Surgery Versus ATMPs: An Example From Ophthalmology.
Advanced therapy medicinal products (ATMPs) are the new frontier of medicine. Advanced therapy medicinal products are set out to satisfy unmet medical needs and provide new innovative, cutting-edge therapies for serious or life-threatening diseases, thus providing new therapeutic options for people with few or no possibility of treatment. They are divided into four groups including gene therapy medicinal products, cell-based therapy medicinal products, tissue-engineered products, and combined ATMPs, which in Europe refer to products that incorporate one or more medical devices with any of the previously mentioned ATMPs as part of the advanced medicine product (AIFA, 2017; Ten Ham et al., 2018). Advanced therapy medicinal products can potentially have long-term benefits, thus bringing a long-lasting positive impact on patient health. Advanced therapy medicinal product therapies are often administered just once or twice, which gives patients the possibility to heal quickly compared to traditional therapies. They also provide a long-term saving opportunity, both in terms of costs of treatments and procedures that are no longer necessary and in terms of quality of life and productivity. The resolution of the patient's illness has a monetary impact on the patient, the patient's caretakers, and especially on the society (Alliance for Regenerative Medicine, 2019). The aim of this paper was to provide an overview on the use of ATMPs approved in Europe, with a focus on blindness and visual impairment and the related economic burden. In this case study, the effective cost of a blind patient in different European countries was compared after treatment with ATMPs or traditional therapies, focusing on visual impairment caused by corneal opacity. Our evaluation includes an overview of the global economic impact of the two types of therapies on the society. We estimated direct healthcare costs, direct non-healthcare costs, and labor productivity losses, to include costs on healthcare, services, patients, their families and for the society in general. We could conclude that the costs of the two therapeutic approaches are comparable.


Post genomics era for orchid research.
Among 300,000 species in angiosperms, Orchidaceae containing 30,000 species is one of the largest families. Almost every habitats on earth have orchid plants successfully colonized, and it indicates that orchids are among the plants with significant ecological and evolutionary importance. So far, four orchid genomes have been sequenced, including Phalaenopsis equestris, Dendrobium catenatum, Dendrobium officinale, and Apostaceae shengen. Here, we review the current progress and the direction of orchid research in the post genomics era. These include the orchid genome evolution, genome mapping (genome-wide association analysis, genetic map, physical map), comparative genomics (especially receptor-like kinase and terpene synthase), secondary metabolomics, and genome editing.


Long-Term Rupture Risk in Patients with Unruptured Intracranial Aneurysms Treated with Endovascular Therapy: A Systematic Review and Meta-Analysis.
Surveillance imaging of previously unruptured, coiled aneurysms remains routine even though reports of rupture of these aneurysms are extremely rare. We performed meta-analysis to examine long-term rupture risk over ≥1-year follow-up duration in patients with unruptured intracranial aneurysm who underwent endovascular therapy. Multiple databases were searched for relevant publications between 1995 and 2018. Studies reporting outcome of long-term rupture risk over ≥1-year follow-up in treated patients with unruptured intracranial aneurysms were included. Random effects meta-analysis was used, and results were expressed as long-term rupture rate per 100 patient-year with respective 95% CIs. For ruptured aneurysms during follow-up, data were collected on size and completeness of initial Treatment. Twenty-four studies were identified. Among 4842 patients with a mean follow-up duration of 3.2 years, a total of 12 patients (0.25%) experienced rupture of previous unruptured intracranial aneurysms after endovascular treatment. Nine of these 12 patients harbored aneurysms that were large, incompletely treated, or both. A total of 2 anterior circulation, small, completely coiled aneurysms subsequently ruptured. The long-term rupture rate per 100 patient-year for unruptured intracranial aneurysms treated with endovascular therapy was 0.48 (95% CI, 0.45-0.51). Retreatment was carried out in 236 (4.9%) of these 4842 patients. A limitation of the study is that a lack of systematic nature of follow-up and mean follow-up duration of 3.2 years are not sufficient to make general recommendations about aneurysm followup paradigms. Given a 5% retreatment rate, postcoil embolization spontaneous rupture of previously unruptured, small- and medium-sized, well-treated aneurysms is exceedingly rare.


The topical effect of grape seed extract 2% cream on surgery wound healing.
Reducing the wound healing time is crucial in wound as it lowers the chance of infection and decreases complications and cost. Grape seed extract has the ability to release endothelial growth factor and its topical application results in contraction and closure of the skin wound. Furthermore, it possesses antioxidant and antibacterial properties. In several studies it has been proved effective in animals. Therefore, due to low side effects and recognition of herbal medicine, we decided to evaluate the effect of grape seed extract 2% herbal cream on human skin lesions. This study is a double blind clinical trial conducted on two groups of treatment and placebo. Surgery was performed on skin lesions such as skin tags and moles which were found on the neck, trunk and limbs (except for face). After enrollment and obtaining informed consent from participants, they were randomized into two groups of treatment and placebo. Excision of the lesions was done by surgical scissors. The lesions got restored by secondary intention method. After the first day of treatment, the patients were visited on the 3rd, 7th, 10th, 14th, and 21st day. Grape seed extract cream 2% was produced and coded by the Faculty of Pharmacy, Ahvaz University of Medical Sciences. In order to compare the two groups, T-test was used. For time assessing, analysis of variance with repeated measures was employed. The results showed complete repair of wounds averagely on day 8 for the treatment group and on day 14 for the placebo group, which was clearly significant in terms of statistical difference (p=0.00). Proanthocyanidins in grape seed extract trigger the release of vascular endothelial growth factor and its topical application causes wound contraction and closure. Curing skin lesions with grape seed extract caused proliferation areas with protected boundaries in epithelium, increased cell density and increased deposition of connective tissue at the wound site which in general improves cellular structure in wound. In addition, its anti-inflammatory and anti-microbial properties are effective in wound healing.


Peripheral myelin protein 22 alters membrane architecture.
Peripheral myelin protein 22 (PMP22) is highly expressed in myelinating Schwann cells of the peripheral nervous system. PMP22 genetic alterations cause the most common forms of Charcot-Marie-Tooth disease (CMTD), which is characterized by severe dysmyelination in the peripheral nerves. However, the functions of PMP22 in Schwann cell membranes remain unclear. We demonstrate that reconstitution of purified PMP22 into lipid vesicles results in the formation of compressed and cylindrically wrapped protein-lipid vesicles that share common organizational traits with compact myelin of peripheral nerves in vivo. The formation of these myelin-like assemblies depends on the lipid-to-PMP22 ratio, as well as on the PMP22 extracellular loops. Formation of the myelin-like assemblies is disrupted by a CMTD-causing mutation. This study provides both a biochemical assay for PMP22 function and evidence that PMP22 directly contributes to membrane organization in compact myelin.


Knock-out and transgenic mouse models of tauopathies.
Tauopathies, characterized by the dysfunction and aggregation of the microtubule-associated protein tau (MAPT), represent some of the most devastating neurodegenerative disorders afflicting the elderly, including Alzheimer's disease and progressive supranuclear palsy. Here we review the range of Mapt knock-out and MAPT transgenic mouse models which have proven successful at providing insights into the molecular mechanisms of neurodegenerative disease. In this overview we highlight several themes, including the insights such models provide into the cellular and molecular mechanisms of tauopathy, the direct relationship between neuropathology and behaviour, and the use of mouse models to help provide a platform for testing novel therapies. Mouse models have helped clarify the relationship between pathological forms of tau, cell death, and the emergence of disease, as well as the interaction between tau and other disease-associated molecules, such as the A beta peptide. Finally, we discuss potential future MAPT genomic DNA models to investigate the importance of alternative splicing of the MAPT locus and its role in sporadic tauopathies.


The Irritable Bowel Syndrome Outcome Study (IBSOS): rationale and design of a randomized, placebo-controlled trial with 12 month follow up of self- versus clinician-administered CBT for moderate to severe irritable bowel syndrome.
Irritable bowel syndrome is a common, oftentimes disabling, gastrointestinal disorder whose full range of symptoms has no satisfactory medical or dietary treatment. One of the few empirically validated treatments includes a specific psychological therapy called cognitive behavior therapy which, if available, is typically administered over several months by trained practitioners in tertiary care settings. There is an urgent need to develop more efficient versions of CBT that require minimal professional assistance but retain the efficacy profile of clinic based CBT. The Irritable Bowel Syndrome Outcome Study (IBSOS) is a multicenter, placebo-controlled randomized trial to evaluate whether a self-administered version of CBT is, at least as efficacious as standard CBT and more efficacious than an attention control in reducing core GI symptoms of IBS and its burden (e.g. distress, quality of life impairment, etc.) in moderately to severely affected IBS patients. Additional goals are to assess, at quarterly intervals, the durability of treatment response over a 12 month period; to identify clinically useful patient characteristics associated with outcome as a way of gaining an understanding of subgroups of participants for whom CBT is most beneficial; to identify theory-based change mechanisms (active ingredients) that explain how and why CBT works; and evaluate the economic costs and benefits of CBT. Between August 2010 when IBSOS began recruiting subjects and February 2012, the IBSOS randomized 171 of 480 patients. Findings have the potential to improve the health of IBS patients, reduce its social and economic costs, conserve scarce health care resources, and inform evidence-based practice guidelines.


Cognitive Contributions to Freezing of Gait in Parkinson Disease: Implications for Physical Rehabilitation.
People with Parkinson disease (PD) who show freezing of gait also have dysfunction in cognitive domains that interact with mobility. Specifically, freezing of gait is associated with executive dysfunction involving response inhibition, divided attention or switching attention, and visuospatial function. The neural control impairments leading to freezing of gait have recently been attributed to higher-level, executive and attentional cortical processes involved in coordinating posture and gait rather than to lower-level, sensorimotor impairments. To date, rehabilitation for freezing of gait primarily has focused on compensatory mobility training to overcome freezing events, such as sensory cueing and voluntary step planning. Recently, a few interventions have focused on restitutive, rather than compensatory, therapy. Given the documented impairments in executive function specific to patients with PD who freeze and increasing evidence of overlap between cognitive and motor function, incorporating cognitive challenges with mobility training may have important benefits for patients with freezing of gait. Thus, a novel theoretical framework is proposed for exercise interventions that jointly address both the specific cognitive and mobility challenges of people with PD who freeze.


Modeling thalamocortical cell: impact of ca channel distribution and cell geometry on firing pattern.
The influence of calcium channel distribution and geometry of the thalamocortical cell upon its tonic firing and the low threshold spike (LTS) generation was studied in a 3-compartment model, which represents soma, proximal and distal dendrites as well as in multi-compartment model using the morphology of a real reconstructed neuron. Using an uniform distribution of Ca(2+) channels, we determined the minimal number of low threshold voltage-activated calcium channels and their permeability required for the onset of LTS in response to a hyperpolarizing current pulse. In the 3-compartment model, we found that the channel distribution influences the firing pattern only in the range of 3% below the threshold value of total T-channel density. In the multi-compartmental model, the LTS could be generated by only 64% of unequally distributed T-channels compared to the minimal number of equally distributed T-channels. For a given channel density and injected current, the tonic firing frequency was found to be inversely proportional to the size of the cell. However, when the Ca(2+) channel density was elevated in soma or proximal dendrites, then the amplitude of LTS response and burst spike frequencies were determined by the ratio of total to threshold number of T-channels in the cell for a specific geometry.


Cytokine immunoreactivity in plasma does not change after moderate endurance exercise.
We investigated whether increased concentrations of circulating cytokines may be responsible for exercise-induced priming of blood neutrophils (J. A. Smith et al. Int. J. Sports Med. 11: 179-187, 1990). The plasma concentrations of tumor necrosis factor-alpha, interleukin- (IL) 1 beta, IL-6, granulocyte-macrophage colony-stimulating factor, and neopterin in trained and untrained human subjects were measured by immunoassay before and after 1 h of cycling at 60% of maximal oxygen uptake. C-reactive protein and creatine kinase (CK) were also measured before and 24 h after exercise as markers of the "acute-phase response" and muscle damage (C. Taylor et al. J. Appl. Physiol. 62: 464-469, 1987), respectively. The small changes in the plasma concentrations of cytokines or neopterin observed after exercise in both trained and untrained subjects were not significantly different to those found in a control group of nonexercised subjects. However, untrained subjects did exhibit an acute-phase response (P = 0.04) 24 h after exercise without additional release of CK into plasma. Baseline training differences were confined to a twofold elevation in CK activity (P = 0.04). The results show that circulating cytokines are unlikely to be responsible for the priming of neutrophil microbicidal activity observed after moderate endurance exercise (J. A. Smith et al. Int. J. Sports Med. 11: 179-187, 1990).


The causal cascade to multiple sclerosis: a model for MS pathogenesis.
MS pathogenesis seems to involve both genetic susceptibility and environmental risk factors. Three sequential factors are implicated in the environmental risk. The first acts near birth, the second acts during childhood, and the third acts long thereafter. Two candidate factors (vitamin D deficiency and Epstein-Barr viral infection) seem well suited to the first two environmental events. A mathematical Model for MS pathogenesis is developed, incorporating these environmental and genetic factors into a causal scheme that can explain some of the recent changes in MS-epidemiology (e.g., increasing disease prevalence, a changing sex-ratio, and regional variations in monozygotic twin concordance rates). This Model suggests that genetic susceptibility is overwhelmingly the most important determinant of MS pathogenesis. Indeed, over 99% of individuals seem genetically incapable of developing MS, regardless of what environmental exposures they experience. Nevertheless, the contribution of specific genes to MS-susceptibility seems only modest. Thus, despite HLA DRB1*1501 being the most consistently identified genetic marker of MS-susceptibility (being present in over 50% of northern MS patient populations), only about 1% of individuals with this allele are even genetically susceptible to getting MS. Moreover, because genetic susceptibility seems so similar throughout North America and Europe, environmental differences principally determine the regional variations in disease characteristics. Additionally, despite 75% of MS-patients being women, men are 60% more likely to be genetically-susceptible than women. Also, men develop MS at lower levels of environmental exposure than women. Nevertheless, women are more responsive to the recent changes in environmental-exposure (whatever these have been). This explains both the changing sex-ratio and the increasing disease prevalence (which has increased by a minimum of 32% in Canada over the past 35 years). As noted, environmental risk seems to result from three sequential components of environmental exposure. The potential importance of this Model for MS pathogenesis is that, if correct, a therapeutic strategy, designed to interrupt one or more of these sequential factors, has the potential to markedly reduce or eliminate disease prevalence in the future.


Start2quit: a randomised clinical controlled trial to evaluate the effectiveness and cost-effectiveness of using personal tailored risk information and taster sessions to increase the uptake of the NHS Stop Smoking Services.
The NHS Stop Smoking Services (SSSs) offer help to smokers who want to quit. However, the proportion of smokers attending the SSSs is low and current figures show a continuing downward trend. This research addressed the problem of how to motivate more smokers to accept help to quit. To assess the relative effectiveness, and cost-effectiveness, of an intervention consisting of proactive recruitment by a brief computer-tailored personal risk letter and an invitation to a 'Come and Try it' taster session to provide information about the SSSs, compared with a standard generic letter advertising the service, in terms of attendance at the SSSs of at least one session and validated 7-day point prevalent abstinence at the 6-month follow-up. Randomised controlled trial of a complex intervention with follow-up 6 months after the date of randomisation. SSSs and general practices in England. All smokers aged ≥ 16 years identified from medical records in participating practices who were motivated to quit and who had not attended the SSS in the previous 12 months. Participants were randomised in the ratio 3 : 2 (intervention to control) by a computer program. Intervention - brief personalised and tailored letter sent from the general practitioner using information obtained from the screening questionnaire and from medical records, and an invitation to attend a taster session, run by the local SSS. Control - standard generic letter from the general practice advertising the local SSS and the therapies available, and asking the smoker to contact the service to make an appointment. (1) Proportion of people attending the first session of a 6-week course over a period of 6 months from the receipt of the invitation letter, measured by records of attendance at the SSSs; (2) 7-day point prevalent abstinence at the 6-month follow-up, validated by salivary cotinine analysis; and (3) cost-effectiveness of the intervention. Eighteen SSSs and 99 practices within the SSS areas participated; 4384 participants were randomised to the intervention (n = 2636) or control (n = 1748). One participant withdrew and 4383 were analysed. The proportion of people attending the first session of a SSS course was significantly higher in the intervention group than in the control group [17.4% vs. 9.0%; unadjusted odds ratio (OR) 2.12, 95% confidence interval (CI) 1.75 to 2.57; p < 0.001]. The validated 7-day point prevalent abstinence at the 6-month follow-up was significantly higher in the intervention group than in the control group (9.0% vs. 5.6%; unadjusted OR 1.68, 95% CI 1.32 to 2.15; p < 0.001), as was the validated 3-month prolonged abstinence and all other periods of abstinence measured by self-report. Using the National Institute for Health and Care Excellence decision-making threshold range of £20,000-30,000 per quality-adjusted life-year gained, the probability that the intervention was more cost-effective than the control was up to 27% at 6 months and > 86% over a lifetime horizon. Participating SSSs may not be representative of all SSSs in England. Recruitment was low, at 4%. The Start2quit trial added to evidence that a proactive approach with an intensive intervention to deliver personalised risk information and offer a no-commitment introductory session can be successful in reaching more smokers and increasing the uptake of the SSS and quit rates. The intervention appears less likely to be cost-effective in the short term, but is highly likely to be cost-effective over a lifetime horizon. Further research could assess the separate effects of these components. Current Controlled Trials ISRCTN76561916. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 3. See the NIHR Journals Library website for further project information.


A canine in vitro model for evaluation of marrow-derived mesenchymal stromal cell-based bone scaffolds.
Tissue engineered bone grafts based on bone marrow mesenchymal stromal cells (MSCs) are being actively developed for craniomaxillofacial (CMF) applications. As for all tissue engineered implants, the bone-regenerating capacity of these MSC-based grafts must first be evaluated in animal models prior to human trials. Canine models have traditionally resulted in improved clinical translation of CMF grafts relative to other animal models. However, the utility of canine CMF models for evaluating MSC-based bone grafts rests on canine MSCs (cMSCs) responding in a similar manner to scaffold-based stimuli as human MSCs (hMSCs). Herein, cMSC and hMSC responses to polyethylene glycol (PEG)-based scaffolds were therefore compared in the presence or absence of osteoinductive polydimethylsiloxane (PDMS). Notably, the conjugation of PDMS to PEG-based constructs resulted in increases in both cMSC and hMSC osteopontin and calcium deposition. Based on these results, cMSCs were further used to assess the efficacy of tethered bone morphogenic protein 2 (BMP2) in enhancing PEG-PDMS scaffold osteoinductivity. Addition of low doses of tethered BMP2 (100 ng/mL) to PEG-PDMS systems increased cMSC expression of osterix and osteopontin compared to both PEG-PDMS and PEG-BMP2 controls. Furthermore, these increases were comparable to effects seen with up to five-times higher BMP2 doses noted in literature. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A:2382-2393, 2018.


The role of primary androgen deprivation therapy in localized prostate cancer.
Primary androgen deprivation therapy (PADT) is frequently used as a sole modality of treatment in men with localized prostate cancer, despite a lack of clinical trial data supporting its use. To measure the impact of treatment with PADT compared to observation on overall survival in men with organ-confined prostate cancer. The design was for an observational cohort from Surveillance, Epidemiology, and End Results (SEER) Medicare data. The cohort consisted of 16,535 men aged 65-80 yr at diagnosis with organ-confined well-differentiated or moderately differentiated prostate cancer who survived >1 yr past diagnosis and did not undergo treatment with prostatectomy or radiation therapy within 6 mo of diagnosis. They were diagnosed between 1991 and 1999 and followed until death or until the end of the study period (December 31, 2002). Study subjects were selected to receive PADT alone if they received luteinizing hormone-releasing hormone agonists or bilateral orchiectomy in the first 6 mo after diagnosis, and they were selected to be observed if they did not have claims for PADT during the same interval. Overall survival. After adjusting for potential confounders (ie, tumor characteristics, comorbidities, and demographics), patients who received ADT had a worse overall survival rate than patients who were observed (hazard ratio: 1.20; 95% confidence interval: 1.13-1.27). In observational studies there may be unmeasured differences between the treated and untreated groups. The SEER database does not provide information on prostate-specific antigen levels. This large, population-based study suggests that PADT did not improve survival in men with localized prostate cancer, but it suggests that PADT may instead result in worse outcomes compared with observation. Patients and physicians should be cognizant of the potential long-term side effects of ADT in a patient population for which expectant observation is an acceptable treatment strategy.


Comparative genomics provides evidence for an ancient genome duplication event in fish.
There are approximately 25 000 species in the division Teleostei and most are believed to have arisen during a relatively short period of time ca. 200 Myr ago. The discovery of 'extra' Hox gene clusters in zebrafish (Danio rerio), medaka (Oryzias latipes), and pufferfish (Fugu rubripes), has led to the hypothesis that genome duplication provided the genetic raw material necessary for the teleost radiation. We identified 27 groups of orthologous genes which included one gene from man, mouse and chicken, one or two genes from tetraploid Xenopus and two genes from zebrafish. A genome duplication in the ancestor of teleost fishes is the most parsimonious explanation for the observations that for 15 of these genes, the two zebrafish orthologues are sister sequences in phylogenies that otherwise match the expected organismal tree, the zebrafish gene pairs appear to have been formed at approximately the same time, and are unlinked. Phylogenies of nine genes differ a little from the tree predicted by the fish-specific genome duplication hypothesis: one tree shows a sister sequence relationship for the zebrafish genes but differs slightly from the expected organismal tree and in eight trees, one zebrafish gene is the sister sequence to a clade which includes the second zebrafish gene and orthologues from Xenopus, chicken, mouse and man. For these nine gene trees, deviations from the predictions of the fish-specific genome duplication hypothesis are poorly supported. The two zebrafish orthologues for each of the three remaining genes are tightly linked and are, therefore, unlikely to have been formed during a genome duplication event. We estimated that the unlinked duplicated zebrafish genes are between 300 and 450 Myr. Thus, genome duplication could have provided the genetic raw material for teleost radiation. Alternatively, the loss of different duplicates in different populations (i.e. 'divergent resolution') may have promoted speciation in ancient teleost populations.


Economic Burden of Cancer in Korea during 2000-2010.
This study estimated the economic burden of cancer in Korea during 2000-2010 by cancer site, gender, age group, and cost component. Data came from national health insurance claims data and information from Statistics Korea. Based on the cost of illness method, this study calculated direct, morbidity and mortality cost of cancer in the nation during 2000-2010 by cancer site, gender, and age group. With an average annual growth rate of 8.9%, the economic burden of cancer in Korea increased from 11,424 to 20,858 million US$ (current US dollars) during 2000-2010. Colorectal, thyroid, and breast cancers became more significant during the period, i.e., the 5th/837, the 11th/257, and the 7th/529 in 2000 to the 3rd/2,210, the 5th/1,724, and the 6th/1,659 in 2010, respectively (rank/amount in million US$ for the total population). In addition, liver and stomach cancers were prominent during the period in terms of the same measures, i.e., the 1st/2,065 and the 2nd/2,036 in 2000 to the 1st/3,114 and the 2nd/3,046 in 2010, respectively. Finally, the share of mortality cost in the total burden dropped from 71% to 51% in Korea during 2000-2010, led by colorectal, thyroid, breast, and prostate cancers during the period. These results show that the economic burden of cancer in Korea is characterized by an increasing importance of chronic components. Incorporation of distinctive epidemiological, sociocultural contexts into Korea's cancer control program, with greater emphasis on primary prevention such as sodium-controlled diet and hepatitis B vaccination, may be needed.


Three-dimensional fluorescence enhanced optical tomography using referenced frequency-domain photon migration measurements at emission and excitation wavelengths.
The ultimate success of near-infrared optical tomography rests on the precise measurement of light propagation within tissues or random media, the accurate prediction of these measurements from a light propagation model, and an efficient three-dimensional solution of the inverse imaging problem. To date, optical tomography algorithms have focused on frequency-domain photon migration (FDPM) measurements of phase-delay and amplitude attenuation, which are reported relative to the incident light, even though phase-delay and amplitude of incident light are nearly impossible to measure directly. In this contribution, we examine referenced, fluorescence-enhanced frequency-domain photon migration measured at excitation and/or emission wavelengths and report on a measurement strategy to minimize measurement and calibration error for efficient coupling of data to a distorted Born iterative imaging algorithm. We examine three referencing approaches and develop associated inversion algorithms for (1) normalizing detected emission FDPM data to the predicted emission wave arising from a homogeneous medium, (2) referencing detected emission FDPM data to that detected at a reference point, and (3) referencing detected emission FDPM data to detected excitation FDPM data detected at a reference point. Our results show the latter approach to be practical while reducing the nonlinearity of the inverse problem. Finally, in light of our results, we demonstrate the method for eliminating the influence of source strength and instrument functions for effective fluorescence-enhanced optical tomography using FDPM.


A first glimpse at the genome of the Baikalian amphipod Eulimnogammarus verrucosus.
Eulimnogammarus verrucosus is an amphipod endemic to the unique ecosystem of Lake Baikal and serves as an emerging model in ecotoxicological studies. We report here on a survey sequencing of its genome as a first step to establish sequence resources for this species. From a single lane of paired-end sequencing data, we estimated the genome size as nearly 10 Gb and we obtained an overview of the repeat content. At least two-thirds of the genome are non-unique DNA, and a third of the genomic DNA is composed of just five families of repetitive elements, including low-complexity sequences. Attempts to use off-the-shelf assembly tools failed on the available low-coverage data both before and after removal of highly repetitive components. Using a seed-based approach we nevertheless assembled short contigs covering 33 pre-microRNAs and the homeodomain-containing exon of nine Hox genes. The absence of clear evidence for paralogs implies that a genome duplication did not contribute to the large genome size. We furthermore report the assembly of the mitochondrial genome using a new, guided "crystallization" procedure. The initial results presented here set the stage for a more complete sequencing and analysis of this large genome.


SSMART: sequence-structure motif identification for RNA-binding proteins.
RNA-binding proteins (RBPs) regulate every aspect of RNA metabolism and function. There are hundreds of RBPs encoded in the eukaryotic genomes, and each recognize its RNA targets through a specific mixture of RNA sequence and structure properties. For most RBPs, however, only a primary sequence motif has been determined, while the structure of the binding sites is uncharacterized. We developed SSMART, an RNA motif finder that simultaneously models the primary sequence and the structural properties of the RNA targets sites. The sequence-structure motifs are represented as consensus strings over a degenerate alphabet, extending the IUPAC codes for nucleotides to account for secondary structure preferences. Evaluation on synthetic data showed that SSMART is able to recover both sequence and structure motifs implanted into 3'UTR-like sequences, for various degrees of structured/unstructured binding sites. In addition, we successfully used SSMART on high-throughput in vivo and in vitro data, showing that we not only recover the known sequence motif, but also gain insight into the structural preferences of the RBP. SSMART is freely available at https://ohlerlab.mdc-berlin.de/software/SSMART_137/. Supplementary data are available at Bioinformatics online.


Estrogenic microenvironment generated by organochlorine residues in adipose mammary tissue modulates biomarker expression in ERalpha-positive breast carcinomas.
Breast cancer is the most frequent malignant disease in women. Exposure to estrogens throughout a woman's life is a risk factor for the development of breast cancer. Organochlorine compounds (OCCs), such as pesticides and polychlorinated biphenyls, are persistent lipophilic chemicals identified as endocrine disruptors, mainly with estrogenic effects. To test the hypothesis that the amount and quality of organochlorine residues in adipose tissue adjacent to breast carcinoma affect the biological behavior of the tumor, we studied biomarker expression in breast carcinoma and the OCC body burden in patients from an urban area adjacent to Paraná fluvial system, Argentina. The studied patients were 55 women who had undergone excision biopsies of a breast lesion diagnosed as invasive breast carcinoma. Analysis of OCC residues in breast adipose tissue was conducted by electron-capture gas-liquid chromatography. Estrogen receptor alpha (ERalpha), progesterone receptor (PR) and proliferative activity (Ki-67) levels were measured in paraffin-embedded biopsies of breast tumors by immunohistochemistry. All patients had high levels of organochlorine pesticides in their breast adipose tissue. The most frequently detected compounds were p,p'-dichlorodiphenyldichloroethylene, hexachlorobenzene and beta-hexachlorocyclohexane. When the whole sample was analyzed, no correlation between ERalpha or PR expression and OCC levels were found. In the subgroup of ERalpha-positive breast carcinoma patients, however, there was a positive correlation between PR expression (an estrogen-induced protein) in the neoplastic cells and OCC levels in adipose tissue surrounding the tumor. More significantly, all the ERalpha-positive breast carcinomas from postmenopausal women exhibited high proliferation when organochlorine levels in the surrounding adipose tissue reached levels higher than 2600 ppb. No associations were found between the organochlorine body burden and any other marker of tumor aggressiveness, such as node involvement or tumor size. The present results support the hypothesis that organochlorine residues in adipose tissue adjacent to breast carcinoma generate an estrogenic microenvironment that may influence the biological behavior of the tumor through ERalpha activation and ERalpha-dependent proliferation. These findings may have therapeutic implications, since interference between organochlorine compounds and hormonal therapy could be expected to occur.


Inducible cardiomyocyte-specific gene disruption directed by the rat Tnnt2 promoter in the mouse.
We developed a conditional and inducible gene knockout methodology that allows effective gene deletion in mouse cardiomyocytes. This transgenic mouse line was generated by coinjection of two transgenes, a "reverse" tetracycline-controlled transactivator (rtTA) directed by a rat cardiac troponin T (Tnnt2) promoter and a Cre recombinase driven by a tetracycline-responsive promoter (TetO). Here, Tnnt2-rtTA activated TetO-Cre expression takes place in cardiomyocytes following doxycycline treatment. Using two different mouse Cre reporter lines, we demonstrated that expression of Cre recombinase was specifically and robustly induced in the cardiomyocytes of embryonic or adult hearts following doxycycline induction, thus, allowing cardiomyocyte-specific gene disruption and lineage tracing. We also showed that rtTA expression and doxycycline treatment did not compromise cardiac function. These features make the Tnnt2-rtTA;TetO-Cre transgenic line a valuable genetic tool for analysis of spatiotemporal gene function and cardiomyocyte lineage tracing during developmental and postnatal periods.


Regenerative capacity of old muscle stem cells declines without significant accumulation of DNA damage.
The performance of adult stem cells is crucial for tissue homeostasis but their regenerative capacity declines with age, leading to failure of multiple organs. In skeletal muscle this failure is manifested by the loss of functional tissue, the accumulation of fibrosis, and reduced satellite cell-mediated myogenesis in response to injury. While recent studies have shown that changes in the composition of the satellite cell niche are at least in part responsible for the impaired function observed with aging, little is known about the effects of aging on the intrinsic properties of satellite cells. For instance, their ability to repair DNA damage and the effects of a potential accumulation of DNA double strand breaks (DSBs) on their regenerative performance remain unclear. This work demonstrates that old muscle stem cells display no significant accumulation of DNA DSBs when compared to those of young, as assayed after cell isolation and in tissue sections, either in uninjured muscle or at multiple time points after injury. Additionally, there is no significant difference in the expression of DNA DSB repair proteins or globally assayed DNA damage response genes, suggesting that not only DNA DSBs, but also other types of DNA damage, do not significantly mark aged muscle stem cells. Satellite cells from DNA DSB-repair-deficient SCID mice do have an unsurprisingly higher level of innate DNA DSBs and a weakened recovery from gamma-radiation-induced DNA damage. Interestingly, they are as myogenic in vitro and in vivo as satellite cells from young wild type mice, suggesting that the inefficiency in DNA DSB repair does not directly correlate with the ability to regenerate muscle after injury. Overall, our findings suggest that a DNA DSB-repair deficiency is unlikely to be a key factor in the decline in muscle regeneration observed upon aging.


Diversity and Ecological Characterization of Sporulating Higher Filamentous Marine Fungi Associated with Spartina maritima (Curtis) Fernald in Two Portuguese Salt Marshes.
Fungal communities associated with early stages of decomposition of Spartina maritima (Curtis) Fernald were assessed in two geographically distinct salt marshes in Portugal by direct observation of fungal sporulating structures. Twenty-three fungal taxa were identified from 390 plant samples, 11 of which were common to both study sites. Natantispora retorquens, Byssothecium obiones, Phaeosphaeria spartinicola, Phoma sp. 1 and Stagonospora sp. were the most frequent fungal taxa in the studied communities. The fungal species Anthostomella spissitecta, Camarosporium roumeguerii, Coniothyrium obiones, Decorospora gaudefroyi, Halosarpheia trullifera, Leptosphaeria marina and Stagonospora haliclysta were recorded for the first time on S. maritima plants; with the exception of C. roumeguerii and L. marina, all of these species were also new records for Portugal. The differences between species composition of the communities associated with S. maritima were attributed to differences in abiotic conditions of the salt marshes. Although the fungal taxa were distributed differently along the host plants, common species to both fungal communities were found on the same relative position, e.g. B. obiones, Lulworthia sp. and N. retorquens occurred on the basal plant portions, Buergenerula spartinae, Dictyosporium pelagicum and Phoma sp. 1 on the middle plant portions and P. spartinicola and Stagonospora sp. on the top plant portions. The distinct vertical distribution patterns reflected species-specific salinity requirements and flooding tolerance, but specially substrate preferences. The most frequent fungi in both communities also exhibited wider distribution ranges and produced a higher number of fruiting structures, suggesting a more active key role in the decay process of S. maritima.


Meta-analysis of Androgen Insensitivity in Preoperative Hormone Therapy in Hypospadias.
To define androgen insensitivity prevalence in hypospadias patients treated with preoperative hormone therapy. We searched databases that were published in English and Chinese up to September 10, 2014 for our studies. Eligibility criteria were pre-established. Title, abstract, and full-text screenings were conducted by 2 authors independently. Discrepancies were resolved by consensus. Quality assessment of included studies was completed. Meta-analysis was done when appropriate using R, version 3.1.1 for Windows. Heterogeneity among individual studies was tested using the Cochran chi-square Q test and quantified by calculating the I(2) index. Thirteen of 1278 publications met inclusion criteria and were incorporated into this study. Of 306 patients with preoperative hormone therapy, 25 displayed androgen resistance. Meta-analysis demonstrated that the random-effects model generates a pooled estimate of 7.14% (95% confidence interval [CI], 3.16%-15.31%), whereas the fixed-effect model provides an estimate of 14.61% (95% CI, 10.00%-20.85%). Heterogeneity among included studies was found above medium (I(2) = 67.1% [95% CI, 41.2%-81.6%]; P = .0003]. After exclusion of the heterogeneity, both random-effects and fixed-effect models produce a consistent pooled estimate of 6.95% (95% CI, 0%-47.8%). We have defined that the prevalence of androgen resistance in hypospadias is 7.14% (95% CI, 3.16%-15.31%). To distinguish isolated hypospadias from patients with androgen insensitivity syndrome, we recommend that androgen-resistant patients should be specifically targeted by molecularly focused diagnosis. Management strategies should include identification of mutations in the androgen receptor gene, timely surgery to repair hypospadias, and long-term follow-up of sexual function and fertility later in life.


Practice nurses and older people: a case management approach to care.
This paper reports on aspects of a study designed to answer the research questions: (i) To what extent do practice nurses use the five cyclical elements of a case management approach when caring for people aged over 75 years? (ii) What determines or deters practice nurses' use of the cyclical elements of a case management approach in caring for older people? Case management is an approach that uses a cyclical process of assessment, planning, implementation, monitoring and evaluation to provide systematic proactive care to people with complex health and social care needs. In England, specialist practice nurse case managers for older people have been piloted in ten primary care trusts and the posts are to be implemented nationally by 2008. No baseline work has, however, considered the applicability of developing the existing generalist practice nurse workforce. A 26-item structured postal questionnaire was used to explore both practice nurses' use of a case management approach when working with older people, and what factors influenced the care provided. A random sample of 500 practice nurses was selected from the Royal College of Nursing Practice Nurse Association member database. A 45% response rate was achieved. Practice nurses assessed, planned and implemented care, but reviewing medication opportunistically and evaluating the care were uncommon. A case management approach was significantly (P = 0.005) more likely to be used in on-going management activities than in one-off treatment room care. Practice nurses with postregistration education in district nursing were significantly (P = 0.016) more likely to refer patients to social care services. Lack of time and the central role of the general practitioner were the main reasons for not incorporating case management into practice. CONCLUSIONS. The extent to which practice nurses used elements of a case management approach was highly variable and influenced by individual professional expertise, the nature of the consultation and the practice nurse's position in the general practice.


Multilaboratory evaluation of methods for detecting enteric viruses in soils.
Two candidate methods for the recovery and detection of viruses in soil were subjected to round robin comparative testing by members of the American Society for Testing and Materials D19:24:04:04 Subcommittee Task Group. Selection of the methods, designated "Berg" and "Goyal," was based on results of an initial screening which indicated that both met basic criteria considered essential by the task group. Both methods utilized beef extract solutions to achieve desorption and recovery of viruses from representative soils: a fine sand soil, an organic muck soil, a sandy loam soil, and a clay loam soil. One of the two methods, Goyal, also used a secondary concentration of resulting soil eluants via low-pH organic flocculation to achieve a smaller final assay volume. Evaluation of the two methods was simultaneously performed in replicate by nine different laboratories. Each of the produced samples was divided into portions, and these were respectively subjected to quantitative viral plaque assay by both the individual, termed independent, laboratory which had done the soil processing and a single common reference laboratory, using a single cell line and passage level. The Berg method seemed to produce slightly higher virus recovery values; however, the differences in virus assay titers for samples produced by the two methods were not statistically significant (P less than or equal to 0.05) for any one of the four soils. Despite this lack of a method effect, there was a statistically significant laboratory effect exhibited by assay titers from the independent versus reference laboratories for two of the soils, sandy loam and clay loam.


Topological data analysis: A promising big data exploration tool in biology, analytical chemistry and physical chemistry.
An important feature of experimental science is that data of various kinds is being produced at an unprecedented rate. This is mainly due to the development of new instrumental concepts and experimental methodologies. It is also clear that the nature of acquired data is significantly different. Indeed in every areas of science, data take the form of always bigger tables, where all but a few of the columns (i.e. variables) turn out to be irrelevant to the questions of interest, and further that we do not necessary know which coordinates are the interesting ones. Big data in our lab of biology, analytical chemistry or physical chemistry is a future that might be closer than any of us suppose. It is in this sense that new tools have to be developed in order to explore and valorize such data sets. Topological data analysis (TDA) is one of these. It was developed recently by topologists who discovered that topological concept could be useful for data analysis. The main objective of this paper is to answer the question why topology is well suited for the analysis of big data set in many areas and even more efficient than conventional data analysis methods. Raman analysis of single bacteria should be providing a good opportunity to demonstrate the potential of TDA for the exploration of various spectroscopic data sets considering different experimental conditions (with high noise level, with/without spectral preprocessing, with wavelength shift, with different spectral resolution, with missing data).


The impact of hospital attributes on patient choice for first visit: evidence from a discrete choice experiment in Shanghai, China.
The underutilization of primary care in urban China threatens the efficiency and effectiveness of the Chinese health system. To guide patient flow to primary care, the Chinese government has rolled out a sequence of health care reforms which improve the affordability, the infrastructure and workforce of the primary care system. However, these measures have not yielded the desired effect on the utilization of primary care, which is lowest in urban areas. It is unclear how the factors identified to influence facility choice in urban China are actually impacting choice behaviour. We conducted a discrete choice experiment to elicit the quantitative impact of facility attributes when choosing a health care facility for first visit and analysed how the stated choice varies with these attributes. We found that the respondents placed different weights on the identified attributes, depending on whether they perceived their condition to be minor or severe. For conditions perceived as minor, the respondents valued visit time, equipment and medical skill most. For conditions perceived as severe, they placed most importance on equipment, travel time and facility size. We found that for conditions perceived as minor, only 14% preferred visiting a facility over opting out, a percentage which would more than double to 37% if community health centres were maximally improved. For conditions perceived as severe, improvements in community health centres may almost double first visits to primary care, mostly from patients who would otherwise choose higher-level facilities. Our findings suggest that for both severity conditions, improvements to medical equipment and medical skill at community health centres in urban China can effectively direct patient flow to primary care and promote the efficiency and effectiveness of the urban health system.


De novo design of a D2-symmetrical protein that reproduces the diheme four-helix bundle in cytochrome bc1.
An idealized, water-soluble D(2)-symmetric diheme protein is constructed based on a mathematical parametrization of the backbone coordinates of the transmembrane diheme four-helix bundle in cytochrome bc(1). Each heme is coordinated by two His residues from diagonally apposed helices. In the model, the imidazole rings of the His ligands are held in a somewhat unusual perpendicular orientation as found in cytochrome bc(1), which is maintained by a second-shell hydrogen bond to a Thr side chain on a neighboring helix. The resulting peptide is unfolded in the apo state but assembles cooperatively upon binding to heme into a well-folded tetramer. Each tetramer binds two hemes with high affinity at low micromolar concentrations. The equilibrium reduction midpoint potential varies between -76 mV and -124 mV vs SHE in the reducing and oxidizing direction, respectively. The EPR spectrum of the ferric complex indicates the presence of a low-spin species, with a g(max) value of 3.35 comparable to those obtained for hemes b of cytochrome bc(1) (3.79 and 3.44). This provides strong support for the designed perpendicular orientation of the imidazole ligands. Moreover, NMR spectra show that the protein exists in solution in a unique conformation and is amenable to structural studies. This protein may provide a useful scaffold for determining how second-shell ligands affect the redox potential of the heme cofactor.


Hybrid protein assembly-histone modification mechanism for PRC2-based epigenetic switching and memory.
The histone modification H3K27me3 plays a central role in Polycomb-mediated epigenetic silencing. H3K27me3 recruits and allosterically activates Polycomb Repressive Complex 2 (PRC2), which adds this modification to nearby histones, providing a read/write mechanism for inheritance through DNA replication. However, for some PRC2 targets, a purely histone-based system for epigenetic inheritance may be insufficient. We address this issue at the Polycomb target FLOWERING LOCUS C (FLC) in Arabidopsis thaliana, as a narrow nucleation region of only ~three nucleosomes within FLC mediates epigenetic state switching and subsequent memory over many cell cycles. To explain the memory's unexpected persistence, we introduce a mathematical model incorporating extra protein memory storage elements with positive feedback that persist at the locus through DNA replication, in addition to histone modifications. Our hybrid model explains many features of epigenetic switching/memory at FLC and encapsulates generic mechanisms that may be widely applicable.


Simulated lumbar minimally invasive surgery educational model with didactic and technical components.
The learning and development of technical skills are paramount for neurosurgical trainees. External influences and a need for maximizing efficiency and proficiency have encouraged advancements in simulator-based learning models. To confirm the importance of establishing an educational curriculum for teaching minimally invasive techniques of pedicle screw placement using a computer-enhanced physical model of percutaneous pedicle screw placement with simultaneous didactic and technical components. A 2-hour educational curriculum was created to educate neurosurgical residents on anatomy, pathophysiology, and technical aspects associated with image-guided pedicle screw placement. Predidactic and postdidactic practical and written scores were analyzed and compared. Scores were calculated for each participant on the basis of the optimal pedicle screw starting point and trajectory for both fluoroscopy and computed tomographic navigation. Eight trainees participated in this module. Average mean scores on the written didactic test improved from 78% to 100%. The technical component scores for fluoroscopic guidance improved from 58.8 to 52.9. Technical score for computed tomography-navigated guidance also improved from 28.3 to 26.6. Didactic and technical quantitative scores with a simulator-based educational curriculum improved objectively measured resident performance. A minimally invasive spine simulation model and curriculum may serve a valuable function in the education of neurosurgical residents and outcomes for patients.


Planar polarity, tissue polarity and planar morphogenesis in plants.
Plant tissues commonly undergo morphogenesis within a single tissue layer or between associated cells of the same tissue type such as vascular cells. Tissue morphogenesis may rely on an underlying tissue polarity marked by coordinated unidirectional asymmetric localisation of molecules to ends of cells. When observed in the plane of the tissue layer this is referred to as planar polarity and planar morphogenesis. However, planar morphogenesis can also involve multidirectional or differential growth of cells relying on cell-cell communication. Here, we review recent progress towards an understanding of hormonal coordination and molecular mechanisms underlying planar and tissue polarity as well as planar morphogenesis. Furthermore, we discuss the role of physical forces in planar morphogenesis and the contribution of tissue polarity to plant organ shape.


Metabolic imaging of human cumulus cells reveals associations among metabolic profiles of cumulus cells, patient clinical factors, and oocyte maturity.
To determine whether fluorescence lifetime imaging microscopy (FLIM) detects differences in metabolic state among cumulus cell samples and whether their metabolic state is associated with patient age, body mass index (BMI), and antimüllerian hormone (AMH) level and maturity of the oocyte. Prospective observational study. Academic laboratory. Cumulus cell (CC) clusters from cumulus-oocyte complexes were collected from patients undergoing assisted reproductive technology treatment after oocyte retrieval and vitrified. Cumulus cell metabolism was assessed using FLIM to measure autofluorescence of nicotinamide adenine (phosphate) dinucleotide and flavine adenine dinucleotide, endogenous coenzymes essential for cellular respiration and glycolysis. Patient age, BMI, and AMH level and the maturity of the corresponding oocytes were recorded. Quantitative information from FLIM was obtained regarding metabolite concentrations from fluorescence intensity and metabolite enzyme engagement from fluorescence lifetimes. Associations were investigated between each FLIM parameter and oocyte maturity and patient age, BMI, and AMH. Variance between CC clusters within and between patients was determined. Of 619 CC clusters from 193 patients, 90 were associated with immature oocytes and 505 with metaphase II oocytes. FLIM enabled quantitative measurements of the metabolic state of CC clusters. These parameters were significantly correlated with patient age and AMH independently, but not with BMI. Cumulus cell nicotinamide adenine (phosphate) dinucleotide FLIM parameters and redox ratio were significantly associated with maturity of the enclosed oocyte. FLIM detects variations in the metabolic state of CCs, showing a greater variance among clusters from each patient than between patients. Fluorescence lifetime imaging microscopy can detect CC metabolic associations with patient age and AMH and variations between mature and immature oocytes, suggesting the potential utility of this technique to help identify superior oocytes.


Neuronal gene expression in the waking state: a role for the locus coeruleus.
Several transcription factors are expressed at higher levels in the waking than in the sleeping brain. In experiments with rats, the locus coeruleus, a noradrenergic nucleus with diffuse projections, was found to regulate such expression. In brain regions depleted of noradrenergic innervation, amounts of c-Fos and nerve growth factor-induced A after waking were as low as after sleep. Phosphorylation of cyclic adenosine monophosphate response element-binding protein was also reduced. In contrast, electroencephalographic activity was unchanged. The reduced activity of locus coeruleus neurons may explain why the induction of certain transcription factors, with potential effects on plasticity and learning, does not occur during sleep.


Adherence and persistence with oral adjuvant chemotherapy in older women with early-stage breast cancer in CALGB 49907: adherence companion study 60104.
Patient adherence is critical in evaluating the effectiveness of an oral therapy. We sought to measure adherence among women randomly assigned to capecitabine in a preplanned substudy of a multicenter clinical trial. Cancer and Leukemia Group B study CALGB 49907 was a randomly assigned trial comparing standard chemotherapy versus oral chemotherapy with capecitabine in patients age 65 years or older with early-stage breast cancer. We used microelectronic monitoring system (MEMS) caps on participants' capecitabine bottles to record pill bottle openings. Capecitabine was given in two divided daily doses for 14 consecutive days of a 21-day cycle for six cycles. Adherence was calculated as the number of doses taken divided by doses expected, taking into account toxicity-related dosing changes. A participant was defined as adherent if 80% or more of expected doses were recorded by MEMS. Overall, 161 patients were enrolled. Median age was 71 years (range, 65 to 89 years); 124 patients (83%) persisted with capecitabine to completion of planned protocol therapy. Adherence was 78% across all cycles, and adherence did not vary by cycle (P = .32). Twenty-five percent of participants took fewer than 80% of expected doses and were nonadherent. In a logistic regression model, participants with node-negative disease (P = .01) and mastectomy (P = .01) were more likely to be nonadherent. Adherence was not related to age, tumor stage, or hormone receptor status. Adherence was not significantly associated with relapse-free survival or grade 3 or 4 toxicity. Most older women with early-stage breast cancer were adherent to short-term oral chemotherapy in a randomized clinical trial. Age was not associated with adherence.


Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke.
The timely delivery of guideline-concordant care may reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes. To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide. This cohort study included 8201 patients with TIA or minor stroke cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014). Patients with length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis were excluded. Outlier facilities for each process of care were identified by constructing 95% CIs around the facility pass rate and national pass rate sites when the 95% CIs did not overlap. Data analysis occurred from January 16, 2016, through June 30, 2017. Ten elements of care were assessed using validated electronic quality measures. In the 8201 patients included in the study (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white), performance varied across elements of care: brain imaging by day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use by day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation by day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), deep vein thrombosis prophylaxis by day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control by day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation by day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography by day 2 or within 1 day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging by day 2 or within 6 months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription by day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%). Performance varied substantially across facilities (eg, neurology consultation had a facility outlier rate of 53.0%). Performance was higher for admitted patients than for patients cared for only in EDs with the greatest disparity for carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001). This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED. Health care systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.


Effects of Hybrid and Non-hybrid Epichloë Endophytes and Their Associated Host Genotypes on the Response of a Native Grass to Varying Environments.
Asexual Epichloë endophytes are prevalent in cool season grasses, and many are of hybrid origin. Hybridization of asexual endophytes is thought to provide a rapid influx of genetic variation that may be adaptive to endophyte-host grass symbiota in stressful environments. For Arizona fescue (Festuca arizonica), hybrid symbiota are commonly found in resource-poor environments, whereas non-hybrid symbiota are more common in resource-rich environments. There have been very few experimental tests where infection, hybrid and non-hybrid status, and plant genotype have been controlled to tease apart their effects on host phenotype and fitness in different environments. We conducted a greenhouse experiment where hybrid (H) and non-hybrid (NH) endophytes were inoculated into plant genotypes that were originally uninfected (E-) or once infected with either the H or NH endophytes. Nine endophyte and plant genotypic group combinations were grown under low and high water and nutrient treatments. Inoculation with the resident H endophyte enhanced growth and altered allocation to roots and shoots, but these effects were greatest in resource-rich environments, contrary to expectations. We found no evidence of co-adaptation between endophyte species and their associated host genotypes. However, naturally E- plants performed better when inoculated with the hybrid endophyte, suggesting these plants were derived from H infected lineages. Our results show complex interactions between endophyte species of hybrid and non-hybrid origin with their host plant genotypes and environmental factors.


Generation and characterisation of CD1d tetramer produced by a lentiviral expression system.
The alpha-galactosylceramide (alphaGalCer)-loaded CD1d tetramer remains the most powerful tool in identifying natural killer T (NKT) cells, a subpopulation of T cells that express an unusual semi-invariant T cell antigen receptor, and mediate a variety of proinflammatory and immunoregulatory functions. The difficulty of generating large amounts of the alphaGalCer-CD1d tetramer has limited its availability and consequently hampered the study of NKT cells. In this report, we used a lentiviral system to generate stable cell lines producing beta2m-CD1d single chain protein in large quantities and in a relatively short period of time. When the protein was loaded with alphaGalCer and tetramerised with fluorescence-labelled streptavidin, its ability to efficiently bind to NKT cells was confirmed both by phenotype analysis and functional study. The CD1d tetramer generated from these stable cell lines should facilitate a wide range of studies on the biology and clinical applications of CD1d-restricted NKT cells.


Differential receivers with highly -uniform MSM Germanium photodetectors capped by SiGe layer.
Waveguide integrated MSM (metal-semiconductor-metal) Germanium (Ge) photodetectors (PDs) with a SiGe capping layer were exploited for silicon photonics integration. Under optimized epitaxial growth conditions, the capping layer passivated the Ge surface, resulting in sufficiently low dark current of the PDs. In addition, the PDs exhibited a narrower distribution of the dark current than PDs with a Si capping layer, probably due to the lower surface leakage current. Low-noise differential receivers with uniform MSM Ge PDs exhibiting 10 Gbps data transmission were realized.


Distribution of Toxocara infection in the environment and in definitive and paratenic hosts in Estonia.
The aim of the study was to elucidate the distribution and possible transmission routes of Toxocara spp. infection in Estonia. Out of 454 faecal and sand samples collected from park lawns and sandpits in the town of Tartu, 19 were Toxocara positive (4.2%). Out of the 45 sandpit samples 17.8% were Toxocara positive. Cat faeces was found in 21 sandpit samples. Parasitological necropsies were performed on 41 euthanised stray dogs and 27 cats in the Tallinn Dog Home. Additionally, 13 wild free-roaming brown rats (Rattus norvegicus) were captured from the Tallinn Dog Home territory, necropsied and studied for the presence of Toxocara larvae. Toxocara canis adults were found in 14.6% of the dogs and Toxocara cati (syn. mystax) adults in the small intestines of 48.2% of the cats examined. Larval infection was detected in the kidney and liver in 5 dogs (12.2%). Our study demonstrated only low-level larval Toxocara infections in adult dogs. Toxocara larvae were not found in cats and brown rats. According to the results of this study, cats more often carry Toxocara infection than dogs. Under our conditions, stray and free-roaming cats are the main contaminators of the environment with Toxocara eggs. Children playing in sandpits are the main risk group for larval toxocarosis.


Safe use of radioisotopes.
The use of radioisotopes to label specific molecules in a defined way has greatly advanced the discovery and dissection of biochemical pathways. The development of methods to inexpensively synthesize such tagged biological compounds on an industrial scale has enabled them to be used routinely in laboratory protocols, including many detailed in this manual. Although most of these protocols involve the use of only microcurie (mCi) amounts of radioactivity, some (particularly those describing the metabolic labeling of proteins or nucleic acids within cells) require amounts on the order of millicuries (mCi). In all cases where radioisotopes are used, depending on the quantity and nature of the isotope, certain precautions must be taken to ensure the safety of the investigator. It is essential to use good safety practices and proper protection to handle radioactive substances. This unit discusses storage, handling, and disposal of 35S, 32P, 33P, and 125I.


A direct role for c-fos in AP-1-dependent gene transcription.
Transcription factor activator protein 1 (AP-1) is a protein fraction that contains c-fos, c-jun, and several other related proteins. Although this protein fraction can stimulate transcription in vitro, the relative contributions of c-fos and c-jun to the transcriptional effect of AP-1 are not clear. In order to approach this question, we have overexpressed both proteins using a baculovirus-mediated expression system and defined their DNA-binding and transcriptional enhancement activities in vitro. Gel mobility-shift and DNase 1 footprinting assays showed that c-jun protein specifically binds to DNA through an AP-1 binding site. Under the same conditions, no detectable binding of c-fos protein was observed. However, when the DNA binding assays were performed in the presence of both c-jun and c-fos, a marked increase in the affinity of c-jun for the AP-1 site was observed. An AP-1-dependent transcription assay was used to test the capability of both proteins to stimulate correctly initiated RNA synthesis in vitro. Under our conditions, c-jun protein was capable of stimulating specific RNA transcription in an AP-1 site-dependent manner. In contrast, c-fos protein showed no detectable transcriptional activation by itself. However, a transcription assay carried out in the presence of both c-fos and c-jun proteins showed that the c-fos/c-jun complex was more active as a transcriptional regulator than c-jun protein alone. These experimental results indicate that c-fos and c-jun proteins are required to reconstitute full AP-1-dependent transcriptional activation and directly demonstrate that c-fos is a regulator of gene expression.


Hypoglycemic and anti-lipemic effects of the aqueous extract from Cissus sicyoides.
Cissus sicyoides (Vitaceae) is a medicinal plant popularly known in Brazil as "cipó-pucá, anil-trepador, cortina, and insulina". The plant is used in several diseases, including rheumatism, epilepsy, stroke and also in the treatment of diabetes. In the present work, we studied the hypoglycemic and anti-lipemic effects of the aqueous extract prepared from fresh leaves of the plant (AECS), in the model of alloxan-induced diabetes in rats. In addition, hepatic enzyme levels were also determined. Results showed that the daily treatment of diabetic rats with AECS for 7 days (100 and 200 mg/kg, p.o.) significantly decreased blood glucose levels in 25 and 22% respectively, as compared to the same groups before AECS treatment. No significant changes were seen in control diabetic rats before (48 h after alloxan administration) and after distilled water treatment. While no changes were seen in total cholesterol levels, a significant decrease was observed in plasma triglyceride levels, in the alloxan-induced diabetic rats after AECS treatment with both doses, as compared to the same groups before treatment. Significant decreases in blood glucose (25%) and triglyceride levels (48%) were also observed in the alloxan-induced diabetic rats after 4 days treatment with AECS (200 mg/kg, p.o.). Aspartate (AST) and alanine (ALT) aminotransferases levels, in diabetic controls and AECS-treated rats, were in the range of reference values presented by normal rats. The results justify the popular use of C. sicyoides, pointing out to the potential benefit of the plant aqueous extract (AECS) in alternative medicine, in the treatment of type 2 diabetes mellitus.


Temporal variation in selection on body length and date of return in a wild population of coho salmon, Oncorhynchus kisutch.
A number of studies have measured selection in nature to understand how populations adapt to their environment; however, the temporal dynamics of selection are rarely investigated. The aim of this study was to assess the temporal variation in selection by comparing the mode, direction and strength of selection on fitness-related traits between two cohorts of coho salmon (Oncorhynchus kisutch). Specifically, we quantified individual reproductive success and examined selection on date of return and body length in a wild population at Big Beef Creek, Washington (USA). Reproductive success and the mode, direction and strength of selection on date of return and body length differed between two cohorts sampled in 2006 and 2007. Adults of the first brood year had greater success over those of the second. In 2006, disruptive selection favored early and late returning individuals in 2-year-old males, and earlier returning 3-year-old males had higher fitness. No evidence of selection on date of return was detected in females. In 2007, selection on date of return was not observed in males of either age class, but stabilizing selection on date of return was observed in females. No selection on body length was detected in males of both age classes in 2006, and large size was associated with higher fitness in females. In 2007, selection favored larger size in 3-year-old males and intermediate size in females. Correlational selection between date of return and body length was observed only in 2-year-old males in 2006. We found evidence of selection on body length and date of return to the spawning ground, both of which are important fitness-related traits in salmonid species, but this selection varied over time. Fluctuation in the mode, direction and strength of selection between two cohorts was likely to be due to factors such as changes in precipitation, occurrence of catastrophic events (flooding), the proportion of younger- versus older-maturing males, sex ratio and densities of spawners.


The Efficacy of Rituximab Combined with 131I for Ophthalmic Outcomes of Graves' Ophthalmopathy Patients.
The purpose of this study is to examine the effectiveness of introducing both rituximab (RTX) and 131I for active Graves' ophthalmopathy (GO) with hyperthyroidism. In total, 217 patients suffering from active GO with hyperthyroidism were included in this research. All subjects were randomly assigned to 3 groups. Patients in group A solely received 131I treatment; group B1 underwent a methylprednisolone treatment in combination with 131I treatment; and group B2 received an RTX in combination with 131I treatment. Hyperthyroidism treatment outcomes, orbital volumetry, ophthalmic assessments, serum cytokine levels, and adverse effects were measured after treatment. The orbital volumetry principle was significantly different from 24 weeks after the start of treatment among all 3 groups, and improvements in most ophthalmic parameters were regarded significantly different among 3 groups (all p < 0.05). The expression levels of miR-146a and most serum cytokines were regarded significantly different from 24 weeks after the start of treatment among 3 groups (all p < 0.05). In comparison with other therapies, RTX treatment in combination with 131I treatment is considered to be more effective for hyperthyroidism with active GO.


Effects of TZD Use and Discontinuation on Fracture Rates in ACCORD Bone Study.
In trials, thiazolidinediones (TZDs) increase fracture risk in women, but the effects of discontinuation are unknown. The objective was to investigate the effects of TZD use and discontinuation on fractures in women and men. This was a longitudinal observational cohort study using data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial bone ancillary study. Duration of TZD use and discontinuation during ACCORD, assessed every 2-4 months at clinic visits, were modeled as time-varying covariates in proportional hazards models for occurrence of first non-spine fracture. We studied a total of 6865 participants in ACCORD BONE. Main outcome measures were centrally adjudicated non-spine fracture. Average age was 62.4 (SD, 6.6) years; average duration of diabetes was 11.1 (SD, 7.8) years. Rosiglitazone was used by 74% and pioglitazone by 13% of participants. During a mean follow-up of 4.8 (SD, 1.5) years, 262 men and 287 women experienced at least one non-spine fracture. The fracture rate was higher in women with 1-2 years of TZD use (hazard ratio [HR] = 2.32; 95% confidence interval [CI], 1.49, 3.62) or >2 years of TZD use (HR = 2.01; 95% CI, 1.35, 2.98), compared with no use. The fracture rate was reduced in women who had discontinued TZD use for 1-2 years (HR = 0.57; 95% CI, 0.35, 0.92) or > 2 years (HR = 0.42; 95% CI, 0.24, 0.74) compared with current users. TZD use and discontinuation were not associated with non-spine fractures in men. TZD use was associated with increased non-spine fractures in women, but not men, with type 2 diabetes. When women discontinued TZD use, the fracture effects were attenuated.


Cannabinoids decrease the th17 inflammatory autoimmune phenotype.
Cannabinoids, the Cannabis constituents, are known to possess anti-inflammatory properties but the mechanisms involved are not understood. Here we show that the main psychoactive cannabinoid, Δ-9-tetrahydrocannabinol (THC), and the main nonpsychoactive cannabinoid, cannabidiol (CBD), markedly reduce the Th17 phenotype which is known to be increased in inflammatory autoimmune pathologies such as Multiple Sclerosis. We found that reactivation by MOG35-55 of MOG35-55-specific encephalitogenic T cells (cells that induce Experimental Autoimmune Encephalitis when injected to mice) in the presence of spleen derived antigen presenting cells led to a large increase in IL-17 production and secretion. In addition, we found that the cannabinoids CBD and THC dose-dependently (at 0.1-5 μM) suppressed the production and secretion of this cytokine. Moreover, the mRNA and protein of IL-6, a key factor in Th17 induction, were also decreased. Pretreatment with CBD also resulted in increased levels of the anti-inflammatory cytokine IL-10. Interestingly, CBD and THC did not affect the levels of TNFα and IFNγ. The downregulation of IL-17 secretion by these cannabinoids does not seem to involve the CB1, CB2, PPARγ, 5-HT1A or TRPV1 receptors. In conclusion, the results show a unique cannabinoid modulation of the autoimmune cytokine milieu combining suppression of the pathogenic IL-17 and IL-6 cytokines along with boosting the expression of the anti-inflammatory cytokine IL-10.


Robust structure and motion from outlines of smooth curved surfaces.
This paper addresses the problem of estimating the motion of a camera as it observes the outline (or apparent contour) of a solid bounded by a smooth surface in successive image frames. In this context, the surface points that project onto the outline of an object depend on the viewpoint and the only true correspondences between two outlines of the same object are the projections of frontier points where the viewing rays intersect in the tangent plane of the surface. In turn, the epipolar geometry is easily estimated once these correspondences have been identified. Given the apparent contours detected in an image sequence, a robust procedure based on RANSAC and a voting strategy is proposed to simultaneously estimate the camera configurations and a consistent set of frontier point projections by enforcing the redundancy of multiview epipolar geometry. The proposed approach is, in principle, applicable to orthographic, weak-perspective, and affine projection models. Experiments with nine real image sequences are presented for the orthographic projection case, including a quantitative comparison with the ground-truth data for the six data sets for which the latter information is available. Sample visual hulls have been computed from all image sequences for qualitative evaluation.


Maternal nutritional risk factors for pre-eclampsia incidence: findings from a narrative scoping review.
Pre-eclampsia is a leading cause of maternal mortality and morbidity that involves pregnancy-related stressors on the maternal cardiovascular and metabolic systems. As nutrition is important to support optimal development of the placenta and for the developing fetus, maternal diets may play a role in preventing pre-eclampsia. The purpose of this scoping review is to map the maternal nutritional deficiencies and imbalances associated with pre-eclampsia incidence and discuss evidence consistency and linkages with current understandings of the etiology of pre-eclampsia. A narrative scoping review was conducted to provide a descriptive account of available research, summarize research findings and identify gaps in the evidence base. Relevant observational studies and reviews of observational studies were identified in an iterative two-stage process first involving electronic database searches then more sensitive searches as familiarity with the literature increased. Results were considered in terms of their consistency of evidence, effect sizes and biological plausibility. The review found evidence for associations between nutritional inadequacies and a greater risk of pre-eclampsia. These associations were most likely mediated through oxidative stress, inflammation, maternal endothelial dysfunction and blood pressure in the pathophysiology of pre-eclampsia. Maternal nutritional risk factors for pre-eclampsia incidence with the strongest consistency, effect and biological plausibility include vitamin C and its potential relationship with iron status, vitamin D (both on its own and combined with calcium and magnesium), and healthy dietary patterns featuring high consumption of fruits, vegetables, whole grains, fish, seafood and monounsaturated vegetable oils. Foods high in added sugar, such as sugary drinks, were associated with increased risk of pre-eclampsia incidence. A growing body of literature highlights the involvement of maternal dietary factors in the development of pre-eclampsia. Our review findings support the need for further investigation into potential interactions between dietary factors and consideration of nutritional homeostasis and healthy dietary patterns. Further research is recommended to explore gestational age, potential non-linear relationships, dietary diversity and social, cultural contexts of food and meals.


Perceived sources of stress among Malaysian dental students.
The study objectives were to identify the stress levels and to explore the impact of students' year of study and gender on the perceived sources of stress among Malaysian dental students. This was a cross-sectional study involving dental students from year one to year five from private and public universities in Malaysia. The study was formally approved by the Research and Ethics Committee, International Medical University Malaysia. Dental Environment Stress (DES) questionnaire was used for data collection and the gathered data were analyzed using SPSS® version 18. The Kruskal-Wallis and the Mann-Whitney U tests were used to compare stress items across various academic years and universities. A total of five hundred and twenty nine (529) students participated in this study. Fear of failing the course at the end of year exams (mean stress level=5.57); concerns regarding completion of clinical work (mean=5.30); and examination results and grades (mean=5.27) were found as top stressors among dental students. Female students had higher stress scores than males with respect to personal issues, academic performance, educational environment and learning of clinical skills. Students from public universities had higher stress scores than their counterparts from private universities. The Malaysian dental students reported higher levels of stress. Present study identified stressors affecting dental students' academic life, and highlights the importance of stress management programs and other measures to minimize the impact of stress on both academic and personal lives of the students.


Potassium-induced vascular relaxation in two kidney-one clip, renal hypertensive rats.
This study was designed to characterize potassium-induced relaxation in vascular smooth muscle in two kidney-one clip (2K-1C), renal hypertensive rats. Potassium-induced relaxation was evaluated in the isolated tail artery and in the isolated pump perfused renal vasculature. Both preparations relaxed in response to potassium after contraction induced by norepinephrine in potassium-free solution. Arterial preparations from hypertensive rats showed greater relaxation than did those from normotensive rats. Potassium-induced relaxation in tail arteries from hypertensive rats was more sensitive to ouabain inhibition than those from normotensive rats; the renal vasculature of hypertensive rats did not differ from controls with respect to ouabain sensitivity. Relaxation in response to potassium in isolated tail artery segments varied with the: 1. length of incubation in potassium-free solution; 2. concentration of added potassium; and 3. concentration of norepinephrine added during the potassium-free interval. The amplitude of potassium relaxation is believed to be a functional measure of the electrogenic sodium pump. These experiments support the hypothesis that vascular smooth muscle from 2K-1C renal hypertensive rats has increased electrogenic sodium pump activity, in vitro.


'Early-onset schizophrenia' after teenage head injury. A case report with magnetic resonance imaging.
A 14-year-old youth sustained an injury to the left frontoparietal area, which was followed by evident change in personality and subsequently by an early-onset schizophrenia-like psychosis. Magnetic resonance imaging revealed ventricular dilatation, slightly more marked in the left hemisphere, and cortical atrophy. Some implications of this case for research on schizophrenia itself are discussed.


Wounding of Arabidopsis halleri leaves enhances cadmium accumulation that acts as a defense against herbivory.
Approximately 0.2% of all angiosperms are classified as metal hyperaccumulators based on their extraordinarily high leaf metal contents, for example >1% zinc, >0.1% nickel or >0.01% cadmium (Cd) in dry biomass. So far, metal hyperaccumulation has been considered to be a taxon-wide, constitutively expressed trait, the extent of which depends solely on available metal concentrations in the soil. Here we show that in the facultative metallophyte Arabidopsis halleri, both insect herbivory and mechanical wounding of leaves trigger an increase specifically in leaf Cd accumulation. Moreover, the Cd concentrations accumulated in leaves can serve as an elemental defense against herbivory by larvae of the Brassicaceae specialist small white (Pieris rapae), thus allowing the plant to take advantage of this non-essential trace element and toxin. Metal homeostasis genes are overrepresented in the systemic transcriptional response of roots to the wounding of leaves in A. halleri, supporting that leaf Cd accumulation is preceded by systemic signaling events. A similar, but quantitatively less pronounced transcriptional response was observed in A. thaliana, suggesting that the systemically regulated modulation of metal homeostasis in response to leaf wounding also occurs in non-hyperaccumulator plants. This is the first report of an environmental stimulus influencing metal hyperaccumulation.


Psychological drivers in doping: the life-cycle model of performance enhancement.
Performance enhancement (PE) is a natural and essential ingredient of competitive sport. Except for nutritional supplement contamination, accidental use of doping is highly unlikely. It requires deliberation, planning and commitment; and is influenced by a host of protective and risk factors. In the course of their career, athletes constantly set goals and make choices regarding the way these goals can be achieved. The cycle of choice - goal commitment - execution - feedback on goal attainment - goal evaluation/adjustment has numerous exit points, each providing an opportunity for behaviour change, which may or may not be related to the use of prohibited methods. The interplay between facilitating and inhibiting systemic and personality factors, constantly influenced by situational factors could result in an outcome vector of 'doping attitudes', which combines with subjective norms to influence intentions to choose prohibited PE methods. These influences also vary from one stage of athlete development to the next, making some athletes more vulnerable to engaging in doping practices than others, and more vulnerable at certain time periods - and not others. Model-testing requires a series of carefully planned and coordinated studies. Correlational studies can establish relationships where the directionality is not-known or not important. Experimental studies with the manipulation of doping expectancies and risk factors can be used to demonstrate causality and evaluate potential intervention strategies. The final model can be tested via a behavioural simulation, with outcomes compared to those expected from literature precedence or used as a simulated computer game for empirical data collection. A hypothesized life-cycle model of PE identifies vulnerability factors across the stages of athlete development with the view of informing the design of anti-doping assessment and intervention. The model suggests that, instead of focusing on the actual engagement in prohibited PE practices, deterrence strategies are likely to be more effective if they target the influencing factors at the appropriate stage and identify groups of athletes and their respective career stages, which pose particular risks of engagement in doping practices. This enables a more effective intervention approach by targeting specific risk factors and expectancies.


CYP2D6 genotype in relation to tamoxifen efficacy in a Dutch cohort of the tamoxifen exemestane adjuvant multinational (TEAM) trial.
The clinical importance of CYP2D6 genotype as predictor of tamoxifen efficacy is still unclear. Recent genotyping studies on CYP2D6 using DNA derived from tumor blocks have been criticized because loss of heterozygosity (LOH) in tumors may lead to false genotype assignment. Postmenopausal early breast cancer patients who were randomized to receive tamoxifen, followed by exemestane in a large randomized controlled trial were genotyped for five CYP2D6 alleles. CYP2D6 genotypes and phenotypes were related to disease-free survival during tamoxifen use (DFS-t) in 731 patients. By analyzing microsatellites flanking the CYP2D6 gene, patients whose genotyping results were potentially affected by LOH were excluded. In addition, exploratory analyses on 24 genetic variants of other metabolic enzymes and the estrogen receptor were performed. For the CYP2D6 analysis, only 2.3 % of the samples were excluded, because influence of LOH could not be ruled out. No association was found between the CYP2D6 genotype or predicted phenotype and DFS-t (poor vs. extensive metabolizers: unadjusted hazard ratio 1.33, 95 % CI 0.52-3.43; P = 0.55). DFS-t was associated with UGT2B15*2 (Vt/Vt + Wt/Vt vs. Wt/Wt: adjusted hazard ratio 0.47, 95 % CI 0.25-0.89; P = 0.019) and the estrogen receptor-1 polymorphism ESR1 PvuII (gene-dose effect: adjusted hazard ratio 1.63, 95 % CI 1.04-2.54; P = 0.033). In postmenopausal early breast cancer patients treated with adjuvant tamoxifen followed by exemestane neither CYP2D6 genotype nor phenotype did affect DFS-t. This is in accordance with two recent studies in the BIG1-98 and ATAC trials. Our study is the first CYP2D6 association study using DNA from paraffin-embedded tumor tissue in which potentially false interpretation of genotyping results because of LOH was excluded. Polymorphisms in the estrogen receptor-1 and UGT2B15 may be associated with tamoxifen efficacy, but these findings need replication.


Social determinants of health on glycemic control in pediatric type 1 diabetes.
To evaluate the relationship between the social determinants of health (SDH) and glycemic control in a large pediatric type 1 diabetes (T1D) population. Deprivation Indices (DI) were used to ascertain population-level measures of socioeconomic status, family structure, and ethnicity in patients with T1D followed at The Hospital for Sick Children August 2010-2011 (n = 854). DI quintile scores were determined for individual patients based on de-identified postal codes, and linked to mean patient A1Cs as a measure of glycemic control. We compared mean A1C between the most and least deprived DI quintiles. Associations were estimated controlling for age and sex, and repeated for insulin pump use. The T1D population evaluated in this study was most concentrated in the least and most deprived quintiles of the Material DI. A1C levels were highest in patients with the greatest degree of deprivation (fifth vs first quintile) on the Material DI (9.2% vs 8.3%, P < .0001), Social DI (9.1% vs 8.3%, P < .0001), and Ethnic Concentration Index (8.9% vs 8.4%, P = .03). These relationships between measures of the SDH and A1C were not evident for patients on insulin pumps. On regression analysis, higher A1C was predicted by older age, female sex, not using pump therapy, and being in the most deprived quintile for Material and Social Deprivation, but not Ethnic Concentration. Measures of the SDH comprising Material and Social Deprivation were significantly associated with suboptimal glycemic control in our pediatric T1D cohort. Use of insulin pump therapy also predicted A1C and may have a moderating effect on these relationships.


Post-stroke depression and lesion location: A hospital based cross-sectional study.
Depression is a common neuro-psychiatric consequence of stroke, affecting approximately 40% of the patients. Many studies show that in addition to the psychosocial stress, neurobiological factors such as site of infarct and brain atrophy may also be related to Post Stroke Depression (PSD). There are conflicting results in this area of research and paucity of such data in Indian literature. Thus the aim of this study is to weigh the importance of lesion location in PSD. Sixty two subjects with their first ever stroke were interviewed using a semi-structured proforma and PSD diagnosed using MINI Plus interview. Scales of Beck Depression Inventory and Montgomery Asberg Depression Rating Scale were used to assess severity of depression. Mini mental state examination was used to assess cognitive impairment and Barthel Index to measure Activities of Daily Living. Neuro-imaging provided information on site and side of lesion. Collected data was analysed using SPSS version 15.0. PSD was diagnosed in 28 subjects, amongst who 19 had left sided lesions. Left sided cortical infarcts and sub cortical infarcts showed statistically significant association with PSD. Results are in keeping with previous landmark studies. Differences in emotional reactions depending on hemisphere and site of the infarct as shown in this study suggest organic biological basis for post stroke depression. Understanding the etiological basis would allow clinicians to monitor patients at risk of developing PSD, enabling early detection and treatment thus improving their quality of life and rehabilitation.


Willingness to participate in a clinical trial and understanding of informed consent information among medical students.
Studies have shown that the decision to participate or not participate in a clinical trial does not necessarily imply that the volunteers have completely understood the clinical trial process. A study carried out among medical and non-medical student volunteers revealed that even though the former group had a better recollection of the key facts, their understanding was still below expectation. In our study, medical students were invited to voluntarily take part in a hypothetical exercise in which they were presented with an informed consent form to indicate their willingness to participate in an anti-malarial drug trial. They were encouraged to clarify their doubts and asked to answer a questionnaire to determine their willingness/unwillingness. They were asked to state their reasons and recall key information given in the informed consent form. Responses were submitted by 155 students and 51% of the respondents consented to participate in the trial. As many as 13.5% did not know the name of the drug under study, 14.8% could not recall the main adverse effects to be expected, and 12.3% did not know that they could opt out of the study, this being significantly more in those who had consented to participate (p0.0. As is evident from our study, even presenting a detailed consent form containing an explanation might leave a considerably large number of potential volunteers with an incomplete understanding of the study. Therefore, it is necessary to make an active effort to ensure that the counselling of the volunteers is based on their ability to comprehend the information provided.