Age Differences in Work-Disability Duration Across Canada: Examining Variations by Follow-Up Time and Context.
Purpose This study aimed to understand age differences in wage-replacement duration by focusing on variations in the relationship across different periods of follow-up time. Methods We used administrative claims data provided by six workers' compensation systems in Canada. Included were time-loss claims for workers aged 15-80 years with a work-related injury/illness during the 2011 to 2015 period (N = 751,679 claims). Data were coded for comparability across cohorts. Survival analysis examined age-related differences in the hazard of transitioning off (versus remaining on) disability benefits, allowing for relaxed proportionality constraints on the hazard rates over time. Differences were examined on the absolute (hazard difference) and relative (hazard ratios [HR]) scales. Results Older age groups had a lower likelihood of transitioning off wage-replacement benefits compared to younger age groups in the overall models (e.g., 55-64 vs. 15-24 years: HR 0.62). However, absolute and relative differences in age-specific hazard rates varied as a function of follow-up time. The greatest age-related differences were observed at earlier event times and were attenuated towards a null difference across later follow-up event times. Conclusions Our study provides new insight into the workplace injury/illness claim and recovery processes and suggests that older age is not always strongly associated with worse disability duration outcomes. The use of data from multiple jurisdictions lends external validity to our findings and demonstrates the utility of using cross-jurisdictional data extracts. Future work should examine the social and contextual determinants that operate during various recovery phases, and how these factors interact with age.


Synthesis of Deoxyradicinin, an Inhibitor of Xylella fastidiosa and Liberibacter crescens, a Culturable Surrogate for Candidatus Liberibacter asiaticus.
Pierce's disease of grapevine and citrus huanglongbing are caused by the bacterial pathogens Xylella fastidiosa and Candidatus Liberibacter asiaticus (CLas), respectively. Both pathogens reside within the plant vascular system, occluding water and nutrient transport, leading to a decrease in productivity and fruit marketability and ultimately death of their hosts. Field observations of apparently healthy plants in disease-affected vineyards and groves led to the hypothesis that natural products from endophytes may inhibit these bacterial pathogens. Previously, we showed that the natural product radicinin from Cochliobolus sp. inhibits X. fastidiosa. Herein we describe a chemical synthesis of deoxyradicinin and establish it as an inhibitor of both X. fastidiosa and Liberibacter crescens, a culturable surrogate for CLas. The key to this three-step route is a zinc-mediated enolate C-acylation, which allows for direct introduction of the propenyl side chain without extraneous redox manipulations.


RNAi and Antiviral Defense in the Honey Bee.
Honey bees play an important agricultural and ecological role as pollinators of numerous agricultural crops and other plant species. Therefore, investigating the factors associated with high annual losses of honey bee colonies in the US is an important and active area of research. Pathogen incidence and abundance correlate with Colony Collapse Disorder- (CCD-) affected colonies in the US and colony losses in the US and in some European countries. Honey bees are readily infected by single-stranded positive sense RNA viruses. Largely dependent on the host immune response, virus infections can either remain asymptomatic or result in deformities, paralysis, or death of adults or larvae. RNA interference (RNAi) is an important antiviral defense mechanism in insects, including honey bees. Herein, we review the role of RNAi in honey bee antiviral defense and highlight some parallels between insect and mammalian immune systems. A more thorough understanding of the role of pathogens on honey bee health and the immune mechanisms bees utilize to combat infectious agents may lead to the development of strategies that enhance honey bee health and result in the discovery of additional mechanisms of immunity in metazoans.


Ultrasound Measures of Brain Pulsatility Correlate with Subcortical Brain Volumes in Healthy Young Adults.
Increasing evidence suggests that brain pulsatility is involved in the pathophysiology of various neurological and psychiatric disorders. However, it remains unclear whether high brain pulsatility is damaging to or protective of the brain in normal conditions, and this could depend on the age of the individual and the methods used to measure brain pulsatility. The goal of our study was to investigate associations between subcortical volumes and brain pulsatility as assessed with ultrasound in healthy young adults using both a conventional method (transcranial Doppler pulsatility index [TCD-PI]) and the innovative method of tissue pulsatility imaging (TPI), which allows a high level of detection of small brain movements (micrometers). Twenty-five females aged 18-55 with no history of significant medical disorder underwent magnetic resonance imaging and ultrasound assessment. The volumes of six subcortical regions known to be particularly sensitive to change in cerebral blood flow were measured and compared with brain pulsatility as assessed with TCD-PI and TPI. TCD-PI and TPI measures positively correlated with all subcortical regions, with the caudate nucleus having the strongest association. Linear regressions found that TCD-PI and TPI measures of brain pulsatility explained 16% to 67% of the variance of the subcortical volumes. Our results suggest that a greater pulsatility as assessed with ultrasound in healthy young adults may constitute a protective factor for brain structure. Ultrasound measures of brain pulsatility may be appropriate to provide costless, non-invasive, portable and highly sensitive markers of cerebral blood flow pulsatility related to brain structure.


Highly potent chimeric inhibitors targeting two steps of HIV cell entry.
Blocking HIV-1 cell entry has long been a major goal of anti-HIV drug development. Here, we report a successful design of two highly potent chimeric HIV entry inhibitors composed of one CCR5-targeting RANTES (regulated on activation normal T cell expressed and secreted) variant (5P12-RANTES or 5P14-RANTES (Gaertner, H., Cerini, F., Escola, J. M., Kuenzi, G., Melotti, A., Offord, R., Rossitto-Borlat, I., Nedellec, R., Salkowitz, J., Gorochov, G., Mosier, D., and Hartley, O. (2008) Proc. Natl. Acad. Sci. U.S.A. 105, 17706-17711)) linked to a gp41 fusion inhibitor, C37. Chimeric inhibitors 5P12-linker-C37 and 5P14-linker-C37 showed extremely high antiviral potency in single cycle and replication-competent viral assays against R5-tropic viruses, with IC(50) values as low as 0.004 nm. This inhibition was somewhat strain-dependent and was up to 100-fold better than the RANTES variant alone or in combination with unlinked C37. The chimeric inhibitors also fully retained the antiviral activity of C37 against X4-tropic viruses, and this inhibition can be further enhanced significantly if the target cell co-expresses CCR5 receptor. On human peripheral blood mononuclear cells, the inhibitors showed very strong inhibition against R5-tropic Ba-L strain and X4-tropic IIIB strain, with IC(50) values as low as 0.015 and 0.44 nm, which are 45- and 16-fold better than the parent inhibitors, respectively. A clear delivery mechanism requiring a covalent linkage between the two segments of the chimera was observed and characterized. Furthermore, the two chimeric inhibitors are fully recombinant and are easily produced at low cost. These attributes make them excellent candidates for anti-HIV microbicides. The results of this study also suggest a potent approach for optimizing existing HIV entry inhibitors or designing new inhibitors.


Combined modality therapy of lung cancer.
Combined modality therapy for lung cancer was first demonstrated to be successful in limited-stage small cell lung cancer. Concurrent administration of chemotherapy with chest and elective brain irradiation appears to produce the best results, with cisplatin/etoposide as the core chemotherapy. Using such programs, 2-year survival in the 40% range and 5-year survivals in excess of 20% may be expected, based on the results of multiple studies. Attempts to improve on these results through the use of altered schemes of chest irradiation or the delivery of high-dose consolidation chemotherapy are ongoing but to date have not been shown to affect survival significantly. We remain at a plateau in the effectiveness of combined modality therapy for small cell lung cancer, with little evidence that it impacts survival at all in extensive-stage disease. The incorporation of new agents in combination chemotherapy regimens, more "specific" immunotherapy directed at tumor-associated antigens, and the potential adjunctive use of broad-spectrum neuropeptide antagonists offer promise for the future. In non-small cell lung cancer, the sequential use of platinum-based chemotherapy and chest irradiation appears superior in survival to standard, daily fractionated radiation therapy used alone, with long-term survival increased from 5-10% to 15-20%. Concurrent administration of chemotherapy with cisplatin/etoposide and chest irradiation produces 2-year survival in the range of 30%, about twice that would be expected for radiation therapy alone, but has not been compared to it in the setting of a randomized trial. Low-dose cisplatin on a daily basis has been combined as a "sensitizer" with chest irradiation, producing initial results that appeared encouraging. However, these have not been reproduced in subsequent, randomized trials. Another approach to combined modalities has been to give chemotherapy or chemotherapy/radiation therapy as induction, followed by surgical resection, with or without subsequent additional treatment. Most patients (80-85%) can be resected, with encouraging survival at 2 and 3 years in the Southwest Oncology Group experience (37 and 26%, respectively). However, toxicity is greater, and such an approach is associated with an overall mortality risk in the range of 10%. A current intergroup study attempts to define the role of surgery in this setting. The major recent development that is likely to influence the future of combined modality therapy for this disease is the advent of multiple new chemotherapeutic agents, such as the taxanes, gemcitabine, vinorelbine, and the topoisomerase-I inhibitors, which have activity in stage IV disease. The immediate challenge is how to combine these agents with platinum analogues, radiation, and surgery. Aiding this process may be the use of molecular biological "markers" that may predict the chance of success or failure with a given systemic agent. The next decade is likely to see substantial improvements in the outcome of treatment for patients with stages I-III non-small cell lung cancer, based on the systemic exploration of combined modalities.


Genetic background of Japanese patients with antineutrophil cytoplasmic antibody-associated vasculitis: association of HLA-DRB1*0901 with microscopic polyangiitis.
To examine association of 8 candidate genes with susceptibility to antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in Japanese patients. Little is known on the genetic background of AAV in Japanese patients mainly because of the difficulty in collecting a sufficient number of samples for the genetics study. Sixty-nine patients, including 50 with microscopic polyangiitis (MPA), were recruited in a multicenter study. Among them, 64 patients were positive for myeloperoxidase (MPO)-ANCA. Associations of HLA-DRB1, tumor necrosis factor-alpha promoter (TNF), TNF receptor 2 (TNFR2), Fcgamma receptor IIa (FCGR2A), IIb (FCGR2B), IIIa (FCGR3A), IIIb (FCGR3B), and CTLA-4 (CTLA4) polymorphisms were examined in a case-control analysis. A significant association of HLA-DRB1*0901 with MPA (p = 0.0037, OR 2.44, 95% CI 1.33-4.46), as well as with MPO-ANCA positivity (p = 0.0014, OR 2.44, 95% CI 1.41-4.22), was detected. There was no difference in the TNF promoter haplotype frequencies between patients with MPA and controls, excluding the possibility that the association of DRB1*0901 was secondarily caused by linkage disequilibrium with TNF. No association was observed for TNFR2, FCGR, or CTLA4 with MPA, nor with the presence of MPO-ANCA, although the combined genotype FCGR2A-131H/H and 3A-176F/F was increased in patients with MPA (p = 0.025). There was an association of HLA-DRB1*0901 with MPA and MPO-ANCA positive vasculitis in Japanese patients.


Individual Motile CD4(+) T Cells Can Participate in Efficient Multikilling through Conjugation to Multiple Tumor Cells.
T cells genetically modified to express a CD19-specific chimeric antigen receptor (CAR) for the investigational treatment of B-cell malignancies comprise a heterogeneous population, and their ability to persist and participate in serial killing of tumor cells is a predictor of therapeutic success. We implemented Timelapse Imaging Microscopy in Nanowell Grids (TIMING) to provide direct evidence that CD4(+)CAR(+) T cells (CAR4 cells) can engage in multikilling via simultaneous conjugation to multiple tumor cells. Comparisons of the CAR4 cells and CD8(+)CAR(+) T cells (CAR8 cells) demonstrate that, although CAR4 cells can participate in killing and multikilling, they do so at slower rates, likely due to the lower granzyme B content. Significantly, in both sets of T cells, a minor subpopulation of individual T cells identified by their high motility demonstrated efficient killing of single tumor cells. A comparison of the multikiller and single-killer CAR(+) T cells revealed that the propensity and kinetics of T-cell apoptosis were modulated by the number of functional conjugations. T cells underwent rapid apoptosis, and at higher frequencies, when conjugated to single tumor cells in isolation, and this effect was more pronounced on CAR8 cells. Our results suggest that the ability of CAR(+) T cells to participate in multikilling should be evaluated in the context of their ability to resist activation-induced cell death. We anticipate that TIMING may be used to rapidly determine the potency of T-cell populations and may facilitate the design and manufacture of next-generation CAR(+) T cells with improved efficacy.


Reactions to total dose infusion of iron dextran in rheumatoid arthritis.
Ten patients with active rheumatoid arthritis were given a total dose infusion of iron dextran for anaemia. One had an immediate anaphylactoid reaction; the other nine had a brief exacerbation of arthralgia and joint dysfunction of up to seven days' duration. The erythrocyte sedimentation rate rose by an average of 23 mm. in one hour (Westergren), but this often took longer than seven days to settle to the preinfusion level.It is suggested that this response is probably not due to an exacerbation of rheumatoid arthritis but to a delayed hypersensitivity reaction to the dextran portion of the iron dextran complex. This treatment is potentially dangerous in rheumatoid arthritis; we recommend a preliminary test dose and that the infusion be started very slowly under supervision.


Management of recurrent venous thromboembolism in patients with cancer: A review.
Venous thromboembolism (VTE) occurs in 10-20%% of patients with cancer and is associated with significant mortality and morbidity in these patients. The current standard of care recommended by international guidelines is to use low-molecular-weight heparin (LMWH) for 6months for the management of cancer-associated thrombosis (CAT), which is based on evidence from randomized controlled trials demonstrating that LMWH significantly reduced the risk of recurrent VTE compared with vitamin K antagonists. However, patients with CAT have a high risk of VTE recurrence of up to 20% despite receiving anticoagulation. Reasons for recurrent VTE may include non-compliance, temporary cessation of therapy due to bleeding or for procedures, inadequate dosing, cancer progression, and the presence of heparin-induced thrombocytopenia. Management of patients with CAT and recurrent VTE is not well defined. Management strategies for recurrent VTE include switching to LMWH if an oral anticoagulant is employed, dose escalation of LMWH, or as a last resort option consider insertion of a vena cava filter. In this review, we discuss the acute, long-term, and extended management of CAT, risk factors for recurrent VTE, and management of recurrent VTE.


Dermoscopy--the ultimate tool for melanoma diagnosis.
"We are beginning to move away from clinicopathologic diagnosis into an era of clinicoimaging diagnosis." This vision became a fact, as the dermatoscope represents nowadays the dermatologist stethoscope. This is not only because dermoscopy reveals a new and fascinating morphologic dimension of pigmented and nonpigmented skin tumors, but also because it improves the recognition of a growing number of skin symptoms in general dermatology. Melanoma detection remains the most important indication of dermoscopy and in melanoma screening the aim of dermoscopy is to maximize early detection while minimizing the unnecessary excision of benign skin tumors. In the last few years, 3 meta-analyses and 2 randomized studies have definitely proven that dermoscopy allows improving sensitivity for melanoma as compared to the naked eye examination alone. This is the consequence of at least 3 issues: first, the presence of early dermoscopy signs that are visible in melanoma much before the appearance of the classical clinical features; second, an increased attitude of clinicians to check more closely clinically banal-looking lesions; third, an improved attitude of clinicians to monitor their patients.


Thromboembolism.
DVT or pulmonary embolism may occur in almost 2 in 1000 people each year, with up to 25% of those having a recurrence. Around 5-15% of people with untreated DVT may die from pulmonary embolism. Risk factors for deep vein thrombosis include immobility, surgery (particularly orthopaedic), malignancy, pregnancy, older age, and inherited or acquired prothrombotic clotting disorders. We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for: proximal deep vein thrombosis; isolated calf deep vein thrombosis; and pulmonary embolism? What are the effects of computerised decision support on oral anticoagulation management? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We found 40 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. In this systematic review we present information relating to the effectiveness and safety of the following interventions: anticoagulation, compression stockings, low molecular weight heparin (short and long term, once or twice daily, home treatment), oral anticoagulants (short and long term, high intensity, abrupt discontinuation, computerised decision support), prolonged duration of anticoagulation, thrombolysis, vena cava filters, and warfarin.


The E3 ubiquitin-protein ligase Rbx1 regulates cardiac wall morphogenesis in zebrafish.
Cardiac trabeculae are muscular ridge-like structures within the ventricular wall that are crucial for cardiac function. In zebrafish, these structures first form primarily through the delamination of compact wall cardiomyocytes (CMs). Although defects in proteasomal degradation have been associated with decreased cardiac function, whether they also affect cardiac development has not been extensively analyzed. Here we report a role during cardiac wall morphogenesis in zebrafish for the E3 ubiquitin-protein ligase Rbx1, which has been shown to regulate the degradation of key signaling molecules. Although development is largely unperturbed in zebrafish rbx1 mutant larvae, they exhibit CM multi-layering. This phenotype is not affected by blocking ErbB signaling, but fails to manifest itself in the absence of blood flow/cardiac contractility. Surprisingly, rbx1 mutants display ErbB independent Notch reporter expression in the myocardium. We generated tissue-specific rbx1 overexpression lines and found that endothelial, but not myocardial, specific rbx1 expression normalizes the cardiac wall morphogenesis phenotype. In addition, we found that pharmacological activation of Hedgehog signaling ameliorates the multi-layered myocardial wall phenotype in rbx1 mutants. Collectively, our data indicate that endocardial activity of Rbx1 is essential for cardiac wall morphogenesis.


Susceptibility to inflammatory disease in HLA-B27 transgenic rat lines correlates with the level of B27 expression.
To investigate the role of the class I MHC molecule HLA-B27 in the spondyloarthropathies, we produced rats transgenic for HLA-B27 and human beta 2-microglobulin. Of five lines bearing > 1 copy of each transgene and showing hemizygous expression of both transgenes, two (lines 21-4H and 33-3) developed spontaneous inflammatory disease that closely resembled B27-associated human disease. Two lines, 21-4L and 25-6, remained healthy even when homozygous for the transgene locus, whereas the 21-3 line, bearing the third highest transgene copy number, developed disease similar to that of the 21-4H and 33-3 lines only when homozygous for the transgene locus. The disease-prone lines showed higher expression of B27--thymic mRNA in utero, splenic mRNA by 5 days of age, and splenic cell surface protein by the time of disease onset--than the disease-resistant lines. Disease susceptibility thus appeared to correlate with gene copy number and the quantity of B27 in lymphoid cells. The increase in the amount of B27 protein did not appear to be simply a consequence of the inflammatory disease because 1) there was no similar change in endogenous RT1 class I expression; 2) no alteration of B27 expression occurred in 21-4H rats with adjuvant-induced arthritis; 3) in rats with inflammatory disease transgenic for HLA-A2 and the 21-4H transgene locus, A2 expression was the same as in healthy rats transgenic for A2 but not B27; and 4) the transgenes in disease-prone and disease-resistant lines were equally susceptible to induction by IFN-gamma. Immunocytochemistry of the distal colon, an early site of inflammation, showed that the B27 Ag is expressed at high levels in cells of the lamina propria, but not at all in colonic epithelial cells. Taken together, the data suggest that the B27 transgene is expressed in a copy number dependent, position-independent manner in lymphoid tissue and that disease results from the expression of B27 above a critical threshold level.


Racial difference in the incidence of retinal detachment in Singapore.
To determine the incidence of retinal detachment (RD) operations in a multiracial Southeast Asian population. Population-based incidence study using a universal medical savings database in Singapore. Information on all RD operations performed for rhegmatogenous RD (International Classification of Diseases, Ninth Revision, Clinical Modification code 361.0) between 1993 and 1996 was retrieved and analyzed from a population-wide, government-administered medical savings database. Exudative, tractional, and unoperated-on rhegmatogenous RD are excluded. The 1990 Singapore population census was used to allow an estimation of age-, sex-, and race-specific annual incidence of RD. Between 1993 and 1996, 1126 RD operations were performed on Singapore residents. The average annual incidence of RD operations was 10.5 per 100,000 population (95% confidence interval [CI], 10.2-10.9). The annual incidence was highest for Chinese (age-adjusted incidence, 11.6 per 100,000), followed by Malays (7.0 per 100,000), and lowest for Indians (3.9 per 100,000). The age-adjusted relative risk of RD operation for Chinese compared with Indians was 3.0 (95% CI, 2.9-3.1). Males were twice as likely as females to require RD surgery (age-adjusted relative risk, 2.0; 95% CI, 1.7-2.4). Chinese men 40 years and older had a 30.9 times higher risk (95% CI, 9.9-96.1) than Indian females younger than 40 years. The incidence of RD is strongly associated with male sex and ethnic origin.


Occupational physical activity and cardiovascular disease in the United States.
Emerging evidence, predominately from European and Asian countries, describes opposing effects of occupational physical activity (OPA) and leisure-time physical activity (LTPA) on cardiovascular health. This analysis examined cardiovascular disease (CVD) prevalence associated with OPA and LTPA. This cross-sectional analysis of 2015 National Health Interview Survey data (n=16 974) employed logistic regression to estimate odds (OR) of self-reported CVD (coronary heart disease, heart attack, stroke or angina) with self-reported total occupational activity (TOA), occupational exertion (OE), occupational standing and walking (OSW) and LTPA. OPA was measured using two questions: 'How often does your job involve…' (1) 'repeated lifting, pushing, pulling or bending?' (OE) and (2) 'standing or walking around?' (OSW) with responses on a 5-item Likert scale (0=never, 4=always). TOA was categorised similarly after summing OE and OSW scores. LTPA was defined as 0, 1-149 or ≥150 min/week of moderate-to-vigorous activity. All models adjusted for common socioeconomic variables and additional analyses were stratified by sex, smoking status and LTPA. Odds for CVD were higher when 'always' performing TOA (OR 1.99 95% CI 1.12 to 3.53), OE (OR 2.15, 95% CI 1.45 to 3.19) or OSW (OR 1.84, 95% CI 1.07 to 3.17) compared with 'never'. When restricting to never-smokers, odds for CVD were higher when 'always' performing TOA (OR 3.00, 95% CI 1.38 to 6.51) and OE (OR 3.00, 95% CI 1.80 to 5.02) versus 'never'. Associations of high OPA with CVD were equally apparent across sexes, stronger in lower LTPA levels and stronger in never-smokers. While uncontrolled confounding is still possible, even after extensive adjustment, the seemingly paradoxical adverse associations with OPA and CVD should be investigated further.


Building a culture of safety through team training and engagement.
Medical errors continue to occur despite multiple strategies devised for their prevention. Although many safety initiatives lead to improvement, they are often short lived and unsustainable. Our goal was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of the healthcare team. Teamwork impacts the effectiveness of care, patient safety and clinical outcomes, and team training has been identified as a strategy for enhancing teamwork, reducing medical errors and building a culture of safety in healthcare. Therefore, we implemented Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based framework which was used for team training to create transformational and/or incremental changes; facilitating transformation of organisational culture, or solving specific problems. To date, TeamSTEPPS (TS) has been implemented in 14 hospitals, two Long Term Care Facilities, and outpatient areas across the North Shore LIJ Health System. 32 150 members of the healthcare team have been trained. TeamSTEPPS was piloted at a community hospital within the framework of the health system's organisational care delivery model, the Collaborative Care Model to facilitate sustainment. AHRQ's Hospital Survey on Patient Safety Culture, (HSOPSC), was administered before and after implementation of TeamSTEPPS, comparing the perception of patient safety by the heathcare team. Pilot hospital results of HSOPSC show significant improvement from 2007 (pre-TeamSTEPPS) to 2010. System-wide results of HSOPSC show similar trends to those seen in the pilot hospital. Valuable lessons for organisational success from the pilot hospital enabled rapid spread of TeamSTEPPS across the rest of the health system.


The value of microbial diversity.
In the past few years, due to the use of molecular methods, our knowledge of microbial diversity has increased dramatically, not only from a phylogenetic and taxonomic perspective but also from an ecological basis. We now know that microorganisms exist in every conceivable place on Earth, even in extreme environments. Temperature may be the only limitation as to where they can and cannot exist and/or function. As more small subunit rDNA sequence information becomes available there is a real need to start turning the information into knowledge that can be applied to better elucidate and understand structure-function relationships within ecosystems, develop new culturing methods, and discover new products and processes. It has been stated on numerous occasions that the 21(st) century is the century for biology. Within that context, we must address the real value of microbial diversity.


Climate as a risk factor for armed conflict.
Research findings on the relationship between climate and conflict are diverse and contested. Here we assess the current understanding of the relationship between climate and conflict, based on the structured judgments of experts from diverse disciplines. These experts agree that climate has affected organized armed conflict within countries. However, other drivers, such as low socioeconomic development and low capabilities of the state, are judged to be substantially more influential, and the mechanisms of climate-conflict linkages remain a key uncertainty. Intensifying climate change is estimated to increase future risks of conflict.


Population genomics of intrapatient HIV-1 evolution.
Many microbial populations rapidly adapt to changing environments with multiple variants competing for survival. To quantify such complex evolutionary dynamics in vivo, time resolved and genome wide data including rare variants are essential. We performed whole-genome deep sequencing of HIV-1 populations in 9 untreated patients, with 6-12 longitudinal samples per patient spanning 5-8 years of infection. The data can be accessed and explored via an interactive web application. We show that patterns of minor diversity are reproducible between patients and mirror global HIV-1 diversity, suggesting a universal landscape of fitness costs that control diversity. Reversions towards the ancestral HIV-1 sequence are observed throughout infection and account for almost one third of all sequence changes. Reversion rates depend strongly on conservation. Frequent recombination limits linkage disequilibrium to about 100 bp in most of the genome, but strong hitch-hiking due to short range linkage limits diversity.


Materials used for reconstruction after orbital floor fracture.
Advances in biotechnology continue to introduce new materials for reconstruction of orbital floor fractures. Which material is best fit for orbital floor reconstruction has been a controversial topic. Individual surgeon preferences have been supported by inconsistent inconclusive data. The purpose of this study was to assess and analyze published evidence supporting various materials used for orbital floor reconstruction and to develop a decision-making algorithm for clinical application. A systematic literature review was performed from which 48 studies were selected after primary and secondary screening based on set inclusion and exclusion criteria. This cumulatively included 3475 separate orbital floor reconstructions. Results revealed risk and benefit profiles for all materials. Autologous calvarial bone grafts, porous polyethylene, and polydioxanone (PDS) were most widely used for orbital floor reconstruction. Increased infection rates were reported with polyglactin 910/PDS composites and silastic rubber. Ocular motility was reduced most with lyophilized dura and PDS. Preoperative and postoperative rates for diplopia and enophthalmos varied among the materials. In conclusion, our results revealed continued inadequate evidence to exclusively support the use of any one biomaterial/implant for orbital floor reconstruction. Results have served to create a decision-making algorithm for clinical application. Our authors propose certain parameters for future studies seeking to demonstrate a comparison between 2 or more materials for orbital floor reconstruction.


The subacromial impingement syndrome of the shoulder treated by conventional physiotherapy, self-training, and a shoulder brace: results of a prospective, randomized study.
This prospective, randomized trial was performed to compare the results of treating subacromial impingement syndrome of the shoulder by a guided self-training program with the treatment by conventional physiotherapy or a functional brace. Sixty patients with the diagnosis of an outlet impingement syndrome of the shoulder (Neer I and II) were treated either by strengthening the depressors of the humeral head with a guided self-training program, by conventional physiotherapy, or by wearing a functional brace. The Constant-Murley score was assessed after 6 and 12 weeks. Shoulder pain was monitored with a visual analog scale. All three groups showed a significant improvement in shoulder function as well as a significant reduction in pain. There were no statistically significant differences among the groups. Guided self-training can lead to results similar to those of conventional physiotherapy. The comparable effect of the functional brace remains unclear and might be explained by an influence on proprioception.


Virtual reality and persecutory delusions: safety and feasibility.
Virtual reality (VR) has begun to be used to research the key psychotic symptom of paranoia. The initial studies have been with non-clinical individuals and individuals at high risk of psychosis. The next step is to develop the technology for the understanding and treatment of clinical delusions. Therefore the present study investigated the acceptability and safety of using VR with individuals with current persecutory delusions. Further, it set out to determine whether patients feel immersed in a VR social environment and, consequently, experience paranoid thoughts. Twenty individuals with persecutory delusions and twenty non-clinical individuals spent 4 min in a VR underground train containing neutral characters. Levels of simulator sickness, distress, sense of presence, and persecutory ideation about the computer characters were measured. A one-week follow-up was conducted to check longer-term side effects. The VR experience did not raise levels of anxiety or symptoms of simulator sickness. No side effects were reported at the follow-up. There was a considerable degree of presence in the VR scenario for all participants. A high proportion of the persecutory delusions group (65%) had persecutory thinking about the computer characters, although this rate was not significantly higher than the non-clinical group. The study indicates that brief experiences in VR are safe and acceptable to people with psychosis. Further, patients with paranoia can feel engaged in VR scenes and experience persecutory thoughts. Exposure to social situations using VR has the potential to be incorporated into cognitive behavioural interventions for paranoia.


Monitor: progress and profiles.
Monitor provides an insight into the latest developments in pharmaceutical science and technology through brief synopses of recent presentations, publications and patents, and expert commentaries on the latest technologies. There are two sections: Progress summarizes the latest developments in pharmaceutical process technology, formulation, analytical technology, sterilization, controlled drug delivery systems and regulatory issues; Profiles offers expert commentary on emerging technologies, novel processes and strategic, organizational and logistic issues underlying pharmaceutical R&D.


Quantity of documentation of maltreatment risk factors in injury-related paediatric hospitalisations.
While child maltreatment is recognised as a global problem, solid epidemiological data on the prevalence of child maltreatment and risk factors associated with child maltreatment is lacking in Australia and internationally. There have been recent calls for action to improve the evidence-base capturing and describing child abuse, particularly those data captured within the health sector. This paper describes the quantity of documentation of maltreatment risk factors in injury-related paediatric hospitalisations in Queensland, Australia. This study involved a retrospective medical record review, text extraction and coding methodology to assess the quantity of documentation of risk factors and the subsequent utility of data in hospital records for describing child maltreatment and data linkage to Child Protection Service (CPS). There were 433 children in the maltreatment group and 462 in the unintentional injury group for whom medical records could be reviewed. Almost 93% of the maltreatment code sample, but only 11% of the unintentional injury sample had documentation identified indicating the presence of any of 20 risk factors. In the maltreatment group the most commonly documented risk factor was history of abuse (41%). In those with an unintentional injury, the most commonly documented risk factor was alcohol abuse of the child or family (3%). More than 93% of the maltreatment sample also linked to a child protection record. Of concern are the 16% of those children who linked to child protection who did not have documented risk factors in the medical record. Given the importance of the medical record as a source of information about children presenting to hospital for treatment and as a potential source of evidence for legal action the lack of documentation is of concern. The details surrounding the injury admission and consideration of any maltreatment related risk factors, both identifying their presence and ruling them out are required for each and every case. This highlights the need for additional training for clinicians to understand the importance of their documentation in child injury cases.


Screening for psychiatric morbidity in subjects presenting with chronic fatigue syndrome.
There is a need for a valid self-rating questionnaire to screen for psychiatric morbidity in patients with chronic fatigue syndrome (CFS). This study had the aim of assessing the utility and validity of two commonly used measures. Scores obtained on the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) were compared with various diagnostic and severity ratings obtained via a validating clinical interview, the Schedules for the Clinical Assessment of Neuropsychiatry (SCAN) in 95 consecutively referred subjects at a medical out-patient clinic who fulfilled standard criteria for CFS, and 48 healthy controls. Outcome measures were validating coefficients and receiver operating characteristics (ROC) for different thresholds and scoring on GHQ and BDI and index of definition (ID) as measured by SCAN; and Pearson and point by serial correlation coefficients for different diagnostic groups derived via SCAN and defined according to ICD-10 and DSM-III-R. GHQ and BDI perform poorly as screeners of psychiatric morbidity in CFS subjects when compared with various SCAN derived ratings although results for controls are comparable with other studies. Neither the GHQ nor BDI alone can be recommended as screeners for psychiatric morbidity in CFS subjects.


Small world effects in evolution.
For asexual organisms point mutations correspond to local displacements in the genotypic space, while other genotypic rearrangements represent long-range jumps. We investigate the spreading properties of an initially homogeneous population in a flat fitness landscape, and the equilibrium properties on a smooth fitness landscape. We show that a small-world effect is present: even a small fraction of quenched long-range jumps makes the results indistinguishable from those obtained by assuming all mutations equiprobable. Moreover, we find that the equilibrium distribution is a Boltzmann one, in which the fitness plays the role of an energy, and mutations that of a temperature.


Impact of Early Antiretroviral Therapy Initiation on HIV-Specific CD4 and CD8 T Cell Function in Perinatally Infected Children.
Early initiation of antiretroviral therapy (ART) in vertically HIV-infected children limits the size of the virus reservoir, but whether the time of treatment initiation (TI) can durably impact host immune responses associated with HIV infection is still unknown. This study was conducted in PBMC of 20 HIV-infected virally suppressed children on ART (mean age 9.4 y), classified as early treated (ET; age at ART initiation ≤0.5 y, n = 14) or late treated (LT; age at ART initiation 1-10 y, n = 6). Frequencies and functions of Ag-specific CD4 (CD40L+) and CD8 (CD69+) T cells were evaluated by intracellular IL-2, IFN-γ, and TNF-α production with IL-21 in CD4 or CD107a, granzyme B and perforin in CD8 T cells following stimulation with HIV gp140 protein (ENV) or GAG peptides by multiparameter flow cytometry. ET showed a higher proportion of cytokine-producing ENV- and GAG-specific CD4 and CD8 T cells compared with LT. In particular, ET were enriched in polyfunctional T cells. RNA sequencing analysis showed upregulation of immune activation pathways in LT compared with ET. Our results suggest that timing of TI in HIV-infected children has a long-term and measurable impact on the quality of the HIV-specific T cell immune responses and transcriptional profiles of PBMC, reinforcing the importance of early TI.


Decisional issues in antibiotic prescribing in French nursing homes: An ethnographic study.
Background:Medication prescription is generally the responsibility of doctors. In nursing homes, the nursing staff is often the first to suspect an infection. Today, physicians are more confident with nursing assessment, relying primarily on nursing staff information. Very few studies have investigated the nurses' influence on decision of medical prescription. This study investigates the role of nurses in antibiotic prescribing for the treatment of suspected infections in nursing home residents. Design and methods:An ethnographic study based on semi-structured interviews and participant observations was conducted. Sixteen nurses and five doctors working in five nursing homes in Paris, France participated between October 2015 and January 2016. Results:Given their proximity to elderly residents, registered nurses at the nursing homes occasionally assisted doctors in their medical diagnostic. However, nurses who are theoretically incompetent have met difficulties in their ability to participate in their decisions to prescribe antibiotics when managing residents' infections. Conclusion: if proximity and nursing skills reinforce the relevance of the clinical judgment of nurses, the effective and collaborative communication between the nurse and the doctor may help the nurse to enhance their role in the antibiotic prescribing in nursing homes, which would enhance antimicrobial stewardship efficiency.


Administration of clomipramine to neonatal mice alters stress response behavior and serotonergic gene expressions in adult mice.
Early life exposure to antidepressants frequently occurs when pregnant mothers take the medication during late pregnancy. Previous studies in animal models have shown that early exposure to certain antidepressants can alter some behaviors in adulthood. We examined whether the administration of clomipramine, a serotonin reuptake inhibitor, to neonatal mice could result in depression-related behavioral alterations in adult mice. In addition, in an attempt to uncover the mechanism underlying these behavioral changes, we examined the expression of candidate genes in different areas of the brain. Here we show that mice chronically injected with clomipramine specifically during early postnatal development demonstrated depression-like behavior as well as altered stress responses in adulthood. An analysis of the expression of serotonergic genes after exposure to social defeat stress revealed small but significant changes in the expression of 5-HT1A receptor gene (Htr1a) and 5-HTT gene (Slc6a4) in the mice treated with clomipramine compared with the mice injected with saline. We concluded that antidepressant exposure in early days of life could alter stress-related behavior in adulthood and that the behavioral alterations are accompanied by altered serotonergic gene expressions.


It is elemental: soil nutrient stoichiometry drives bacterial diversity.
It is well established that resource quantity and elemental stoichiometry play major roles in shaping below and aboveground plant biodiversity, but their importance for shaping microbial diversity in soil remains unclear. Here, we used statistical modeling on a regional database covering 179 locations and six ecosystem types across Scotland to evaluate the roles of total carbon (C), nitrogen (N) and phosphorus (P) availabilities and ratios, together with land use, climate and biotic and abiotic factors, in determining regional scale patterns of soil bacterial diversity. We found that bacterial diversity and composition were primarily driven by variation in soil resource stoichiometry (total C:N:P ratios), itself linked to different land uses, and secondarily driven by other important biodiversity drivers such as climate, soil spatial heterogeneity, soil pH, root influence (plant-soil microbe interactions) and microbial biomass (soil microbe-microbe interactions). In aggregate, these findings provide evidence that nutrient stoichiometry is a strong predictor of bacterial diversity and composition at a regional scale.


Environmental perception and epigenetic memory: mechanistic insight through FLC.
Chromatin plays a central role in orchestrating gene regulation at the transcriptional level. However, our understanding of how chromatin states are altered in response to environmental and developmental cues, and then maintained epigenetically over many cell divisions, remains poor. The floral repressor gene FLOWERING LOCUS C (FLC) in Arabidopsis thaliana is a useful system to address these questions. FLC is transcriptionally repressed during exposure to cold temperatures, allowing studies of how environmental conditions alter expression states at the chromatin level. FLC repression is also epigenetically maintained during subsequent development in warm conditions, so that exposure to cold may be remembered. This memory depends on molecular complexes that are highly conserved among eukaryotes, making FLC not only interesting as a paradigm for understanding biological decision-making in plants, but also an important system for elucidating chromatin-based gene regulation more generally. In this review, we summarize our understanding of how cold temperature induces a switch in the FLC chromatin state, and how this state is epigenetically remembered. We also discuss how the epigenetic state of FLC is reprogrammed in the seed to ensure a requirement for cold exposure in the next generation.


Genes unlinked to the leptin receptor influence urinary albumin excretion in obese Zucker rats.
We have previously shown that 90% of outbred obese Zucker Lepr(fa/fa) rats die prematurely of renal disease. Thus, renal disease in obese Zucker Lepr(fa/fa) rats may be caused by the LEPR mutation on chromosome 5, by the obesity, or it may be influenced by Zucker susceptibility alleles of genes on other chromosomes. We have searched for susceptibility genes on other chromosomes using urinary albumin excretion (UAE) as an early indicator of altered renal function in a backcross of (Brown Norway × inbred Zucker) F1 × inbred Zucker, which we name the BZZ cross. We killed 237 BZZ backcross animals at 15 wk of age. All included animals were homozygous for the fatty mutation of LEPR and were obese. Urinary creatinine measurements were used to calculate the albumin-to-creatinine ratio (ACR). We identified direct effect quantitative trait loci (QTLs) for UAE and ACR on chromosome 1 (LOD scores = 3.6 and 2.86, respectively) in males, and chromosome 4 (LOD score = 2.9) in females. Significant QTLs were identified for left kidney weight for females on chromosomes 3 and 12. We also demonstrated that kidneys from 15 wk old obese inbred Zucker rats already show evidence of kidney pathology: tubular dilation, proteinaceous fluid accumulation, evidence for inflammation, and mild mesangial and tubular membrane basement membrane thickening. Both lean Zucker rats and the Brown Norway rats showed no evidence for these changes. Thus, by removing the influence of the Lepr(fa/fa) mutation from analysis we have identified UAE QTLs unlinked to LEPR.


Evaluation of pulsed-field gel electrophoresis for typing of Shigella dysenteriae type 1.
Pulsed-field gel electrophoresis (PFGE) has been used successfully to discriminate between strains of many different bacterial species. In this study, digestion of bacterial DNA with the restriction endonuclease NotI and PFGE were evaluated for the typing of isolates of Shigella dysenteriae type 1, an important cause of epidemic dysentery. There were 27 isolates from four outbreaks of dysentery, and 44 isolates from endemic dysentery cases and a laboratory culture collection. The epidemic isolates yielded two types each with two subtypes, whereas the endemic isolates and culture collection yielded eight types with numerous subtypes. These findings suggest that S. dysenteriae 1 can be typed by PFGE.


Marine bisindole alkaloid: A potential apoptotic inducer in human cancer cells.
Marine organisms such as corals, sponges and tunicates produce active molecules which could represent a valid starting point for new drug development processes. Among the various structural classes, the attention has been focused on 2,2-bis(6-bromo-3-indolyl) ethylamine, a marine alkaloid which showed a good anticancer activity against several tumor cell lines. Here, for the first time, the mechanisms of action of 2,2-bis(6-bromo-3-indolyl) ethylamine have been evaluated in a U937 tumor cell model. Morpho-functional and molecular analyses, highlighting its preferred signaling pathway, demonstrated that apoptosis is the major death response induced by this marine compund. Chromatin condensation, micronuclei formation, blebbing and in situ DNA fragmentation, occurring through caspase activation (extrinsic and intrinsic pathways), were observed. In particular, the bisindole alkaloid induces a mitochondrial involvement in apoptosis machinery activation with Blc-2/Bcl-x down-regulation and Bax up-regulation. These findings demonstrated that 2,2-bis(6-bromo-3-indolyl) ethylamine alkaloid-induced apoptosis is regulated by the Bcl-2 protein family upstream of caspase activation.


Arthroscopic Repair of Massive Cuff Tears With Large Subscapularis Tendon Ruptures (Lafosse III/IV): A Prospective Magnetic Resonance Imaging-Controlled Case Series of 26 Cases With a Minimum Follow-up of 1 Year.
To prospectively assess arthroscopic repair of massive cuff tears (MCT) in a highly selective patient group with large subscapularis (SSC) tendon tears by means of clinical results and magnetic resonance imaging (MRI) studies. Between April 2009 and December 2010, 26 patients with MCT were treated with arthroscopic rotator cuff repair. Only lesions involving a large tear of the SSC tendon (Lafosse III or IV) in combination with a complete tear of the supraspinatus (SSP) tendon and a tear of at least the anterior third of the infraspinatus (ISP) tendon were included. Minimum follow-up was 1 year. Pre- and postoperative assessment included a standardized clinical examination, subjective patient outcome, and MRI (structural integrity, fatty muscle infiltration, and muscular mass). Mean follow-up was 17 months (range, 12 to 34 months). MRI was performed in 25 patients. In 21 (84%) the cuff repair was intact. A partial retear of the SSC was found in 2 patients (8%). In 2 patients (8%) a full-thickness retear of the posterosuperior cuff was observed (1 SSP, 1 SSP/ISP). A significant increase of the muscle mass and decrease of fatty infiltration was observed for the SSC and SSP but not for the ISP. The mean Constant-Murley score improved from 36 to 86 points (P < .001) with all its subscores as well (P < .001). Muscular strength improved for the SSC (4.9 v 3.0, P < .001), SSP (4.6 v 2.9, P < .001), and ISP (4.8 v 3.4, P < .001). Overall patient satisfaction was high (3.6 ± 0.8). Arthroscopic repair of MCT involving the ISP, SSP, and large tears of the SSC provides a reliable tendon healing, in particular for the SSC tendon, combined with good functional results. Level IV, therapeutic case series.


Predictive values and other quality criteria of the German version of the Nurse-Work Instability Scale (Nurse-WIS) - follow-up survey findings of a prospective study of a cohort of geriatric care workers.
Until now there has been a lack of effective screening instruments for health care workers at risk. To counteract the forecast shortage for health care workers, the offer of early interventions to maintain their work ability will become a central concern. The Nurse-Work Instability Scale (Nurse-WIS) seems to be suitable as a screening instrument and therefore a prospective study of a cohort of nursing staff from nursing homes was undertaken to validate the Nurse-Work Instability Scale (Nurse-WIS). The follow-up data was used to test the sensitivity, specificity and the predictive values of the Nurse-WIS. The participants answered a questionnaire in the baseline investigation (T1) and in a follow-up 12 month after baseline. The hypothesis was that geriatric care workers with an increased risk according to the Nurse-WIS in T1 would be more likely to have taken long-term sick leave or drawn a pension for reduced work capacity in T2. 396 persons took part in T1 (21.3% response), 225 in T2 (42.3% loss-to-follow-up). In T1, 28.4% indicated an increased risk according to the Nurse-WIS. In T2, 10.2% had taken long-term sick leave or had drawn a pension for reduced work capacity. The sensitivity is 73.9% (95%-CI 55.7%-92.3%), the specificity is 76.7% (95%-CI 71.2%-82.8%). The ROC AUC indicated a moderate precision for the scale, at 0.74 (95%-CI 0.64-0.84). The PPV of the Nurse-WIS is 26.6%, and the NPV is 96.3%. For those with an increased risk according to the Nurse-WIS, the probability in T2 of long-term sick leave or a pension for reduced work capacity is around eight times higher (OR 8.3, 95%-CI 2.90-23.07). Persons who had indicated a long-term sick leave or made an application for a pension for reduced work capacity in T1 had a 17 times higher risk (OR 17.4, 95%-CI 3.34-90.55). The German version of the Nurse-WIS appears to be a valid instrument with satisfactory predictive capabilities for recording an impending long-term sick leave. Whether the Nurse-WIS can be used as a screening tool which helps to design risk adjusted prevention programs for the afflicted nurse should be studied.


Antibiotic susceptibility of respiratory pathogens recently isolated in Italy: focus on cefditoren.
The aim of this study was to evaluate the in vitro antibiotic susceptibility of respiratory pathogens recently isolated in Italy to commonly used antibiotics including cefditoren. Six clinical microbiological laboratories collected, between January and September 2009, a total of 2,510 respiratory pathogens from subjects with community-acquired respiratory tract infections (CARTI). Ceftditoren, out of all the beta-lactams studied, had the lowest MIC(90 )against 965 strains of Streptococcus pneumoniae examined, followed by cefotaxime and ceftriaxone (2% resistance in penicillin-resistant S. pneumoniae (PRSP)). Against 470 Haemophilus influenzae , independently of their production of beta-lactamases or ampicillin resistance, cefditoren was the oral cephalosporin with the best in vitro activity, comparable to that of the injectable cephalosporins and levofloxacin. Higher MIC(90)s were found for the macrolides (4 - 16 mg/l) and cefaclor (4 - 32 mg/l). As was foreseeable, Streptococcus pyogenes (225 strains) was uniformly sensitive to all the beta-lactam antibiotics, but the elevated MIC(90 )values reduced (<75%) susceptibility of this pathogen to macrolides. Beta-lactamase-negative Moraxella catarrhalis (100 strains) had reduced susceptibility only to the macrolides, while the 250 beta-lactamase-producing strains also had reduced susceptibility to cefuroxime. Levofloxacin showed the lowest MIC(50)/MIC(90 )values in the producing strains, whereas cefditoren, cefotaxime and ceftriaxone in the non-producers. As regards the enterobacteriaceae, cefditoren and levofloxacin had the lowest MIC(90)s against Klebsiella pneumoniae. Cefditoren and the third-generation injectable cephalosporins had the lowest MIC(90)s against Escherichia coli (100% susceptibility) while levofloxacin was less active (86% susceptibility).In conclusion, cefditoren's wide spectrum and high intrinsic activity, as well as its capacity to overcome most of the resistance that has become consolidated in some classes of antibiotics widely used as empiric therapy for CARTI, allows us to suggest that cefditoren might be included in the european guidelines as one of the first-choice antibiotics in the treatment of CARTI.


Neural correlates of confidence during item recognition and source memory retrieval: evidence for both dual-process and strength memory theories.
Although the medial-temporal lobes (MTL), PFC, and parietal cortex are considered primary nodes in the episodic memory network, there is much debate regarding the contributions of MTL, PFC, and parietal subregions to recollection versus familiarity (dual-process theory) and the feasibility of accounts on the basis of a single memory strength process (strength theory). To investigate these issues, the current fMRI study measured activity during retrieval of memories that differed quantitatively in terms of strength (high vs. low-confidence trials) and qualitatively in terms of recollection versus familiarity (source vs. item memory tasks). Support for each theory varied depending on which node of the episodic memory network was considered. Results from MTL best fit a dual-process account, as a dissociation was found between a right hippocampal region showing high-confidence activity during the source memory task and bilateral rhinal regions showing high-confidence activity during the item memory task. Within PFC, several left-lateralized regions showed greater activity for source than item memory, consistent with recollective orienting, whereas a right-lateralized ventrolateral area showed low-confidence activity in both tasks, consistent with monitoring processes. Parietal findings were generally consistent with strength theory, with dorsal areas showing low-confidence activity and ventral areas showing high-confidence activity in both tasks. This dissociation fits with an attentional account of parietal functions during episodic retrieval. The results suggest that both dual-process and strength theories are partly correct, highlighting the need for an integrated model that links to more general cognitive theories to account for observed neural activity during episodic memory retrieval.


FDE-vdW: A van der Waals inclusive subsystem density-functional theory.
We present a formally exact van der Waals inclusive electronic structure theory, called FDE-vdW, based on the Frozen Density Embedding formulation of subsystem Density-Functional Theory. In subsystem DFT, the energy functional is composed of subsystem additive and non-additive terms. We show that an appropriate definition of the long-range correlation energy is given by the value of the non-additive correlation functional. This functional is evaluated using the fluctuation-dissipation theorem aided by a formally exact decomposition of the response functions into subsystem contributions. FDE-vdW is derived in detail and several approximate schemes are proposed, which lead to practical implementations of the method. We show that FDE-vdW is Casimir-Polder consistent, i.e., it reduces to the generalized Casimir-Polder formula for asymptotic inter-subsystems separations. Pilot calculations of binding energies of 13 weakly bound complexes singled out from the S22 set show a dramatic improvement upon semilocal subsystem DFT, provided that an appropriate exchange functional is employed. The convergence of FDE-vdW with basis set size is discussed, as well as its dependence on the choice of associated density functional approximant.


Essential role of the response regulator Rrp2 in the infectious cycle of Borrelia burgdorferi.
Alteration of surface lipoprotein profiles is a key strategy that the Lyme disease pathogen, Borrelia burgdorferi, has evolved to be maintained within its enzootic cycle between arthropods and mammals. Accumulated evidence indicates that the central regulatory pathway controlling differential gene expression by B. burgdorferi is the RpoN-RpoS pathway (the sigma(54)-sigma(S) sigma factor cascade). It was previously shown that activation of the RpoN-RpoS pathway is controlled by Rrp2, a two-component response regulator and sigma(54)-dependent transcriptional activator. The role of Rrp2 in the infectious cycle of B. burgdorferi has not been determined heretofore. In this report, we demonstrate that an rrp2 mutant defective in activating sigma(54)-dependent transcription was unable to establish infection in mice, but the rrp2 mutant was capable of surviving within ticks during and after tick feeding. Because the rrp2 mutant was defective in the production of OspC, an outer surface lipoprotein essential for mammalian host infection, we further examined whether the loss of infectivity of the rrp2 mutant was solely due to the inability to produce OspC. While transformation with a shuttle vector carrying ospC under the control of a constitutive flaB promoter restored infection to an ospC mutant in immunodeficient SCID mice, it could not rescue the avirulent phenotype of the rrp2 mutant. These data indicate that, in addition to controlling OspC, Rrp2 controls another factor(s) essential for B. burgdorferi to establish infection in mammals. Furthermore, microarray analyses revealed that 125 and 19 genes were positively and negatively regulated, respectively, by Rrp2, which provides a foundation for future identification of additional Rrp2-dependent virulence determinants in B. burgdorferi.


A DDX5 S480A polymorphism is associated with increased transcription of fibrogenic genes in hepatic stellate cells.
We recently identified a missense single nucleotide polymorphism (SNP) in DDX5 (rs1140409, p.S480A) that enhances the risk of developing cirrhosis. DDX5 is an ATP-dependent RNA helicase and transcriptional modulator. We hypothesized that the activity of DDX5 in regulating fibrogenic gene transcription in hepatic stellate cells (HSCs) is altered by the S480A SNP. To test this, we employed two approaches: 1) transient overexpression of DDX5 cDNA or siRNA knockdown of endogenous DDX5, with replacement by either DDX5 wild type (WT) or SNP cDNA, or 2) stable expression of exogenous DDX5 WT and SNP in HSC lines. WT DDX5 mRNA in HSCs was inversely correlated with gene expression for alpha2(I) collagen, tissue inhibitor of metalloproteinase-1, and transforming growth factor-beta1. Stable DDX5 SNP-expressing cells had higher basal and transforming growth factor-beta1-stimulated expression and enhanced promoter activities of fibrogenic genes. DDX5 variant-expressing cells also had higher Smad3 and AP-1-responsive reporter activities. In a one-hybrid GAL4 system, co-expression of the DDX5 SNP variant with chimeras of GAL4 DNA binding domain linked to JunD or Sp1 displayed higher transactivation of a GAL4-responsive reporter than that of DDX5 WT. Increased fibrogenic gene expression in DDX5 SNP-expressing cells was associated with reduced recruitment of DDX5 homodimers to responsive promoters, but there was no difference in the recruitment of the co-repressor HDAC1 (histone deacetylase 1). These data suggest that DDX5 is a repressor of fibrogenic genes in HSCs through interaction with transcriptional complexes. The enhanced fibrogenic activity of the DDX5 risk variant is linked to a reduced repressive function toward these target genes.


FRED (a Framework for Reconstructing Epidemic Dynamics): an open-source software system for modeling infectious diseases and control strategies using census-based populations.
Mathematical and computational models provide valuable tools that help public health planners to evaluate competing health interventions, especially for novel circumstances that cannot be examined through observational or controlled studies, such as pandemic influenza. The spread of diseases like influenza depends on the mixing patterns within the population, and these mixing patterns depend in part on local factors including the spatial distribution and age structure of the population, the distribution of size and composition of households, employment status and commuting patterns of adults, and the size and age structure of schools. Finally, public health planners must take into account the health behavior patterns of the population, patterns that often vary according to socioeconomic factors such as race, household income, and education levels. FRED (a Framework for Reconstructing Epidemic Dynamics) is a freely available open-source agent-based modeling system based closely on models used in previously published studies of pandemic influenza. This version of FRED uses open-access census-based synthetic populations that capture the demographic and geographic heterogeneities of the population, including realistic household, school, and workplace social networks. FRED epidemic models are currently available for every state and county in the United States, and for selected international locations. State and county public health planners can use FRED to explore the effects of possible influenza epidemics in specific geographic regions of interest and to help evaluate the effect of interventions such as vaccination programs and school closure policies. FRED is available under a free open source license in order to contribute to the development of better modeling tools and to encourage open discussion of modeling tools being used to evaluate public health policies. We also welcome participation by other researchers in the further development of FRED.


Functional consequences of structural adaptation of the heart in hypertension.
Extent of myocardial shortening is inversely related to afterload. Maintenance of normal stroke volume (SV) in hypertension will therefore require elevation of cardiac performance. The question of whether left ventricular hypertrophy, which develops during chronic hypertension, enhances or depresses cardiac function has been examined experimentally. Cardiac function curves have been constructed and maximal cardiac output has been determined during rapid volume load in intact animals or in isolated perfused hearts from spontaneously hypertensive rats (SHR) and from normotensive rats. When preload, afterload, heart rate, and contractility are controlled, maximal performance is enhanced in the SHR heart, and its ability to increase contractility on elevations in afterload (homeometric autoregulation) is reset in proportion to the increase in arterial blood pressure. Although a reduced volume compliance of the SHR left ventricle has not been documented, its diastolic properties will still be influenced by the increased wall thickness. The reason is that a higher pressure is required to induce a given diastolic wall stress when wall thickness/radius ratio is increased according to Laplace's law. Since wall stress in turn determines the extent of myocardial shortening, maintenance of normal stroke volume in SHR calls for increased diastolic pressures or increased inotropic stimulation. The structural adaptation of the heart to hypertension will thus enhance its systolic performance, but will influence its diastolic properties so that secondary adjustments are required to enhance ventricular filling or the inotropic state of the heart, or both.


Multiethnic Exome-Wide Association Study of Subclinical Atherosclerosis.
The burden of subclinical atherosclerosis in asymptomatic individuals is heritable and associated with elevated risk of developing clinical coronary heart disease. We sought to identify genetic variants in protein-coding regions associated with subclinical atherosclerosis and the risk of subsequent coronary heart disease. We studied a total of 25 109 European ancestry and African ancestry participants with coronary artery calcification (CAC) measured by cardiac computed tomography and 52 869 participants with common carotid intima-media thickness measured by ultrasonography within the CHARGE Consortium (Cohorts for Heart and Aging Research in Genomic Epidemiology). Participants were genotyped for 247 870 DNA sequence variants (231 539 in exons) across the genome. A meta-analysis of exome-wide association studies was performed across cohorts for CAC and carotid intima-media thickness. APOB p.Arg3527Gln was associated with 4-fold excess CAC (P=3×10-10). The APOE ε2 allele (p.Arg176Cys) was associated with both 22.3% reduced CAC (P=1×10-12) and 1.4% reduced carotid intima-media thickness (P=4×10-14) in carriers compared with noncarriers. In secondary analyses conditioning on low-density lipoprotein cholesterol concentration, the ε2 protective association with CAC, although attenuated, remained strongly significant. Additionally, the presence of ε2 was associated with reduced risk for coronary heart disease (odds ratio 0.77; P=1×10-11). Exome-wide association meta-analysis demonstrates that protein-coding variants in APOB and APOE associate with subclinical atherosclerosis. APOE ε2 represents the first significant association for multiple subclinical atherosclerosis traits across multiple ethnicities, as well as clinical coronary heart disease.


Neural correlates of lexical access during visual word recognition.
People can discriminate real words from nonwords even when the latter are orthographically and phonologically word-like, presumably because words activate specific lexical and/or semantic information. We investigated the neural correlates of this identification process using event-related functional magnetic resonance imaging (fMRI). Participants performed a visual lexical decision task under conditions that encouraged specific word identification: Nonwords were matched to words on orthographic and phonologic characteristics, and accuracy was emphasized over speed. To identify neural responses associated with activation of nonsemantic lexical information, processing of words and nonwords with many lexical neighbors was contrasted with processing of items with no neighbors. The fMRI data showed robust differences in activation by words and word-like nonwords, with stronger word activation occurring in a distributed, left hemisphere network previously associated with semantic processing, and stronger nonword activation occurring in a posterior inferior frontal area previously associated with grapheme-to-phoneme mapping. Contrary to lexicon-based models of word recognition, there were no brain areas in which activation increased with neighborhood size. For words, activation in the left prefrontal, angular gyrus, and ventrolateral temporal areas was stronger for items without neighbors, probably because accurate responses to these items were more dependent on activation of semantic information. The results show neural correlates of access to specific word information. The absence of facilitatory lexical neighborhood effects on activation in these brain regions argues for an interpretation in terms of semantic access. Because subjects performed the same task throughout, the results are unlikely to be due to task-specific attentional, strategic, or expectancy effects.


Blood pressure levels decrease during Mohs micrographic surgery.
A common practice is not to operate on patients with elevated blood pressure (BP) levels to avoid cardiovascular and cerebrovascular complications. We therefore designed a study to evaluate the effect of prolonged surgery under local anesthesia on BP levels, and to compare the outcome of patients with elevated BP to those with normal BP. We studied 121 patients (65 males) with a mean age of 60 ++/-14 years (range 31-89) who were referred for Mohs micrographic surgery (MMS) during 2 consecutive months. Forty six patients had a history of hypertension. Blood pressure was measured in all subjects in the supine position with an automated device 5 times during surgery. Blood pressure decreased significantly during surgery from 152 +/- 2/85 +/- 1 mm Hg at baseline to 139 +/- 2/79 +/- 1 at the end of the surgery (p < .05). Forty two patients (34%) had elevated BP levels at baseline whereas only 18 patients had these levels at the end of the first stage. There was no difference in surgery outcomes between those with elevated and those with normal BP levels at baseline. Blood pressure levels decrease during MMS under local anesthesia and the outcome of patients with elevated BP is good. Thus, patients with elevated BP can safely undergo surgery under local anesthesia.


A study to quantify the effectiveness of daily endorectal balloon for prostate intrafraction motion management.
To quantify intrafraction prostate motion between patient groups treated with and without daily endorectal balloon (ERB) employed during prostate radiotherapy and establish the effectiveness of the ERB. Real-time intrafraction prostate motion from 29 non-ERB (1,061 sessions) and 30 ERB (1,008 sessions) patients was evaluated based on three-dimensional (3D), left, right, cranial, caudal, anterior, and posterior displacements. The average percentage of time with 3D and unidirectional prostate displacements >2, 3, 4, 5, 6, 7, 8, 9, and 10 mm in 1-min intervals was calculated for up to 6 min of treatment time. The Kolmogorov-Smirnov method was used to evaluate the intrafraction prostate motion pattern between both groups. Large 3D motion (up to 1 cm or more) was only observed in the non-ERB group. The motion increased as a function of elapsed time for displacements >2-8 mm for the non-ERB group and >2-4 mm for the ERB group (p < 0.05). The percentage time distributions between the two groups were significantly different for motion >5 mm (p < 0.05). The 3D symmetrical internal margin (IM) can be reduced from 5 to 3 mm (40% reduction), whereas the asymmetrical IM can be reduced from 3 to 2 mm (33% reduction) in cranial, caudal, anterior, and posterior for 6 min of treatment, when ERB is used. Beyond 6 min, the symmetrical 3D and asymmetrical cranial, caudal, anterior, and posterior IMs can be reduced from 9, 4, 7, 7, and 8 to 5, 2, 5, 3, and 4 mm, respectively (up to 57% reduction). The percentage of time that the prostate was displaced in any direction was less in the ERB group for almost all magnitudes of motion considered. The directional analysis shows that the ERB reduced IMs in almost all directions, especially the anterior-posterior direction.


Identification and functional characterization of a new agonist site on nicotinic acetylcholine receptors of cultured hippocampal neurons.
Electrophysiological and biochemical techniques were used to demonstrate that alpha-bungarotoxin-, methyllycaconitine-sensitive neuronal nicotinic acetylcholine receptors (nAChRs) can be activated via a novel agonist site(s). The residue proposed to be essential to this site is the amino acid Lys-125 of the receptor alpha subunit. In outside-out patches excised from cultured hippocampal neurons, physostigmine (PHY) and 1-methyl-PHY activated single channels whose main conductances were 46 and 23 pS. This action was insensitive to DL-2-amino-5-phosphonovaleric acid, atropine, tetrodotoxin and competitive nicotinic antagonists, but blocked by benzoquinonium or FK1, a nAChR-specific antibody raised against rat muscle nAChR alpha subunits that binds to the novel site. Indirect immunofluorescence staining demonstrated that FK1 binds to the hippocampal neurons, as would be expected based on the high degree of homology among nAChR alpha subunits from diverse sources in the region surrounding Lys-125. PHY prevented the binding of FK1, thus supporting that FK1 is a specific probe for the PHY site. High-affinity sites (KD approximately 35 nM) for 1-methyl-PHY were identified in hippocampal neurons. Similar to PHY, benzoquinonium (0.1-10 microM) and galanthamine (1-10 microM) activated nicotinic single channels. The agonists benzoquinonium and PHY were also open-channel blockers at the neuronal nAChRs, whereas galanthamine was predominantly a desensitizing agent. In mouse fibroblasts transfected with cDNAs of alpha 4 and beta 2 neuronal nAChR subunits, PHY also activated single channels that were blocked by FK1. In these cells, dihydro-beta-erythroidine blocked single channels activated by (+)-anatoxin-a and did not affect those opened by PHY. Thus, the present results suggest that the novel agonist site located on the receptor alpha subunit is a common feature of neuronal nAChRs.


The Nuclear Proteome of White and Gray Matter from Schizophrenia Postmortem Brains.
Schizophrenia (SCZ) is a serious neuropsychiatric disorder that manifests through several symptoms from early adulthood. Numerous studies over the last decades have led to significant advances in increasing our understanding of the factors involved in SCZ. For example, mass spectrometry-based proteomic analysis has provided important insights by uncovering protein dysfunctions inherent to SCZ. Here, we present a comprehensive analysis of the nuclear proteome of postmortem brain tissues from corpus callosum (CC) and anterior temporal lobe (ATL). We show an overview of the role of deregulated nuclear proteins in these two main regions of the brain: the first, mostly composed of glial cells and axons of neurons, and the second, represented mainly by neuronal cell bodies. These samples were collected from SCZ patients in an attempt to characterize the role of the nucleus in the disease process. With the ATL nucleus enrichment, we found 224 proteins present at different levels, and 76 of these were nuclear proteins. In the CC analysis, we identified 119 present at different levels, and 24 of these were nuclear proteins. The differentially expressed nuclear proteins of ATL are mainly associated with the spliceosome, whereas those of the CC region are associated with calcium/calmodulin signaling.


A PCR-free electrochemical method for messenger RNA detection in cancer tissue samples.
Despite having reliable and excellent diagnostic performances, the currently available messenger RNA (mRNA) detection methods mostly use enzymatic amplification steps of the target mRNA which is generally affected by the sample manipulations, amplification bias and longer assay time. This paper reports an amplification-free electrochemical approach for the sensitive and selective detection of mRNA using a screen-printed gold electrode (SPE-Au). The target mRNA is selectively isolated by magnetic separation and adsorbed directly onto an unmodified SPE-Au. The surface-attached mRNA is then measured by differential pulse voltammetry (DPV) in the presence of [Fe(CN)6]4-/3- redox system. This method circumvents the PCR amplification steps as well as simplifies the assay construction by avoiding multiple steps involved in conventional biosensing approaches of using recognition and transduction layers. Our method has demonstrated good sensitivity (LOD = 1.0pM) and reproducibility (% RSD = <5%, for n = 3) for detecting FAM134B mRNA in two cancer cell lines and a small cohort of clinical samples (number of samples = 26) collected from patients with oesophageal cancer. The analytical performance of our method is validated with a standard qRT-PCR analysis. We believe that our PCR-free approach holds a great promise for the analysis of tumor-specific mRNA in clinical samples.


Hindgut visceral mesoderm requires an ectodermal template for normal development in Drosophila.
During Drosophila embryogenesis, the development of the midgut endoderm depends on interactions with the overlying visceral mesoderm. Here we show that the development of the hindgut also depends on cellular interactions, in this case between the inner ectoderm and outer visceral mesoderm. In this section of the gut, the ectoderm is essential for the proper specification and differentiation of the mesoderm, whereas the mesoderm is not required for the normal development of the ectoderm. Wingless and the fibroblast growth factor receptor Heartless act over sequential but interdependent phases of hindgut visceral mesoderm development. Wingless is required to establish the primordium and to enhance Heartless expression. Later, Heartless is required to promote the proper differentiation of the hindgut visceral mesoderm itself.


Hospital rapid response team and patients with life-limiting illness: a multicentre retrospective cohort study.
Approximately one-third of rapid response team consultations involve issues of end-of-life care. We postulate a greater occurrence in patients with a life-limiting illness, in whom the opportunity for advance care planning and palliative care involvement should be offered. We aim to review the characteristics and compare outcomes of rapid response team consultations on patients with and without a life-limiting illness. A 3-month retrospective cohort study of all rapid response team consultations was conducted. The sample population included all adult inpatients in a major teaching hospital network. We identified 351 patients - including 139 with a life-limiting illness - receiving a total of 456 rapid response team consultations. The median time from admission to the first rapid response team consultation was 3 days. Patients with a life-limiting illness had a significantly higher mortality rate (41.7% vs 13.2%), were older (72.6 vs 63.5 years), more likely to come from a residential aged-care facility (29.5% vs 4.1%) and had a shorter hospital stay (10 vs 13 days). Rapid response team consultations resulted in a change to more palliative goals of care in 28.5% of patients, of whom two-thirds had a life-limiting illness. Patients with a life-limiting illness had worse outcomes post-rapid response team consultation. Our findings suggest that a routine clarification of goals of care for this cohort, within 3 days of hospital admission, may be advantageous. These discussions may provide clarity of purpose to treating teams, reduce the burden of unnecessary interventions and promote patient-centred care agreed upon in advance of any deterioration.


Correlation of magnetic resonance imaging findings and reported symptoms in patients with chronic cervical dysfunction.
Information gathered from the patient history, physical examination, and advanced testing augments the decision-making process and is proposed to improve the probability of diagnostic and prognostic accuracy. However, these findings may provide inconsistent results and can lead to errors in decision-making. The purpose of this study was to examine the relationship between common clinical complaints and specific findings on magnetic resonance imaging (MRI) in patients with chronic neck dysfunction. Forty-five English-speaking participants (25 female), with mean age of 52 (SD = 13.4), were evaluated by a neurosurgeon for complaints of symptoms related to the cervical spine. All participants answered a subjective questionnaire and received an MRI of the cervical spine. Cramer's V nominal correlation was performed to explore the relationship between the targeted variables. The correlation matrix calculations captured three significant findings. Evidence of spinal cord compression was significantly correlated to 1) anteroposterior canal diameter of less than or equal to 9 mm (r = .31; p<0.05) and 2) diminished subarachnoid fluid around the cord (r = .48; p<0.01). Report of loss of dexterity was significantly correlated with 3) report of lower extremity clumsiness (r = .33; p<0.05). In this study, no definitive relationships were found between the clinical complaints of neck pain, hand function, or clumsiness and specific MRI findings of spinal cord compression. Further research is needed to investigate the diagnostic utility of subjective complaints and their association with advanced testing.


Update: Drug treatment options for coronavirus disease 2019 (COVID-19).
Coronavirus disease 19 (COVID-19) continues to rage as a global pandemic. A number of potential therapeutic agents have been explored over the past year or two. However, numerous drugs that were expected to prove highly effective, such as lopinavir/ritonavir and remdesivir, have been found to have little benefit in large clinical trials. Interleukin-6 receptor antagonists, glucocorticoids, Janus kinase inhibitors, and some antivirals have been found to provide significant benefits in terms of reducing viral load, reducing the time of nucleic acid conversion, or improving survival. For example, bamlanivimab and etesevimab, which are newly designed monoclonal antibodies against the surface spike protein S1 subunit receptor-binding domain (RBD) of SARS-CoV-2, have a significant effect on reducing the viral load and the hospitalization rate of patients with mild COVID-19. Several vaccines against SARS-CoV-2 have been widely administered worldwide and have provided good protection. Nevertheless, the increasingly hardy variants of the virus have raised the requirements for vaccine design. Perhaps RBD-based vaccines are a viable way to defend against variants, but this still needs to be verified in a large sample. Therefore, this paper provides an update on the treatment options for COVID-19 based on three previously proposed dimensions of drug screening: standard assays of existing broad-spectrum antivirals, screening of chemical libraries, and redevelopment of new, specific drugs.


The effect of a tall tower on flow and dispersion through a model urban neighborhood: part 1. Flow characteristics.
Wind tunnel experiments were performed to examine the effect of a tall tower on the flow around an otherwise uniform array of buildings. Additionally, preliminary CFD simulations were run to visualize the flow with more resolution. The model used in both the wind tunnel and CFD studies was designed to simulate an area of Brooklyn, NY, USA, where blocks of residential row houses form a neighborhood bordering a major urban highway. This area was the site of a field study that, along with the work reported here, had the goal of improving the understanding of airflow and dispersion patterns within urban microenvironments. Results reveal that a tall tower has a dramatic effect on the flow in the street canyons in the neighboring blocks, enhancing the exchange between the street canyon flow and the freestream flow aloft. In particular, vertical motion down the windward side and up the leeward side of the tower resulted in strong flows in the lateral street canyons and increased winds in the street canyons in the immediate vicinity of the tower. These phenomena were visible in both the wind tunnel and CFD results, although some minor differences in the flow fields were noted.


Postsurgical Cystoid Macular Edema.
Cystoid macular edema (CME) is a primary cause of reduced vision following both cataract and successful vitreoretinal surgery. The incidence of clinical CME following modern cataract surgery is 0.1-2.35%. Preexisting conditions such as diabetes mellitus and uveitis as well as intraoperative complications can raise the risk of postsurgical CME. The etiology of CME is not completely understood. Prolapsed or incarcerated vitreous and postoperative inflammatory processes have been proposed as causative agents. Pseudophakic CME is characterized by poor postoperative visual acuity. Fluorescein angiography shows the classical perifoveal petaloid staining pattern and late leakage of the optic disk. Optical coherence tomography is a useful diagnostic tool, which displays cystic spaces in the outer nuclear layer. The most important differential diagnoses include age-related macular degeneration and other causes of CME such as diabetic macular edema. Most cases of pseudophakic CME resolve spontaneously. The value of prophylactic treatment is doubtful. First-line treatment of postsurgical CME should include topical nonsteroidal anti-inflammatory drugs and corticosteroids. Oral carbonic anhydrase inhibitors can be considered complementary. In cases of resistant CME, periocular or intraocular corticosteroids present an option. Antiangiogenic agents, though experimental, should be considered for nonresponsive persistent CME. Surgical options should be reserved for special indications.


Risk transfer formula for individual and small group markets under the Affordable Care Act.
The Affordable Care Act provides for a program of risk adjustment in the individual and small group health insurance markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge. The risk adjustment methodology includes the risk adjustment model and the risk transfer formula. This article is the third of three in this issue of the Medicare & Medicaid Research Review that describe the ACA risk adjustment methodology and focuses on the risk transfer formula. In our first companion article, we discussed the key issues and choices in developing the methodology. In our second companion paper, we described the risk adjustment model that is used to calculate risk scores. In this article we present the risk transfer formula. We first describe how the plan risk score is combined with factors for the plan allowable premium rating, actuarial value, induced demand, geographic cost, and the statewide average premium in a formula that calculates transfers among plans. We then show how each plan factor is determined, as well as how the factors relate to each other in the risk transfer formula. The goal of risk transfers is to offset the effects of risk selection on plan costs while preserving premium differences due to factors such as actuarial value differences. Illustrative numerical simulations show the risk transfer formula operating as anticipated in hypothetical scenarios.


Significant evidence of one or more susceptibility loci for endometriosis with near-Mendelian inheritance on chromosome 7p13-15.
Endometriosis is a common disease with a heritable component. The collaborative International Endogene Study consists of two data sets (Oxford and Australia) comprising 1176 families with multiple affected. The aim was to investigate whether the apparent concentration of cases in a proportion of families could be explained by one or more rare variants with (near-)Mendelian autosomal inheritance. Linkage analyses (aimed at finding chromosomal regions harbouring disease-predisposing genes) were conducted in families with three or more affected (Oxford: n = 52; Australia: n = 196). In the Oxford data set, a non-parametric linkage score (Kong & Cox (K&C) Log of ODds (LOD)) of 3.52 was observed on chromosome 7p (genome-wide significance P = 0.011). A parametric MOD score (equal to maximum LOD maximized over 357 possible inheritance models) of 3.89 was found at 65.72 cM (D7S510) for a dominant model with reduced penetrance. After including the Australian data set, the non-parametric K&C LOD of the combined data set was 1.46 at 57.3 cM; the parametric analysis found an MOD score of 3.30 at D7S484 (empirical significance: P = 0.035) for a recessive model with high penetrance. Critical recombinant analysis narrowed the probable region of linkage down to overlapping 6.4 Mb and 11 Mb intervals containing 48 and 96 genes, respectively. This is the first report to suggest that there may be one or more high-penetrance susceptibility loci for endometriosis with (near-)Mendelian inheritance.


Mesoporous silica nanoparticles trigger mitophagy in endothelial cells and perturb neuronal network activity in a size- and time-dependent manner.
Mesoporous silica nanoparticles (MSNPs) are excellent candidates for biomedical applications and drug delivery to different human body areas, the brain included. Although toxicity at cellular level has been investigated, we are still far from using MSNPs in the clinic, because the mechanisms involved in the cellular responses activated by MSNPs have not yet been elucidated. This study used an in vitro multiparametric approach to clarify relationships among size, dose, and time of exposure of MSNPs (0.05-1 mg/mL dose range), and cellular responses by analyzing the morphology, viability, and functionality of human vascular endothelial cells and neurons. The results showed that 24 hours of exposure of endothelial cells to 250 nm MSNPs exerted higher toxicity in terms of mitochondrial activity and membrane integrity than 30 nm MSN at the same dose. This was due to induced cell autophagy (in particular mitophagy), probably consequent to MSNP cellular uptake (>20%). Interestingly, after 24 hours of treatment with 30 nm MSNPs, very low MSNP uptake (<1%) and an increase in nitric oxide production (30%, P<0.01) were measured. This suggests that MSNPs were able to affect endothelial functionality from outside the cells. These differences could be attributed to the different protein-corona composition of the MSNPs used, as suggested by sodium dodecyl sulfate polyacrylamide-gel electrophoresis analysis of the plasma proteins covering the MSNP surface. Moreover, doses of MSNPs up to 0.25 mg/mL perturbed network activity by increasing excitability, as detected by multielectrode-array technology, without affecting neuronal cell viability. These results suggest that MSNPs may be low-risk if prepared with a diameter <30 nm and if they reach human tissues at doses <0.25 mg/mL. These important advances could help the rational design of NPs intended for biomedical uses, demonstrating that careful toxicity evaluation is necessary before using MSNPs in patients.


PKC inhibitors prevent endothelial dysfunction after myocardial ischemia-reperfusion in rats.
The intracellular mechanism for endothelial dysfunction after myocardial ischemia-reperfusion remains to be elucidated. It has been reported that activation of protein kinase C (PKC) occurs after myocardial ischemia-reperfusion and that the activation impairs endothelium-dependent relaxation. Thus we examined the role of PKC activation in the ischemia-reperfusion-induced endothelial dysfunction. Isolated rat hearts perfused with a constant flow were subjected to global ischemia for 15 min followed by reperfusion for 20 min. Coronary vascular responses to the endothelium-dependent vasodilators acetylcholine (ACh) and bradykinin (BK) and the endothelium-independent vasodilator sodium nitroprusside (SNP) were examined before and after the ischemia-reperfusion. Endothelium-dependent relaxations to ACh and BK were impaired after the ischemia-reperfusion, whereas endothelium-independent relaxations to SNP were unaffected. Pretreatment with a PKC inhibitor, staurosporine, H7, or calphostin C, prevented the impairments. Phorbol 12-myristate 13-acetate, a PKC-activating phorbol ester, attenuated the relaxations to ACh and BK but not those to SNP. These results suggest that PKC activation may be involved in part in the ischemia-reperfusion-induced endothelial dysfunction.


Immunoregulation in atopic dermatitis: functional analysis of T-B cell interactions and the enumeration of Fc receptor-bearing T cells.
Immune aberrations in atopic dermatitis (AD) are multiple and interrelated. We investigated immunoregulatory cell markers and functional interactions of purified T- and B-enriched cells in a pokeweed mitogen (PWM)-stimulated IgG production assay in patients with AD. Atopic mononuclear leukocytes and autologous recombinations of purified atopic T and B cells were hyporesponsive to PWM stimulation of IgG synthesis. When atopic B cells were cultured with normal T cells, they were still less responsive than normal B cells. Atopic T cells generated normal levels of suppression in three responder systems. Radioresistant T-cell help was also in the normal range whereas nonirradiated AD T cells produced slightly less help than normal T cells. We noted reduced levels of T lymphocytes with FcIgG receptors (T gamma) and found that T gamma reduction correlated inversely with log serum IgE. In the light of normal T suppression, we critically examined AD cell adherence and contamination at various steps in the T gamma assay to rule out technical causes of T gamma reduction in AD. Lowered T gamma cells in AD were not associated with circulating IgG immune complexes and subsequent blockade of the FcIgG receptors. Thus, we have identified defects in the numbers of an immunoregulatory T cell, and in the generation of PWM-responsive B cells. A model is proposed in which the alterations in atopic cyclic nucleotide metabolism of T-cell helpers could result in abnormalities of immunoregulatory T cells and PWM-recruitable B cells.