Mesenchymal Stem Cell-mediated delivery of the sodium iodide symporter supports radionuclide imaging and treatment of breast cancer.
Mesenchymal Stem Cells (MSCs) migrate specifically to tumors in vivo, and coupled with their capacity to bypass immune surveillance, are attractive vehicles for tumor-targeted delivery of therapeutic agents. This study aimed to introduce MSC-mediated expression of the sodium iodide symporter (NIS) for imaging and therapy of breast cancer. Tumor bearing animals received an intravenous or intratumoral injection of NIS expressing MSCs (MSC-NIS), followed by (99m) Technetium pertechnetate imaging 3-14 days later using a BazookaSPECT γ-camera. Tissue was harvested for analysis of human NIS (hNIS) expression by relative quantitative-polymerase chain reaction. Therapy animals received an i.p. injection of (131) I or saline 14 days after injection of MSC-NIS, and tumor volume was monitored for 8 weeks. After injection of MSC-NIS, BazookaSPECT imaging revealed an image of animal intestines and chest area at day 3, along with a visible weak tumor image. By day 14, the tumor was visible with a significant reduction in radionuclide accumulation in nontarget tissue observed. hNIS gene expression was detected in the intestines, heart, lungs, and tumors at early time points but later depleted in nontarget tissues and persisted at the tumor site. Based on imaging/biodistribution data, animals received a therapeutic dose of (131) I 14 days after MSC-NIS injection. This resulted in a significant reduction in tumor growth (mean ± SEM, 236 ± 62 mm(3) vs. 665 ± 204 mm(3) in controls). The ability to track MSC migration and transgene expression noninvasively in real time before therapy is a major advantage to this strategy. This promising data supports the feasibility of this approach as a novel therapy for breast cancer.


Pathology of Haplosporidium patagon affecting siphonariid gastropods in Patagonia.
Haplosporidium patagon was found parasitizing Siphonaria lessonii and S. lateralis, 2 siphonariid gastropods co-occurring on the littoral rocky shore at Puerto Deseado, Santa Cruz, Argentina. Gastropods from 2 habitats representing 2 different levels of environmental harshness were studied. In both cases, S. lessonii showed a higher prevalence of infection (3.78%) over the entire 14 mo study period than S. lateralis (0.13%). Very different values of prevalence of infection were observed at the different sampling sites: Site 1, the more restrictive habitat (exposed for long periods to desiccation during low tides, higher ultraviolet exposure, and high ranges of temperature variation) showed a higher prevalence value (5.99%) than Site 2 (1.46%). Statistical differences in prevalence were also found between values corresponding to the austral spring (3.35% at Site 1 and 0.74% at Site 2) and winter (13.79% at Site 1 and 2.13% at Site 2). The presence/absence of H. patagon did not vary significantly with gastropod shell length. Infection affected the digestive gland, whose normal histology was greatly modified. The hermaphroditic gonads were also affected; the female germinal cells disappeared or only a few primary or previtellogenic oocytes were present, and vitellogenesis was inhibited. The function of the male germinal epithelium, as well as spermatogenesis and spermiogenesis processes and associated organs (seminal vesicles and seminal receptacles), were not affected. However, the glandular pallial complex of the reproductive systemwas affected, and we observed a significant reduction in development in parasitized gastropods. H. patagon sporocysts also invaded the supporting connective tissues of both the kidney and pseudobranch.


The visual analogue pain intensity scale: what is moderate pain in millimetres?
One way to ensure adequate sensitivity for analgesic trials is to test the intervention on patients who have established pain of moderate to severe intensity. The usual criterion is at least moderate pain on a categorical pain intensity scale. When visual analogue scales (VAS) are the only pain measure in trials we need to know what point on a VAS represents moderate pain, so that these trials can be included in meta-analysis when baseline pain of at least moderate intensity is an inclusion criterion. To investigate this we used individual patient data from 1080 patients from randomised controlled trials of various analgesics. Baseline pain was measured using a 4-point categorical pain intensity scale and a pain intensity VAS under identical conditions. The distribution of the VAS scores was examined for 736 patients reporting moderate pain and for 344 reporting severe pain. The VAS scores corresponding to moderate or severe pain were also examined by gender. Baseline VAS scores recorded by patients reporting moderate pain were significantly different from those of patients reporting severe pain. Of the patients reporting moderate pain 85% scored over 30 mm on the corresponding VAS, with a mean score of 49 mm. For those reporting severe pain 85% scored over 54 mm with a mean score of 75 mm. There was no difference between the corresponding VAS scores of men and women. Our results indicate that if a patient records a baseline VAS score in excess of 30 mm they would probably have recorded at least moderate pain on a 4-point categorical scale.


A pilot study of the impact of housing first-supported housing for intensive users of medical hospitalization and sobering services.
We examined changes in service use in a Housing First (HF) pilot program for adults who were homeless with medical illnesses and high prior acute-care use relative to a similar comparison group. We used a 1-year pre-post comparison group design. The 29 participants and 31 comparison group members were adults who were homeless with inpatient claims of at least $10 000 or at least 60 sobering "sleep off" center contacts in the prior year. Participants showed a significantly greater reduction in emergency department and sobering center use relative to the comparison group. At a trend level, participants had greater reductions in hospital admissions and jail bookings. Reductions in estimated costs for participants and comparison group members were $62 504 and $25 925 per person per year-a difference of $36 579, far outweighing program costs of $18 600 per person per year. HF participants showed striking reductions in acute-care use relative to the comparison group, demonstrating that HF can be a successful model for people with complex medical conditions and high prior acute-care use. Despite notable methodological limitations, these findings could be used to inform a larger multisite study that would establish greater generalizability.


The Italian version of the quick mild cognitive impairment (Qmci-I) screen: normative study on 307 healthy subjects.
To devise an Italian version of the quick mild cognitive impairment screen (Qmci) and to obtain normative data. An Italian version of the Qmci screen (Qmci-I) was administered to 307 subjects free from cognitive impairment. The normative sample was divided into three age levels (50-59; 60-69 and 70-80 years) and four education levels (3-5; 6-8; 9-13; >13 years of school attendance). Multiple regression analyses were used to evaluate the effect of age, sex and schooling on Qmci-I scores (overall and by domains) and to calculate cut-off values, with reference to the confidence interval on the fifth centile. The mean Qmci-I score was 64/100 (SD = 11). The age variable showed a significant negative effect on the overall Qmci-I score, with older people performing worse than younger ones. Conversely, education was associated with higher scores. Significant effects of age and education affected logical memory alone. For the other domains, the following effects were found: (1) higher age associated with lower scores on delayed recall; (2) higher education levels associated with higher scores on immediate recall, clock drawing and word fluency. The adjusted cut-off score for the Qmci-I screen in this sample was 49.4. Qmci-I scores were weakly correlated with those of MMSE (rho = 0.20). The Qmci-I is a rapid and multi-domain short cognitive screening instrument useful for evaluating cognitive functions. However, like other screening tools, it is significantly influenced by age and education, requiring normative data and correction of values when used in the clinical practice.


The human plasma proteome: history, character, and diagnostic prospects.
The human plasma proteome holds the promise of a revolution in disease diagnosis and therapeutic monitoring provided that major challenges in proteomics and related disciplines can be addressed. Plasma is not only the primary clinical specimen but also represents the largest and deepest version of the human proteome present in any sample: in addition to the classical "plasma proteins," it contains all tissue proteins (as leakage markers) plus very numerous distinct immunoglobulin sequences, and it has an extraordinary dynamic range in that more than 10 orders of magnitude in concentration separate albumin and the rarest proteins now measured clinically. Although the restricted dynamic range of conventional proteomic technology (two-dimensional gels and mass spectrometry) has limited its contribution to the list of 289 proteins (tabulated here) that have been reported in plasma to date, very recent advances in multidimensional survey techniques promise at least double this number in the near future. Abundant scientific evidence, from proteomics and other disciplines, suggests that among these are proteins whose abundances and structures change in ways indicative of many, if not most, human diseases. Nevertheless, only a handful of proteins are currently used in routine clinical diagnosis, and the rate of introduction of new protein tests approved by the United States Food and Drug Administration (FDA) has paradoxically declined over the last decade to less than one new protein diagnostic marker per year. We speculate on the reasons behind this large discrepancy between the expectations arising from proteomics and the realities of clinical diagnostics and suggest approaches by which protein-disease associations may be more effectively translated into diagnostic tools in the future.


BMPs are necessary for stomach gland formation in the chicken embryo: a study using virally induced BMP-2 and Noggin expression.
Epithelial-mesenchymal interactions are necessary for the normal development of various digestive organs. In chicken proventriculus (glandular stomach), morphogenesis and differentiation of the epithelium depend upon the inductive signals coming from underlying mesenchyme. However, the nature of such signals is still unclear despite extensive analyses carried out using experimental tissue recombinations. In this study we have examined the possible involvement of bone morphogenetic proteins (BMPs) in the formation of stomach glands in the chicken embryo. Analysis of the expression patterns of BMP-2, -4 and -7 showed that these BMPs were present in the proventricular mesenchyme prior to the initiation of the proventricular gland formation. BMP-2 expression, in particular, was restricted to the proventriculus among anterior digestive organs. Virus-mediated BMP-2 overexpression resulted in an increase in the number of glands formed. Moreover, ectopic expression of Noggin, which antagonizes the effect of BMPs, in the proventricular mesenchyme or epithelium, led to the complete inhibition of gland formation, indicating that BMP signals are necessary for the proventricular gland formation. These findings suggest that BMPs are of prime importance as mesenchymal signals for inducing proventricular glands.


METTL23, a transcriptional partner of GABPA, is essential for human cognition.
Whereas many genes associated with intellectual disability (ID) encode synaptic proteins, transcriptional defects leading to ID are less well understood. We studied a large, consanguineous pedigree of Arab origin with seven members affected with ID and mild dysmorphic features. Homozygosity mapping and linkage analysis identified a candidate region on chromosome 17 with a maximum multipoint logarithm of odds score of 6.01. Targeted high-throughput sequencing of the exons in the candidate region identified a homozygous 4-bp deletion (c.169_172delCACT) in the METTL23 (methyltransferase like 23) gene, which is predicted to result in a frameshift and premature truncation (p.His57Valfs*11). Overexpressed METTL23 protein localized to both nucleus and cytoplasm, and physically interacted with GABPA (GA-binding protein transcription factor, alpha subunit). GABP, of which GABPA is a component, is known to regulate the expression of genes such as THPO (thrombopoietin) and ATP5B (ATP synthase, H+ transporting, mitochondrial F1 complex, beta polypeptide) and is implicated in a wide variety of important cellular functions. Overexpression of METTL23 resulted in increased transcriptional activity at the THPO promoter, whereas knockdown of METTL23 with siRNA resulted in decreased expression of ATP5B, thus revealing the importance of METTL23 as a regulator of GABPA function. The METTL23 mutation highlights a new transcriptional pathway underlying human intellectual function.


Cerebellar ataxia due to isolated vitamin E deficiency.
Ataxia is a common and important neurological finding in medical practice. Severe deficiency of Vitamin E can profoundly affect the central nervous system and can cause ataxia and peripheral neuropathy resembling Friedreich's ataxia. Vitamin E deficiency can occur with abetalipoproteinemia, cholestatic liver disease or fat malabsorption. Ataxia with isolated Vit E deficiency (AVED) is an Autosomal Recessive genetic disorder with a mutation in the alpha tocopherol transfer protein gene (TTPA). This condition responds to high dose of Vit E and is one of the important causes of treatable ataxia. We report a young patient with Ataxia with isolated Vit E deficiency (AVED) who responded partially to replacement of Vitamin E.


Continuous epicapsular ropivacaine 0.3% infusion after minimally invasive hip arthroplasty: a prospective, randomized, double-blinded, placebo-controlled study comparing continuous wound infusion with morphine patient-controlled analgesia.
In this study, we investigated the impact of a continuous wound infusion with ropivacaine 0.3% on pain and morphine consumption after minimally invasive hip arthroplasty. Seventy-six consecutive patients scheduled for elective minimally invasive hip replacement using spinal anesthesia were prospectively included in this double-blind study. Epicapsular placement of a 15-cm fenestrated catheter was performed by the surgeon. Patients were randomized to receive either 20 mL ropivacaine 0.3% (R-group) or 20 mL NaCl 0.9% (P-group) applied into the wound as a bolus before wound closure. A continuous infusion of either ropivacaine 0.3% or placebo was then infused at 8 mL/h for 48 hours after surgery with an elastomeric pump. Morphine IV-patient-controlled analgesia was offered to all patients. Morphine consumption, pain at rest and with motion, and total and unbound ropivacaine plasma concentration were recorded during the 48-hour study period. Postoperative follow-up was performed at 3 months. Demographic and surgical data were similar in both groups. Mean morphine consumption was significantly lower in the R-group than in the P-group during the first 48 postoperative hours: 45.4 ± 9.5 vs 69.7 ± 9.6 (P < 0.0001). There was a mean reduction of 14.4 mg for the first 24 postoperative hours (95% confidence interval [CI] 12.6 to 16.1) and 20.8 mg for the next 24 hours (95% CI 19.1 to 22.4). Pain scores at rest and with motion were lower in the R-group (P < 0.0001). Mean patient satisfaction increased 22.7% from baseline (CI 95% 15.9 to 29.6) in the R-group. Total and unbound ropivacaine plasma concentrations were below toxic levels in the R-group. The free ropivacaine concentration was 0.14 and 0.11 μgmol/L at T(24) and T(48), respectively, in the R-group. At 3 months postoperatively, hip pain and analgesic consumption were similar, but a significant reduction in wound discomfort to touch (31.2; 95% CI 27.7 to 34.7) and pressure (24; 95% CI 20.1 to 27.9) was observed in the R-group (P < 0.0001). Continuous epicapsular wound infusion with ropivacaine 0.3% after minimally invasive hip replacement is an efficient technique for reducing morphine consumption and improving the quality of postoperative analgesia. The beneficial effects of this technique are still present 3 months after surgery.


Intestinal Aspergillosis: Systematic Review on Patterns of Clinical Presentation and Management.
Background: Intestinal aspergillosis (IA) is a rare entity primarily discovered in immunocompromised patients. Because of its low incidence, IA is not considered routinely in the differential of abdominal pain, distension, and diarrhea. A systematic characterization of demographics, comorbidities, clinical presentations, and outcomes can help surgeons recognize and manage IA in critically ill patients. Methods: Two independent authors carried out the literature search using PubMed, MEDLINE, and Scopus databases. The Mesh terms utilized were: 'intestinal' and 'aspergillosis' combined with the Boolean operator 'AND' (synonyms were combined with the Boolean operator 'OR'). Intestinal aspergillosis was defined as inflammation of the gastrointestinal tract (duodenum to rectum) caused by Aspergillus spp. All articles reporting IA were included. Articles describing aspergillosis of the esophagus or stomach were excluded. Statistical analysis was performed using SPSS software (version 18; SPSS Inc., Chicago, IL). Results: Forty-two articles reporting 56 cases were included in the study. Mean age was 44.9 ± 20.5 years. Male to female ratio was 29:27. The most common condition in patients who developed IA was transplantation (19 patients; 34%). The most common clinical presentations of IA were abdominal pain (21 patients; 38%) and diarrhea 12 patients; 21%). Sixty-six percent of patients had primary IA whereas 34% developed IA secondarily to systemic infection. Diagnostic modalities included exploratory laparotomy (35 patients; 63%) and endoscopy (7 patients; 13%). Mean time to diagnosis was 8.6 ± 11.3 days. Intestinal aspergillosis was limited to the small bowel in 61% of patients. In 43 (77%) patients, bowel resection is the definitive treatment, whereas 13 (23%) patients underwent antifungal therapy alone. Mortality rate was 39%. Sixty-three percent of patients treated with surgery survived, compared with 46% treated with antifungal therapy alone (p = 0.34). Conclusion: Intestinal aspergillosis is a life-threatening condition with a mortality rate of 39%. Extrapulmonary IA is seen in patients with neutropenia, sepsis, inflammatory conditions, and immunosuppression. Patients who undergo surgery are more likely to survive this infection.


Rapamycin Modulates Glucocorticoid Receptor Function, Blocks Atrophogene REDD1, and Protects Skin from Steroid Atrophy.
Glucocorticoids have excellent therapeutic properties; however, they cause significant adverse atrophogenic effects. The mTORC1 inhibitor REDD1 has been recently identified as a key mediator of glucocorticoid-induced atrophy. We performed computational screening of a connectivity map database to identify putative REDD1 inhibitors. The top selected candidates included rapamycin, which was unexpected because it inhibits pro-proliferative mTOR signaling. Indeed, rapamycin inhibited REDD1 induction by glucocorticoids dexamethasone, clobetasol propionate, and fluocinolone acetonide in keratinocytes, lymphoid cells, and mouse skin. We also showed blunting of glucocorticoid-induced REDD1 induction by either catalytic inhibitor of mTORC1/2 (OSI-027) or genetic inhibition of mTORC1, highlighting role of mTOR in glucocorticoid receptor signaling. Moreover, rapamycin inhibited glucocorticoid receptor phosphorylation, nuclear translocation, and loading on glucocorticoid-responsive elements in REDD1 promoter. Using microarrays, we quantified a global effect of rapamycin on gene expression regulation by fluocinolone acetonide in human keratinocytes. Rapamycin inhibited activation of glucocorticoid receptor target genes yet enhanced the repression of pro-proliferative and proinflammatory genes. Remarkably, rapamycin protected skin against glucocorticoid-induced atrophy but had no effect on the glucocorticoid anti-inflammatory activity in different in vivo models, suggesting the clinical potential of combining rapamycin with glucocorticoids for the treatment of inflammatory diseases.


Hierarchical Dynamical Model for Multiple Cortical Neural Decoding.
Motor brain machine interfaces (BMIs) interpret neural activities from motor-related cortical areas in the brain into movement commands to control a prosthesis. As the subject adapts to control the neural prosthesis, the medial prefrontal cortex (mPFC), upstream of the primary motor cortex (M1), is heavily involved in reward-guided motor learning. Thus, considering mPFC and M1 functionality within a hierarchical structure could potentially improve the effectiveness of BMI decoding while subjects are learning. The commonly used Kalman decoding method with only one simple state model may not be able to represent the multiple brain states that evolve over time as well as along the neural pathway. In addition, the performance of Kalman decoders degenerates in heavy-tailed nongaussian noise, which is usually generated due to the nonlinear neural system or influences of movement-related noise in online neural recording. In this letter, we propose a hierarchical model to represent the brain states from multiple cortical areas that evolve along the neural pathway. We then introduce correntropy theory into the hierarchical structure to address the heavy-tailed noise existing in neural recordings. We test the proposed algorithm on in vivo recordings collected from the mPFC and M1 of two rats when the subjects were learning to perform a lever-pressing task. Compared with the classic Kalman filter, our results demonstrate better movement decoding performance due to the hierarchical structure that integrates the past failed trial information over multisite recording and the combination with correntropy criterion to deal with noisy heavy-tailed neural recordings.


Intra-hydrogel culture prevents transformation of mesenchymal stem cells induced by monolayer expansion.
In this study, we report that the intra-hydrogel culture system mitigates the transformation of mesenchymal stem cells (MSCs) induced by two-dimensional (2D) expansion. MSCs expanded in monolayer culture prior to encapsulation in collagen hydrogels (group eMSCs-CH) featured impaired stemness in chondrogenesis, comparing with the freshly isolated bone marrow mononuclear cells seeded directly in collagen hydrogels (group fMSCs-CH). The molecular mechanism of the in vitro expansion-triggered damage to MSCs was detected through genome-wide microarray analysis. Results indicated that pathways such as proteoglycans in cancer and pathways in cancer expansion were highly enriched in eMSCs-CH. And multiple up-regulated oncoma-associated genes were verified in eMSCs-CH compared with fMSCs-CH, indicating that expansion in vitro triggered cellular transformation was associated with signaling pathways related to tumorigenicity. Besides, focal adhesion (FA) and mitogen-activated protein kinase (MAPK) signaling pathways were also involved in in vitro expansion, indicating restructuring of the cell architecture. Thus, monolayer expansion in vitro may contribute to vulnerability of MSCs through the regulation of FA and MAPK. This study indicates that intra-hydrogel culture can mitigate the monolayer expansion induced transformation of MSCs and maintain the uniformity of the stem cells, which is a viable in vitro culture system for stem cell therapy.


Decidualization of the human endometrium: mechanisms, functions, and clinical perspectives.
The fetomaternal interface, consisting of the maternal decidua and the invading fetal trophoblast, critically regulates placental function and the growth and development of the conceptus. In its broadest sense, decidualization could be viewed as the postovulatory process of endometrial remodeling in preparation for pregnancy, which includes secretory transformation of the uterine glands, influx of specialized uterine natural killer cells, and vascular remodeling. A more restricted definition of the decidual process denotes the morphological and biochemical reprogramming of the endometrial stromal compartment. This differentiation process is dependent entirely on the convergence of the cyclic adenosine monophosphate and progesterone signaling pathways that drives integrated changes at both the transcriptome and the proteome level. As a consequence, decidualizing stromal cells acquire the unique ability to regulate trophoblast invasion, to resist inflammatory and oxidative insults, and to dampen local maternal immune responses. In humans, decidualization of the stromal compartment occurs in the mid-luteal phase of the menstrual cycle, independently of pregnancy. This raises the possibility that biochemical analysis of timed endometrial biopsy samples taken in a nonconception cycle could be informative of subsequent pregnancy outcome.


Next-generation invaders? Hotspots for naturalised sleeper weeds in Australia under future climates.
Naturalised, but not yet invasive plants, pose a nascent threat to biodiversity. As climate regimes continue to change, it is likely that a new suite of invaders will emerge from the established pool of naturalised plants. Pre-emptive management of locations that may be most suitable for a large number of potentially invasive plants will help to target monitoring, and is vital for effective control. We used species distribution models (SDM) and invasion-hotspot analysis to determine where in Australia suitable habitat may occur for 292 naturalised plants. SDMs were built in MaxEnt using both climate and soil variables for current baseline conditions. Modelled relationships were projected onto two Representative Concentration Pathways for future climates (RCP 4.5 and 8.5), based on seven global climate models, for two time periods (2035, 2065). Model outputs for each of the 292 species were then aggregated into single 'hotspot' maps at two scales: continental, and for each of Australia's 37 ecoregions. Across Australia, areas in the south-east and south-west corners of the continent were identified as potential hotspots for naturalised plants under current and future climates. These regions provided suitable habitat for 288 and 239 species respectively under baseline climates. The areal extent of the continental hotspot was projected to decrease by 8.8% under climates for 2035, and by a further 5.2% by 2065. A similar pattern of hotspot contraction under future climates was seen for the majority of ecoregions examined. However, two ecoregions - Tasmanian temperate forests and Australian Alps montane grasslands - showed increases in the areal extent of hotspots of >45% under climate scenarios for 2065. The alpine ecoregion also had an increase in the number of naturalised plant species with abiotically suitable habitat under future climate scenarios, indicating that this area may be particularly vulnerable to future incursions by naturalised plants.


Tapering with Pharmaceutical GHB or Benzodiazepines for Detoxification in GHB-Dependent Patients: A Matched-Subject Observational Study of Treatment-as-Usual in Belgium and The Netherlands.
The gamma-hydroxybutyric acid (GHB) withdrawal syndrome often has a fulminant course, with a rapid onset and swift progression of severe complications. In clinical practice, two pharmacological regimens are commonly used to counteract withdrawal symptoms during GHB detoxification: tapering with benzodiazepines (BZDs) or tapering with pharmaceutical GHB. In Belgium, standard treatment is tapering with BZDs, while in the Netherlands, pharmaceutical GHB is the preferred treatment method. Though BZDs are cheaper and readily available, case studies suggest GHB tapering results in less severe withdrawal and fewer complications. This study aimed to compare two treatments-as-usual in tapering methods on withdrawal, craving and adverse events during detoxification in GHB-dependent patients. In this multicentre non-randomised indirect comparison of two treatments-as-usual, patients with GHB dependence received BZD tapering (Belgian sample: n = 42) or GHB tapering (Dutch sample: n = 42, matched historical sample). Withdrawal was assessed using the Subjective and Objective Withdrawal Scales, craving was assessed with a Visual Analogue Scale and adverse events were systematically recorded. Differences in withdrawal and craving were analysed using a linear mixed-model analysis, with 'days in admission' and 'detoxification method' as fixed factors. Differences in adverse events were analysed using a Chi-square analysis. Withdrawal decreased over time in both groups. Withdrawal severity was higher in patients receiving BZD tapering (subjective mean = 36.50, standard deviation = 21.08; objective mean = 8.05, standard deviation = 4.68) than in patients receiving pharmaceutical GHB tapering (subjective mean = 15.90; standard deviation = 13.83; objective mean = 3.72; standard deviation = 2.56). No differences in craving were found. Adverse events were more common in the BZD than the GHB group, especially delirium (20 vs 2.5%, respectively). These results support earlier work that BZD tapering might not always sufficiently dampen withdrawal in GHB-dependent patients. However, it needs to be taken into account that both treatments were assessed in separate countries. Based on the current findings, tapering with pharmaceutical GHB could be considered for patients with GHB dependence during detoxification, as it has potentially less severe withdrawal and fewer complications than BZD tapering.


Identification of oscillatory firing neurons associated with locomotion in the earthworm through synapse imaging.
We used FM imaging to identify neurons that receive sensory feedback from the body wall in a circuit for octopamine (OA)-evoked rhythmic locomotion in the earthworm, Eisenia fetida. We visualized synapses in which postsynaptic neurons receive the sensory feedback, by using FM1-43 dye to label the synapses of both motor and sensory pathways that are associated with locomotion, then clearing the motor pathway synapse labeling, and finally identifying the target synapses by distinguishing physiologically functional synapses through destaining using a high-K(+) solution. A pair of synaptic regions associated with the sensory feedback was found to be located two or three cell body-widths away from the midline, between the anterior parts of the roots of the second lateral nerves (LNs) at the segmental ganglia (SGs). Using conventional intracellular recording and dye loading of the cell bodies surrounding these synaptic regions, we identified a pair of bilateral neurons with cell bodies larger than those of other cells in these regions, and named them "Oscillatory firing neurons Projecting to Peripheral nerves" (OPPs). These had a bipolar shape and projected neurites to the ipsilateral first and third LNs, fired rhythmically, and had a burst timing synchronized with the motor pattern bursts from the ipsilateral first LNs. Current injection into an OPP caused firing in the ipsilateral first LNs, supporting the hypothesis that OPPs functionally project to the peripheral nerves. OPPs also sent neurites to the adjacent anterior and posterior SGs, suggesting connections with the adjacent segments. We conclude that FM imaging can be used to identify neurons involved in specific functions, and that OPPs are the first neurons to be associated with OA-induced locomotion in the earthworm.


Peer-based education and the integration of HIV and Sexual and Reproductive Health services for young people in Vietnam: evidence from a project evaluation.
This paper reports changes in behavioral outcomes related to the use of HIV testing service of a project that employed peer-based education strategies and integration of HIV voluntary counseling and testing (VCT) and Sexual and Reproductive Health (SRH) services targeting young people aged 15-24 across 5 provinces in Vietnam. A pre-test/post-test, non-experimental evaluation design was used. Data were collected from cross-sectional surveys of youth and client exit interviews at project supported SRH clinics conducted at baseline and again at 24 months following implementation. The baseline samples consisted of 813 youth and 399 exit clients. The end line samples included 501 youths and 399 exit clients. Z test was used to assess changes in behavioral outcomes. Results show that there was a significant increase (p<0.05) in the percentage of youth who wanted to obtain a HIV test (from 33% to 51%), who had ever had a test (from 7.5% to 15%), and who had a repeat test in the last 12 months (from 54.5% to 67.5%). Exit client interviews found a nearly five-fold increase in the percentage of clients seeking HIV VCT in their current visit (5.0% vs. 24.5%) and almost two-fold increase in the percentage of those having their last test at a project supported clinic (9.3% vs. 17.8%). There were also positive changes in some aspects of youth HIV/AIDS knowledge, attitudes, and risk perceptions. This study provides preliminary evidence regarding the benefits of the integration of HIV VCT-SRH services in terms of increased access to HIV services and testing in Vietnam. Benefits of peer-based education regarding increased HIV knowledge were also identified. Further investigations, including experimental studies with assessment of health outcomes and the uptake of HIV testing services, are required to better elucidate the effectiveness and challenges of this intervention model in Vietnam.


Endoscopic findings and management of dengue patients with upper gastrointestinal bleeding.
There are 100 million cases of dengue infection, 500,000 cases of dengue hemorrhagic fever, and 25,000 deaths annually due to dengue worldwide. Gastrointestinal bleeding is the most common type of severe hemorrhage in dengue fever. However, there are no reports about the clinical applications of endoscopic therapy for upper gastrointestinal bleeding (UGI) in dengue patients. From June 17, 2002 to January 30, 2003, 1,156 patients with confirmed dengue virus infection were treated at Kaohsiung Chang Gung Memorial Hospital in Taiwan. We analyzed those patients who had received endoscopic therapy for UGI. The characteristic endoscopic findings, therapeutic courses, and amount of blood component transfused were collected from their charts for statistical analysis. Among the 1,156 dengue patients, 97 (8.4%) had complications of UGI bleeding during hospitalization. The endoscopic findings included hemorrhagic (and/or erosive) gastritis in 67% of the patients, gastric ulcer in 57.7%, duodenal ulcer in 26.8%, and esophageal ulcer in 3.1%. Of the 73 patients with peptic ulcer, 42 (57.5%) met the endoscopic criteria (recent hemorrhage) for endoscopic hemostasis therapy. Peptic ulcer patients with recent hemorrhage required more transfusions with packed red blood cells (P = 0.002) and fresh frozen plasma (P = 0.05) than those without recent hemorrhage. Among these 42 patients with recent hemorrhage, endoscopic injection therapy was conducted in 15 patients (group A). The other 27 patients (group B) did not receive endoscopic therapy. After endoscopy, patients in group A required more transfusions with packed red blood cells (P = 0.03) and fresh frozen plasma (P = 0.014) than did patients in group B. There were no significant differences between groups A and B in duration of hospital stay and amounts of transfused platelet concentrate after endoscopy. Medical treatment with blood transfusion is the mainstay of management of UGI bleeding in dengue patients. Patients having peptic ulcer with recent hemorrhage require more transfusions with packed red blood cells and fresh frozen plasma for management of UGI bleeding than those without recent hemorrhage. However, when peptic ulcer with recent hemorrhage is encountered during the endoscopic procedure, endoscopic injection therapy is not an effective adjuvant treatment of hemostasis in dengue patients with UGI bleeding.


Impact of systemic lupus erythematosus on burden of illness and work productivity in the United States.
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by clinical manifestations that can cause diminished activity and productivity. The objectives of this study were to: (a) longitudinally evaluate patient-reported SLE disease activity, and (b) measure work productivity, missed work hours, and associated lost income among employed patients with SLE. Three cohorts (employed subjects with SLE (n = 281), nonemployed subjects with SLE (n = 265), and a control group of employed individuals without SLE (n = 300)) completed a baseline survey. Employed subjects with SLE completed follow-up surveys every two weeks during a six-month period. Measured outcomes included perceived health, disease manifestations and severity, the Lupus Impact Tracker, the Modified Systemic Lupus Activity Questionnaire, and Work Productivity and Activity Impairment Questionnaire. Higher self-reported SLE disease severity was directly associated with experiencing more frequent and more severe symptoms as well as higher levels of lost work time and lost work productivity. Though patient self-assessment may differ from physician's clinical assessment, it is important to incorporate the patient perspective in clinical decision-making to optimally manage SLE patients. Given the evidence associating SLE with work disability and job loss, it may be beneficial for professionals addressing worksite modifications or compensatory strategies to be included as members of SLE medical teams.


The Effectiveness of Hyperbaric Oxygen Therapy as a Treatment for Postconcussion Symptoms.
Clinical Scenario: Concussions are a prevalent topic in medicine. Concussion symptoms include headaches, dizziness, nausea, neuropsychiatric symptoms, and cognitive impairments, the persistence of which is referred to as postconcussion syndrome. Hyperbaric oxygen therapy (HBOT) has been proposed and evaluated as an additional treatment of these symptoms. HBOT is an innovative approach that has been considered by many but has received both criticism and acceptance. Is HBOT an effective means of reducing symptoms for individuals suffering from postconcussion syndrome (persistence of symptoms for >3 mo)? Summary of Search: The literature was searched for studies that were relevant to the clinical question. Literature provided 5 level 1 studies that were relevant enough to be considered. Clinical Bottom Line: Based on the research that is available, the authors conclude that there is more evidence to refute the use of HBOT for postconcussion syndrome than to support it. Strength of Recommendation: Four studies disprove the use of HBOT; 1 study supported the use of HBOT. These 5 studies are the same level of evidence (level 1) and provide significant findings in their studies. The strength of this recommendation is a B according to the Centre for Evidence-Based Medicine.


Prevalence of Beta-Lactam and Quinolone/Fluoroquinolone Resistance in Enterobacteriaceae From Dogs in France and Spain-Characterization of ESBL/pAmpC Isolates, Genes, and Conjugative Plasmids.
Quantitative data on fecal shedding of antimicrobial-resistant bacteria are crucial to assess the risk of transmission from dogs to humans. Our first objective was to investigate the prevalence of quinolone/fluoroquinolone-resistant and beta-lactam-resistant Enterobacteriaceae in dogs in France and Spain. Due to the particular concern about possible transmission of extended-spectrum cephalosporin (ESC)-resistant isolates from dogs to their owners, we characterized the ESBL/pAmpC producers collected from dogs. Rectal swabs from 188 dogs, without signs of diarrhea and that had not received antimicrobials for 4 weeks before the study, were quantified for total and resistant Enterobacteriaceae on selective media alone or containing relevant antibiotic concentrations. Information that might explain antibiotic resistance was collected for each dog. Extended-spectrum cephalosporin-resistant isolates were subjected to bacterial species identification (API20E), genetic lineage characterization (MLST), ESBL/pAmpC genes identification (sequencing), and plasmid characterization (pMLST). Regarding beta-lactam resistance, amoxicillin- (AMX) and cefotaxime- (CTX) resistant Enterobacteriaceae were detected in 70 and 18% of the dogs, respectively, whereas for quinolone/fluoroquinolone-resistance, Nalidixic acid- (NAL) and ciprofloxacin- (CIP) resistant Enterobacteriaceae were detected in 36 and 18% of the dogs, respectively. Medical rather than preventive consultation was a risk marker for the presence of NAL and CIP resistance. CTX resistance was mainly due to a combination of specific ESBL/pAmpC genes and particular conjugative plasmids already identified in human patients: bla CTX-M-1/IncI1/ST3 (n = 4), bla CMY-2/IncI1/ST12 (n = 2), and bla CTX-M-15/IncI1/ST31 (n = 1). bla SHV-12 (n = 3) was detected in various plasmid lineages (InI1/ST3, IncI1/ST26, and IncFII). ESBL/pAmpC plasmids were located in different genetic lineages of E. coli, with the exception of two strains in France (ST6998) and two in Spain (ST602). Our study highlights dogs as a potential source of Q/FQ-resistant and ESBL/pAmpC-producing bacteria that might further disseminate to humans, and notably a serious risk of future acquisition of CTX-M-1 and CMY-2 plasmids by the owners of dogs.


Imaging features of avulsion injuries.
Avulsion injuries are common among participants in organized sports, especially among adolescent participants. Imaging features of both acute and chronic avulsion injuries of the pelvis, knee, ankle and foot, shoulder, and elbow were evaluated to help distinguish these injuries from more serious disease processes such as neoplasm and infection. At radiography, acute injuries (ie, those resulting from extreme, unbalanced, often eccentric muscular contractions) may be associated with avulsed bone fragments, whereas subacute injuries have an aggressive appearance that may include areas of mixed lysis and sclerosis. Chronic injuries (ie, those resulting from repetitive microtrauma or overuse) or old inactive injuries may be associated with a protuberant mass of bone and may bear a striking resemblance to a neoplastic or infectious process. Although not usually required, computed tomography is helpful in the diagnosis if radiographic findings are equivocal or if the injury is not in the acute phase. MR imaging is best suited for the evaluation of injuries to muscles, tendons, and ligaments. Recognition of characteristic imaging features and familiarity with musculotendinous anatomy will aid in accurate diagnosis of avulsion injuries.


2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.
To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.


A study of the neurotoxic effect of MDMA ('ecstasy') on 5-HT neurones in the brains of mothers and neonates following administration of the drug during pregnancy.
1. It is well established that 3,4-methylenedioxymethamphetamine (MDMA or 'ecstasy') is neurotoxic and produces long term degeneration of cerebral 5-hydroxytryptamine (5-HT) nerve terminals in many species. Since MDMA is used extensively as a recreational drug by young people, it is being ingested by many women of child bearing age. We have therefore examined the effect of administering high doses of MDMA to rats during pregnancy on the cerebral content of both the dams and the neonates. 2. MDMA (20 mg kg-1, s.c.) was injected twice daily on days 14-17 of the gestation period. The initial dose produced a marked hyperthermic response in the dam which was progressively attenuated in both peak height and area under the curve following further doses of the drug. The body weight of the dams decreased during the period of treatment. 3. There was a modest decrease in litter size (-20%) of the MDMA-treated dams. 4. The concentration of 5-HT and its metabolite 5-HIAA was decreased by over 65% in the hippocampus and striatum and 40% in the cortex of the dams 1 week after parturition. In contrast, the content of 5-HT and 5-HIAA in the dorsal telencephalon of the pups of the MDMA-treated dams was the same as that seen in tissue from pups born to control animals. 5. Administration of MDMA (40 mg kg-1, s.c.) to adult rats increased thiobarbituric acid reacting substances (TBARS) in cortical tissue 3 h and 6 h later, indicating increased lipid peroxidation. No increase in TBARS was seen in the cortical tissue of 7-10 day neonates injected with this dose of MDMA 3 h or 6 h earlier. 6. The data suggest that exposure to MDMA in utero during the maturation phase does not produce damage to 5-HT nerve terminals in the foetal rat brain, in contrast to the damage seen in the brains of the mothers. This may be due to MDMA being metabolized to free radical producing entities in the adult brain but not in the immature brain or, alternatively, to more effective or more active free radical scavenging mechanisms being present in the immature brain.


Doxazosin versus bendrofluazide: a comparison of the metabolic effects in British South Asians with hypertension.
People from British South Asian communities have an increased risk of mortality from coronary heart disease (CHD). Doxazosin, a selective alpha(1)-adrenergic blocker, in addition to lowering blood pressure, has been shown to have positive effects on glucose metabolism and lipid profiles in patients with hypertension. We studied doxazosin (1-8 mg) and bendrofluazide (2.5 mg) in patients of British South Asian origin with existing mild to moderate hypertension (doxazosin n = 78; bendrofluazide n = 82), to compare their effects on glucose and lipid metabolism in this group. A 34-week randomised, double-blind, parallel-group, multicentre study. Primary care in the UK. All doxazosin patients started with an initial dose of 1 mg once daily, titrated to a maximum 8 mg once daily if diastolic blood pressure was >90 mmHg or was not <5 mmHg of the baseline value. The primary efficacy variables were mean glucose and total cholesterol concentrations at week 21. Doxazosin reduced glucose, total cholesterol, low-density lipoprotein-cholesterol and triglycerides and increased high-density lipoprotein-cholesterol. There were significant differences between doxazosin and bendrofluazide for glucose concentrations at week 21 (P = 0.029) and week 34 (P = 0.015), total cholesterol at week 21 (P = 0.048) and triglycerides at week 21 (P = 0.047) and week 34 (P = 0.009). There was no significant difference in blood pressure lowering between the two treatments. Doxazosin exhibits beneficial effects on glucose concentrations and lipid profile, in particular in lowering triglyceride concentrations in British South Asians. Whether these desirable characteristics translate to improved overall cardiovascular risk requires formal evaluation.


[PHYSICAL, CHEMICAL AND MORPHOLOGICAL URINE EXAMINATION: RECOMMENDATIONS FOR THE POST ANALYTICAL PHASE FROM THE INTERDISCIPLINARY URINALYSIS GROUP (GIAU)].
With these recommendations the Interdisciplinary Urinalysis Group (GIAU) aims to stimulate the following aspects : improvement and standardization of the post analytical approach to physical, chemical and morphological urine examination (ECMU); emphasize the value added to ECMU by selection of clinically significant parameters, indication of analytical methods, of units of measurement, of reference values; improvement of interpretation of dip stick urinalysis with particular regard to the reconsideration of the diagnostic significance of the evaluated parameters together with an increasing awareness of the limits of sensitivity and specificity of this analytical method. Accompanied by the skills to propose and carry out in-depth investigations with analytical methods that are more sensitive and specific;increase the awareness of the importance of professional skills in the field of urinary morphology and their relationships with the clinicians. through the introduction, in the report, of descriptive and interpretative comments depending on the type of request, the complexity of the laboratory, the competence of the pathologist;implement a policy of evaluation of the analytical quality by using, in addition to traditional internal and external controls, a program for the evaluation of morphological competence. The hope is to revalue the enormous potential diagnostic of ECMU, implementing a urinalysis on personalized diagnostic needs that each patient brings with it.


Transition to chemical turbulence.
Experiments have been conducted on Turing-type chemical spatial patterns and their variants in a quasi-two-dimensional open spatial reactor with a chlorite-iodide-malonic acid reaction. A variety of stationary spatial structures-hexagons, stripes, and mixed states-were observed, and transitions to these states were studied. For conditions beyond those corresponding to the emergence of patterns, a transition was observed from stationary spatial patterns to chemical turbulence, which is marked by a continuous motion of the pattern within a domain and of the grain boundaries between domains. The transition to chemical turbulence was analyzed by measuring the correlation length, the average pattern speed, and the total length of the domain boundaries. The emergence of chemical turbulence is accompanied by a large increase in the defects in the pattern, which suggests that this is an example of defect-mediated turbulence.


Expression and function of the Drosophila gene runt in early stages of neural development.
The Drosophila gene runt was initially identified on the basis of its role during segmentation. Recent molecular and genetic studies have demonstrated that the runt gene encodes a novel nuclear protein whose developmental importance is not exclusive to segmentation. This report addresses the functional relevance of runt expression in the developmental pathway of neurogenesis. Antibodies against the runt protein reveal that it is expressed in a subset of neuroblasts, ganglion-mother cells and neurons. A subset of these neurons also co-express the segmentation gene even-skipped (eve). Using eve as a marker, we show that runt is required for the normal development of these neurons. A runt P-transposon that lacks neural cis-regulatory elements is used to show that these neurons require runt activity independent of its activity during segmentation. These results are confirmed using a temperature-sensitive runt allele. Further temperature-shift experiments indicate that the requirement for runt is during an early stage of neurogenesis. Based on its pattern of expression and its temporal requirements, runt is distinguished as one of the earliest acting genes involved in the generation of diverse cell fates in the developing Drosophila nervous system.


Randomised controlled trial of colloid infusions in hypotensive preterm infants.
Colloid infusions are often given to treat hypotension in preterm infants. The aim of this work was to assess whether it was the amount of protein or the volume of the colloid infused which accounted for the observed increase in blood pressure. Sixty preterm infants were randomised (20 in each group) to receive 5 ml/kg 20% albumin, 15 ml/kg fresh frozen plasma, or 15 ml/kg 4.5% albumin. All infusions were given at a rate of 5 ml/kg/hour in addition to maintenance fluids. The infants were randomised when hypotensive (systolic blood pressure less than 40 mm Hg for two hours). There was no significant difference in the blood pressure of the three groups before or one hour after beginning the infusion. The mean increase in blood pressure one hour after completing the infusion, however, was significantly lower in infants receiving 20% albumin: 9% compared with 17% in the group receiving 4.5% albumin, and 19% in the group receiving fresh frozen plasma. It is concluded that the volume infused rather than albumin load is important in producing a sustained increase in blood pressure.


Lobar microbleeds are associated with a decline in executive functioning in older adults.
Normal aging is associated with a decline in cognitive abilities, particularly in the domains of psychomotor speed and executive functioning. However, 'aging,' per se, is not a cause of cognitive decline but rather a variable that likely captures multiple accumulating biological changes over time that collectively affect mental abilities. Recent work has focused on the role of cerebrovascular disease as one of the biological changes. In the current study, we examined whether lobar microbleeds - magnetic resonance imaging (MRI) signal voids due to hemosiderin deposits secondary to cerebral amyloid angiopathy - are associated with cognitive decline in normal aging. Previous studies that reported a relationship between the presence of lobar microbleeds and decreased cognitive abilities have been primarily cross-sectional. Here, we used a retrospective longitudinal design to examine whether the presence of lobar microbleeds is associated with the rate of cognitive decline among non-demented older adults. Participants came from an ongoing longitudinal community-based aging study, in which subjects are evaluated at 18-24 months intervals and received a full medical, neurological, and neuropsychological examination at each of the follow-up visits. Gradient echo MRI scans were available on 197 non-demented participants (mean age: 84.15 ± 5.02 years). Microbleeds were rated visually on axial view and divided into subcortical (basal ganglia, cerebellum) and lobar (frontal, temporal, parietal, occipital lobe) regions, and confirmed with coronal and sagittal views to exclude artifacts. Cognition was assessed with a neuropsychological battery, providing summary scores for memory, language, executive, and visuospatial abilities. Using general estimating equations (GEE), we compared cognition cross-sectionally between individuals with 2 or more (n = 11) and fewer than 2 (n = 186) lobar microbleeds and examined longitudinal cognitive change beginning 9.47 ± 3.13 years before the MRI scan. Subjects with 2 or more lobar microbleeds had worse executive functioning at the visit closest to the MRI scan (β = -0.044; p < 0.001) and had a faster decline in executive function over time (β = -0.072; p = 0.012) than subjects with fewer than 2 lobar microbleeds. The two groups were similar in age at scan date, education, ethnicity, sex distribution, and cognitive performance at first visit. Lobar microbleeds, a marker of cerebral amyloid angiopathy, are associated with an accelerated rate of executive function decline. The presence of cerebral amyloid angiopathy may be an important source of cognitive decline in aging. Future work should examine how cerebral amyloid angiopathy interacts with neurodegenerative processes, such as Alzheimer's disease.


Prophenoloxidase activation: nonself recognition and cell cooperation in insect immunity.
The mechanism of nonself recognition by the immune system of insects is unknown. In this report the activation of the prophenoloxidase system in the wax moth Galleria mellonella by a microbial product is shown to enhance the recognition of nonself material. These results explain previous observations of the interaction of two different blood cell populations in the cellular defense reactions of insects.


Revisiting carbon flux through the ocean's twilight zone.
The oceanic biological pump drives sequestration of carbon dioxide in the deep sea via sinking particles. Rapid biological consumption and remineralization of carbon in the "twilight zone" (depths between the euphotic zone and 1000 meters) reduce the efficiency of sequestration. By using neutrally buoyant sediment traps to sample this chronically understudied realm, we measured a transfer efficiency of sinking particulate organic carbon between 150 and 500 meters of 20 and 50% at two contrasting sites. This large variability in transfer efficiency is poorly represented in biogeochemical models. If applied globally, this is equivalent to a difference in carbon sequestration of more than 3 petagrams of carbon per year.


Resistance in human pathogenic yeasts and filamentous fungi: prevalence, underlying molecular mechanisms and link to the use of antifungals in humans and the environment.
Antifungal drug resistance is a multifaceted clinical challenge, and when present, a primary cause of treatment failure in patients with severe fungal infections. Changing epidemiology, increasing resistance rates and a narrow antifungal armamentarium may further underline the required attention on resistance particularly within the most prevalent invasive fungal infections caused by Candida yeasts and Aspergillus moulds. In Denmark, the resistance epidemiology remains to be fully elucidated. This thesis sought to address this demand as well as provide insight into the landscape of underlying molecular resistance mechanisms. Paper I and II both contributed to the understanding of FKS (β-glucan synthase) mediated echinocandin resistance in Candida species. Paper I covered a unique stepwise acquisition of a homozygous mutation in FKS1 of Candida tropicalis leading to an amino acid change corresponding to a well-known S645P in Candida albicans. Paper II presented a failure case due to Candida krusei displaying high-level echinocandin resistance likely attributable to an acquired D662Y amino acid substitution in FKS1. Intrinsic differences in FKS1 among Candida species may explain why the level of resistance both depends on the mutation as well as the species and cannot be easily translated to the level of clinical resistance. Intrinsic fluconazole resistance in C. krusei further substantiated the clinical implications of acquired echinocandin resistance. Paper III presented a rare multidrug resistance case in a series of isogenic C. albicans isolates, almost covering the entire spectrum of known resistance mechanisms in Candida and involved the proposal of novel resistance mutations. An A61E change in ERG11 was potentially involved in reduced susceptibility to long-structured azoles. Increased expression levels of azole efflux pumps were probably accredited to novel gain-of-function variants in the transcription factor TAC1 (R688Q and R673L). Echinocandin resistance was induced by the well-known S645P variant of FKS1 and polyene resistance was likely inflicted by a frameshift mutation in ERG2 leading to loss of function of the encoded protein and subsequent ergosterol depletion. The number of acquired resistance cases is increasing in our settings and Paper IV sought to illuminate whether antifungal resistance is overlooked in the current fungaemia programme. This involved the acquisition of post-treatment oral isolates from 193 candidaemia patients among which 114 received azoles (primarily fluconazole) and 85 received an echinocandin (and some both). Azole-exposed patients carried a significantly higher proportion of species less susceptible to fluconazole (primarily Candida glabrata) among colonising Candida compared to baseline blood isolates (p<0.001). A similar trend was seen for echinocandin-treated patients although not statistically significant. Interestingly, there was a high frequency of acquired resistance, 29.4% to fluconazole and 21.6% to echinocandins, among colonising C. glabrata isolates post treatment. These figures were both significantly higher compared to baseline blood isolates as well as oral isolates from patients with no or minimal exposure to either drug class. In contrast, acquired resistance among C. albicans oral isolates was rare (<5). Thus, the oral cavity may be an unrecognized reservoir of resistant Candida species, especially C. glabrata following azole or echinocandin treatment. This underlines the care of which therapeutic stewardship must be taken both for antifungal naïve patients, to avoid resistance development, as well as for patients previously exposed to antifungals. Paper V presented four fatal cases of invasive aspergillosis involving azole resistant Aspergillus fumigatus harbouring resistance mechanisms (TR34/L98H and TR46/Y121F/T289A), which are thought to derive from environmental fungicide use. The clinical concern is evident because the route of infection is through inhalation of potentially azole resistant spores. Still, recent environmental surveys were unable to detect azole resistant A. fumigatus in numerous soil samples but seasonal variations could be one explanation for this paradox. Paper VI was a retrospective laboratory-based study and aimed to elucidate the prevalence of azole resistance in A. fumigatus isolates from 2010-2014 in Denmark. This study also sought to uncover the underlying resistance mechanisms, primarily attributable to CYP51A mutations, and finally to assess the accumulated genotyping data. Among 1,162 A. fumigatus isolates, 94.5% were screened for azole resistance and a significant increasing trend was observed for the number of azole-resistant isolates to approximately 6% in 2014 (p<0.001) and 4% in corresponding patients (p<0.05). The underlying resistance mutations were diverse but still dominated by the TR34/L98H resistance mechanism responsible for >50% of all our azole-resistant isolates. The genotyping data of resistant and a selection of susceptible A. fumigatus showed high identity to foreign isolates (>15%). This could argue for the hypothesis on clonal expansion, which has previously been suggested for TR34/L98H clones in the Netherlands and India, but could also indicate an insufficient discriminatory power of such analysis. Still, a proposed A. fumigatus outbreak in a haematology ward was unresolved since no genetically identical isolates were recovered from patients and air samples, illustrating the ubiquitous nature of this organism. Overall, the main concerns are a changing Candida epidemiology towards species less susceptible to fluconazole combined with the rapid acquisition of echinocandin resistance, especially among C. glabrata isolates. For A. fumigatus, the concern is the emergence of azole resistant strains in the environment, displaying cross-resistance to clinical azoles, and thus posing unforeseen clinical challenges in the management of invasive aspergillosis. Collectively, these findings call for an increased awareness especially at clinical microbiology laboratories, which ideally would lead to susceptibility testing of all clinically relevant isolates by reference or validated methods. Moreover, novel diagnostic approaches for non-culturable pathogens are warranted and especially DNA-based detection by PCR may serve as a solid complimentary tool for improved diagnostics of invasive fungal infections.


Electrophysiological confirmation of the zona incerta as a target for surgical treatment of disabling involuntary arm movements in multiple sclerosis: use of local field potentials.
Lesioning or chronic deep brain stimulation (DBS) of the nucleus ventralis intermedius results in abolition of tremor in the contralateral limbs in Parkinson's disease (PD) and also in essential tremor. Recently, chronic DBS of the subthalamic nucleus has also proved to be very effective in reducing contralateral limb tremor in PD. These targets have been less effective in controlling the complex limb tremor often seen in multiple sclerosis (MS). Consequently, other targets have been sought in cases of MS with tremor. We describe a patient with MS with disabling proximal and distal involuntary arm movements in whom we were able to obtain sustained control of contralateral arm tremor and achieve functional improvement of the affected arm by chronic DBS of the region of the zona incerta. We also highlight the important role played by local field potentials recorded from the brain, with simultaneous recording of corresponding EMGs, in target localisation.


Time-Resolved X-ray Diffraction Study of Solid Combustion Reactions.
Real-time synchrotron diffraction has been used to monitor the phase transformations of highly exothermic, fast self-propagating solid combustion reactions on a subsecond time scale down to 100 milliseconds and in some instances to 10 milliseconds. Three systems were investigated: Ti + C --> TiC; Ti + C + xNi --> TiC + Ni-Ti alloy; and Al + Ni --> AlNi. In all three reactions, the first step was the melting of the metal reactants. Formation of TiC in the first two reactions was completed within 400 milliseconds of the melting of the Ti metal, indicating that the formation of TiC took place during the passage of the combustion wave front. In the Al + Ni reaction, however, passage of the wave front was followed by the appearance and disappearance of at least one intermediate in the afterburn region. The final AlNi was formed some 5 seconds later and exhibited a delayed appearance of the (210) reflection, which tends to support a phase transformation from a disordered AlNi phase at high temperature to an ordered CsCl structure some 20 seconds later. This new experimental approach can be used to study the chemical dynamics of high-temperature solid-state phenomena and to provide the needed database to test various models for solid combustion.


Neoadjuvant chemotherapy versus debulking surgery in advanced tubo-ovarian cancers: pooled analysis of individual patient data from the EORTC 55971 and CHORUS trials.
Individual patient data from two randomised trials comparing neoadjuvant chemotherapy with upfront debulking surgery in advanced tubo-ovarian cancer were analysed to examine long-term outcomes for patients and to identify any preferable therapeutic approaches for subgroup populations. We did a per-protocol pooled analysis of individual patient data from the European Organisation for Research and Treatment of Cancer (EORTC) 55971 trial (NCT00003636) and the Medical Research Council Chemotherapy Or Upfront Surgery (CHORUS) trial (ISRCTN74802813). In the EORTC trial, eligible women had biopsy-proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC or IV invasive epithelial tubo-ovarian carcinoma. In the CHORUS trial, inclusion criteria were similar to those of the EORTC trial, and women with apparent FIGO stage IIIA and IIIB disease were also eligible. The main aim of the pooled analysis was to show non-inferiority in overall survival with neoadjuvant chemotherapy compared with upfront debulking surgery, using the reverse Kaplan-Meier method. Tests for heterogeneity were based on Cochran's Q heterogeneity statistic. Data for 1220 women were included in the pooled analysis, 670 from the EORTC trial and 550 from the CHORUS trial. 612 women were randomly allocated to receive upfront debulking surgery and 608 to receive neoadjuvant chemotherapy. Median follow-up was 7·6 years (IQR 6·0-9·6; EORTC, 9·2 years [IQR 7·3-10·4]; CHORUS, 5·9 years [IQR 4·3-7·4]). Median age was 63 years (IQR 56-71) and median size of the largest metastatic tumour at diagnosis was 8 cm (IQR 4·8-13·0). 55 (5%) women had FIGO stage II-IIIB disease, 831 (68%) had stage IIIC disease, and 230 (19%) had stage IV disease, with staging data missing for 104 (9%) women. In the entire population, no difference in median overall survival was noted between patients who underwent neoadjuvant chemotherapy and upfront debulking surgery (27·6 months [IQR 14·1-51·3] and 26·9 months [12·7-50·1], respectively; hazard ratio [HR] 0·97, 95% CI 0·86-1·09; p=0·586). Median overall survival for EORTC and CHORUS patients was significantly different at 30·2 months (IQR 15·7-53·7) and 23·6 months (10·5-46·9), respectively (HR 1·20, 95% CI 1·06-1·36; p=0·004), but was not heterogeneous (Cochran's Q, p=0·17). Women with stage IV disease had significantly better outcomes with neoadjuvant chemotherapy compared with upfront debulking surgery (median overall survival 24·3 months [IQR 14·1-47·6] and 21·2 months [10·0-36·4], respectively; HR 0·76, 95% CI 0·58-1·00; p=0·048; median progression-free survival 10·6 months [7·9-15·0] and 9·7 months [5·2-13·2], respectively; HR 0·77, 95% CI 0·59-1·00; p=0·049). Long-term follow-up data substantiate previous results showing that neoadjuvant chemotherapy and upfront debulking surgery result in similar overall survival in advanced tubo-ovarian cancer, with better survival in women with stage IV disease with neoadjuvant chemotherapy. This pooled analysis, with long-term follow-up, shows that neoadjuvant chemotherapy is a valuable treatment option for patients with stage IIIC-IV tubo-ovarian cancer, particularly in patients with a high tumour burden at presentation or poor performance status. National Cancer Institute and Vlaamse Liga tegen kanker (Flemish League against Cancer).


The Post-Embargo Open Access Citation Advantage: It Exists (Probably), Its Modest (Usually), and the Rich Get Richer (of Course).
Many studies show that open access (OA) articles-articles from scholarly journals made freely available to readers without requiring subscription fees-are downloaded, and presumably read, more often than closed access/subscription-only articles. Assertions that OA articles are also cited more often generate more controversy. Confounding factors (authors may self-select only the best articles to make OA; absence of an appropriate control group of non-OA articles with which to compare citation figures; conflation of pre-publication vs. published/publisher versions of articles, etc.) make demonstrating a real citation difference difficult. This study addresses those factors and shows that an open access citation advantage as high as 19% exists, even when articles are embargoed during some or all of their prime citation years. Not surprisingly, better (defined as above median) articles gain more when made OA.


Ultrasound confidence maps using random walks.
Advances in ultrasound system development have led to a substantial improvement of image quality and to an increased use of ultrasound in clinical practice. Nevertheless, ultrasound attenuation and shadowing artifacts cannot be entirely avoided and continue to challenge medical image computing algorithms. We introduce a method for estimating a per-pixel confidence in the information depicted by ultrasound images, referred to as an ultrasound confidence map, which emphasizes uncertainty in attenuated and/or shadow regions. Our main novelty is the modeling of the confidence estimation problem within a random walks framework by taking into account ultrasound specific constraints. The solution to the random walks equilibrium problem is global and takes the entire image content into account. As a result, our method is applicable to a variety of ultrasound image acquisition setups. We demonstrate the applicability of our confidence maps for ultrasound shadow detection, 3D freehand ultrasound reconstruction, and multi-modal image registration.


Quantitative Assessment of Improvement with Single Corticosteroid Injection in Thumb CMC Joint Osteoarthritis?
We present a unique prospective study to estimate the median sustained stage-related improvement in pain and hand function in patients with trapezio-metacarpal joint osteoarthritis after administration of a single corticosteroid injection. Response to the corticosteroid injection was assessed using Disability of Arm Shoulder and Hand (DASH) and Visual Analogue Scale (VAS) pain scores. Self assessment scores revealed a reduction in pain and improvement in hand function. All patients reported a significant improvement in pain and hand function (p </= 0.05), regardless of the disease stage. Additionally, we observed a marked difference in the duration of improvement in hand function between early and late stages of the disease (p = 0.0046). In conclusion, it is possible to predict the period of symptomatic improvement at each of the four radiological stages of the disease. This would allow the treating clinician to judge the outcome of treatment with reasonable accuracy.


The Short antennae gene of Tribolium is required for limb development and encodes the orthologue of the Drosophila Distal-less protein.
Insects bear a stereotyped set of limbs, or ventral body appendages. In the highly derived dipteran Drosophila melanogaster, the homeodomain transcription factor encoded by the Distal-less (Dll) gene plays a major role in establishing distal limb structures. We have isolated the Dll orthologue (TcDll) from the beetle Tribolium castaneum, which, unlike Drosophila, develops well-formed limbs during embryogenesis. TcDll is initially expressed at the sites of limb primordia formation in the young embryo and subsequently in the distal region of developing legs, antennae and mouthparts except the mandibles. Mutations in the Short antennae (Sa) gene of Tribolium delete distal limb structures, closely resembling the Dll phenotype in Drosophila. TcDll expression is severely reduced or absent in strong Sa alleles. Genetic mapping and molecular analysis of Sa alleles also support the conclusion that TcDll corresponds to the Sa gene. Our data indicate functional conservation of the Dll gene in evolutionarily distant insect species. Implications for evolutionary changes in limb development are discussed.


Injury, imagery, and self-esteem in dance healthy minds in injured bodies?
The purpose of this study was to investigate a selection of psychological variables (help-seeking behaviors, mental imagery, self-esteem) in relation to injury among UK dancers. We recruited 216 participants from eight dance styles and six levels of involvement. It was found that 83.5% of the participants had experienced at least one injury in the past year. The most common response to injury was to inform someone, and most continued to dance when injured, albeit carefully. Physical therapy was the most common treatment sought when an injury occurred (38.1%), and dancers seemed to follow recommendations offered. Injured and non-injured dancers did not differ in their imagery frequencies (facilitative, debilitative, or injury-related) and scored similarly (and relatively high) in self-esteem. Neither facilitative nor debilitative imagery was correlated with self-esteem, but dancers who engaged in more facilitative imagery in general also reported doing so when injured. Altogether, it appears that injury is not related to dancers' self-esteem or imagery, at least not when injuries are mild or moderate. Even so, such conclusions should be made with caution, given that most dancers do sustain at least one injury each year.


Erlotinib-induced purpuric papulopustular eruption treated with pulsed azithromycin.
Erlotinib belongs to the targeted cancer treatments acting through epidermal growth factor receptor inhibition. Papulopustular eruption is the most common cutaneous toxicity. The pathogenesis of the rash is not clear. There is no consensus on treatment. In this report, we describe a 73-year-old female patient who was referred to our outpatient clinic for evaluation and treatment of a widespread acneiform eruption. She was put on erlotinib therapy for 3 months for the treatment of lung adenocarcinoma. The patient has developed nonpruritic papules and pustules widespread over the body except the face for the past 2 weeks. Bacterial culture obtained from a pustule on the back grew methicillin-sensitive Staphylococcus aureus (SA). Histopathological examination of a papule demonstrated vacuolar degeneration of basal layer, prominent walls of vessels, a mixed infiltration of eosinophils, and lymphocytes and erythrocyte extravasation. The eruption was successfully treated with two weekly pulses of azithromycin 500 mg for 3 consecutive days. This case demonstrated that erlotinib may cause purpuric papular eruption secondarily infected with SA. Routine bacterial culture should be performed from pustules before any treatment.


Systemic Candidiasis in Mice: New Insights From an Old Model.
Animal models are essential to understand the pathophysiology of infections, to test novel antifungal compounds, and to determine the potential of adjunctive therapies, e.g. immune modulation. The murine model of systemic candidiasis induced by intravenous infection is technically straightforward, highly reproducible, and well-characterized. However, intravenous inoculation circumvents the necessity for the fungus to translocate across mucosal barriers, and the use of SPF mice that are immunologically naïve to Candida does not reflect the situation in human patients, in whom adaptive immune responses have been induced by mucosal colonization prior to infection. Therefore, mouse models that combine intestinal colonization and systemic infection have been developed, resulting in novel insights into host-fungal interactions and immunity. In this review, we summarize the main findings, current questions, and discuss how these might impact the translatability of results from mice to humans.


The cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa.
Many HIV-positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced-prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3 . We investigated the cost-effectiveness of this enhanced-prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. The REALITY trial enrolled from June 2013 to April 2015. A decision-analytic model was developed to estimate the cost-effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard-prophylaxis, enhanced-prophylaxis, standard-prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced-prophylaxis (CrAg-positive) or standard-prophylaxis (CrAg-negative), the second to enhanced-prophylaxis (CrAg-positive) or enhanced-prophylaxis without fluconazole (CrAg-negative) and the third to standard-prophylaxis with fluconazole (CrAg-positive) or without fluconazole (CrAg-negative). The model estimated costs, life-years and quality-adjusted life-years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Enhanced-prophylaxis was cost-effective at cost-effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost-effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced-prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced-prophylaxis components. Enhanced-prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced-prophylaxis still conveyed health gains in CrAg-negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost-effective unless the price of CrAg testing fell below US$2.30. The REALITY enhanced-prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost-effective. Efforts should continue to ensure that components are accessed at lowest available prices.


Enhancing clinically-relevant shoulder function assessment using only essential movements.
Kinematic functional evaluation with body-worn sensors provides discriminative and responsive scores after shoulder surgery, but the optimal movements' combination has not yet been scientifically investigated. The aim of this study was the development of a simplified shoulder function kinematic score including only essential movements. The P Score, a seven-movement kinematic score developed on 31 healthy participants and 35 patients before surgery and at 3, 6 and 12 months after shoulder surgery, served as a reference. Principal component analysis and multiple regression were used to create simplified scoring models. The candidate models were compared to the reference score. ROC curve for shoulder pathology detection and correlations with clinical questionnaires were calculated. The B-B Score (hand to the Back and hand upwards as to change a Bulb) showed no difference to the P Score in time*score interaction (P > .05) and its relation with the reference score was highly linear (R(2) > .97). Absolute value of correlations with clinical questionnaires ranged from 0.51 to 0.77. Sensitivity was 97% and specificity 94%. The B-B and reference scores are equivalent for the measurement of group responses. The validated simplified scoring model presents practical advantages that facilitate the objective evaluation of shoulder function in clinical practice.


Clinical expression and new SPINK5 splicing defects in Netherton syndrome: unmasking a frequent founder synonymous mutation and unconventional intronic mutations.
Netherton syndrome (NS) is a severe skin disease caused by loss-of-function mutations in SPINK5 (serine protease inhibitor Kazal-type 5) encoding the serine protease inhibitor LEKTI (lympho-epithelial Kazal type-related inhibitor). Here, we disclose new SPINK5 defects in 12 patients, who presented a clinical triad suggestive of NS with variations in inter- and intra-familial disease expression. We identified a new and frequent synonymous mutation c.891C>T (p.Cys297Cys) in exon 11 of the 12 NS patients. This mutation disrupts an exonic splicing enhancer sequence and causes out-of-frame skipping of exon 11. Haplotype analysis indicates that this mutation is a founder mutation in Greece. Two other new deep intronic mutations, c.283-12T>A in intron 4 and c.1820+53G>A in intron 19, induced partial intronic sequence retention. A new nonsense c.2557C>T (p.Arg853X) mutation was also identified. All mutations led to a premature termination codon resulting in no detectable LEKTI on skin sections. Two patients with deep intronic mutations showed residual LEKTI fragments in cultured keratinocytes. These fragments retained some functional activity, and could therefore, together with other determinants, contribute to modulate the disease phenotype. This new founder mutation, the most frequent mutation described in European populations so far, and these unusual intronic mutations, widen the clinical and molecular spectrum of NS and offer new diagnostic perspectives for NS patients.


Insulin demand regulates β cell number via the unfolded protein response.
Although stem cell populations mediate regeneration of rapid turnover tissues, such as skin, blood, and gut, a stem cell reservoir has not been identified for some slower turnover tissues, such as the pancreatic islet. Despite lacking identifiable stem cells, murine pancreatic β cell number expands in response to an increase in insulin demand. Lineage tracing shows that new β cells are generated from proliferation of mature, differentiated β cells; however, the mechanism by which these mature cells sense systemic insulin demand and initiate a proliferative response remains unknown. Here, we identified the β cell unfolded protein response (UPR), which senses insulin production, as a regulator of β cell proliferation. Using genetic and physiologic models, we determined that among the population of β cells, those with an active UPR are more likely to proliferate. Moreover, subthreshold endoplasmic reticulum stress (ER stress) drove insulin demand-induced β cell proliferation, through activation of ATF6. We also confirmed that the UPR regulates proliferation of human β cells, suggesting that therapeutic UPR modulation has potential to expand β cell mass in people at risk for diabetes. Together, this work defines a stem cell-independent model of tissue homeostasis, in which differentiated secretory cells use the UPR sensor to adapt organ size to meet demand.


Integrating proteomic, transcriptional, and interactome data reveals hidden components of signaling and regulatory networks.
Cellular signaling and regulatory networks underlie fundamental biological processes such as growth, differentiation, and response to the environment. Although there are now various high-throughput methods for studying these processes, knowledge of them remains fragmentary. Typically, the majority of hits identified by transcriptional, proteomic, and genetic assays lie outside of the expected pathways. These unexpected components of the cellular response are often the most interesting, because they can provide new insights into biological processes and potentially reveal new therapeutic approaches. However, they are also the most difficult to interpret. We present a technique, based on the Steiner tree problem, that uses previously reported protein-protein and protein-DNA interactions to determine how these hits are organized into functionally coherent pathways, revealing many components of the cellular response that are not readily apparent in the original data. Applied simultaneously to phosphoproteomic and transcriptional data for the yeast pheromone response, it identifies changes in diverse cellular processes that extend far beyond the expected pathways.


Understanding human infectious Cryptosporidium risk in drinking water supply catchments.
Treating drinking water appropriately depends, in part, on the robustness of source water quality risk assessments, however quantifying the proportion of infectious, human pathogenic Cryptosporidium oocysts remains a significant challenge. We analysed 962 source water samples across nine locations to profile the occurrence, rate and timing of infectious, human pathogenic Cryptosporidium in surface waters entering drinking water reservoirs during rainfall-runoff conditions. At the catchment level, average infectivity over the four-year study period reached 18%; however, most locations averaged <5%. The maximum recorded infectivity fraction within a single rainfall runoff event was 65.4%, and was dominated by C. parvum. Twenty-two Cryptosporidium species and genotypes were identified using PCR-based molecular techniques; the most common being C. parvum, detected in 23% of water samples. Associations between landuse and livestock stocking characteristics with Cryptosporidium were determined using a linear mixed-effects model. The concentration of pathogens in water were significantly influenced by flow and dominance of land-use by commercial grazing properties (as opposed to lifestyle properties) in the catchment (p < 0.01). Inclusion of measured infectivity and human pathogenicity data into a quantitative microbial risk assessment (QMRA) could reduce the source water treatment requirements by up to 2.67 log removal values, depending on the catchment, and demonstrated the potential benefit of collating such data for QMRAs.


Competitive antagonism of AMPA receptors by ligands of different classes: crystal structure of ATPO bound to the GluR2 ligand-binding core, in comparison with DNQX.
Ionotropic glutamate receptors (iGluRs) constitute a family of ligand-gated ion channels that are essential for mediating fast synaptic transmission in the central nervous system. This study presents a high-resolution X-ray structure of the competitive antagonist (S)-2-amino-3-[5-tert-butyl-3-(phosphonomethoxy)-4-isoxazolyl]propionic acid (ATPO) in complex with the ligand-binding core of the receptor. Comparison with the only previous structure of the ligand-binding core in complex with an antagonist, 6,7-dinitro-2,3-quinoxalinedione (DNQX) (Armstrong, N.; Gouaux, E. Neuron 2000, 28, 165-181), reveals that ATPO and DNQX stabilize an open form of the ligand-binding core by different sets of interactions. Computational techniques are used to quantify the differences between these two ligands and to map the binding site. The isoxazole moiety of ATPO acts primarily as a spacer, and other scaffolds could potentially be used. Whereas agonists induce substantial domain closures compared to the apo structure, ATPO only induces minor conformational changes. These results are consistent with the hypothesis that domain closure is related to receptor activation. To facilitate the design of novel AMPA receptor antagonists, we present a modified model of the binding site that includes key residues involved in ligand recognition.


Effect of 7 yr of experimental drought on vegetation dynamics and biomass storage of an eastern Amazonian rainforest.
*At least one climate model predicts severe reductions of rainfall over Amazonia during this century. Long-term throughfall exclusion (TFE) experiments represent the best available means to investigate the resilience of the Amazon rainforest to such droughts. *Results are presented from a 7 yr TFE study at Caxiuanã National Forest, eastern Amazonia. We focus on the impacts of the drought on tree mortality, wood production and above-ground biomass. *Tree mortality in the TFE plot over the experimental period was 2.5% yr(-1), compared with 1.25% yr(-1) in a nearby control plot experiencing normal rainfall. Differences in stem mortality between plots were greatest in the largest (> 40 cm diameter at breast height (dbh)) size class (4.1% yr(-1) in the TFE and 1.4% yr(-1) in the control). Wood production in the TFE plot was c. 30% lower than in the control plot. Together, these changes resulted in a loss of 37.8 +/- 2.0 Mg carbon (C) ha(-1) in the TFE plot (2002-2008), compared with no change in the control. *These results are remarkably consistent with those from another TFE (at Tapajós National Forest), suggesting that eastern Amazonian forests may respond to prolonged drought in a predictable manner.


Pattern of skin diseases in an Indian village.
Disease pattern in a given population is generally determined by different ecological factors. Thus the objective of our study was to find out the pattern of skin diseases in a given population. Analysis of 3673 patients attending a medical camp at Kumble in Kerala state showed 410(11.16%) patients with dermatological problems. 260(63.41%) of them were males and 150(36.59%) females with a male to female ratio of 1.7:1. Of these patients, 178(43.41%) had cutaneous infections and 234(57.07%) had non-infectious dermatoses. Few patients had more than one dermatoses. Fungal infection was the commonest infection seen (22.92%) and eczemas took an upper hand in non-infectious group (32.19%). Improvement in the standard of living, education of the general public, improvement in the environmental sanitation and good nutritious food may help us to bring down the skin disease in this area.


Reflexive assessment of practical and holistic sanitation development tools using the rural and peri-urban case of Mexico.
Lack of sanitation affects the lives of billions of people worldwide. It is now generally agreed that sustainable solutions to this complex problem require social and cultural factors to be addressed in addition to the habitual economic and technical aspects. Increasingly, sector professionals view the fragmented approaches to sanitation as a limiting factor. This refers to the fragmentation of the knowledge on the subject among often hermetic disciplines and to the distribution of political mandates on sanitation across many institutions, which independently tackle specific aspects of the issue. Holistic approaches have often been suggested as a solution. This paper presents the development of such a holistic approach, designed to assess sanitation development in rural and peri-urban settings. Tested in three Mexican communities, it relies on qualitative research tools to identify critical influences to sanitation development. This article presents generic results about micro and macro-factors affecting sanitation development in Mexican villages, and reflexively examines the research process as well as the strengths and limitations of the approach. The conceptual map developed for each case study successfully highlights the interconnectedness of all factors affecting sanitation development. Despite some weaknesses, these maps constitute a practical assessment tool for interdisciplinary teams deployed in integrated water and sanitation development programs and a valuable didactic tool for training activities.


Vaginal use of micronized progesterone for luteal support.A randomized study comparing Utrogestan® and Crinone® 8.
Luteal phase physiology is distorted by in vitro fertilization (IVF) cycles using gonadotropin-releasing hormone (GnRH) agonists and antagonists, Controlled ovarian hyperstimulation leads to luteal phase defect and for this reason, luteal phase support is now an integral part of IVF/ICSI-ET programs. The support is provided by hCG, progesterone or GnRH-a. This study compared the efficiency, safety and tolerance of two vaginal micronized progesterones, Utrogestan and Crinone 8%. 111 women, 18-40 years old, FSH < 10 IU/L and normal uterus findings were included. The efficiency of the two preparations to provide luteal support was evaluated by the fertilization, implantation, pregnancy and take-home baby rates. The safety was compared through the results of vaginal findings and vaginal inflammation markers before and after treatment. Comparison of tolerance was made by evaluating 21 subjective patient questionnaire parameters. There were no significant differences between the preparations in terms of efficiency or safety though Crinone 8% was better tolerated. The outcomes of this study suggest that a vaginal gel with micronized progesterone (Crinone 8%) is the optimal choice at this time for luteal support.


Estimated prevalence of anabolic steroid use among male high school seniors.
The use of anabolic-androgenic steroids (AS) is perceived by the media, by segments of the sports medicine and athletic communities, and by the public to have grown to epidemic proportions. Unfortunately, the incidence and prevalence of AS use among elite, amateur, and recreational athletes is poorly documented. This study was designed to help identify AS use patterns among the male portion of the general adolescent population. The overall participation rate on a schoolwide basis was 68.7% and on an individual basis reached 50.3%. Participants in this investigation were 12th-grade male students (N = 3403) in 46 private and public high schools across the nation who completed a questionnaire that established current or previous use of AS as well as user and nonuser characteristics. Results indicate that 6.6% of 12th grade male students use or have used AS and that over two thirds of the user group initiated use when they were 16 years of age or younger. Approximately 21% of users reported that a health professional was their primary source. The evidence indicates that educational intervention strategies should begin as early as junior high school; the intervention should not be directed only toward those individuals who participate in school-based athletics.


The technology path to deep greenhouse gas emissions cuts by 2050: the pivotal role of electricity.
Several states and countries have adopted targets for deep reductions in greenhouse gas emissions by 2050, but there has been little physically realistic modeling of the energy and economic transformations required. We analyzed the infrastructure and technology path required to meet California's goal of an 80% reduction below 1990 levels, using detailed modeling of infrastructure stocks, resource constraints, and electricity system operability. We found that technically feasible levels of energy efficiency and decarbonized energy supply alone are not sufficient; widespread electrification of transportation and other sectors is required. Decarbonized electricity would become the dominant form of energy supply, posing challenges and opportunities for economic growth and climate policy. This transformation demands technologies that are not yet commercialized, as well as coordination of investment, technology development, and infrastructure deployment.