Ultrasensitive fluorescent proteins for imaging neuronal activity.
Fluorescent calcium sensors are widely used to image neural activity. Using structure-based mutagenesis and neuron-based screening, we developed a family of ultrasensitive protein calcium sensors (GCaMP6) that outperformed other sensors in cultured neurons and in zebrafish, flies and mice in vivo. In layer 2/3 pyramidal neurons of the mouse visual cortex, GCaMP6 reliably detected single action potentials in neuronal somata and orientation-tuned synaptic calcium transients in individual dendritic spines. The orientation tuning of structurally persistent spines was largely stable over timescales of weeks. Orientation tuning averaged across spine populations predicted the tuning of their parent cell. Although the somata of GABAergic neurons showed little orientation tuning, their dendrites included highly tuned dendritic segments (5-40-µm long). GCaMP6 sensors thus provide new windows into the organization and dynamics of neural circuits over multiple spatial and temporal scales.


Tunable colors and white-light emission based on a microporous luminescent Zn(II)-MOF.
Metal-organic frameworks (MOFs) are a rapidly growing class of hybrid materials with many multifunctional properties. The permanent porosity plays a central role in the functional properties. In particular, the luminescent MOFs with a permanent porosity have wide applications in guest species recognition and adsorption. In this contribution, we aim to develop tunable colors and white-light luminescence materials by the encapsulation of Ln(3+) species in microporous luminescent MOFs. A semi-rigid trivalent carboxylic acid 1,3,5-tri(4-carboxyphenoxy)benzene (H3TCPB) was selected as the organic building block, not only because it is suitable to construct microporous frameworks, but also by reason of its blue luminescent emission. Under solvothermal reactions, a microporous MOF material, [Zn3(TCPB)2(H2O)2]·2H2O·4DMF (JUC-113, JUC = Jilin University, China), was synthesized, which has a permanent porosity and emits blue light. According to three-primary colors, the guest luminescent species should be Tb(3+) and Eu(3+) owing to their distinctive colors (Tb(3+), green; Eu(3+), red). In addition, the luminescent properties of JUC-113 can be easily tuned by different combinations of the encapsulation amount of Tb(3+) and Eu(3+), obtaining white-light emission materials.


Difference between the effects of one-site and three-site abdominal hot-stone stimulation on the skin-temperature changes of the lower limbs.
To determine whether any difference exists in the skin-temperature responses of the lower limbs to hot-stone application relative to one-site and three-site abdominal application. Twenty-five female students participated in experimental sessions after a random allocation: 14 participants received a hot-stone application on the umbilicus, superior-umbilicus, and inferior-umbilicus regions (hereafter referred to as the three-site stimulation group); and 11 participants received the hot-stone application on the umbilicus region only (hereafter referred to as the one-site stimulation group). Heated stones were applied for 9 min to participants in both groups. Four arbitrary frames (the lower leg, ankle, proximal foot, and distal foot regions) were created in order to observe and analyze the skin temperature of a lower limb using a thermograph. Observation periods were as follows: before hot-stone stimulation, immediately after stimulation, and 5, 10, 15, and 20 min after stimulation. There was a significant offset interaction of distal foot skin temperature between the groups. The left-side distal foot skin temperature increased at 15 and 20 min following the three-site abdominal hot-stone stimulation. The right-side distal foot skin temperature increased immediately and at 5, 10, 15, and 20 min following the three-site abdominal hot-stone stimulation. No significant change in distal foot skin temperature was observed following the one-site stimulation. Lower-limb skin temperature was altered following hot-stone stimulation applied to the abdomen, and the one-site stimulation and three-site stimulation yielded different distal foot skin-temperature reactions.


Improving Screening Methods for Hepatitis C Among People Who Inject Drugs: Findings from the HepTLC Initiative, 2012-2014.
People who inject drugs (PWID) are at increased risk for hepatitis C virus (HCV) infection. We examined HCV testing outcomes among PWID through CDC's Hepatitis Testing and Linkage to Care initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites during 2012-2014. Ten grantees in nine geographically diverse cities conducted HCV testing among PWID. Among those testing positive for HCV antibody (anti-HCV), we calculated the proportion who were offered a confirmatory HCV ribonucleic acid (RNA) test, positively diagnosed, and referred to a specialist for care. We stratified anti-HCV-positive people who completed each step by same-day testing (i.e., an HCV RNA test administered on the same date as an anti-HCV test) vs. person not receiving same-day testing to evaluate whether the need for follow-up testing affected diagnosis of chronic infection and linkage to care. A total of 15,274 people received an anti-HCV test at 84 testing sites targeting PWID. Of those, 11,159 (73%) reported having injected drugs in their lifetime, 7,789 (51%) reported injecting drugs in the past 12 months, and 3,495 (23%) tested anti-HCV positive. A total of 1,630 people received testing for HCV RNA, of whom 1,244 (76%) were HCV RNA positive. When not receiving both tests on the same day, 601 of 2,465 (24%) anti-HCV-positive people received an HCV RNA test. Strategies to diagnose PWID for HCV infection are needed to reduce associated morbidity and mortality. Agencies can substantially increase the number of PWID who are diagnosed and informed of their HCV infection by administering both anti-HCV and HCV RNA tests during a single testing event.


Character of the effect of microwave on conduction velocity of frog ventricular muscle.
Thirty-two frog hearts were divided into four groups and placed individually in temperature-controlled waveguides filled with Ringer's solution. The pacemaker was removed, and stimulation was provided at 0.3 Hz by three carbon-loaded Teflon electrodes located on the aorta and the ventricular muscle. Conduction velocity was measured from the difference between two action potentials. One group served as control; the three other groups were exposed for 2 h to pulsed 2,450 MHz microwave fields (10 microseconds, 0.001 duty cycle, 16 Hz modulation) at specific absorption rates (SARs) of 0.003, 2, and 6 W/kg, respectively. No significant difference in conduction velocity was found between the control and the exposed groups.


Standard basic emergency obstetric and neonatal care training in Addis Ababa; trainees reaction and knowledge acquisition.
In 2010, the Federal Ministry of Health of Ethiopia (FMOH) has developed standard Basic Emergency Obstetric and Neonatal Care (BEmONC) in-service training curricula to respond to the high demand for competency in EmONC. However, the effectiveness of the training curricula has not been well documented. A collaborative intervention project in Addis Ababa has trained providers using the standard BEmONC curricula where this paper presents Krikpartick level 1 and level 2 evaluation of the training. The project has been conducted in 10 randomly selected public health centers (HC) in Addis Ababa. Providers working in the labour wards of the selected HCs have received the standard BEmONC training between May and July 2013. Using standard tools, trainees' reaction to the course and factual knowledge during the immediate post-course and six months after the training were assessed. Descriptive statistics and t-tests were done. Of the total 82 providers who received the training, 30 (36.6%) were male, 61 (74.4%) were midwives. Providers' work experiences ranged from 1 month to 37 years. Seventy-four (89%) providers reported that the training was appropriate for their work, 95% reported that the training have updated their knowledge & skills, while 27 (32.9%) reported that the training facilities & arrangements were unsatisfactory. The mean immediate post-course knowledge score was 83.5% and 33 (40%) providers did not achieve knowledge-based mastery in their first attempt. The midwives were more likely to achieve knowledge-based mastery than the nurses (p < 0.05). The mean knowledge score six-months post-training was 80.2% and 40% have scored knowledge based mastery. Being one of the first papers reporting the implementation of the standard in-service BEmONC training curriculum, we have identified an important limitation on the course evaluations of the curriculum, which need urgent consideration. The majority of the trainees has reported favourable reaction to the training, but many of them did not achieve knowledge-based mastery in the immediate post training although the knowledge retention six months post training was encouraging.


Stable neurovisual servoing for robot manipulators.
In this paper, we propose a stable neurovisual servoing algorithm for set-point control of planar robot manipulators in a fixed-camera configuration an show that all the closed-loop signals are uniformly ultimately bounded (UUB) and converge exponentially to a small compact set. We assume that the gravity term and Jacobian matrix are unknown. Radial basis function neural networks (RBFNNs) with online real-time learning are proposed for compensating both gravitational forces and errors in the robot Jacobian matrix. The learning rule for updating the neural network weights, similar to a back propagation algorithm, is obtained from a Lyapunov stability analysis. Experimental results on a two degrees of freedom manipulator are presented to evaluate the proposed controller.


Convergence of Inflammatory Pathways in Allergic Asthma and Sickle Cell Disease.
The underlying pathologies of sickle cell disease and asthma share many characteristics in terms of respiratory inflammation. The principal mechanisms of pulmonary inflammation are largely distinct, but activation of common pathways downstream of the initial inflammatory triggers may lead to exacerbation of both disease states. The altered inflammatory landscape of these respiratory pathologies can differentially impact respiratory pathogen susceptibility in patients with sickle cell disease and asthma. How these two distinct diseases behave in a comorbid setting can further exacerbate pulmonary complications associated with both disease states and impact susceptibility to respiratory infection. This review will provide a concise overview of how asthma distinctly affects individuals with sickle cell disease and how pulmonary physiology and inflammation are impacted during comorbidity.


Data withholding and the next generation of scientists: results of a national survey.
To provide the first national data on the nature, extent, and consequences of withholding among life science trainees. In 2003, the authors surveyed 1,077 second-year doctoral students and postdoctoral fellows in life sciences at 50 U.S. universities, with a comparison group of trainees in computer science and chemical engineering. The study variables examined trainees' exposure to and the consequences of data withholding. Two hundred forty-six trainees (23.0%) reported that they had asked for and been denied access to information, data, materials, or programming associated with published research and 221 (20.6%) to unpublished research. Eighty-five trainees (7.9%) reported that they had denied another academic scientist's request(s) related to their own published research. Five hundred thirty-three trainees (50.8%) reported that withholding had had a negative effect on the progress of their research, 508 (48.5%) on the rate of discovery in their lab/research group, 472 (45.0%) on the quality of their relationships with academic scientists, 346 (33.0%) on the quality of their education, and 299 (28.5%) on the level of communication in their lab/research group. Trainees denied access to research were significantly more likely to report that data withholding had had a negative effect on several aspects of the educational experience. Data withholding had demonstrated negative effects on trainees. The life sciences, more so than chemical engineering or computer science, will have to address this issue among its trainees. Failure to do so could result in delayed research, inefficient training, and a culture of withholding among future life scientists.


A segment of 97 amino acids within the translocation domain of Clostridium difficile toxin B is essential for toxicity.
Clostridium difficile toxin B (TcdB) intoxicates target cells by glucosylating Rho GTPases. TcdB (269 kDa) consists of at least 4 functional domains including a glucosyltransferase domain (GTD), a cysteine protease domain (CPD), a translocation domain (TD), and a receptor binding domain (RBD). The function and molecular mode of action of the TD, which is the largest segment of TcdB and comprises nearly 50% of the protein, remain largely unknown. Here we show that a 97-amino-acid segment (AA1756 - 1852, designated as ?97 or D97), located in the C-terminus of the TD and adjacent to the RBD, is essential for the cellular activity of TcdB. Deletion of this segment in TcdB (designated as TxB-D97), did not adversely alter toxin enzymatic activities or its cellular binding and uptake capacity. TxB-D97 bound to and entered cells in a manner similar to TcdB holotoxin. Both wild type and mutant toxins released their GTDs similarly in the presence of inositol hexakisphosphate (InsP6), and showed a similar glucosyltransferase activity in a cell-free glucosylating assay. Despite these similarities, the cytotoxic activity of TxB-D97 was reduced by more than 5 logs compared to wild type toxin, supported by the inability of TxB-D97 to glucosylate Rac1 of target cells. Moreover, the mutant toxin failed to elicit tumor necrosis factor alpha (TNF-α) in macrophages, a process dependent on the glucosyltransferase activity of the toxin. Cellular fractionation of toxin-exposed cells revealed that TxB-D97 was unable to efficiently release the GTD into cytosol. Thereby, we conclude the 97-amino-acid region of the TD C-terminus of TcdB adjacent to the RBD, is essential for the toxicity of TcdB.


Co-localization and regulation of basic fibroblast growth factor and arginine vasopressin in neuroendocrine cells of the rat and human brain.
Adult rat hypothalamo-pituitary axis and choroid plexus are rich in basic fibroblast growth factor (FGF2) which likely has a role in fluid homeostasis. Towards this end, we characterized the distribution and modulation of FGF2 in the human and rat central nervous system. To ascertain a functional link between arginine vasopressin (AVP) and FGF2, a rat model of chronic dehydration was used to test the hypothesis that FGF2 expression, like that of AVP, is altered by perturbed fluid balance. Immunohistochemistry and confocal microscopy were used to examine the distribution of FGF2 and AVP neuropeptides in the normal human brain. In order to assess effects of chronic dehydration, Sprague-Dawley rats were water deprived for 3 days. AVP neuropeptide expression and changes in FGF2 distribution in the brain, neural lobe of the pituitary and kidney were assessed by immunohistochemistry, and western blotting (FGF2 isoforms). In human hypothalamus, FGF2 and AVP were co-localized in the cytoplasm of supraoptic and paraventricular magnocellular neurons and axonal processes. Immunoreactive FGF2 was associated with small granular structures distributed throughout neuronal cytoplasm. Neurohypophysial FGF2 immunostaining was found in axonal processes, pituicytes and Herring bodies. Following chronic dehydration in rats, there was substantially-enhanced FGF2 staining in basement membranes underlying blood vessels, pituicytes and other glia. This accompanied remodeling of extracellular matrix. Western blot data revealed that dehydration increased expression of the hypothalamic FGF2 isoforms of ca. 18, 23 and 24 kDa. In lateral ventricle choroid plexus of dehydrated rats, FGF2 expression was augmented in the epithelium (Ab773 as immunomarker) but reduced interstitially (Ab106 immunostaining). Dehydration altered FGF2 expression patterns in AVP-containing magnocellular neurons and neurohypophysis, as well as in choroid plexus epithelium. This supports the involvement of centrally-synthesized FGF2, putatively coupled to that of AVP, in homeostatic mechanisms that regulate fluid balance.


First-pass contrast-enhanced myocardial perfusion MRI in mice on a 3-T clinical MR scanner.
First-pass contrast-enhanced myocardial perfusion MRI in rodents has so far not been possible due to the temporal and spatial resolution requirements. We developed a new first-pass perfusion MR method for rodent imaging on a clinical 3.0-T scanner (Philips Healthcare, Best, The Netherlands) that employed 10-fold k-space and time domain undersampling with constrained image reconstruction, using temporal basis sets (k-t principle component analysis) to achieve a spatial resolution of 0.2 × 0.2 × 1.5mm(3) and an acquisition window of 43 msec. The method was successfully tested in five healthy and four infarcted mice (C57BL/6J) at heart rates of 495.1 ± 45.8 beats/min. Signal-intensity-time profiles showed a percentage myocardial signal increase of 141.3 ± 38.9% in normal mice, compared with 44.7 ± 32.4% in infarcted segments. Mean myocardial blood flow by Fermi function for constrained deconvolution in control mice was 7.3 ± 1.5 mL/g/min, comparable to published literature, with no significant differences between three myocardial segments. In infarcted segments, myocardial blood flow was significantly reduced to 1.2 ± 0.8 mL/g/min (P < 0.01). This is the first report of first-pass myocardial perfusion MR in a mouse model on a clinical 3-T MR scanner and using a k-t undersampling method. Data were acquired on a 3-T scanner, using an approach similar to clinical acquisition protocols, thus facilitating translation of imaging findings between rodent and human studies.


Foregut endoderm is required at head process stages for anteriormost neural patterning in chick.
Anterior definitive endoderm, the future pharynx and foregut lining, emerges from the anterior primitive streak and Hensen's node as a cell monolayer that replaces hypoblast during chick gastrulation. At early head process stages (4+ to 6; Hamburger and Hamilton) it lies beneath, lateral to and ahead of the ingressed axial mesoderm. Removal of the monolayer beneath and ahead of the node at stage 4 is followed by normal development, the removed cells being replaced by further ingressing cells from the node. However, similar removal during stages 4+ and 5 results in a permanent window denuded of definitive endoderm, beneath prechordal mesoderm and a variable sector of anterior notochord. The foregut tunnel then fails to form, heart development is confined to separated lateral regions, and the neural tube undergoes no ventral flexures at the normal positions in brain structure. Reduction in forebrain pattern is evident by the 12-somite stage, with most neuraxes lacking telencephalon and eyes, while forebrain expressions of the transcription factor genes GANF and BF1, and of FGF8, are absent or severely reduced. When the foregut endoderm removal is delayed until stage 6, later forebrain pattern appears once again complete, despite lack of foregut formation, of ventral flexure and of heart migration. Important gene expressions within axial mesoderm (chordin, Shh and BMP7) appear unaffected in all embryos, including those due to be pattern-deleted, during the hours following the operation when anterior brain pattern is believed to be determined. A specific system of neural anterior patterning signals, rather than an anterior sector of the initially neurally induced area, is lost following operation. Heterotopic lower layer replacement operations strongly suggest that these patterning signals are positionally specific to anteriormost presumptive foregut. The homeobox gene Hex and the chick Frizbee homologue Crescent are both expressed prominently within anterior definitive endoderm at the time when removal of this tissue results in forebrain defects, and the possible implications of this are discussed. The experiments also demonstrate how stomodeal ectoderm, the tissue that will, much later, form Rathke's pouch and the anterior pituitary, is independently specified by anteriormost lower layer signals at an early stage.


"If it ain't broke, don't fix it": a commentary on the positive-negative results of the ACCORD Lipid study.
Even using intensive statin monotherapy, many patients fail to achieve all the desired lipid goals and remain at high residual risk of cardiovascular events. In view of the still unproven decisively intensive "statin as monotherapy" strategy and "residual risk" concept, it is logical to ask whether other strategies, particularly fibrate/statin combination therapy, could be more beneficial and safer. A clear benefit of fibrate monotherapy did emerge previously among patients with atherogenic dyslipidemia (particularly high triglycerides and low high density lipoprotein cholesterol [HDL-C]) typically present in the metabolic syndrome and type 2 diabetes. In contrast, in patients without atherogenic dyslipidemia this favorable effect was not demonstrated. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study investigated whether combination therapy with a statin plus a fibrate, as compared with statin monotherapy, would reduce the risk of cardiovascular disease in patients with type 2 diabetes mellitus. However, relevant patients with atherogenic dyslipidemia represented less than 17 percent of the ACCORD Lipid population (941 out of 5518 patients). In this prespecified subgroup, the patients benefited from fenofibrate therapy in addition to simvastatin similar to the previous "fibrate's as monotherapy" trials: the primary outcome rate was 12.4% in the fenofibrate group, versus 17.3% in the placebo group (28% crude HR reduction, CI less than 1, e.g. statistically significant findings). Among all other 4548 patients without atherogenic dyslipidemia such rates were 10.1% in both fenofibrate and placebo study groups. Authors concluded that in the overall cohort of patients the combination of fenofibrate and simvastatin did not reduce the rate of the cardiovascular events as compared with simvastatin alone. Thus, their results do not support the routine use of combination therapy with fenofibrate and simvastatin to reduce cardiovascular risk in the general patients with type 2 diabetes. A recent large meta-analysis regarding effects of fibrates on cardiovascular outcomes noted greater effect sizes in trials that recorded a higher mean baseline triglyceride concentration (p = 0.030). As expected, in a so called "general population", reflecting a blend of effects in patients with and without atherogenic dyslipidemia, a mean "diluted" effect of fibrate therapy was reduced, but still producing a significant 10% relative risk (RR) decrease in major cardiovascular events (p = 0.048) and a 13% RR reduction for coronary events (p < 0.0001). It should be pinpointed that the epidemiological characteristics of the ACCORD Lipid study depart from those seen in real clinical practice: among people with type 2 diabetes, there is a high prevalence of atherogenic dyslipidemia and metabolic syndrome. For example, an analysis of NHANES III data in adults aged >or=50 years showed that approximately 86% of patients with type 2 diabetes also had the metabolic syndrome. Therefore, an important finding of ACCORD Lipid study was the observation that fibrates may lead to cardiovascular risk reduction in patients with atherogenic dyslipidemia not only as monotherapy but in combination with statins as well. In conclusion, in patients with atherogenic dyslipidemia (high triglycerides and low HDL-C, fibrates -- either as monotherapy or combined with statins - were associated with reduced risk of cardiovascular events. In patients without dyslipidemia this favorable effect - as expected - was absent.


Male rats develop more severe experimental autoimmune encephalomyelitis than female rats: sexual dimorphism and diergism at the spinal cord level.
Compared with females, male Dark Agouti (DA) rats immunized for experimental autoimmune encephalomyelitis (EAE) with rat spinal cord homogenate in complete Freund's adjuvant (CFA) exhibited lower incidence of the disease, but the maximal neurological deficit was greater in the animals that developed the disease. Consistently, at the peak of the disease greater number of reactivated CD4+CD134+CD45RC- T lymphocytes was retrieved from male rat spinal cord. Their microglia/macrophages were more activated and produced greater amount of prototypic proinflammatory cytokines in vitro. Additionally, oppositely to the expression of mRNAs for IL-12/p35, IL-10 and IL-27/p28, the expression of mRNA for IL-23/p19 was upregulated in male rat spinal cord mononuclear cells. Consequently, the IL-17+:IFN-γ+ cell ratio within T lymphocytes from their spinal cord was skewed towards IL-17+ cells. Within this subpopulation, the IL-17+IFN-γ+:IL-17+IL-10+ cell ratio was shifted towards IL-17+IFN-γ+ cells, which have prominent tissue damaging capacity. This was associated with an upregulated expression of mRNAs for IL-1β and IL-6, but downregulated TGF-β mRNA expression in male rat spinal cord mononuclear cells. The enhanced GM-CSF mRNA expression in these cells supported the greater pathogenicity of IL-17+ T lymphocytes infiltrating male spinal cord. In the inductive phase of the disease, contrary to the draining lymph node, in the spinal cord the frequency of CD134+ cells among CD4+ T lymphocytes and the frequency of IL-17+ cells among T lymphocytes were greater in male than in female rats. This most likely reflected an enhanced transmigration of mononuclear cells into the spinal cord (judging by the lesser spinal cord CXCL12 mRNA expression), the greater frequency of activated microglia/macrophages and the increased expression of mRNAs for Th17 polarizing cytokines in male rat spinal cord mononuclear cells. Collectively, the results showed cellular and molecular mechanisms underlying the target organ specific sexual dimorphism in the T lymphocyte-dependent immune/inflammatory response, and suggested a substantial role for the target organ in shaping the sexually dimorphic clinical outcome of EAE.


Glutamate dehydrogenase: a reliable marker of liver cell necrosis in the alcoholic.
The usefulness of blood enzyme determinations as markers of liver necrosis was tested in 100 alcoholics who underwent biopsy during clinical investigation. Mean values of glutamate dehydrogenase (GDH), serum aspartate and alanine transferase (SGOT and SGPT), ornithine carbamoyltransferase (OCT), and gamma-glutamyltranspeptidase (gamma-GTP) tended to rise with increasing liver cell necrosis, though values of SGOT, SGPT, OCT, and gamma-GTP showed considerable overlap between the 32 patients with histologically proved hepatitis and the 68 without. By contrast, GDH values showed virtually no overlap between patients with and without hepatitis, and a value of two and a half times the normal value discriminated between the two groups. Because of its easy determination and its reliable reflection of liver cell necrosis the GDH concentration should be estimated routinely in alcoholic patients.


Health status of children with moderate to severe cerebral palsy.
The aim of the study was to evaluate the health of children with cerebral palsy (CP) using a global assessment of quality of life, condition-specific measures, and assessments of health care use. A multicenter population-based cross-sectional survey of 235 children, aged 2 to 18 years, with moderate to severe impairment, was carried out using Gross Motor Function Classification System (GMFCS) levels III (n = 56), IV (n = 55), and V (n = 122). This study group scored significantly below the mean on the Child Health Questionnaire (CHQ) for Pain, General Health, Physical Functioning, and Impact on Parents. These children used more medications than children without CP from a national sample. Fifty-nine children used feeding tubes. Children in GMFCS level V who used a feeding tube had the lowest estimate of mental age, required the most health care resources, used the most medications, had the most respiratory problems, and had the lowest Global Health scores. Children with the most severe motor disability who have feeding tubes are an especially frail group who require numerous health-related resources and treatments. Also, there is a relationship among measures of health status such as the CHQ, functional abilities, use of resources, and mental age, but each appears to measure different aspects of health and well-being and should be used in combination to reflect children's overall health status.


Physical activity as a treatment for depression: the TREAD randomised trial protocol.
Depression is one of the most common reasons for consulting a General Practitioner (GP) within the UK. Whilst antidepressants have been shown to be clinically effective, many patients and healthcare professionals would like to access other forms of treatment as an alternative or adjunct to drug therapy for depression. A recent systematic review presented some evidence that physical activity could offer one such option, although further investigation is needed to test its effectiveness within the context of the National Health Service.The aim of this paper is to describe the protocol for a randomised, controlled trial (RCT) designed to evaluate an intervention developed to increase physical activity as a treatment for depression within primary care. The TREAD study is a pragmatic, multi-centre, two-arm RCT which targets patients presenting with a new episode of depression. Patients were approached if they were aged 18-69, had recently consulted their GP for depression and, where appropriate, had been taking antidepressants for less than one month. Only those patients with a confirmed diagnosis of a depressive episode as assessed by the Clinical Interview Schedule-Revised (CIS-R), a Beck Depression Inventory (BDI) score of at least 14 and informed written consent were included in the study. Eligible patients were individually randomised to one of two treatment groups; usual GP care or usual GP care plus facilitated physical activity. The primary outcome of the trial is clinical symptoms of depression assessed using the BDI four months after randomisation. A number of secondary outcomes are also measured at the 4-, 8- and 12-month follow-up points including quality of life, attitude to and involvement in physical activity and antidepressant use/adherence. Outcomes will be analysed on an intention-to-treat (ITT) basis and will use linear and logistic regression models to compare treatments. The results of the trial will provide information about the effectiveness of physical activity as a treatment for depression. Given the current prevalence of depression and its associated economic burden, it is hoped that TREAD will provide a timely contribution to the evidence on treatment options for patients, clinicians and policy-makers. ISRCTN 16900744.


Symptoms of common mental disorders among professional football referees: a one-season prospective study across Europe.
The primary aim of this study was to determine the prevalence and one-season incidence of symptoms of common mental disorders (CMD; distress, anxiety/depression, sleep disturbance, eating disorders, adverse alcohol use) among European professional football referees. A secondary aim was to explore the view of European professional football referees on consequences, support and needs related to these symptoms. An observational prospective cohort study with three measurements over a follow-up period of one season (2015-2016) was conducted among central or assistant professional football referees from Belgium, Finland, France, Germany, Norway, Russia, Scotland and Sweden. Using validated questionnaires to assess symptoms of CMD (self-reported and not clinically diagnosed), an electronic questionnaire in English and French was set up and distributed by the eight football federations involved. A total of 391 referees (mean age of 33 years old; mean career duration of 7 years) were enrolled, of which 292 completed the follow-up period. Baseline 4-week prevalence rates were 6% for distress, 12% for anxiety/depression, 9% for sleep disturbance, 19% for eating disorders and 17% for adverse alcohol use. The one-season incidence of symptoms of CMD was 10% for distress, 16% for anxiety/depression, 14% for sleep disturbance, 29% for eating disorders and 8% for adverse alcohol use. While symptoms of CMD occur among professional football referees and can influence negatively refereeing performances, the development of specific support measures for referees are needed in order to manage properly these symptoms of CMD.


Templates for rejection can specify semantic properties of nontargets in natural scenes.
In contrast to standard search templates that specify a target object's expected features, templates for rejection (TFR) may specify features of nontargets, biasing attention away from irrelevant objects. Little is known about TFR, and virtually nothing is known about their role in guiding search across natural scenes. In such scenes, targets and nontargets may not be easily distinguished on the basis of their visual features; it has been claimed that standard search templates may therefore specify target objects' semantic features to guide attention. Here, we ask whether TFR can do so. Noting a limitation of previous procedures used to study standard search templates, we trialed an alternative method to examine semantic templates for nontarget exclusion in natural scene search. We found that when nontargets belonged unpredictably to either of two physically distinct categories, search was less efficient than when targets belonged to one known category. This two-category cost, attributed to inefficient application of search templates, was absent for two physically dissimilar but semantically related categories. Adding a training phase to highlight semantic distinctiveness of two object categories reinstated the two-category cost, precluding stimulus-based accounts of the effect. These patterns were not observed for one-image displays or when observers searched for object categories rather than ignoring them, demonstrating their specificity to TFR, the inadequacy of search-and-destroy models to account for them, and likely basis in attentional guidance. TFR can specify semantic information to guide attention away from nontargets.


Reliability and Agreement of the 10-Repetition Maximum Test in Breast Cancer Survivors.
The aim of this study was to evaluate the reliability and agreement between the test and retest of the 10-repetition maximum (10-RM) test for leg press and bench press in breast cancer survivors (BCS). Thirty-one BCS participated in this study, age 54.87 ± 5.7 years. All performed 10-RM tests and retests for the leg press 45° and the bench press. For reliability analyses, an intraclass coefficient correlation (ICC) and coefficient of variation (CV) were performed. The limits of agreement were calculated using a Bland-Altman plot with 95% CIs. For absolute and relative error of measurement, we used standard error of measurement and minimally detectable change. The result showed a high reliability for the bench press and leg press; ICC of 0.94 and 0.98, respectively. CV was <10% for both exercises. The systematic error were 1.5 kg (10%) and 6.1 (8%) for the bench press and leg press, respectively. The standard errors of measurements were 0.96 kg (6.08%) and 4.11 kg (5.27%) for the bench press and leg press, respectively. The minimally detectable changes were 2.72 kg (17.20%) and 5.62 kg (7.21%) for the bench press and leg press, respectively. In breast cancer survivors, the muscular strength measurement for the 10-RM test showed a high to very high rate of reliability and agreement, with acceptable error of measurement.


Global transcriptome analysis of the scorpion Centruroides noxius: new toxin families and evolutionary insights from an ancestral scorpion species.
Scorpion venoms have been studied for decades, leading to the identification of hundreds of different toxins with medical and pharmacological implications. However, little emphasis has been given to the description of these arthropods from cellular and evolutionary perspectives. In this report, we describe a transcriptomic analysis of the Mexican scorpion Centruroides noxius Hoffmann, performed with a pyrosequencing platform. Three independent sequencing experiments were carried out, each including three different cDNA libraries constructed from RNA extracted from the whole body of the scorpion after telson removal, and from the venom gland before and after venom extraction. Over three million reads were obtained and assembled in almost 19000 isogroups. Within the telson-specific sequences, 72 isogroups (0.4% of total unique transcripts) were found to be similar to toxins previously reported in other scorpion species, spiders and sea anemones. The annotation pipeline also revealed the presence of important elements of the small non-coding RNA processing machinery, as well as microRNA candidates. A phylogenomic analysis of concatenated essential genes evidenced differential evolution rates in this species, particularly in ribosomal proteins and proteasome components. Additionally, statistical comparison of transcript abundance before and after venom extraction showed that 3% and 2% of the assembled isogroups had higher expression levels in the active and replenishing gland, respectively. Thus, our sequencing and annotation strategies provide a general view of the cellular and molecular processes that take place in these arthropods, allowed the discovery of new pharmacological and biotechnological targets and uncovered several regulatory and metabolic responses behind the assembly of the scorpion venom. The results obtained in this report represent the first high-throughput study that thoroughly describes the universe of genes that are expressed in the scorpion Centruroides noxius Hoffmann, a highly relevant organism from medical and evolutionary perspectives.


Optimized aeration by carbon dioxide gas for microalgal production and mass transfer characterization in a vertical flat-plate photobioreactor.
To optimize the aeration conditions for microalgal biomass production in a vertical flat-plate photobioreactor (VFPP), the effect of the aeration rate on biomass productivity was investigated under given conditions. Air enriched with 5% or 10% (v/v) CO(2) was supplied for the investigation at rates of 0.025-1 vvm. The CO(2) utilization efficiency, change of pH in the medium, and the optimum aeration rate were determined by evaluating biomass productivity. To investigate the VFPP mass transfer characteristics, the overall volumetric mass transfer coefficient, k(L)a, was evaluated for several different flat-plate sizes. Increasing the height of the VFPP could improve both the mass transfer of CO(2) and the illumination conditions, so this appeared to be a good method for scaling up. Based on a comparison of the k(L)a value at the optimum aeration rate with previously reported results, it was confirmed that the range of CO(2) concentration used in the experiments was cost-effective for mass culture.


Inhibition of autophagy as a therapeutic strategy of iron-induced brain injury after hemorrhage.
Premenopausal women have better survival than men after intracerebral hemorrhage, which is associated with iron overproduction and autophagy induction. To examine the participation of neuronal autophagy and estrogen receptor α (ERα) in the E 2-mediated protection, PC12 neurons treated with Atg7 (autophagy-related protein 7) siRNA, rapamycin (an autophagy inducer), or Erα siRNA were applied. To study whether autophagy involves in β-estradiol 3-benzoate (E 2)-mediated neuroprotection against iron-induced striatal injury, castration and E 2 capsule implantation were performed at 2 weeks and 24 h, respectively, before ferrous citrate (FC) infusion into the caudate nucleus (CN) of Sprague Dawley male and female rats. Furthermore, the role of neuronal autophagy in the sex difference of FC-induced CN injury was confirmed by using conditional knockout Atg7 in dopamine receptor 2 (DRD2)-containing neurons in mice. The results showed that the suppression of FC-induced autophagy by E 2 was abolished by Erα siRNA preincubation. Atg7 silencing simulates and rapamycin diminishes E 2-mediated neuroprotection against FC-induced neurotoxicity. In vivo, FC induced a lower degree of autophagy, autophagic cell death, injury severity, histological lesion and behavioral deficit in female rats than in males. E 2 implantation decreased the levels of both FC-induced autophagy and injury in ovariectomized rats. Moreover, the sex difference of FC-induced CN injury was diminished in Atg7 knockout mice. Thus, suppression of autophagy by E 2 via ERα contributes to less severity of iron-induced brain injury in females than in male. This finding opens up the prospect for a therapeutic strategy targeting autophagic inhibition for patients suffering from intracerebral iron overload.


Challenges in the Discovery of Indoleamine 2,3-Dioxygenase 1 (IDO1) Inhibitors.
Since the discovery of indoleamine 2,3-dioxygenase 1 (IDO1) as an attractive target for anticancer therapy in 2003, the search for inhibitors has been intensely pursued both in academia and in pharmaceutical companies. Many novel IDO1 inhibitor scaffolds have been described, and a few potent compounds have entered clinical trials. However, a significant number of the reported compounds contain problematic functional groups, suggesting that enzyme inhibition could be the result of undesirable side reactions instead of selective binding to IDO1. Here, we describe issues in the employed experimental protocols, review and classify reported IDO1 inhibitors, and suggest different approaches for confirming viable inhibitor scaffolds.


N-cyclobutylmethyl analog of normorphinone, N-CBM-TAMO: a short-term opioid agonist and long-term Mu-selective irreversible opioid antagonist.
The antinociceptive and opioid binding properties of the N-cyclobutylmethyl analog of normorphinone, 14 alpha, 14' beta-[dithiobis[(2-oxo-2, 1-ethanediyl)imino]]bis[7,8-dihydro-N-(cyclobutylmethyl)-normor phinone] (N-CBM-TAMO) were investigated. This compound is a dimer, containing a disulfide capable of binding to thiol groups on the opioid receptor. Competition radioligand binding assays with bovine striatal membranes demonstrated that N-CBM-TAMO displayed a higher affinity for mu opioid receptors than for kappa and delta receptors. Incubation of membranes with N-CBM-TAMO resulted in wash-resistant inhibition of the binding of the mu-selective peptide [3H][D-Ala2,(Me)Phe4, Gly(ol)5]-enkephalin, the kappa-selective opioid [3H]U69,593 ((trans)-3, 4-dichloro-N-methyl-N-[2-(1-pyrrolidinyl)-cyclohexyl]benzenacetamide+ ++ methanesulfonate hydrate)) and, to a lesser extent, the delta-selective peptide [D-Pen2, p-Cl-phenylalanine4, D-Pen5]enkephalin. Scatchard analysis of saturation binding data showed that N-CBM-TAMO decreased the Bmax value without affecting the Kd value for [3H][D-Ala2,(Me)Phe4, Gly(ol)5]enkephalin binding, whereas, N-CBM-TAMO increased the Kd value without altering the Bmax value for [3H]U69,593, which suggests that N-CBM-TAMO interacted covalently with the mu but not the kappa receptor. In the mouse 55 degrees C warm-water tail-flick test, N-CBM-TAMO given supraspinally acted as an agonist with low efficacy because only submaximal antinociception was observed at doses up to 100 nmol. The antinociception induced by N-CBM-TAMO in the tail-flick test was partially blocked by both the mu-selective antagonist beta-funaltrexamine and the kappa-selective antagonist nor-binaltorphimine. In the mouse acetic acid writhing test, N-CBM-TAMO acted as a full agonist with a D50 value of 0.08 (0.04-0.14) nmol, and the antinociception was blocked by coadministration of the kappa-selective antagonist nor-binaltorphimine. Pretreatment of mice with an i.c.v. dose of N-CBM-TAMO of 10 nmol, a dose that exhibited modest short-term antinociception in the tail-flick test, produced a time- and dose-dependent long-term antagonism of morphine-induced antinociception in an irreversible manner in this assay. Pretreatment of mice with i.c.v. N-CBM-TAMO at doses of 3 nmol and higher, which produced supermaximal short-term antinociception in the writhing test, produced a time- and dose-dependent long-term antagonism of U50,488 (trans)-3, 4-dichloro-N-methyl-N-[2-(1-pyrrolidinyl)-cyclohexyl]benzeneacetamide methanesulfonate hydrate)-induced antinociception in a reversible manner, probably because of the development of tolerance. These in vivo data, together with the in vitro binding data, demonstrate that N-CBM-TAMO is a potent kappa agonist and at higher doses produces antinociception mediated by mu receptors. N-CBM-TAMO also produces long-term noncompetitive antagonism of antinociception mediated by mu opioid receptors.


HIV-exposed uninfected children: a growing population with a vulnerable immune system?
Through the successful implementation of policies to prevent mother-to-child-transmission (PMTCT) of HIV-1 infection, children born to HIV-1-infected mothers are now much less likely to acquire HIV-1 infection than previously. Nevertheless, HIV-1-exposed uninfected (HEU) children have substantially increased morbidity and mortality compared with children born to uninfected mothers (unexposed uninfected, UU), predominantly from infectious causes. Moreover, a range of phenotypical and functional immunological differences between HEU and UU children has been reported. As the number of HEU children continues to increase worldwide, two questions with clear public health importance need to be addressed: first, does exposure to HIV-1 and/or ART in utero or during infancy have direct immunological consequences, or are these poor outcomes simply attributable to the obvious disadvantages of being born into an HIV-affected household? Secondly, can we expect improved maternal care and ART regimens during and after pregnancy, together with optimized infant immunization schedules, to reduce the excess morbidity and mortality of HEU children?


Informed consent comprehension in African research settings.
Previous reviews on participants' comprehension of informed consent information have focused on developed countries. Experience has shown that ethical standards developed on Western values may not be appropriate for African settings where research concepts are unfamiliar. We undertook this review to describe how informed consent comprehension is defined and measured in African research settings. We conducted a comprehensive search involving five electronic databases: Medline, Embase, Global Health, EthxWeb and Bioethics Literature Database (BELIT). We also examined African Index Medicus and Google Scholar for relevant publications on informed consent comprehension in clinical studies conducted in sub-Saharan Africa. 29 studies satisfied the inclusion criteria; meta-analysis was possible in 21 studies. We further conducted a direct comparison of participants' comprehension on domains of informed consent in all eligible studies. Comprehension of key concepts of informed consent varies considerably from country to country and depends on the nature and complexity of the study. Meta-analysis showed that 47% of a total of 1633 participants across four studies demonstrated comprehension about randomisation (95% CI 13.9-80.9%). Similarly, 48% of 3946 participants in six studies had understanding about placebo (95% CI 19.0-77.5%), while only 30% of 753 participants in five studies understood the concept of therapeutic misconception (95% CI 4.6-66.7%). Measurement tools for informed consent comprehension were developed with little or no validation. Assessment of comprehension was carried out at variable times after disclosure of study information. No uniform definition of informed consent comprehension exists to form the basis for development of an appropriate tool to measure comprehension in African participants. Comprehension of key concepts of informed consent is poor among study participants across Africa. There is a vital need to develop a uniform definition for informed consent comprehension in low literacy research settings in Africa. This will be an essential step towards developing appropriate tools that can adequately measure informed consent comprehension. This may consequently suggest adequate measures to improve the informed consent procedure.


Race and end-stage renal disease. Socioeconomic status and access to health care as mediating factors.
To examine whether lower socioeconomic status and limited access to health care explain the racial inequities in the incidence of end-stage renal disease (ESRD), and whether these factors are independently associated with ESRD. This case-control study compared 716 patients with ESRD with 361 population controls of the same age, 20 to 64 years old, from Maryland, Virginia, West Virginia, and Washington, DC. Race, indicators of socioeconomic status (household annual income, years of education), and indicators of access to health care (health insurance status, number of missing teeth, usual source of care, use of preventive services) were assessed via a telephone interview. Independent risk factors for ESRD included non-white race (odds ratio for blacks, 5.5; 95% confidence interval, 3.8 to 8.0; odds ratio for other nonwhites, 3.5; 95% confidence interval, 1.2 to 10.0), categories of income (odds ratio gradient, 1.0 to 4.5; 95% confidence interval, 2.6 to 7.8), receipt of Medicaid benefits (odds ratio, 3.5; 95% confidence interval, 1.5 to 8.4), and number of missing teeth (odds ratio gradient, 1.0 to 2.2; 95% confidence interval, 1.2 to 4.1). Adjustment for socioeconomic variables reduced the odds ratio for blacks only partially, from 8.1 to 5.5. The proportions of ESRD incidence that could be attributed to each risk factor were 46% for minority race, 53% for income categories, and 33% for missing teeth. Low socioeconomic status and limited access to health care were strong risk factors for kidney failure, but they explained only part of the excess of ESRD in blacks. Racial and social factors account for a large part of ESRD incidence. The mechanisms of these associations should be targeted by further research.


Go with Your Gut: Emotion and Evaluation in Job Interviews.
This article presents hiring as an emotional process rooted in interpersonal evaluation. Drawing from Randall Collins's theory of interaction ritual, the author offers a qualitative case study of elite professional service firms to unpack how employers' emotional reactions to applicants in job interviews affect hiring evaluations. She finds that employers use subjective feelings of excitement and enthusiasm toward candidates-akin to Collins's concept of emotional energy--to-evaluate applicants and make hiring decisions. With these data, she constructs an original theoretical framework of emotional energy development, which highlights the qualities that tend to produce or inhibit the subjective experience of emotional energy in job interviews. Additionally, she outlines the particular phases of an encounter where energy gains and losses are most consequential for influencing hiring outcomes and inequalities. She discusses the implications of these findings for research on hiring, labor market stratification, and interaction rituals.


Management of epilepsy in pregnancy: a report from the International League Against Epilepsy Task Force on Women and Pregnancy.
The risks associated with use of antiepileptic drugs during pregnancy are a major concern for all women with epilepsy with childbearing potential. These risks have to be balanced against foetal and maternal risks associated with uncontrolled seizures. This report from the International League Against Epilepsy Task Force on Women and Pregnancy aims to provide a summary of relevant data on these risks as a basis for expert opinion recommendations for the management of epilepsy in pregnancy. The report reviews data on maternal and foetal risks associated with seizures as well as teratogenic risks associated with antiepileptic drug exposure, including effects on intrauterine growth, major congenital malformations, and developmental and behavioural outcomes. The impact of pregnancy on seizure control and on the pharmacokinetics of antiepileptic drugs are also discussed. This information is used to discuss how treatment may be optimized before conception and further managed during pregnancy.


Complex wavelets for extended depth-of-field: a new method for the fusion of multichannel microscopy images.
Microscopy imaging often suffers from limited depth-of-field. However, the specimen can be "optically sectioned" by moving the object along the optical axis. Then different areas appear in focus in different images. Extended depth-of-field is a fusion algorithm that combines those images into one single sharp composite. One promising method is based on the wavelet transform. Here, we show how the wavelet-based image fusion technique can be improved and easily extended to multichannel data. First, we propose the use of complex-valued wavelet bases, which seem to outperform traditional real-valued wavelet transforms. Second, we introduce a way to apply this technique for multichannel images that suppresses artifacts and does not introduce false colors, an important requirement for multichannel optical microscopy imaging. We evaluate our method on simulated image stacks and give results relevant to biological imaging.


Clinical EFT (Emotional Freedom Techniques) Improves Multiple Physiological Markers of Health.
Emotional Freedom Technique (EFT) is an evidence-based self-help therapeutic method and over 100 studies demonstrate its efficacy. However, information about the physiological effects of EFT is limited. The current study sought to elucidate EFTs mechanisms of action across the central nervous system (CNS) by measuring heart rate variability (HRV) and heart coherence (HC); the circulatory system using resting heart rate (RHR) and blood pressure (BP); the endocrine system using cortisol, and the immune system using salivary immunoglobulin A (SigA). The second aim was to measure psychological symptoms. Participants (N = 203) were enrolled in a 4-day training workshop held in different locations. At one workshop (n = 31), participants also received comprehensive physiological testing. Posttest, significant declines were found in anxiety (-40%), depression (-35%), posttraumatic stress disorder (-32%), pain (-57%), and cravings (-74%), all P < .000. Happiness increased (+31%, P = .000) as did SigA (+113%, P = .017). Significant improvements were found in RHR (-8%, P = .001), cortisol (-37%, P < .000), systolic BP (-6%, P = .001), and diastolic BP (-8%, P < .000). Positive trends were observed for HRV and HC and gains were maintained on follow-up, indicating EFT results in positive health effects as well as increased mental well-being.


Lymphocyte migration into collagen gels: role of lymph.
In the present investigation we found that the presence of lymph within a 3-D collagen gel potentiates the invasion of mature recirculating lymphocytes into the gel. Preferential accumulation of lymphocytes in lymph-containing gels follows the same rules that apply for both in vitro lymphocyte adhesion to high endothelial venules of frozen sections of the lymph nodes and in vivo lymph node entry of lymphocytes. Furthermore, the results obtained suggest that lymph is chemotactic for lymphocytes. This chemoattractant activity of lymph could be assigned mainly to a protein fraction precipitating in the range of 40-60% concentration of ammonium sulphate. The biological significance of these findings for the selective process of lymphocyte emigration from blood to lymph, across the parenchyma of the nodes, is discussed.


Bioinformatic analysis of the distribution of inorganic carbon transporters and prospective targets for bioengineering to increase Ci uptake by cyanobacteria.
Cyanobacteria have evolved a carbon-concentrating mechanism (CCM) which has enabled them to inhabit diverse environments encompassing a range of inorganic carbon (Ci: [Formula: see text] and CO2) concentrations. Several uptake systems facilitate inorganic carbon accumulation in the cell, which can in turn be fixed by ribulose 1,5-bisphosphate carboxylase/oxygenase. Here we survey the distribution of genes encoding known Ci uptake systems in cyanobacterial genomes and, using a pfam- and gene context-based approach, identify in the marine (alpha) cyanobacteria a heretofore unrecognized number of putative counterparts to the well-known Ci transporters of beta cyanobacteria. In addition, our analysis shows that there is a huge repertoire of transport systems in cyanobacteria of unknown function, many with homology to characterized Ci transporters. These can be viewed as prospective targets for conversion into ancillary Ci transporters through bioengineering. Increasing intracellular Ci concentration coupled with efforts to increase carbon fixation will be beneficial for the downstream conversion of fixed carbon into value-added products including biofuels. In addition to CCM transporter homologs, we also survey the occurrence of rhodopsin homologs in cyanobacteria, including bacteriorhodopsin, a class of retinal-binding, light-activated proton pumps. Because they are light driven and because of the apparent ease of altering their ion selectivity, we use this as an example of re-purposing an endogenous transporter for the augmentation of Ci uptake by cyanobacteria and potentially chloroplasts.


Long-term treatment with rituximab in severe juvenile idiopathic arthritis-associated uveitis.
To evaluate retrospectively the long-term efficacy of rituximab in patients with severe juvenile idiopathic arthritis (JIA)-associated uveitis. Eight patients (15 eyes) with severe and longstanding JIA uveitis, who had an inadequate response in controlling uveitis to one or more biologic agents including tumour necrosis factor blockers and abatacept, received rituximab therapy. Rituximab was given at a dose of 1000 mg per infusion on days 1 and 15 and then every 6 months. Clinical responses to treatment, including decrease in uveitis activity, visual acuity changes, reduction of concomitant local and systemic corticosteroid and/or immunosuppressants, and occurrence of adverse events, were assessed. Eight patients with a mean±SD age of 22.8±5.5 years were treated. The mean ocular disease duration was 17.7 years; the mean±SD follow-up time on rituximab was 44.75±4.9 months; and the mean number of rituximab infusions received was 8.75 (range 6-12). All patients achieved complete control of uveitis, but in two patients rituximab was discontinued due to inefficacy in treating arthritis. The decrease in uveitis activity was evident 4-5 months after the first infusion. Systemic corticosteroids and immunosuppressants used in association with rituximab were discontinued in five patients at the end of follow-up. None of the patients experienced visual worsening during the follow-up. No drug-related complications were encountered. Rituximab may be a promising effective treatment option for refractory uveitis associated with JIA leading to long-term quiescence of uveitis, particularly for patients who have not previously responded to other biologic therapies.


B-type natriuretic peptide and C-reactive protein in the prediction of atrial fibrillation risk: the CHARGE-AF Consortium of community-based cohort studies.
B-type natriuretic peptide (BNP) and C-reactive protein (CRP) predict atrial fibrillation (AF) risk. However, their risk stratification abilities in the broad community remain uncertain. We sought to improve risk stratification for AF using biomarker information. We ascertained AF incidence in 18 556 Whites and African Americans from the Atherosclerosis Risk in Communities Study (ARIC, n=10 675), Cardiovascular Health Study (CHS, n = 5043), and Framingham Heart Study (FHS, n = 2838), followed for 5 years (prediction horizon). We added BNP (ARIC/CHS: N-terminal pro-B-type natriuretic peptide; FHS: BNP), CRP, or both to a previously reported AF risk score, and assessed model calibration and predictive ability [C-statistic, integrated discrimination improvement (IDI), and net reclassification improvement (NRI)]. We replicated models in two independent European cohorts: Age, Gene/Environment Susceptibility Reykjavik Study (AGES), n = 4467; Rotterdam Study (RS), n = 3203. B-type natriuretic peptide and CRP were significantly associated with AF incidence (n = 1186): hazard ratio per 1-SD ln-transformed biomarker 1.66 [95% confidence interval (CI), 1.56-1.76], P < 0.0001 and 1.18 (95% CI, 1.11-1.25), P < 0.0001, respectively. Model calibration was sufficient (BNP, χ(2) = 17.0; CRP, χ(2) = 10.5; BNP and CRP, χ(2) = 13.1). B-type natriuretic peptide improved the C-statistic from 0.765 to 0.790, yielded an IDI of 0.027 (95% CI, 0.022-0.032), a relative IDI of 41.5%, and a continuous NRI of 0.389 (95% CI, 0.322-0.455). The predictive ability of CRP was limited (C-statistic increment 0.003). B-type natriuretic peptide consistently improved prediction in AGES and RS. B-type natriuretic peptide, not CRP, substantially improved AF risk prediction beyond clinical factors in an independently replicated, heterogeneous population. B-type natriuretic peptide may serve as a benchmark to evaluate novel putative AF risk biomarkers.


Autophagy in heart disease: a strong hypothesis for an untouched metabolic reserve.
Autophagy is a conserved catabolic process for long-lived proteins and organelles and is primarily responsible for nonspecific degradation of redundant or faulty cell components. Although autophagy has been described as the cell's major adaptive strategy in response to metabolic challenges, its influence on the cell's energy profile is poorly understood. In the myocardium, autophagy is active at basal levels and is crucial for maintaining its contractile function. Defects in the autophagic machinery cause cardiac dysfunction and heart failure. In this paper we propose that (1) autophagy contributes significantly to the metabolic balance sheet of the heart. (2) Increased autophagy contributes to an improved myocardial energy profile through changing the cardiac substrate preference. (3) Substrates generated through autophagy give rise to an alternative for ATP production with an oxygen-sparing effect. These elements identify autophagy in a new context of myocardial metabolic interregulation, which we discuss in the settings of myocardial infarction, heart failure and the diabetic heart. It is hoped that the hypothesis presented can lead to new insights aimed at exploiting autophagy to improve existing metabolic-based therapy in heart disease.


Uniocular miotic therapy.
The beneficial and harmful effects of 2% pilocarpine and 0.125% echothiophate iodide were evaluated on the prospective study of uniocular miotic therapy using the fellow eye as a control. Thirty primary open-angle glaucoma patients were treated with pilocarpine alone over a median time of 55 months. Twenty-nine similar patients were treated initially with echothiophate iodide and subsequently with pilocarpine over a median time of 54 months. Pilocarpine is cataractogenic but the changes are less marked and require more time than those induced by echothiophate iodide. In the combined group of 118 eves of 59 patients there were 11 optic disc changes and dix glaucomatous field defects. There was no difference in incidence between the treated and control eyes. The results suggest that one should be conservative in prescribing miotics, including pilocarpine alone, for patients suspected of having glaucoma.


A Dual Role for P2X7 Receptor during Porphyromonas gingivalis Infection.
Emerging evidence suggests a role for purinergic signaling in the activation of multiprotein intracellular complexes called inflammasomes, which control the release of potent inflammatory cytokines, such as interleukin (IL) -1β and -18. Porphyromonas gingivalis is intimately associated with periodontitis and is currently considered one of the pathogens that can subvert the immune system by limiting the activation of the NLRP3 inflammasome. We recently showed that P. gingivalis can dampen eATP-induced IL-1β secretion by means of its fimbriae in a purinergic P2X7 receptor-dependent manner. Here, we further explore the role of this purinergic receptor during eATP-induced IL-1β processing and secretion by P. gingivalis-infected macrophages. We found that NLRP3 was necessary for eATP-induced IL-1β secretion as well as for caspase 1 activation irrespective of P. gingivalis fimbriae. Additionally, although the secretion of IL-1β from P. gingivalis-infected macrophages was dependent on NLRP3, its adaptor protein ASC, or caspase 1, the cleavage of intracellular pro-IL-1β to the mature form was found to occur independently of NLRP3, its adaptor protein ASC, or caspase 1. Our in vitro findings revealed that P2X7 receptor has a dual role, being critical not only for eATP-induced IL-1β secretion but also for intracellular pro-IL-1β processing. These results were relevant in vivo since P2X7 receptor expression was upregulated in a P. gingivalis oral infection model, and reduced IFN-γ and IL-17 were detected in draining lymph node cells from P2rx7(-/-) mice. Furthermore, we demonstrated that P2X7 receptor and NLRP3 transcription were modulated in human chronic periodontitis. Overall, we conclude that the P2X7 receptor has a role in periodontal immunopathogenesis and suggest that targeting of the P2X7/NLRP3 pathway should be considered in future therapeutic interventions in periodontitis.


Purification of human cytotrophoblast from term amniochorion by flow cytometry.
Term cytotrophoblast do not express polymorphic MHC Class I antigens, unlike other fetal and maternal cells in the amniochorion/decidua. This allows cytotrophoblast to be isolated and purified from this tissue, utilizing 4E, a monoclonal antibody specific for HLA-B, which labels only non-trophoblast. We have developed a method using enzymic dispersion and Percoll gradient centrifugation, followed by flow cytometry, that yields, on average, a total of 5 X 10(6) term extravillous cytotrophoblast, 97 per cent pure. The availability of highly purified extravillous cytotrophoblast, for the first time, permits precise investigation of trophoblast function.


Impaired autophagosome clearance contributes to cardiomyocyte death in ischemia/reperfusion injury.
In myocardial ischemia, induction of autophagy via the AMP-induced protein kinase pathway is protective, whereas reperfusion stimulates autophagy with BECLIN-1 upregulation and is implicated in causing cell death. We examined flux through the macroautophagy pathway as a determinant of the discrepant outcomes in cardiomyocyte cell death in this setting. Reversible left anterior descending coronary artery ligation was performed in mice with cardiomyocyte-restricted expression of green fluorescent protein-tagged microtubule-associated protein light chain-3 to induce ischemia (120 minutes) or ischemia/reperfusion (30-90 minutes) with saline or chloroquine pretreatment (n=4 per group). Autophagosome clearance, assessed as the ratio of punctate light chain-3 abundance in saline to chloroquine-treated samples, was markedly impaired with ischemia/reperfusion compared with sham controls. Reoxygenation increased cell death in neonatal rat cardiomyocytes compared with hypoxia alone, markedly increased autophagosomes but not autolysosomes (assessed as punctate dual fluorescent mCherry-green fluorescent protein tandem-tagged light chain-3 expression), and impaired clearance of polyglutamine aggregates, indicating impaired autophagic flux. The resultant autophagosome accumulation was associated with increased reactive oxygen species and mitochondrial permeabilization, leading to cell death, which was attenuated by cyclosporine A pretreatment. Hypoxia-reoxygenation injury was accompanied by reactive oxygen species-mediated BECLIN-1 upregulation and a reduction in lysosome-associated membrane protein-2, a critical determinant of autophagosome-lysosome fusion. Restoration of lysosome-associated membrane protein-2 levels synergizes with partial BECLIN-1 knockdown to restore autophagosome processing and to attenuate cell death after hypoxia-reoxygenation. Ischemia/reperfusion injury impairs autophagosome clearance mediated in part by reactive oxygen species-induced decline in lysosome-associated membrane protein-2 and upregulation of BECLIN-1, contributing to increased cardiomyocyte death.


Dose effect relationship between the number of normal progenitor muscle cells grafted in mdx mouse skeletal striated muscle and the number of dystrophin-positive fibres.
The transplantation of progenitor muscle cells in striated skeletal muscle of mdx mice, a model of dystrophin deficiency, is well known to induce the formation of mosaic fibres expressing dystrophin near the site of injection. We tried to determine if the number of injected cells is related to the number of dystrophin-positive fibres. The grafted cells provided by 5 day-old C57Bl10 mice are syngenic to mdx mice and were cultured to select undifferentiated progenitors. Dystrophin-positive fibres distinct to 'revertant' fibres were detectable 10 days following the graft of as few as 10(3) cells. The number of dystrophin-positive fibres increases logarithmically with the number of grafted cells. The data indicate that the number of dystrophin-positive fibres plateaus above 5x10(5)-10(6) grafted cells and that a greater number of progenitor cells is not required to obtain a better result.


Comparative pathology and pathogenesis of spontaneous and experimentally induced fibropapillomas of green turtles (Chelonia mydas).
Tumor biopsy samples from 25 Floridian and 15 Hawaiian green turtles (Chelonia mydas) with spontaneous green turtle fibropapillomatosis (GTFP) and from 27 captive-reared green turtles with experimentally induced GTFP were examined microscopically to differentiate the histologic features that result from GTFP pathogenesis and those that result from incidental factors that may vary according to geographic region. Common histologic features for spontaneous and experimentally induced tumors included fibroblast proliferation in the superficial dermis, epidermal acanthosis and hyperkeratosis, epidermal basal cell degeneration with dermal-epidermal cleft formation, spinous layer degeneration with intraepidermal vesicle and pustule formation, and ulceration. Visceral tumors, found in eight of 10 (80%) free-ranging turtles with cutaneous disease that were examined after death, had extensive interstitial fibrous proliferation. The presence of spirorchid trematode eggs and associated foreign body granulomas, common secondary findings within spontaneous tumors, varied by geographic location, and these findings were not observed in experimentally induced tumors. Eosinophilic intranuclear inclusions and intranuclear herpesvirus-associated antigen immunoreactivity were found in 18 of 38 (47%) experimentally induced cutaneous tumors and nine of 119 (7.5%) spontaneous tumors from Floridian but not Hawaiian turtles. The possible involvement of GTFP-associated herpesvirus in the pathogenesis of epidermal degenerative changes and GTFP pathogenesis is discussed.


Brag2 differentially regulates β1- and β3-integrin-dependent adhesion in endothelial cells and is involved in developmental and pathological angiogenesis.
β1-Integrins are essential for angiogenesis. The mechanisms regulating integrin function in endothelial cells (EC) and their contribution to angiogenesis remain elusive. Brag2 is a guanine nucleotide exchange factor for the small Arf-GTPases Arf5 and Arf6. The role of Brag2 in EC and angiogenesis and the underlying molecular mechanisms remain unclear. siRNA-mediated Brag2-silencing reduced EC angiogenic sprouting and migration. Brag2-siRNA transfection differentially affected α5β1- and αVβ3-integrin function: specifically, Brag2-silencing increased focal/fibrillar adhesions and adhesion on β1-integrin ligands (fibronectin and collagen), while reducing the adhesion on the αVβ3-integrin ligand, vitronectin. Consistent with these results, Brag2-silencing enhanced surface expression of α5β1-integrin, while reducing surface expression of αVβ3-integrin. Mechanistically, Brag2-mediated αVβ3-integrin-recycling and β1-integrin endocytosis and specifically of the active/matrix-bound α5β1-integrin present in fibrillar/focal adhesions (FA), suggesting that Brag2 contributes to the disassembly of FA via β1-integrin endocytosis. Arf5 and Arf6 are promoting downstream of Brag2 angiogenic sprouting, β1-integrin endocytosis and the regulation of FA. In vivo silencing of the Brag2-orthologues in zebrafish embryos using morpholinos perturbed vascular development. Furthermore, in vivo intravitreal injection of plasmids containing Brag2-shRNA reduced pathological ischemia-induced retinal and choroidal neovascularization. These data reveal that Brag2 is essential for developmental and pathological angiogenesis by promoting EC sprouting through regulation of adhesion by mediating β1-integrin internalization and link for the first time the process of β1-integrin endocytosis with angiogenesis.


Anxiety and panic fear in adults with asthma: prevalence in primary care.
Patients may find it difficult to distinguish between the symptoms of anxiety and those of asthma. Findings are equivocal on whether there is a specific link between anxiety and asthma. The aims of this study were to i) to identify the prevalence of anxiety, depression and panic fear in adults with asthma compared with that of the general population ii) to investigate whether there is a specific relationship between asthma and anxiety. An epidemiological survey of 872 adults with a diagnosis of asthma identified from six General Practices in Sheffield, England. Community postal survey using self-completion questionnaire. The response rate was 59%. People with asthma had higher mean Hospital Anxiety and Depression Scale (HADS) anxiety scores than UK norms with a higher proportion above the clinical cut-off. Mean HADS depression scores were significantly higher than UK norms and norms for a general population sample of people registered with the same practice. These effects were age-related with the relationship between asthma and psychological distress most marked over the age of 45. The prevalence of asthma-specific panic fear was 15.7%. A significant minority of people have high levels of panic fear (as measured by the Asthma Symptom Checklist) associated with asthma. However, in adults with asthma there is also high prevalence of both generalised anxiety and depression (as measured by the HADS), suggesting that the link of anxiety to asthma may be part of a broader relationship between psychological distress and chronic disease rather than a specific one.


Serial pediatric symptom checklist screening in children with prenatal drug exposure.
To examine screening results obtained by serial annual behavioral assessment of children with prenatal drug exposure. The Maternal Lifestyle Study enrolled children with prenatal cocaine exposure (PCE) at birth for longitudinal assessments of developmental, behavioral, and health outcomes. At 8, 9, 10, 11, and 12 years of age, caregivers rated participants on the Pediatric Symptom Checklist (PSC). Serial PSC results were compared with an established broad-based behavioral measure at 9, 11, and 13 years. PSC results were analyzed for 1081 children who had at least 2 annual screens during the 5-year time span. Most subjects (87%) had 4 or more annual screens rated by the same caregiver (80%). PSC scores (and Positive screens) over time were compared at different time points for those with and without PCE. Covariates, including demographic factors and exposures to certain other substances, were controlled. Children with PCE had significantly higher scores overall, with more Positive screens for behavior problems than children without PCE. Children with PCE had more externalizing behavior problems. Children exposed to tobacco prenatally and postnatally also showed higher PSC scores. Over time, PSC scores differed slightly from the 8-year scores, without clear directional trend. Earlier PSC results predicted later behavioral outcomes. Findings of increased total PSC scores and Positive PSC screens for behavioral concerns in this group of children with prenatal substance exposure support the growing body of evidence that additional attention to identification of mental health problems may be warranted in this high-risk group.


All-purpose finite element formulation for arbitrarily shaped crossed-gratings embedded in a multilayered stack.
We propose a novel formulation of the finite element method adapted to the calculation of the vector field diffracted by an arbitrarily shaped crossed-grating embedded in a multilayered stack and illuminated by an arbitrarily polarized plane wave under oblique incidence. A complete energy balance (transmitted and reflected diffraction efficiencies and losses) is deduced from field maps. The accuracy of the proposed formulation has been tested using classical cases computed with independent methods. Moreover, to illustrate the independence of our method with respect to the shape of the diffractive object, we present the global energy balance resulting from the diffraction of a plane wave by a lossy thin torus crossed-grating. Finally, computation time and convergence as a function of the mesh refinement are discussed. As far as integrated energy values are concerned, the presented method shows a remarkable convergence even for coarse meshes.


ProkSeq for complete analysis of RNA-Seq data from prokaryotes.
Since its introduction, RNA-Seq technology has been used extensively in studies of pathogenic bacteria to identify and quantify differences in gene expression across multiple samples from bacteria exposed to different conditions. With some exceptions, tools for studying gene expression, determination of differential gene expression, downstream pathway analysis and normalization of data collected in extreme biological conditions is still lacking. Here, we describe ProkSeq, a user-friendly, fully automated RNA-Seq data analysis pipeline designed for prokaryotes. ProkSeq provides a wide variety of options for analysing differential expression, normalizing expression data and visualizing data and results. ProkSeq is implemented in Python and is published under the MIT source license. The pipeline is available as a Docker container https://hub.docker.com/repository/docker/snandids/prokseq-v2.0, or can be used through Anaconda: https://anaconda.org/snandiDS/prokseq. The code is available on Github: https://github.com/snandiDS/prokseq and a detailed user documentation, including a manual and tutorial can be found at https://prokseqV20.readthedocs.io. Supplementary data are available at Bioinformatics online.


Factorial structure of the Pain Rehabilitation Expectations Scale: a preliminary study.
The aim of this study was to report the preliminary validation results for the Pain Rehabilitation Expectations Scale (PRES). The PRES is a clinical tool developed to measure the expectations about rehabilitation treatment and outcome for people with back pain. Fifty people with chronic back pain were recruited from 11 physiotherapy outpatient clinics in Hong Kong for this study. Multitrait scaling analysis indicated that the three subscales of the PRES (working alliance, proxy efficacy, and motivation/expectation) were internally consistent, with Cronbach's alpha reliability coefficients ranging from 0.93 to 0.96. Proxy efficacy was found to be related to working alliance, and working alliance was positively related to client motivation and expectations. The preliminary psychometric analysis results suggested that the PRES could potentially be used to measure chronic pain patients' expectations about pain rehabilitation treatments. However, this study is based on a very small sample size; psychometric validation of the PRES with a larger sample of chronic pain patients to confirm the measurement structure of the PRES using confirmatory factor analysis is warranted.


Sex, race, and geographic region influence clinical outcomes following primary HIV-1 infection.
It is unknown whether sex and race influence clinical outcomes following primary human immunodeficiency virus type 1 (HIV-1) infection. Data were evaluated from an observational, multicenter, primarily North American cohort of HIV-1 seroconverters. Of 2277 seroconverters, 5.4% were women. At enrollment, women averaged .40 log₁₀ fewer copies/mL of HIV-1 RNA (P < .001) and 66 more CD4(+) T cells/μL (P = .006) than men, controlling for age and race. Antiretroviral therapy (ART) was less likely to be initiated at any time point by nonwhite women and men compared to white men (P < .005), and by individuals from the southern United States compared to others (P = .047). Sex and race did not affect responses to ART after 6 months (P > .73). Women were 2.17-fold more likely than men to experience >1 HIV/AIDS-related event (P < .001). Nonwhite women were most likely to experience an HIV/AIDS-related event compared to all others (P = .035), after adjusting for intravenous drug use and ART. Eight years after diagnosis, >1 HIV/AIDS-related event had occurred in 78% of nonwhites and 37% of whites from the southern United States, and 24% of whites and 17% of nonwhites from other regions (P < .001). Despite more favorable clinical parameters initially, female HIV-1-seroconverters had worse outcomes than did male seroconverters. Elevated morbidity was associated with being nonwhite and residing in the southern United States.


Refractive and topographic fluctuations due to intracorneal ring segments motility.
To describe a patient with refractive and topographic fluctuations 5 years after intracorneal ring segments (ICRS) implantation for the management of corneal ectasia after LASIK. Case report. A 48-year-old woman presented complaining of intermittent decreased vision over 1 year that improved with eye rubbing. Slit-lamp and optical coherence tomography (OCT) examinations revealed overriding ring segments that could be restored to normal position after minor corneal massage. Topographic and refractive findings were significantly influenced by the ICRS positioning and caused decreased visual function when overriding. To avoid ICRS override, surgical dissection of the corneal tunnel along with ring segment repositioning was performed. A suture was placed through the ring's positioning hole to stabilize the ICRS at its optimal position and to avoid recurrence of this phenomenon. Patients undergoing femtosecond laser-assisted ICRS implantation may experience ring segment migration and override of the segments that could lead to decreased visual function. Proper surgical repositioning and ring segment fixation may address this complication and offer satisfactory visual and refractive outcomes along with avoidance of ICRS migration and override.


The alcohol hangover research group consensus statement on best practice in alcohol hangover research.
Alcohol-induced hangover, defined by a series of symptoms, is the most commonly reported consequence of excessive alcohol consumption. Alcohol hangovers contribute to workplace absenteeism, impaired job performance, reduced productivity, poor academic achievement, and may compromise potentially dangerous daily activities such as driving a car or operating heavy machinery. These socioeconomic consequences and health risks of alcohol hangover are much higher when compared to various common diseases and other health risk factors. Nevertheless, unlike alcohol intoxication the hangover has received very little scientific attention and studies have often yielded inconclusive results. Systematic research is important to increase our knowledge on alcohol hangover and its consequences. This consensus paper of the Alcohol Hangover Research Group discusses methodological issues that should be taken into account when performing future alcohol hangover research. Future research should aim to (1) further determine the pathology of alcohol hangover, (2) examine the role of genetics, (3) determine the economic costs of alcohol hangover, (4) examine sex and age differences, (5) develop common research tools and methodologies to study hangover effects, (6) focus on factor that aggravate hangover severity (e.g., congeners), and (7) develop effective hangover remedies.


Global convergence in the vulnerability of forests to drought.
Shifts in rainfall patterns and increasing temperatures associated with climate change are likely to cause widespread forest decline in regions where droughts are predicted to increase in duration and severity. One primary cause of productivity loss and plant mortality during drought is hydraulic failure. Drought stress creates trapped gas emboli in the water transport system, which reduces the ability of plants to supply water to leaves for photosynthetic gas exchange and can ultimately result in desiccation and mortality. At present we lack a clear picture of how thresholds to hydraulic failure vary across a broad range of species and environments, despite many individual experiments. Here we draw together published and unpublished data on the vulnerability of the transport system to drought-induced embolism for a large number of woody species, with a view to examining the likely consequences of climate change for forest biomes. We show that 70% of 226 forest species from 81 sites worldwide operate with narrow (<1 megapascal) hydraulic safety margins against injurious levels of drought stress and therefore potentially face long-term reductions in productivity and survival if temperature and aridity increase as predicted for many regions across the globe. Safety margins are largely independent of mean annual precipitation, showing that there is global convergence in the vulnerability of forests to drought, with all forest biomes equally vulnerable to hydraulic failure regardless of their current rainfall environment. These findings provide insight into why drought-induced forest decline is occurring not only in arid regions but also in wet forests not normally considered at drought risk.


Gold nanomaterials for the selective capturing and SERS diagnosis of toxins in aqueous and biological fluids.
A highly sensitive nanosensing method for the combined selective capture and SERS detection of Microcystin-LR (MC-LR) in blood plasma has been developed. The new method utilizes gold coated magnetic nanoparticles that are functionalized with anti MC-LR antibody Fab' fragments for the selective capture of MC-LR from aqueous media and blood plasma. Using an oriented immobilization approach, the Fab' fragments are covalently attached to gold surface to form a monolayer with high capture efficiency towards the toxin. After the selective capture, the purified MC-LR molecules were released from the extractor nanoparticles within 5min by manipulating the pH environment of the nanoparticles. The regenerated extractor nanoparticles maintained their capture efficiency and, therefore, were re-used to capture of MC-LR from successive samples. The released purified toxin was screened within 10min on gold coated silicon nanopillars and a new paper-based SERS substrate by handheld Raman spectrometer. The SERS enhancement factors of the nanopillars and the new paper-based substrate were 2.5×106 and 3×105 respectively. The lower limit of quantification (LOQ) of MC-LR by SERS on the nanopillar substrate was 10fM (R2=0.9975) which is well below the clinically required detection limit of the toxin. The SERS determination of MC-LR was cross validated against ELISA. By using antibody fragments that are specific to the target biomolecule, the new methodology can be extended to the rapid extraction and detection of other toxins and proteins.


Advancing spinal fellowship training: an international multi-centre educational perspective.
The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery. Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training. Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training. Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.


Aortic Arch Morphology and Aortic Length in Patients with Dissection, Traumatic, and Aneurysmal Disease.
To assess aortic arch morphology and aortic length in patients with dissection, traumatic injury, and aneurysm undergoing TEVAR, and to identify characteristics specific to different pathologies. This was a retrospective analysis of the aortic arch morphology and aortic length of dissection, traumatic injury, and aneurysmal patients. Computed tomography imaging was evaluated of 210 patients (49 dissection, 99 traumatic injury, 62 aneurysm) enrolled in three trials that received the conformable GORE TAG thoracic endoprosthesis. The mean age of trauma patients was 43 ± 19.6 years, 57 ± 11.7 years for dissection and 72 ± 9.6 years for aneurysm patients. A standardized protocol was used to measure aortic arch diameter, length, and take-off angle and clockface orientation of branch vessels. Differences in arch anatomy and length were assessed using ANOVA and independent t tests. Of the 210 arches evaluated, 22% had arch vessel common trunk configurations. The aortic diameter and the distance from the left main coronary (LMC) to the left common carotid (LCC) were greater in dissection patients than in trauma or aneurysm patients (p < .001). Aortic diameter in aneurysm patients was greater compared with trauma patients (p < .05). The distances from the branch vessels to the celiac artery (CA) were greater in dissection and aneurysm patients than in trauma patients (p < .001). The take-off angle of the innominate (I), LCCA, and left subclavian (LS) were greater, between 19% and 36%, in trauma patients than in dissection and aneurysm patients (p < .001). Clockface orientation of the arch vessels varies between pathologies. Arch anatomy has significant morphologic differences when comparing aortic pathologies. Describing these differences in a large sample of patients is beneficial for device designs and patient selection.


Time Dependent Assessment of Morphological Changes: Leukodepleted Packed Red Blood Cells Stored in SAGM.
Usually packed red blood cells (pRBCs) require specific conditions in storage procedures to ensure the maximum shelf life of up to 42 days in 2-6°C. However, molecular and biochemical consequences can affect the stored blood cells; these changes are collectively labeled as storage lesions. In this study, the effect of prolonged storage was assessed through investigating morphological changes and evaluating oxidative stress. Samples from leukodepleted pRBC in SAGM stored at 4°C for 42 days were withdrawn aseptically on day 0, day 14, day 28, and day 42. Morphological changes were observed using scanning electron microscopy and correlated with osmotic fragility and hematocrit. Oxidative injury was studied through assessing MDA level as a marker for lipid peroxidation. Osmotic fragility test showed that extended storage time caused increase in the osmotic fragility. The hematocrit increased by 6.6% from day 0 to day 42. The last 2 weeks show alteration in the morphology with the appearance of echinocytes and spherocytes. Storage lesions and morphological alterations appeared to affect RBCs during the storage period. Further studies should be performed to develop strategies that will aid in the improvement of stored pRBC quality and efficacy.


Low postseroconversion CD4 count and rapid decrease of CD4 density identify HIV+ fast progressors.
CD4 expression in HIV replication is paradoxical: HIV entry requires high cell-surface CD4 densities, but replication requires CD4 down-modulation. However, is CD4 density in HIV+ patients affected over time? Do changes in CD4 density correlate with disease progression? Here, we examined the role of CD4 density for HIV disease progression by longitudinally quantifying CD4 densities on CD4+ T cells and monocytes of ART-naive HIV+ patients with different disease progression rates. This was a retrospective study. We defined three groups of HIV+ patients by their rate of CD4+ T cell loss, calculated by the time between infection and reaching a CD4 level of 200 cells/microl: fast (<7.5 years), intermediate (7.5-12 years), and slow progressors (>12 years). Mathematical modeling permitted us to determine the maximum CD4+ T cell count after HIV seroconversion (defined as "postseroconversion CD4 count") and longitudinal profiles of CD4 count and density. CD4 densities were quantified on CD4+ T cells and monocytes from these patients and from healthy individuals by flow cytometry. Fast progressors had significantly lower postseroconversion CD4 counts than other progressors. CD4 density on T cells was lower in HIV+ patients than in healthy individuals and decreased more rapidly in fast than in slow progressors. Antiretroviral therapy (ART) did not normalize CD4 density. Thus, postseroconversion CD4 counts define individual HIV disease progression rates that may help to identify patients who might benefit most from early ART. Early discrimination of slow and fast progressors suggests that critical events during primary infection define long-term outcome. A more rapid CD4 density decrease in fast progressors might contribute to progressive functional impairments of the immune response in advanced HIV infection. The lack of an effect of ART on CD4 density implies a persistent dysfunctional immune response by uncontrolled HIV infection.


Timing of opioid administration as a quality indicator for pain crises in sickle cell disease.
Time to opioid administration (TTO) has been suggested as a quality of care measure for sickle cell disease patients with vaso-occlusive crisis (VOC). We sought to determine whether TTO was associated with outcomes of emergency department (ED) visits for VOC. We conducted a single-center retrospective cohort study of ED visits for VOC. The primary outcome was hospital admission, with secondary outcomes of change between the first 2 pain scores, area under the curve (AUC) for pain scores at 4 hours (pain score AUC), total ED length of stay, and total intravenous opioids. In both univariate and multivariate analyses, mixed regression (logistic for admission, linear for secondary outcome variables) was used to evaluate association of TTO with outcome. In 177 subjects, 414 ED visits for VOC were identified. Inpatient admission occurred in 53% of visits. The median TTO for admitted patients was 86 minutes vs 87 minutes for those not admitted. TTO was not associated with inpatient admission in either univariate or multivariate analyses. In multivariate analyses with secondary outcomes, decreased TTO was associated with greater improvement between the first 2 pain scores, decreased pain score AUC, decreased total ED length of stay, and increased total opioids. Although TTO was not associated with admission, it was independently associated with 4 important secondary outcomes: change in initial pain scores, pain score AUC, total ED length of stay, and total intravenous opioids. The association of a process measure, TTO, with these outcomes encourages the institution of TTO reduction efforts in the ED.


Advances in cancer therapeutics and patient access to new drugs.
Globally, there are approximately 7.4 million cancer deaths annually, approximately 13% of deaths from all causes. Cancer is a disease of older people and, as the population ages over the next 10-20 years, we can expect an increase in the cancer incidence. Encouragingly, cancer mortality has stabilized in many countries. Part of this success may be attributed to the development of new cancer agents, collectively called 'targeted therapies', that are more specific to key components of tumour growth. Worldwide, however, one of the main factors that limit patient access to these important new drugs is their cost, which is higher than traditional chemotherapy. In this review, the clinical and pharmacoeconomic data of selected targeted agents are discussed. In the second part of this article, the challenges faced by healthcare systems in making such drugs available to patients is reviewed. Current strategies used by many countries around the world to manage cancer drug budgets are presented, along with a proposed approach using pharmacoeconomic methodology that may increase patient access.