many animal species. We have previously found that developing teeth of children may be sensitive to environmental dioxins via their mother's milk and that rat and mouse teeth are dioxin-sensitive throughout their development. The aryl hydrocarbon receptor (AHR) together with the AHR nuclear translocator (ARNT) protein is believed to mediate the toxic effects of dioxins. To study the potential involvement of the AHR-ARNT pathway in the dental toxicity of TCDD, we analysed the expression of AHR and ARNT by in situ hybridization and immunohistochemistry in developing mouse teeth. AHR mRNA first appeared in the epithelium of E12 first molar tooth buds and both proteins were weakly expressed in the bud. After cytodifferentiation the expression was up regulated and became intense in secretory odontoblasts and ameloblasts. The coexpression of AHR and ARNT during early tooth development as well as during the information and mineralization of the dental matrices is suggestive of the AHR-ARNT pathway as a mediator of dental toxicity of TCDD.


Tobacco control and gender in south-east Asia. Part II: Singapore and Vietnam.
In the World Health Organization's Western Pacific Region, being born male is the single greatest risk marker for tobacco use. While the literature demonstrates that risks associated with tobacco use may vary according to sex, gender refers to the socially determined roles and responsibilities of men and women, who initiate, continue and quit using tobacco for complex and often different reasons. Cigarette advertising frequently appeals to gender roles. Yet tobacco control policy tends to be gender-blind. Using a broad, gender-sensitivity framework, this contradiction is explored in four Western Pacific countries. Part I of the study presented the rationale, methodology and design of the study, discussed issues surrounding gender and tobacco, and analysed developments in Malaysia and the Philippines (see the previous issue of this journal). Part II deals with Singapore and Vietnam. In all four countries gender was salient for the initiation and maintenance of smoking. Yet, with a few exceptions, gender was largely unrecognized in control policy. Suggestions for overcoming this weakness in order to enhance tobacco control are made.


The Heart of Grinnell: A Community-Wide Rural Health Wellness Initiative: a pilot observational study and a prospective study design.
In 2007, the leadership team at Grinnell Regional Medical Center participated in a pilot project with the Institute of HeartMath (IHM) to assess the stress level of individual team members and its effect on the organization. At the beginning of the project, the leadership team completed a Personal and Organizational Quality Assessment (POQA-R). Results showed that a high percentage of the participants were experiencing fatigue, anxiety, difficulty sleeping, and depression. The leadership team participated in a Transforming Stress workshop and began using IHM techniques to deal with the stresses in their personal and professional lives. A 1-month follow up revealed improvement in six of the 10 categories assessed: fatigue, anxiety, depression, anger management, resentfulness, and stress symptoms. Based on this success, GRMC and IHM initiated The Heart of Grinnell: A Community-Wide Rural Health Wellness Initiative to determine if these results could be replicated on a community level. This project is a health and disease promotion, chronic disease prevention, and education wellness initiative. Located in Grinnell and Poweshiek County, Iowa, this initiative is a multicomponent, community-wide intervention that includes Grinnell College, schools, churches, businesses, social service agencies, local government, and Grinnell Regional Medical Center in partnership with IHM and the University of Iowa College of Public Health. At the center of this project is the goal of training community groups on using a scientifically researched program created by the IHM designed to reduce stress and increase coherence. Coherence implies order, structure, harmony, and alignment among systems-whether in cells and organs, entire organisms, or social groups including communities and counties. The primary objective of The Heart of Grinnell project is to measure the results of a community-wide program to increase community coherence and stress reduction in order to improve adherence to positive wellness behaviors; physical biometrics; productivity by reducing absenteeism and improving workplace morale; and coherence in the workplace, schools, homes, and community.


Lanosterol synthase mutations cause cholesterol deficiency-associated cataracts in the Shumiya cataract rat.
The Shumiya cataract rat (SCR) is a hereditary cataractous strain. It is thought that the continuous occurrence of poorly differentiated epithelial cells at the bow area of the lens forms the pathophysiological basis for cataract formation in SCRs. In this study, we attempted to identify the genes associated with cataract formation in SCRs by positional cloning. Genetic linkage analysis revealed the presence of a major cataract locus on chromosome 20 as well as a locus on chromosome 15 that partially suppressed cataract onset. Hypomorphic mutations were identified in genes for lanosterol synthase (Lss) on chromosome 20 and farnesyl diphosphate farnesyl transferase 1 (Fdft1) on chromosome 15, both of which function in the cholesterol biosynthesis pathway. A null mutation for Lss was also identified. Cataract onset was associated with the specific combination of Lss and Fdft1 mutant alleles that decreased cholesterol levels in cataractous lenses to about 57% of normal. Thus, cholesterol insufficiency may underlie the deficient proliferation of lens epithelial cells in SCRs, which results in the loss of homeostatic epithelial cell control of the underlying fiber cells and eventually leads to cataractogenesis. These findings may have some relevance to other types of cataracts, inborn defects of cholesterol synthesis, and the effects of cholesterol-lowering medication.


Clinical and demographic characteristics of psychiatric inpatients admitted via emergency and non-emergency routes at a university hospital in Pakistan.
To examine the differences in the demographic and clinical characteristics of patients admitted through emergency versus non-emergency routes and see if these two groups of patients were significantly different from each other with respect to criteria mentioned in the title. Retrospective data was analysed in all 2576 patient records were reviewed and these patients were divided in two groups with respect to their mode of admission (emergency vs non emergency). These groups were then compared with respect to sex, age, length of stay, discharge status and diagnostic categories. Statistical package for social sciences version 8.0 (SPSS 8.0) was used to analyze the data. The study was conducted at the Aga Khan University Hospital, is a private tertiary care hospital with a 13 bed psychiatric facility. When these two groups were compared, significant differences were found, with ER patients having a shorter length of stay and youngest mean age, proportion of females admitted via ER was greater than those in non-ER group. There were significantly more women in each group who were married. The percentage of patients who left against medical advice was greater in the ER group. In both the groups mood disorders including Bipolar disorder and major depressive disorders was the most prevalent category with psychotic disorders to follow. The percentage of patients in both these categories was greater in the non-ER group where as percentage of patients with conversion disorder was higher in the ER group. Significant differences were found in the patient characteristics admitted via ER versus Non ER. Shorter length of stay in ER group might indicate an acute episode resolving quickly. Studies need to be done prospectively to determine the difference in the two groups thus ascertaining the level of care needed for each group. Lastly, the high proportion of patients coming through the ER also indicates that there exists a need for primary care involvement in mental health care thus reducing the need for emergency room usage. Clinical and Demographic Characteristics of inpatients admitted via emergency and non-emergency routes at a university hospital in Pakistan.


The spectrum of tuberculosis in dialysis patients.
Patients receiving dialysis therapy are known to be at increased risk of tuberculosis (TB). The aim of this study was to evaluate the frequency, clinical characteristics and course of TB disease in dialysis patients treated at our institution. Medical records of 330 regular haemodialysis (n=219) and continuous ambulatory peritoneal dialysis (n=111) patients (172 male, 158 female; mean age 55+/-16 y) who were cared for at our tertiary university hospital between December 2002 and January 2006 were retrospectively evaluated. Nine cases of TB (2.7%) occurred, in the following locations: vertebra (n=3), miliary (n=3), lymph nodes (n=1), peritoneum (n=2; one as peritionitis, 1 as an abscess). Four of these 9 patients died during the follow-up (mean time from diagnosis to death, 7 months); none of the deaths appeared to be caused by the disease itself. The incidence of TB disease in patients receiving renal replacement therapy is high, and occurs primarily in extrapulmonary sites.


The topography of the central and peripheral cornea.
To investigate the topography of the central and peripheral cornea in a group of young adult subjects with a range of normal refractive errors. Corneal topography data were acquired for 100 young adult subjects by a method that allows central and peripheral maps to be combined to produce one large, extended corneal topography map. This computer-based method involves matching the common topographical features in the overlapping maps. Corneal height, axial radius of curvature, and axial power data were analyzed. The corneal height data were also fit with Zernike polynomials. Conic fitting to the corneal height data revealed the average apical radius (Ro) was 7.77 +/- 0.2-mm and asphericity (Q) was -0.19 +/- 0.1 for a 6-mm corneal diameter. The conic fit parameters were both found to change significantly for increasing corneal diameters. For a 10-mm corneal diameter, Ro was 7.72 +/- 0.2 mm and Q was -0.36 +/- 0.1. A slight but significant meridional variation was found in Q, with the steepest principal corneal meridian found to flatten at a slightly greater rate than the flattest meridian. The RMS fit error for the conic section was found to increase markedly for larger corneal diameters. Higher-order polynomial fits were needed to fit the peripheral corneal data adequately. Analysis of the axial power data revealed highly significant changes occurring in the corneal best-fit spherocylinder with increasing distance from the corneal center. The peripheral cornea was found to become significantly flatter and to decrease slightly in its toricity. Individual subjects exhibited a range of different patterns of central and peripheral corneal topography. Several of the higher order corneal surface Zernike coefficients were found to change significantly with increasing corneal diameter. Highly significant changes occur in the shape of the cornea in the periphery. On average, the peripheral cornea becomes significantly flatter and slightly less astigmatic than the central cornea. A conic section is a poor estimator of the peripheral cornea.


Supplementary motor area activations in unconscious inhibition of voluntary action.
It is widely accepted that regions within the dorsal medial frontal cortex are involved in the control of voluntary action. However, recent evidence suggests that a subset of these regions may also be important for unconscious and involuntary motor processes. Indeed, Sumner et al. (Neuron 54:697-711, 2007) showed that two patients with micro-lesions of the supplementary motor area (SMA) and supplementary eye field (SEF) demonstrated an absence of unconscious inhibition as evoked by masked-prime stimuli, while pre-SMA damage had no such effect. Here, we employ fMRI and a similar masked-prime task to test whether SMA and pre-SMA are similarly dissociated in healthy volunteers. Reaction times (RT) revealed that responses to compatible trials were slower than those to incompatible trials (negative compatibility effect, NCE), indicating automatic inhibition in every participant. BOLD signals in the SMA were modulated by prime compatibility, showing greater signal for compatible trials, but there was no change in pre-SMA. There was also no modulation in the hand motor cortex (HMC). These findings imply that the SMA is involved in automatic suppression of manual motor plans.


Active Surveillance for the Management of Localized Prostate Cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology Clinical Practice Guideline Endorsement.
To endorse Cancer Care Ontario's guideline on Active Surveillance for the Management of Localized Prostate Cancer. The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing clinical practice guidelines developed by other professional organizations. The Active Surveillance for the Management of Localized Prostate Cancer guideline was reviewed for developmental rigor by methodologists. The ASCO Endorsement Panel then reviewed the content and the recommendations. The ASCO Endorsement Panel determined that the recommendations from the Active Surveillance for the Management of Localized Prostate Cancer guideline, published in May 2015, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the Active Surveillance for the Management of Localized Prostate Cancer guideline with added qualifying statements. The Cancer Care Ontario recommendation regarding 5-alpha reductase inhibitors was not endorsed by the ASCO panel. For most patients with low-risk (Gleason score ≤ 6) localized prostate cancer, active surveillance is the recommended disease management strategy. Factors including younger age, prostate cancer volume, patient preference, and ethnicity should be taken into account when making management decisions. Select patients with low-volume, intermediate-risk (Gleason 3 + 4 = 7) prostate cancer may be offered active surveillance. Active surveillance protocols should include prostate-specific antigen testing, digital rectal examinations, and serial prostate biopsies. Ancillary radiologic and genomic tests are investigational but may have a role in patients with discordant clinical and/or pathologic findings. Patients who are reclassified to a higher-risk category (Gleason score ≥ 7) or who have significant increases in tumor volume on subsequent biopsies should be offered active therapy.


ProsCan for Couples: randomised controlled trial of a couples-based sexuality intervention for men with localised prostate cancer who receive radical prostatectomy.
Prostate cancer is the most common male cancer in the Western world. The most substantial long term morbidity from this cancer is sexual dysfunction with consequent adverse changes in couple and intimate relationships. Research to date has not identified an effective way to improve sexual and psychosocial adjustment for both men with prostate cancer and their partners. As well, the efficacy and cost effectiveness of peer counselling as opposed to professional models of service delivery has not yet been empirically tested. This paper presents the design of a three arm randomised controlled trial (peer vs. nurse counselling vs. usual care) that will evaluate the efficacy of two couples-based sexuality interventions (ProsCan for Couples: Peer support vs. nurse counselling) on men's and women's sexual and psychosocial adjustment after surgical treatment for localised prostate cancer; in addition to cost-effectiveness. Seventy couples per condition (210 couples in total) will be recruited after diagnosis and before treatment through urology private practices and hospital outpatient clinics and randomised to (1) usual care; (2) eight sessions of peer-delivered telephone support with DVD education; and (3) eight sessions of oncology nurse-delivered telephone counselling with DVD education. Two intervention sessions will be delivered before surgery and six over the six months post-surgery. The intervention will utilise a cognitive behavioural approach along with couple relationship education focussed on relationship enhancement and helping the couple to conjointly manage the stresses of cancer diagnosis and treatment. Participants will be assessed at baseline (before surgery) and 3, 6 and 12 months post-surgery. Outcome measures include: sexual adjustment; unmet sexuality supportive care needs; attitudes to sexual help seeking; psychological adjustment; benefit finding and quality of life. The study will provide recommendations about the efficacy of peer support vs. nurse counselling to facilitate better sexual and couple adjustment after prostate cancer as well as recommendations on whether the interventions represent efficient health service delivery. ACTRN12608000358347.


A reflective qualitative appreciative inquiry approach to restoring compassionate care deficits at one United Kingdom health care site.
Following declining health care practices at one UK health care site the subsequent and much publicized Francis Report made several far-reaching recommendations aimed at recovering optimal levels of care including stringent monitoring of practice. The aftermath of these deliberations have had resounding consequences for quality care both nationally and internationally. A reflective qualitative appreciative qualitative inquiry using a hybrid approach combining case study and thematic analysis outlines the development and analysis of a solution-focused intervention aimed at restoring staff confidence and optimal care levels at one key UK hospital site. Personal diaries were used to collect data. Data were analysed using descriptive thematic analysis. The implications of the five emerging themes and the 10-step approach used are discussed in the context of understanding care erosion and ways to effect organisational change. A novel approach to addressing care deficits, which provides a promising bottom-up approach, initiated by health care policy makers is suggested for use in other health care settings when concerns about care arise. It is anticipated this approach will prove useful for nurse managers, particularly in relation to finding positive solutions to addressing problems that surround potential failing standards of care in hospitals.


Water VBAC: exploring a new frontier for women's autonomy.
although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted. Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes. in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit. The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted. the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences. The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section. Three main themes emerged: 'minimising', 'maximising' and 'managing'. Water VBAC entailed an attempt to minimise the medicalisation of the women's childbirth experience. This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences. Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth. The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care. for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process. The value accorded to being able to exercise choice and control over their childbearing experience was high. These women's accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.


The 'M2 DASH'-Manchester-modified Disabilities of Arm Shoulder and Hand score.
The Disability of the Arm, Shoulder, and Hand (DASH) questionnaire was originally designed as a measure of disability in patients with disorders of the upper limb, but the DASH score is also affected by disability because of lower limb disorders. The aim of this study was to investigate the construct validity of the DASH questionnaire and to create a revised DASH questionnaire, the Manchester-modified or M2 DASH, with fewer questions that is more specific to the upper limb. Patients were asked to fill in the DASH questionnaire in a fracture clinic after ethical approval. This included 79 patients with upper limb injuries, 61 patients with lower limb injuries, and 52 control subjects. The mean DASH scores for the three groups varied significantly, and the lower limb group had a mean score of 16. The M2 DASH questionnaire was developed using questions more specific to the upper limb and included questions 1-4, 6, 13-17, 21-23, and 26-30 from the original questionnaire. The mean M2 DASH score for the lower limb group was 9 and, unlike the original DASH score, was not statistically different from the control group. The M2 DASH scores were then calculated for the upper limb group and a correlation study showed highly significant correlation between the original DASH scores and the M(2) DASH scores. Our study shows that the original DASH questionnaire is not specific for the upper limb. The M2 DASH questionnaire has the advantage of being more specific for the upper limb than the DASH questionnaire, and it correlates well with the original DASH questionnaire when looking at isolated upper limb injuries.


Fasting hyperinsulinemia is a predictor of increased body weight gain and obesity in Pima Indian children.
Hyperinsulinemia is commonly associated with obesity, but it has not been determined which defect comes first. Some have proposed that hyperinsulinemia may precede obesity in populations prone to NIDDM, such as Pima Indians or Pacific Islanders. In contrast, longitudinal studies in adults show that insulin sensitivity and low fasting insulin concentrations are associated with increased weight gain, whereas insulin resistance seems to protect against weight gain. The present study examined whether fasting plasma hyperinsulinemia is a risk factor for weight gain in prepubertal children in the Pima Indian population-a population that is prone to obesity. Fasting plasma insulin concentration was measured in 328 5- to 9-year-old Pima Indian children (147 boys and 181 girls) with normal glucose tolerance. Follow-up weight was obtained an average of 9.3 +/- 1.9 years (means +/- SD) later at age 15-19 years. Fasting plasma insulin concentration correlated with the rate of weight gain per year in both boys (r = 0.42; P < 0.0001) and girls (r = 0.20; P < 0.01) and was associated with the rate of weight gain, independent of known determinants of weight change, i.e., initial relative weight, change in height, age, and sex. Similar relationships were found between fasting plasma insulin concentration and the change in relative weight and in triceps skinfold thickness-two indicators of obesity. In conclusion, fasting hyperinsulinemia may be a risk factor for the development of obesity in young children.


Reconciling fisheries catch and ocean productivity.
Photosynthesis fuels marine food webs, yet differences in fish catch across globally distributed marine ecosystems far exceed differences in net primary production (NPP). We consider the hypothesis that ecosystem-level variations in pelagic and benthic energy flows from phytoplankton to fish, trophic transfer efficiencies, and fishing effort can quantitatively reconcile this contrast in an energetically consistent manner. To test this hypothesis, we enlist global fish catch data that include previously neglected contributions from small-scale fisheries, a synthesis of global fishing effort, and plankton food web energy flux estimates from a prototype high-resolution global earth system model (ESM). After removing a small number of lightly fished ecosystems, stark interregional differences in fish catch per unit area can be explained (r = 0.79) with an energy-based model that (i) considers dynamic interregional differences in benthic and pelagic energy pathways connecting phytoplankton and fish, (ii) depresses trophic transfer efficiencies in the tropics and, less critically, (iii) associates elevated trophic transfer efficiencies with benthic-predominant systems. Model catch estimates are generally within a factor of 2 of values spanning two orders of magnitude. Climate change projections show that the same macroecological patterns explaining dramatic regional catch differences in the contemporary ocean amplify catch trends, producing changes that may exceed 50% in some regions by the end of the 21st century under high-emissions scenarios. Models failing to resolve these trophodynamic patterns may significantly underestimate regional fisheries catch trends and hinder adaptation to climate change.


Searching for a perceived gaze direction using eye tracking.
The purpose of the current study was to use eye tracking to better understand the "stare-in-the-crowd effect"-the notion that direct gaze is more easily detected than averted gaze in a crowd of opposite-gaze distractors. Stimuli were displays of four full characters aligned across the monitor (one target and three distractors). Participants completed a visual search task in which they were asked to detect the location of either a direct gaze or an averted gaze target. Reaction time (RT) results indicated faster responses to direct than averted gaze only for characters situated in the far peripheral visual fields. Eye movements confirmed a serial search strategy (definitely ruling out any pop-out effects) and revealed different exploration patterns between hemifields. The latency before the first fixation on target strongly correlated with response RTs. In the LVF, that latency was also faster for direct than averted gaze targets, suggesting that the response asymmetry in favor of direct gaze stemmed from faster direct gaze target detection. In the RVF, however, the response bias to direct gaze seemed not due to a faster visual detection but rather to a different cognitive mechanism. Direct gaze targets were also responded to even faster when their position was congruent with the direction of gaze of distractors. These findings suggest that the detection asymmetry for direct gaze is highly dependent on target position and influenced by social contexts.


Spatiotemporal radiotherapy planning using a global optimization approach.
This paper aims at quantifying the extent of potential therapeutic gain, measured using biologically effective dose (BED), that can be achieved by altering the radiation dose distribution over treatment sessions in fractionated radiotherapy. To that end, a spatiotemporally integrated planning approach is developed, where the spatial and temporal dose modulations are optimized simultaneously. The concept of equivalent uniform BED (EUBED) is used to quantify and compare the clinical quality of spatiotemporally heterogeneous dose distributions in target and critical structures. This gives rise to a large-scale non-convex treatment-plan optimization problem, which is solved using global optimization techniques. The proposed spatiotemporal planning approach is tested on two stylized cancer cases resembling two different tumor sites and sensitivity analysis is performed for radio-biological and EUBED parameters. Numerical results validate that spatiotemporal plans are capable of delivering a larger BED to the target volume without increasing the BED in critical structures compared to conventional time-invariant plans. In particular, this additional gain is attributed to the irradiation of different regions of the target volume at different treatment sessions. Additionally, the trade-off between the potential therapeutic gain and the number of distinct dose distributions is quantified, which suggests a diminishing marginal gain as the number of dose distributions increases.


Neonatal screening for critical cardiovascular anomalies using pulse oximetry.
Babies with cardiac anomalies are often asymptomatic at birth, and many remain undetected despite routine newborn examination. We retrospectively assessed the effect of routine pulse oximetry in detection of such anomalies from a hospital birth population of 31 946 babies born between 1 April 1999 and 31 March 2009. 29 925 babies who were not admitted to the neonatal unit at birth underwent postductal oxygen saturation measurement before discharge. If saturation was below 95% an examination was performed. If this was abnormal or saturation remained low, an echocardiogram was performed. All babies with cardiac anomaly diagnosed before 1-year were identified from the region's fetal abnormality database. Critical anomalies affected 27 infants (1 in 1180); 10 identified prenatally, 2 after echocardiogram was performed because of other anomalies, 2 in preterm infants, 2 when symptomatic before screening, 5 by oximetry screening, 1 when symptomatic in hospital after a normal screen and 5 after discharge home. Serious anomalies affected 50 infants (1 in 640); 8 identified antenatally, 7 because of other anomalies, 3 in the neonatal unit, 5 by pulse oximetry screening, 11 by routine newborn examination, and 16 after discharge home. Routine pulse oximetry aided detection of 5/27 of critical and 5/50 of serious anomalies in this sample, but did not prevent five babies with critical and 15 with serious anomalies being discharged undiagnosed. Results from screening over 250 000 babies have now been published, but this total includes only 49 babies with transposition, and even smaller numbers of rarer anomalies.


Cellular events in the induction of experimental allergic encephalomyelitis in rats.
Although both the T and B cells of the Lewis rat have immunoglobulin receptors for basic protein (BP) of myelin, and both cell types are required for antibody production to BP, the present results demonstrate that the T cells are the only cells required for the induction of experimental allergic encephalomyelitis (EAE). Both EAE and anti-BP were readily induced in thymectomized, irradiated Lewis rats reconstituted with normal thymus and bone marrow cells and challenged with BP in complete Freund's adjuvant. If the thymus cells were first treated with BP heavily labeled with 125I so as to eliminate (sucide) specific T cells, the recipients neither develop EAE nor produce antibody to BP. On the other hand, if the thymus cells were untreated and the specific B cells of bone marrow were eliminated by treatment with 125I-BP, EAE was not inhibited, although no antibody was produced. These results strongly suggest that the T cell is responsible for the induction of EAE although both the T and B cells are competent to respond to BP. Evidence was presented which suggests that neither suppressor T cells nor circulating antibody are involved in the inhibition of EAE by injection of Lewis rats with nonencephalitogenic preparations of BP. The immune status of T and B cells of the Lewis rat to BP was compared with the immune status of these cells in other species to thyroglobulin, where only the B cells appear to be competent. In this context, Brown Norway rats, which are resistant to the induction of EAE, also appear to lack T cells reactive to BP, although competent B cells are present.


Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder.
English Ambulance Services are faced with annual increases in emergency demand. Addressing the demand for low acuity emergency calls relies upon the ability of ambulance clinicians to accurately identify the most appropriate destination or referral pathway. Given the risk of undertriage, the challenge is to develop processes that can safely determine patient dispositions, thereby increasing the number of patients receiving care closer to home. The aim of the study was to evaluate the clinical utility and safety of triage support tools (Paramedic Pathfinders). Two triage filters (Pathfinders) were developed (one medical, one trauma). These were applied by ambulance clinicians to 481 patients who had been transported to emergency departments (EDs). Preferred (gold standard) patient dispositions were established by senior medical practitioners using both ambulance and ED clinical records. The clinical utility of ambulance clinicians using Pathfinders was evaluated against this gold standard. The Medical Pathfinder was applied to 367 patients (76.3%) and the Trauma Pathfinder to 114 (23.7%). Agreement between ambulance clinician and gold standard was achieved in 387 cases (80.5%) giving the tools a combined sensitivity of 94.83% and specificity of 57.9%. 20.9% of medical patients and 30.7% of trauma patients who had been transported to hospital could have been safely cared for elsewhere. Ambulance clinicians using Pathfinders have demonstrated acceptable levels of sensitivity in identifying patients who require ED care. The actual impact of the tools in clinical practice will be dependent on the provision of suitable alternatives to ED.


Nitrogen trace gas emissions from a riparian ecosystem in southern Appalachia.
In this paper, we present two years of seasonal nitric oxide (NO), ammonia (NH3), and nitrous oxide (N2O) trace gas fluxes measured in a recovering riparian zone with cattle excluded and adjacent riparian zone grazed by cattle. In the recovering riparian zone, average NO, NH3, and N2O fluxes were 5.8, 2.0, and 76.7 ng N m(-2) S(-1) (1.83, 0.63, and 24.19 kg N ha(-1) y(-1)), respectively. Fluxes in the grazed riparian zone were larger, especially for NO and NH3, measuring 9.1, 4.3, and 77.6 ng N m(-2) S(-1) (2.87, 1.35, and 24.50 kg N ha(-1) y(-1)) for NO, NH3, and N2O, respectively. On average, N2O accounted for greater than 85% of total trace gas flux in both the recovering and grazed riparian zones, though N2O fluxes were highly variable temporally. In the recovering riparian zone, variability in seasonal average fluxes was explained by variability in soil nitrogen (N) concentrations. Nitric oxide flux was positively correlated with soil ammonium (NH4+) concentration, while N2O flux was positively correlated with soil nitrate (NO3-) concentration. Ammonia flux was positively correlated with the ratio of NH4+ to NO3-. In the grazed riparian zone, average NH3 and N2O fluxes were not correlated with soil temperature, N concentrations, or moisture. This was likely due to high variability in soil microsite conditions related to cattle effects such as compaction and N input. Nitric oxide flux in the grazed riparian zone was positively correlated with soil temperature and NO3- concentration. Restoration appeared to significantly affect NO flux, which increased approximately 600% during the first year following restoration and decreased during the second year to levels encountered at the onset of restoration. By comparing the ratio of total trace gas flux to soil N concentration, we show that the restored riparian zone is likely more efficient than the grazed riparian zone at diverting upper-soil N from the receiving stream to the atmosphere. This is likely due to the recovery of microbiological communities following changes in soil physical characteristics.


Reconstruction of 3-D head geometry from digitized point sets: an evaluation study.
In this paper, we evaluate different methods to estimate patient-specific scalp, skull, and brain surfaces from a set of digitized points from the target's scalp surface. The reconstruction problem is treated as a registration problem: An a priori surface model, consisting of the scalp, skull, and brain surfaces, is registered to the digitized surface points. The surface model is generated from segmented magnetic resonance (MR) volume images. We study both affine and free-form deformation (FFD) registration, the use of average models, the averaging of individual registration results, a model selection procedure, and statistical deformation models. The registration algorithms are mainly previously published, and the objective of this paper is to evaluate these methods in this particular application with sparse data. The main interest of this paper is to generate geometric head models for biomedical applications, such as electroencephalography and magnetoencephalographic. However, the methods can also be applied to other anatomical regions and to other application areas. The methods were validated using 15 MR volume images, from which the scalp, skull, and brain were manually segmented. The best results were achieved by averaging the results of the FFD registrations of the database: the mean distance from the manually segmented target surface to a deformed a priori model surface for the studied anatomical objects was 1.68-2.08 mm, depending on the point set used. The results support the use of the evaluated methods for the reconstruction of geometric models in applications with sparse data.


Apoptosis in the course of granulomatous inflammation in pulmonary sarcoidosis.
Sarcoidosis is a chronic inflammatory disease of unknown aetiology characterized by the formation of non-necrotizing granulomas. The course of disease is usually self-limiting with the spontaneous resolution of granuloma. In the immune system, Fas antigen (Fas) and Fas ligand (FasL) are involved in the down regulation of immune reactions by inducing apoptosis. Therefore, it was hypothesized that the Fas/FasL pathway and apoptosis may be associated with the course of granulomatous inflammation in sarcoidosis. Terminal deoxynucleotidyl transferase-mediated biotin nick end-labelling (TUNEL) was performed to assess deoxyribonucleic acid strand breakages as a characteristic of apoptosis. Immunohistochemistry was also performed to detect Fas and FasL protein, and reverse transcriptase polymerase chain reaction (RT-PCR) and RT in situ PCR to detect FasL messenger ribonucleic acid (mRNA). Positive signals for TUNEL were detected in epithelioid histiocytes and lymphocytes within granulomas and in bronchoalveolar lavage (BAL) lymphocytes from patients with sarcoidosis. Positive signals for Fas were also detected in these cells. FasL mRNA was expressed in BAL lymphocytes from 15 of 20 patients with sarcoidosis, but from only one of 10 patients with normal lung parenchyma. FasL protein was expressed in lymphocytes surrounding and within the granuloma. There was a significant correlation between the result of TUNEL and clinical course in patients with sarcoidosis. Apoptosis in epithelioid histiocytes and inflammatory cells seems to participate in the course of granulomatous inflammation. Further studies are needed to determine the role of Fas, FasL and other regulatory factors in apoptosis in the granulomatous inflammation in pulmonary sarcoidosis.


ACG Clinical Guideline: Treatment of Helicobacter pylori Infection.
Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.


Antimicrobial activities of some amino derivatives of 5,7-dibromo-2-methyl-8-hydroxyquinoline.
The bromine atoms of the title compound, 5,7-dibromo-2-methyl-8-hydroxyquinoline were replaced by the requisite amino compound to afford 6 amino derivatives viz: bis(diethylamino)-, bis(dibutylamino)-, bis(dicyclohexylamino)-, dipyrolidino-, dipiperidino- and dipiperazino derivatives. The antimicrobial activity of these compounds were investigated against selected gram positive (Staphylococcus aureus and Bacillus subtilis), gram negative bacteria (Escherichia coli and Pseudomonas aeruginosa) and yeast (Candida albicans). All the compounds showed significant activity against the test microorganisms, from 5-30 times compared to the title compound. It was observed that all derivatives were more effective against gram positive bacteria. No correlation has been established between the minimum inhibitory (MIC) concentrations of the derivatives and the structural modifications.


Novel psychoactive substance and other drug use by young adults in Western australia.
There is a lack of information regarding the use of novel psychoactive substances (NPS) in Western Australia. The aim of this study was to pilot-test an online survey to obtain data on the prevalence of NPS and other drug use by young Western Australians aged between 18 and 35 years. The Young Adult Drug and Alcohol Survey (YADAS) was a questionnaire deployed online for a period of six months. Participants were recruited via a combined targeted sampling and snowball methodology. There were 472 valid responses. Overall lifetime use of NPS was relatively high (17.6%), while use in the last year was lower (6.6%). These proportions were comparable to that of cocaine use. The most popular NPS were the synthetic cannabinoids. The proportions of respondents drinking alcohol at risky levels, mixing alcohol with energy drinks, and using pharmaceuticals such as ADHD medications for non-medical reasons were high. The YADAS is the first survey to ascertain the prevalence of use of numerous types of NPS in a large sample of young Western Australian adults. The utilization of an online survey methodology yielded valid results as compared to more intensive surveys, and enables researchers greater flexibility in being able to capture current trends.


Evolutionary competitiveness of two natural variants of the IncQ-like plasmids, pRAS3.1 and pRAS3.2.
Plasmids pRAS3.1 and pRAS3.2 are natural variants of the IncQ-2 plasmid family, that except for two differences, have identical plasmid backbones. Plasmid pRAS3.1 has four 22-bp iterons in its oriV region, while pRAS3.2 has only three 6-bp repeats and pRAS3.1 has five 6-bp repeats in the promoter region of the mobB-mobA/repB genes and pRAS3.2 has only four. In previous work, we showed that the overall effect of these differences was that when the plasmid was in an Escherichia coli host, the copy numbers of pRAS3.1 and pRAS3.2 were approximately 41 and 30, respectively. As pRAS3.1 and pRAS3.2 are likely to have arisen from the same ancestor, we addressed the question of whether one of the variants had an evolutionary advantage over the other. By constructing a set of identical plasmids with the number of 22-bp iterons varying from three to seven, it was found that plasmids with four or five iterons displaced plasmids with three iterons even though they had lower copy numbers. Furthermore, the metabolic load that the plasmids placed on E. coli host cells compared with plasmid-free cells increased with copy number from 10.9% at a copy number of 59 to 2.6% at a copy number of 15. Plasmid pRAS3.1 with four 22-bp iterons was able to displace pRAS3.2 with three iterons when both were coresident in the same host. However, the lower-copy-number pRAS3.2 placed 2.8% less of a metabolic burden on an E. coli host population, and therefore, pRAS3.2 has a competitive advantage over pRAS3.1 at the population level, as pRAS3.2-containing cells would be expected to outgrow pRAS3.1-containing cells.


Stereotactic Body Radiation Therapy Versus Nonradiotherapeutic Ablative Procedures (Laser/Cryoablation and Electrocautery) for Early-Stage Non-Small Cell Lung Cancer.
Despite the fact that stereotactic body radiation therapy (SBRT) is the only recommended first-line therapy for inoperable early-stage non-small cell lung cancer (NSCLC), several thermal ablative procedures (TAPs; defined herein as laser/cryoablation and electrocautery) are available. Studies showing outcomes of these procedures and how they compare with SBRT are scarce. We sought to evaluate the comparative efficacy of SBRT versus TAPs using the National Cancer Database (NCDB). The NCDB was queried for patients with early-stage NSCLC who did not undergo surgical resection. Treatment-specific inclusion criteria were applied to select for patients receiving either TAPs or SBRT. Univariate logistic regression and Cox proportional hazards modeling were performed, and Kaplan-Meier curves were generated. Serial propensity matches were performed using a modified greedy 8→n matching 1:1 algorithm. A total of 27,734 patients were analyzed; 26,725 underwent SBRT and 1,009 underwent TAPs. Patients who received SBRT were older and more likely to have clinical stage IB (vs IA) disease. Despite this, SBRT was associated with longer median overall survival (mOS; 37.7 vs 33.5 months; P=.001) and 1-, 2-, and 5-year OS rates compared with the TAPs cohort (86.7% vs 83.1%, 67.5% vs 62.7%, and 30.6% vs 26.9%, respectively; P=.001). Upon propensity matching, improved OS with SBRT remained, with a mOS of 40.4 versus 33.4 months and 1-, 2-, and 5-year OS rates of 89.0% versus 82.9%, 69.7% versus 62.7%, and 34.4% versus 26.4%, respectively (P=.003). Despite being associated with more higher-risk factors, SBRT was associated with higher OS compared with TAPs for treatment of nonoperative patients diagnosed with early-stage NSCLC. However, causation cannot be implied owing to the inherent limitations of large heterogeneous datasets such as the NCDB.


Fluorescence In Situ Hybridization on DNA Halo Preparations to Reveal Whole Chromosomes, Telomeres and Gene Loci.
The genome is associated with several structures inside cell nuclei, in order to regulate its activity and anchor it in specific locations. These structures are collectively known as the nucleoskeleton and include the nuclear lamina, the nucleoli, and nuclear bodies. Although many variants of fluorescence in situ hybridization (FISH) exist to study the genome and its organization, these are often limited by resolution and provide insufficient information on the genome's association with nuclear structures. The DNA halo method uses high salt concentrations and nonionic detergents to generate DNA loops that remain anchored to structures within nuclei through attachment regions within the genome. Here, soluble nuclear proteins, such as histones, lipids, and DNA not tightly bound to the nuclear matrix, are extracted. This leads to the formation of a halo of unattached DNA surrounding a residual nucleus which itself contains DNA closely associated with internal nuclear structures and extraction-resistant proteins. These extended DNA strands enable increased resolution and can facilitate physical mapping. In combination with FISH, this method has the added advantage of studying genomic interactions with all the structures that the genome is anchored by. This technique, termed HALO-FISH, is highly versatile whereby DNA halos can be coupled with nucleic acid probes to reveal gene loci, whole chromosomes, alpha satellite, telomeres and even RNA. This technique provides an insight into nuclear organization and function in normal cells and in disease progression such as with cancer.


Proteomic Landscape and Deduced Functions of the Cardiac 14-3-3 Protein Interactome.
Rationale: The 14-3-3 protein family is known to interact with many proteins in non-cardiac cell types to regulate multiple signaling pathways, particularly those relating to energy and protein homeostasis; and the 14-3-3 network is a therapeutic target of critical metabolic and proteostatic signaling in cancer and neurological diseases. Although the heart is critically sensitive to nutrient and energy alterations, and multiple signaling pathways coordinate to maintain the cardiac cell homeostasis, neither the structure of cardiac 14-3-3 protein interactome, nor potential functional roles of 14-3-3 protein-protein interactions (PPIs) in heart has been explored. Objective: To establish the comprehensive landscape and characterize the functional role of cardiac 14-3-3 PPIs. Methods and Results: We evaluated both RNA expression and protein abundance of 14-3-3 isoforms in mouse heart, followed by co-immunoprecipitation of 14-3-3 proteins and mass spectrometry in left ventricle. We identified 52 proteins comprising the cardiac 14-3-3 interactome. Multiple bioinformatic analyses indicated that more than half of the proteins bound to 14-3-3 are related to mitochondria; and the deduced functions of the mitochondrial 14-3-3 network are to regulate cardiac ATP production via interactions with mitochondrial inner membrane proteins, especially those in mitochondrial complex I. Binding to ribosomal proteins, 14-3-3 proteins likely coordinate protein synthesis and protein quality control. Localizations of 14-3-3 proteins to mitochondria and ribosome were validated via immunofluorescence assays. The deduced function of cardiac 14-3-3 PPIs is to regulate cardiac metabolic homeostasis and proteostasis. Conclusions: Thus, the cardiac 14-3-3 interactome may be a potential therapeutic target in cardiovascular metabolic and proteostatic disease states, as it already is in cancer therapy.


The amphiphilic alkyl ester derivatives of l-ascorbic acid induce reorganization of phospholipid vesicles.
l-ascorbic acid alkyl esters (ASCn) are lipophilic forms of vitamin C, which maintain some of its antioxidant power. Those properties make this drug family attractive to be used in pharmacological preparations protecting other redox-sensible drugs or designed to reduce possible toxic oxidative processes. In this work, we tested the ability of l-ascorbic acid alkyl esters (ASCn) to modulate the structure, permeability, and rheological properties of phospholipid bilayers. The ASCn studied here (ASC16, ASC14, and ASC12) alter the structural integrity as well as the rheological properties of phospholipid membranes without showing any evident detergent activity. ASC14 appeared as the most efficient drug in destabilize the membrane structure of nano- and micro-size phospholipid liposomes inducing vesicle content leakage and shape elongation on giant unilamellar vesicles. It also was the most potent enhancer of membrane microviscosity and surface water structuring. Only ASC16 induced the formation of drug-enriched condensed domains after its incorporation into the lipid bilayer, while ASC12 appeared as the less membrane-disturbing compound, likely because of its poor, and more superficial, partition into the membrane. We also found that incorporation of ASCn into the lipid bilayers enhanced the reduction of membrane components, compared with soluble vitamin C. Our study shows that ASCn compounds, which vary in the length of the acyl chain, show different effects on phospholipid vesicles used as biomembrane models. Those variances may account for subtly differences in the effectiveness on their pharmacological applications.


Relational processing following stroke.
The research examined relational processing following stroke. Stroke patients (14 with frontal, 30 with non-frontal lesions) and 41 matched controls completed four relational processing tasks: sentence comprehension, Latin square matrix completion, modified Dimensional Change Card Sorting, and n-back. Each task included items at two or three levels of relational complexity. Relational processing was impaired in the stroke groups. This was due mainly to items at the intermediate ternary-relational level of complexity. Less complex binary-relational items and more complex quaternary-relational items (the latter are difficult for adults generally) were less sensitive to stroke status. Impairment was greater in frontal than non-frontal stroke patients. Positive inter-correlations among measures supported the domain-general nature of relational processing. Implications for assessment and intervention are discussed.


Intercostal chest drain insertion by general physicians: attitudes, experience and implications for training, service and patient safety.
Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training opportunities and confidence in their procedural skills. We explored clinicians' attitudes, experience and knowledge relating to pleural interventions and ICD insertion in order to determine what changes might be needed to maintain patient safety and quality of training. Consultants and trainees delivering general medical services across five hospitals in England were invited to complete a questionnaire survey over a 5-week period in July and August 2014. 117 general physicians (32.4% of potential participants; comprising 31 consultants, 48 higher specialty trainees, 38 core trainees) responded. Respondents of all grades regarded ICD insertion as a core procedural skill. Respondents were asked to set a minimum requirement for achieving and maintaining independence at ICD insertion; however, only 25% of higher specialty trainees reported being able to attain this self-imposed standard. A knowledge gap was also revealed, with trainees managing clinical scenarios correctly in only 51% of cases. Given the disparity between clinical reality and what is expected of the physician-in-training, it is unclear whether ICD insertion can remain a core procedural skill for general physicians. Consideration should be given to how healthcare providers and training programmes might address issues relating to clinical experience and knowledge given the implications for patient safety and service provision.


Nanoscale polarization of the entry fusion complex of vaccinia virus drives efficient fusion.
To achieve efficient binding and subsequent fusion, most enveloped viruses encode between one and five proteins1. For many viruses, the clustering of fusion proteins-and their distribution on virus particles-is crucial for fusion activity2,3. Poxviruses, the most complex mammalian viruses, dedicate 15 proteins to binding and membrane fusion4. However, the spatial organization of these proteins and how this influences fusion activity is unknown. Here, we show that the membrane of vaccinia virus is organized into distinct functional domains that are critical for the efficiency of membrane fusion. Using super-resolution microscopy and single-particle analysis, we found that the fusion machinery of vaccinia virus resides exclusively in clusters at virion tips. Repression of individual components of the fusion complex disrupts fusion-machinery polarization, consistent with the reported loss of fusion activity5. Furthermore, we show that displacement of functional fusion complexes from virion tips disrupts the formation of fusion pores and infection kinetics. Our results demonstrate how the protein architecture of poxviruses directly contributes to the efficiency of membrane fusion, and suggest that nanoscale organization may be an intrinsic property of these viruses to assure successful infection.