Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness).
Survivors and nonsurvivors among 103 consecutive pediatric patients with massive burns were compared in an effort to define the predictors of mortality in massively burned children. Predictors of mortality in burns that are used commonly are age, burn size, and inhalation injury. In the past, burns over 80% of the body surface area that are mostly full-thickness often were considered fatal, especially in children and in the elderly. In the past 15 years, advances in burn treatment have increased rates of survival in those patients treated at specialized burn centers. The purpose of this study was to document the extent of improvement and to define the current predictors of mortality to further focus burn care. Beginning in 1982, 103 children ages 6 months to 17 years with burns covering at least 80% of the body surface (70% full-thickness), were treated in the authors' institution by early excision and grafting and have been observed to determine outcome. The authors divided collected independent variables from the time of injury into temporally related groups and analyzed the data sequentially and cumulatively through univariate statistics and through pooled, cross-sectional multivariate logistic regression to determine which variables predict the probability of mortality. The mortality rate for this series of massively burned children was 33%. Lower age, larger burn size, presence of inhalation injury, delayed intravenous access, lower admission hematocrit, lower base deficit on admission, higher serum osmolarity at arrival to the authors' hospital, sepsis, inotropic support requirement, platelet count < 20,000, and ventilator dependency during the hospital course significantly predict increased mortality. The authors conclude that mortality has decreased in massively burned children to the extent that nearly all patients should be considered as candidates for survival, regardless of age, burn size, presence of inhalation injury, delay in resuscitation, or laboratory values on initial presentation. During the course of hospitalization, the development of sepsis and multiorgan failure is a harbinger of poor outcome, but the authors have encountered futile cases only rarely. The authors found that those patients who are most apt to die are the very young, those with limited donor sites, those who have inhalation injury, those with delays in resuscitation, and those with burn-associated sepsis or multiorgan failure.


Childhood cognitive skill trajectories and suicide by mid-adulthood: an investigation of the 1958 British Birth Cohort.
Poor cognitive abilities and low intellectual quotient (IQ) are associated with an increased risk of suicide attempts and suicide mortality. However, knowledge of how this association develops across the life-course is limited. Our study aims to establish whether individuals who died by suicide by mid-adulthood are distinguishable by their child-to-adolescence cognitive trajectories. Participants were from the 1958 British Birth Cohort and were assessed for academic performance at ages 7, 11, and 16 and intelligence at 11 years. Suicides occurring by September 2012 were identified from linked national death certificates. We compared mean mathematics and reading abilities and rate of change across 7-16 years for individuals who died by suicide v. those still alive, with and without adjustment for potential early-life confounding factors. Analyses were based on 14 505 participants. Fifty-five participants (48 males) had died by suicide by age 54 years. While males who died by suicide did not differ from participants still alive in reading scores at age 7 [effect size (g) = -0.04, p = 0.759], their reading scores had a less steep improvement up to age 16 compared to other participants. Adjustments for early-life confounding factors explained these differences. A similar pattern was observed for mathematics scores. There was no difference between individuals who died by suicide v. participants still alive on intelligence at 11 years. While no differences in tests of academic performance and IQ were observed, individuals who died by suicide had a less steep improvement in reading abilities over time compared to same-age peers.


Evaluation of a malaria antibody enzyme immunoassay for use in blood screening.
Transfusion-transmitted malaria is rare, but it may produce severe problem in the safety of blood transfusion due to the lack of reliable procedure to evaluate donors potentially exposed to malaria. Here, we evaluated a new enzyme-linked immunosorbent assay malaria antibody test (ELISA malaria antibody test, DiaMed, Switzerland) to detect antibodies to Plasmodium vivax (the indigenous malaria) in the blood samples in the Republic of Korea (ROK). Blood samples of four groups were obtained and analyzed; 100 samples from P.vivax infected patients, 35 from recovery patients, 366 from normal healthy individuals, and 325 from domestic travelers of non-endemic areas residents to risky areas of ROK. P.vivax antibody levels by ELISA were then compared to the results from microscopic examination and polymerase chain reaction (PCR) test. As a result, the ELISA malaria antibody test had a clinical sensitivity of 53.0% and a clinical specificity of 94.0% for P.vivax. Twenty out of 325 domestic travelers (6.2%) were reactive and 28 cases (8.6%) were doubtful. Of the reactive and doubtful cases, only two were confirmed as acute malaria by both microscopy and PCR test. Thus we found that the ELISA malaria antibody test was insufficiently sensitive for blood screening of P.vivax in ROK.


Mental health/illness and prisons as place: frontline clinicians׳ perspectives of mental health work in a penal setting.
This article takes mental health and prisons as its two foci. It explores the links between social and structural aspects of the penal setting, the provision of mental healthcare in prisons, and mental health work in this environment. This analysis utilises qualitative interview data from prison-based fieldwork undertaken in Her Majesty׳s Prison Service, England. Two themes are discussed: (1) the desire and practicalities of doing mental health work and (2) prison staff as mental health work allies. Concepts covered include equivalence, training, ownership, informal communication, mental health knowledge, service gatekeepers, case identification, and unmet need. Implications for practice are (1) the mental health knowledge and understanding of prison wing staff could be appraised and developed to improve mental healthcare and address unmet need. Their role as observers and gatekeepers could be considered. (2) The realities of frontline mental health work for clinicians in the penal environment should be embraced and used to produce and implement improved policy and practice guidance, which is in better accord with the actuality of the context - both socially and structurally.


Planning for tomorrow whilst living for today: the views of people with dementia and their families on advance care planning.
Advance care planning (ACP) is increasingly prominent in many countries; however, the evidence base for its acceptability and effectiveness is limited especially in conditions where cognition is impaired, as in dementia. This qualitative study used semi-structured interviews with people with mild to moderate dementia (n = 17) and family carers (n = 29) to investigate their views about planning for their future generally and ACP specifically. People with dementia and their families make a number of plans for the future. Most people undertook practical, personal, financial, and legal planning. However participants did not make formal advance care plans with the exception of appointing someone to manage their financial affairs. Five barriers to undertaking ACP were identified: lack of knowledge and awareness, difficulty in finding the right time, a preference for informal plans over written documentation, constraints on choice around future care, and lack of support to make choices about future healthcare. Health and social care professionals can build on people's preferences for informal planning by exploring the assumptions underlying them, providing information about the possible illness trajectory and discussing the options of care available. Health and social care professionals also have a role to play in highlighting the aspects of ACP which seem to be most relevant to the wishes and aspirations of people with dementia.


Detection of mycobacteria and chlamydiae in granulomatous inflammation of reptiles: a retrospective study.
A retrospective study on reptile tissues presenting with granulomatous inflammation was performed to detect the possible presence of mycobacteria and chlamydiae in these lesions. Ninety cases including 48 snakes, 27 chelonians, and 15 lizards were selected. Mycobacteria were detected by Ziehl-Neelsen (ZN) staining and a broad-range polymerase chain reaction (PCR) followed by DNA sequencing. To detect chlamydiae, immunohistochemistry with monoclonal antibodies against chlamydial lipopolysaccharide (LPS) and a Chlamydiales order-specific PCR and sequencing were applied. Acid-fast bacilli were found in 14 cases (15.6%) by ZN staining and in 23 cases (25.6%) by PCR. Sequence analysis revealed the presence of Mycobacteria other than Mycobacterium tuberculosis complex (MOTT). Chlamydial LPS antigen was observed within granulomas from five samples (5.6%), whereas the PCR screen revealed 58 positive cases (64.4%). Of these, 9 cases (10%) showed 98-99% similarity to Chlamydophila (Cp.) pneumoniae and 49 cases (54.4%) displayed a high similarity (88-97%) to the newly described "Chlamydia-like" microorganisms Parachlamydia acanthamoebae and Simkania negevensis. Results from this study confirm, on the one hand, that MOTT are probably the most important infectious etiology for granulomatous inflammation in reptiles. On the other hand, they indicate that chlamydia infects reptiles and that Cp. pneumoniae should be considered an etiological agent of granulomatous lesions of reptiles. Because both MOTT and Cp. pneumoniae are human pathogens, the potential of zoonotic transmission from reptiles to humans has to be considered. In contrast, the significance of Chlamydia-like isolates remains completely open, and further studies are needed to evaluate their role.


Developing patient portals in a fragmented healthcare system.
Use of patient portals may contribute to improved patient health and experiences and better organizational performance. In the Netherlands, patient portals have gained considerable attention in recent years, as evidenced by various policy initiatives and practical efforts directed at developing portals. Due to the fragmented setup of the Dutch healthcare system patient portals that give patients access to information and services from across their providers are developed in inter-organizational collaboration. The objective of this paper is to identify and describe the types of collaborations, or networks, that have been established to develop patient portals in the Netherlands. Understanding the characteristics of these networks as well as the development of their respective portals enables us to assess the enabling and constraining effects of different network types on patient portal initiatives. We used qualitative methods including interview and documents analysis. In a first step, we interviewed eighteen experts and reviewed relevant national policy and strategy documents. Based on this orientation, we selected three networks we deemed to be representative of inter-organizational efforts to develop Dutch patient portals in 2012. In a second step, we interviewed twelve representatives of these patient portal networks and collected documents related to the portals. We applied content analytic techniques to analyze data from the three cases. The three studied networks differed in their number and diversity of actors, the degree to which these actors were mutually dependent, the degree to which network governance was decentralized, and the dynamics of the network structures. We observed that the portals developed in networks displaying the highest degree of these characteristics experienced most difficulties associated with developing patient portals - such as achieving interoperability, successful implementation, regulatory complaisance, and financial sustainability. Yet, at the same time, the portals developed in these networks may hold the highest functionality to patients, since they can consolidate information and services from a broad array of health service providers. The early empirical evidence provided here indicates that effective development of patient portals begs a tradeoff between envisioned functionality and ease of development.


Crosslinked urethane doped polyester biphasic scaffolds: Potential for in vivo vascular tissue engineering.
In vivo tissue engineering uses the body as a bioreactor for tissue regeneration, thus placing stringent requirements on tissue scaffolds, which should be mechanically robust for immediate implantation without a long in vitro cell culture time. In addition to mechanical strength, vascular grafts fabricated for in vivo tissue engineering approach must have matching mechanical properties to the target tissues to avoid compliance mismatch, which is one of the reasons for graft failure. We recently synthesized a new generation of strong and elastic biodegradable crosslinked urethane-doped polyesters (CUPE) to address the challenge of developing soft, elastic yet strong biodegradable polymers. This study evaluated the tensile strength, burst pressure, and suture retention of CUPE biphasic scaffolds to determine if the scaffolds met the requirements for immediate implantation in an in vivo tissue engineering approach. In addition, we also examined the hemocompatibility and inflammatory potential of CUPE to demonstrate its potential in serving as a blood-contacting vascular graft material. Tensile strength of CUPE biphasic scaffolds (5.02 ± 0.70 MPa) was greater than native vessels (1.43 ± 0.60 MPa). CUPE scaffolds exhibited tunable burst pressure ranging from 1500 mmHg to 2600 mmHg, and adequate suture retention values (2.45 ± 0.23 N). CUPE showed comparable leukocyte activation and whole blood clotting kinetics to poly(L-lactic acid) PLLA. However, CUPE incited a lesser release of inflammatory cytokines and was found to be non hemolytic. Combined with the mechanical properties and previously demonstrated anti-thrombogenic nature, CUPE may serve as a viable graft material for in vivo blood vessel tissue engineering.


Protein kinase A regulates the disposition of Ca2+ which enters the cytoplasmic space through store-activated Ca2+ channels in rat hepatocytes by diverting inflowing Ca2+ to mitochondria.
The roles of a trimeric GTP-binding regulatory protein, protein kinase A and mitochondria in the regulation of store-activated (thapsigargin-stimulated) Ca2+ inflow in freshly-isolated rat hepatocytes were investigated. Rates of Ca2+ inflow were estimated by measuring the increase in the fluorescence of intracellular fura-2 following the addition of extracellular Ca2+ (Ca2+o) to cells incubated in the absence of added Ca2+o. Guanosine 5'-[gamma-thio]-triphosphate (GTP[S]) and AlF4(-) inhibited the thapsigargin-stimulated Ca2+o-induced increase in cytoplasmic free Ca2+ concentration ([Ca2+]c) and this inhibition was prevented by the Rp diastereoisomer of adenosine 3',5'-(cyclic)phosphoro[thioate]. cAMP, forskolin and glucagon (half-maximal effect at 10 nM) mimicked inhibition of the thapsigargin-stimulated Ca2+o-induced increase in [Ca2+]c by GTP[S], but had little effect on thapsigargin-induced release of Ca2+ from intracellular stores. Azide and carbonyl cyanide p-trifluoromethoxyphenylhydrazone inhibited the thapsigargin-stimulated Ca2+o-induced increase in [Ca2+]c in the presence of increased cAMP (induced by glucagon). In contrast, Ruthenium Red markedly enhanced the thapsigargin-stimulated Ca2+o-induced increase in [Ca2+]c in both the presence and absence of increased cAMP (induced by forskolin and dibutyryl cAMP). It is concluded that, in hepatocytes, protein kinase A regulates the disposition of Ca2+, which enters the cytoplasmic space through store-activated Ca2+ channels, by directing some of this Ca2+ to the mitochondria. The idea that caution should be exercised in using observed values of Ca2+o-induced increase in [Ca2+]c as estimates of rates of agonist-stimulated Ca2+ inflow is briefly discussed.


Gut microbiota and major depressive disorder: A systematic review and meta-analysis.
Growing attention has been paid to the field of gut microbiota for mental disorders over the last decade. However, to our knowledge, no studies have conducted systematic reviews on the association between gut microbiota and major depressive disorder (MDD) in both interventional and non-interventional studies. We conducted a systematic review and meta-analysis of 16 studies (10 observational [701 participants] and six interventional trials [302 participants]) examining gut microbiota in patients with MDD. The primary outcome measures were differences in the profile of microbiota in the observational studies, and symptom changes for depression between pre- and post-intervention with probiotics in the interventional trials. In the observational studies, significant reductions in several taxa at the family and genus levels were observed in patients with MDD compared to non-depressed controls. In the interventional studies with probiotics, a significant improvement was found in depressive symptomatology compared to controls (SMD = -1.62, 95% CI = -2.73 to -0.51, p< 0.01). Lack of consideration of the effects of diet and pharmacotherapy was a possible limitation. Our results indicate that several taxa at the family and genus levels, specifically family Prevotellaceae, genus Corprococcus, and Faecalibacterium, were decreased in MDD compared to non-depressed controls in observational studies, and depressive symptoms were improved compared to controls in interventional studies with probiotics. Due to the limited number of studies, further studies considering diet and pharmacotherapy are needed to explore the relationships between gut microbiota and MDD in humans.


Familial hypobetalipoproteinemia due to a novel early stop mutation.
Familial hypobetalipoproteinemia (FHBL) is a co-dominant disorder associated with low circulating levels of low-density lipoprotein (LDL) cholesterol and apolipoprotein B100 (ApoB). A proband was identified in whom the condition was due to an E110X mutation of APOB, creating a particularly early truncation of ApoB in the region of the molecule necessary for very-low-density lipoprotein (VLDL) assembly. The mutation was also associated with nonalcoholic fatty liver disease. To assess the effect of the mutation on metabolism and the formation of VLDL and LDL subfractions. Both the proband and his son, who had the same mutation, had low LDL cholesterol and decreased ApoB, but an increased small-dense LDL level. Lipoprotein profiles were normal in the proband's sister and grandson, in whom the mutation was absent. In the proband. there was a profoundly diminished rate of production of VLDL-2. VLDL-1 production, however, was relatively preserved and, because of its decreased catabolism, its pool size was increased. Direct formation of intermediate-density lipoprotein (IDL) and LDL was undetectable. Intermediate-density lipoprotein catabolism was greatly increased and its conversion to LDL was increased. The LDL produced was entirely small-dense LDL. High-density lipoprotein cholesterol levels were low, perhaps also related to the relative increase in VLDL-1, which is an avid acceptor of cholesteryl ester. This novel mutation provides evidence to support the hypothesis that hepatic production of large VLDL-1 leads to the creation of small-dense LDL.


Testosterone-cortisol dissociation in children exposed to prenatal maternal stress, and relationship with aggression: Project Ice Storm.
Prenatal maternal stress (PNMS) has been associated with postnatal behavioral alterations that may be partly explained by interactions between the hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-gonadal (HPG) axes. Yet it remains unclear whether PNMS leads to enduring HPA-HPG alterations in the offspring, and whether HPA-HPG interactions can impact behavior during development, in particular levels of aggression in childhood. Here we investigated the relationship between a marker for HPG axis function (baseline testosterone) and a marker for HPA axis response (cortisol area under the curve) in 11½-year-olds whose mothers were exposed to the 1998 Quebec ice storm during pregnancy (n = 59 children; 31 boys, 28 girls). We examined (a) whether the degree of objective or subjective PNMS regulates the testosterone-cortisol relationship at age 11½, and (b) whether this testosterone-cortisol relationship is associated with differences in aggressive behavior. We found that, at lower levels of subjective PNMS, baseline testosterone and cortisol reactivity were positively correlated; in contrast, there was no relationship between these hormones at higher levels of subjective PNMS. Cortisol response moderated the relationship between testosterone and aggression. These results support the notion PNMS may explain variance in fetal HPA-HPG interactions, and that these interactions may be associated with aggressive behavior in late childhood.


Cerebral Microbleeds in Multiple Sclerosis Evaluated on Susceptibility-weighted Images and Quantitative Susceptibility Maps: A Case-Control Study.
Purpose To assess cerebral microbleed (CMB) prevalence in patients with multiple sclerosis (MS) and clinically isolated syndrome (CIS) and associations with clinical outcomes. Materials and Methods CMBs are associated with aging and neurodegenerative disorders. The prevalence of CMBs has not previously been well established. In this study, 445 patients with MS (266 with relapsing-remitting MS, 138 with secondary progressive MS, and 41 with primary progressive MS), 45 patients with CIS, 51 patients with other neurological diseases, and 177 healthy control subjects (HCs) underwent 3-T magnetic resonance (MR) imaging and clinical examinations. A subset of 168 patients with MS and 50 HCs underwent neuropsychological testing. Number of CMBs was assessed on susceptibility-weighted minimum intensity projections by using the Microbleed Anatomic Rating Scale; volume was calculated by using quantitative susceptibility maps. Differences between groups were analyzed with the χ2 test, Fisher exact test, Student t test, and analysis of variance; associations of CMBs with clinical and other MR imaging outcomes were explored with correlation and regression analyses. Because CMB frequency increases with age, prevalence was investigated in participants at least 50 years of age and younger than 50 years. Results Significantly more patients with MS than HCs had CMBs (19.8% vs 7.4%, respectively; P = .01) in the group at least 50 years old. A trend toward greater presence of CMBs was found in patients with MS (P = .016) and patients with CIS who were younger than 50 years (P = .039) compared with HCs. In regression analysis adjusted for age, hypertension, and normalized brain volume, increased number of CMBs was significantly associated with increased physical disability in the MS population (R2 = 0.23, P < .0001). In correlation analysis, increased number of CMBs was significantly associated with deteriorated auditory and verbal learning and memory (P = .006) and visual information processing speed trends (P = .049) in patients with MS. Conclusion Monitoring CMBs may be relevant in patients with MS and CIS at higher risk for developing cognitive and physical disability. © RSNA, 2016 Online supplemental material is available for this article.


The adverse effects of exercise and supraphysiological dose of testosterone-enanthate (TE) on exploratory activity in elevated plus maze (EPM) test - indications for using total exploratory activity (TEA) as a new parameter for ex.
The aim of this study was the estimation of effects induced by chronic administration of supraphysiological dose of TE and prolonged exercise in male rats on anxiety levels (alterations in exploratory activity patterns in EPM). Two sedentary (control - C and testosterone-enanthate - T) and two exercise (exercise - E and testosterone-enanthate plus exercise - T+E) groups (n=32) underwent adequate protocols - the swimming protocol (1 h/day) and TE (20 mg/kg/w, s.c.) for six weeks. Testing was performed in EPM. Anxiolytic effects of exercise were manifested as increased exploratory activity in EPM - increase in cumulative duration in open arms, the number of rearings and head-dippings, and TEA. Supraphysiological dose of TE decreased the number of rearings and head-dippings, cumulative duration in open arms and TEA compared to the control group, while this effect of TE was more pronounced compared to the exercise group. The applied dose of TE attenuated beneficial effects of exercise by means of all estimated parameters. Our results confirmed the beneficial effect of exercise on anxiety levels observed in EPM by means of parameters considering the alterations in exploratory activity. Supraphysiological dose of TE resulted in anxiogenic-like behavior in EPM. The effect of TE was so pronounced that the beneficial effect of exercise was reversed to the control values (or even below them). Based on the results of this trial, we propose that use of the TEA (a new parameter for overall exploratory activity) can improve the evaluation of EPM test results.


Urinary ethyl glucuronide (EtG) and ethyl sulphate (EtS) assessment: valuable tools to improve verification of abstention in alcohol-dependent patients during in-patient treatment and at follow-ups.
The aims of this study were (i) to assess the effect of additional urinary ethyl glucuronide (EtG) and ethyl sulphate (EtS) assessment on diagnosed relapse rates in detoxified alcohol-dependent patients; and (ii) to compare dropout rates between EtG- and EtS-negative and -positive patients. Two studies on detoxified alcohol-dependent patients. If patients had no indication of relapse they were asked for a urinary sample at discharge from in-patient treatment 3, 6 and 12 weeks after discharge (study 1) and 1, 3 and 6 weeks after discharge (study 2), respectively. Department of Psychiatry, University of Luebeck, Germany. A total of 107 and 32 detoxified alcohol-dependent patients having participated in a 3-week in-patient motivation enhancement programme. Personal interviews, breathalyzer tests, assessment of urinary EtG and EtS with liquid chromatography-tandem mass spectrometry (LC-MS/MS analysis). Urinary EtG and EtS were always positive at the same time. In the first study 13.5% of the patients were already positive before being discharged from hospital. At the follow-ups 3, 6 and 12 weeks after discharge 12.2, 19.4 and 28.0%, respectively, of the patients coming to the follow-up and denying relapse were positive on urinary EtG and EtS. In the second study, of those patients showing up for follow-up after 1 week and denying relapse, EtG and EtS were positive in four cases (17.4%). Only one EtG- and EtS-positive relapser (3.1%) came to the next follow-ups. In both studies the rates of detected relapses were significantly higher for early follow-ups if urinary EtG and EtS results were considered additionally. Dropout rates until the next follow-up were significantly higher among positive than EtG- and EtS-negative patients. Urinary EtG and EtS improve verification of abstinence in studies of alcohol-dependent patients.


A two-component regulatory system required for copper-inducible expression of the copper resistance operon of Pseudomonas syringae.
Specific induction of the copper resistance operon (cop) promoter from Pseudomonas syringae was measured by beta-galactosidase production from a cop promoter-lacZ fusion. Induction of the cop promoter in P. syringae pv. syringae required trans-acting factors from copper resistance plasmid pPT23D, from which cop was originally cloned. Tn5 mutagenesis of pPT23D was used to localize two complementation groups immediately downstream from copABCD. Cloning and sequencing of the DNA in this region revealed two genes, copR and copS, expressed in the same orientation as the cop operon but from a separate constitutive promoter. The amino acid sequence deduced from these genes showed distinct similarities to known two-component regulatory systems, including PhoB-PhoR and OmpR-EnvZ. In addition, CopR showed strong similarity to copper resistance activator protein PcoR from Escherichia coli. Functional chromosomal homologs to copRS activated the cop promoter, in a copper-inducible manner, in copper-resistant or -sensitive strains of P. syringae pv. tomato and other Pseudomonas species. This implies that copper-inducible gene regulation is associated with a common chromosomally encoded function, as well as plasmid-borne copper resistance, in Pseudomonas spp.


In Vivo-Selected Compensatory Mutations Restore the Fitness Cost of Mosaic penA Alleles That Confer Ceftriaxone Resistance in Neisseria gonorrhoeae.
Resistance to ceftriaxone in Neisseria gonorrhoeae is mainly conferred by mosaic penA alleles that encode penicillin-binding protein 2 (PBP2) variants with markedly lower rates of acylation by ceftriaxone. To assess the impact of these mosaic penA alleles on gonococcal fitness, we introduced the mosaic penA alleles from two ceftriaxone-resistant (Cror) clinical isolates (H041 and F89) into a Cros strain (FA19) by allelic exchange and showed that the resultant Cror mutants were significantly outcompeted by the Cros parent strain in vitro and in a murine infection model. Four Cror compensatory mutants of FA19 penA41 were isolated independently from mice that outcompeted the parent strain both in vitro and in vivo One of these compensatory mutants (LV41C) displayed a unique growth profile, with rapid log growth followed by a sharp plateau/gradual decline at stationary phase. Genome sequencing of LV41C revealed a mutation (G348D) in the acnB gene encoding the bifunctional aconitate hydratase 2/2 methylisocitrate dehydratase. Introduction of the acnBG348D allele into FA19 penA41 conferred both a growth profile that phenocopied that of LV41C and a fitness advantage, although not as strongly as that exhibited by the original compensatory mutant, suggesting the existence of additional compensatory mutations. The mutant aconitase appears to be a functional knockout with lower activity and expression than wild-type aconitase. Transcriptome sequencing (RNA-seq) analysis of FA19 penA41 acnBG348D revealed a large set of upregulated genes involved in carbon and energy metabolism. We conclude that compensatory mutations can be selected in Cror gonococcal strains that increase metabolism to ameliorate their fitness deficit.IMPORTANCE The emergence of ceftriaxone-resistant (Cror) Neisseria gonorrhoeae has led to the looming threat of untreatable gonorrhea. Whether Cro resistance is likely to spread can be predicted from studies that compare the relative fitnesses of susceptible and resistant strains that differ only in the penA gene that confers Cro resistance. We showed that mosaic penA alleles found in Cror clinical isolates are outcompeted by the Cros parent strain in vitro and in vivo but that compensatory mutations that allow ceftriaxone resistance to be maintained by increasing bacterial fitness are selected during mouse infection. One compensatory mutant that was studied in more detail had a mutation in acnB, which encodes the aconitase that functions in the tricarboxylic acid (TCA) cycle. This study illustrates that compensatory mutations can be selected during infection, which we hypothesize may allow the spread of Cro resistance in nature. This study also provides novel insights into gonococcal metabolism and physiology.


Temporal trends of main reproductive characteristics in ten urban and rural regions of China: the China Kadoorie biobank study of 300 000 women.
Chinese women's reproductive patterns have changed significantly over the past several decades. However, relatively little is known about the pace and characteristics of these changes either overall or by region and socioeconomic status. We examined the cross-sectional data from the China Kadoorie Biobank cohort study that recruited 300 000 women born between 1930 and 1974 (mean age: 51 years) from 10 socially diverse urban and rural regions of China. Temporal trends in several self-reported reproductive characteristics, and effect modification of these trends by area and education (as a surrogate for socioeconomic status), were examined. The overall mean age at menarche was 15.4 (standard deviation 1.9) years, but decreased steadily over the 45 birth cohorts from 16.1 to 14.3 years, except for an anomalous increase of ∼1 year for women exposed to the 1958-61 famine in early adolescence. Similarly large changes were seen for other characteristics: mean parity fell (urban: 4.9 to 1.1; rural: 5.9 to 1.4); mean age at first birth increased (urban: 19.0 to 25.9 years; rural: 18.3 to 23.8 years); and birth spacing increased after 1980 to over 5 years. Breastfeeding declined after 1950 in urban and, after 1980, in rural women; and 68% of urban and 48% of rural women experienced a terminated pregnancy. Mean age at menopause increased from 47.9 to 49.3 years. There have been striking changes in reproductive factors over time and between areas among these Chinese women. Their effects on major chronic diseases should be investigated.


Heart failure causes cholinergic transdifferentiation of cardiac sympathetic nerves via gp130-signaling cytokines in rodents.
Although several cytokines and neurotrophic factors induce sympathetic neurons to transdifferentiate into cholinergic neurons in vitro, the physiological and pathophysiological roles of this remain unknown. During congestive heart failure (CHF), sympathetic neural tone is upregulated, but there is a paradoxical reduction in norepinephrine synthesis and reuptake in the cardiac sympathetic nervous system (SNS). Here we examined whether cholinergic transdifferentiation can occur in the cardiac SNS in rodent models of CHF and investigated the underlying molecular mechanism(s) using genetically modified mice. We used Dahl salt-sensitive rats to model CHF and found that, upon CHF induction, the cardiac SNS clearly acquired cholinergic characteristics. Of the various cholinergic differentiation factors, leukemia inhibitory factor (LIF) and cardiotrophin-1 were strongly upregulated in the ventricles of rats with CHF. Further, LIF and cardiotrophin-1 secreted from cultured failing rat cardiomyocytes induced cholinergic transdifferentiation in cultured sympathetic neurons, and this process was reversed by siRNAs targeting Lif and cardiotrophin-1. Consistent with the data in rats, heart-specific overexpression of LIF in mice caused cholinergic transdifferentiation in the cardiac SNS. Further, SNS-specific targeting of the gene encoding the gp130 subunit of the receptor for LIF and cardiotrophin-1 in mice prevented CHF-induced cholinergic transdifferentiation. Cholinergic transdifferentiation was also observed in the cardiac SNS of autopsied patients with CHF. Thus, CHF causes target-dependent cholinergic transdifferentiation of the cardiac SNS via gp130-signaling cytokines secreted from the failing myocardium.


Consumer use of health-related endorsements on food labels in the United Kingdom and Australia.
The objective of this research was to examine how consumers use health-related food endorsements on food labels. Three endorsement programs were examined: those of the two major retailers in the United Kingdom, Tesco and Sainsbury's, and the "Pick the Tick" program of the National Heart Foundation of Australia. The main methodology used was protocol analysis. This involves the subject "thinking aloud" while performing a task--in this case, (a) shopping normally and (b) shopping "healthily" for foods on a predetermined list--to generate a protocol. Each subject was also interviewed to investigate reported use of endorsements. Subjects were a quota sample (N = 44) of shoppers representative of the U.K. and Australian populations. Information about the subjects, the protocols, and interview data were analyzed quantitatively; the protocols were also analyzed qualitatively. Sainsbury's and Australian shoppers never used the endorsements when shopping but Tesco shoppers did, albeit rarely. Tesco shoppers used the endorsement in complex ways and not just as a trigger to food selection. They sometimes used the endorsement to reject endorsed foods. Subjects claimed to use the endorsements even though the protocol analysis revealed no actual use. There are features of the Tesco endorsement program that make it more helpful to consumers than the other programs.


A mutant of Candida albicans deficient in beta-N-acetylglucosaminidase (chitobiase).
A mutant of Candida albicans ATCC 10261 was isolated that was defective in the production of beta-N-acetylglucosaminidase (chitobiase). The mutant grew normally in minimal medium supplemented with either glucose or N-acetyl-D-glucosamine (GlcNAc) as carbon and energy source, and the cells formed germ-tubes at 37 degrees C when induced to do so with GlcNAc. However, unlike the wild-type parent strain, the mutant strain did not utilize N,N'-diacetylchitobiose for growth. The mutant and parent strains had similar growth rates on glucose or GlcNAc, similar rates of uptake of these sugars and similar rates of 14C-labelled amino acid incorporation. The chitobiase mutant did, however, contain 53-85% more chitin than the wild-type strain. No reversion of the mutant phenotype was observed following induction of mitotic recombination with UV light, suggesting that the mutant allele (chi) was carried homozygously in the chitobiase-deficient mutant. Although the chitobiase-deficient mutant was pathogenic, it was not as virulent as the wild-type strain.


Reducing micropollutants with source control: substance flow analysis of 212 pharmaceuticals in faeces and urine.
Pharmaceuticals in the aquatic environment are raising concern. It is expected that many anthropogenic pharmaceuticals are largely excreted via urine; a popular argument for introducing urine source separation. However, to date, this assumption lacks verification. We close this gap with quantitative screening of official pharmaceutical data. We analysed the excretion pathways of 212 pharmaceuticals' active ingredients (AI), equalling 1,409 products. On average, 64% (+/-27%) of each AI was excreted via urine, and 35% (+/-26%) via faeces. In urine, 42% (+/-28%) of each AI was excreted as metabolites. However, these numbers need cautious interpretation. We found an extreme variability (1) between different therapeutic groups, (2) within some groups and (3) sometimes even between products of the same AI. We discuss various therapeutic groups and include Swiss sales' quantities. For instance, urine source separation could very effectively remove the highly sold and non-degradable x-ray contrast media: 94% (+/-4%) are excreted via urine. However, for different pharmaceuticals belonging to cytostatics, excretion via urine was 6-98%. Because of such large variability we advise caution to introduce the still imperfect urine separation technology solely because of pharmaceuticals. Nonetheless, together with other good arguments for this innovation, removal of pharmaceuticals is a welcome side effect.


Genomic structure, alternative transcripts and chromosome location of the human LIM domain binding protein 1 gene LDB1.
By protein interaction screening using a radioactive LMO2 protein probe we have isolated a LIM domain binding protein. The gene shows high homology to independently isolated genes from mouse, Xenopus and Drosophila called Ldb1/Nli/Clim-2, Xldb1 and Chip, respectively. The human and mouse genes differ by only two amino acids, suggesting that the gene that we have isolated is the human homologue. Here we describe the genomic organization, alternative transcript forms and the chromosome mapping of the human gene LDB1 (alias NLI). The gene is spread over at least 12 kb and has 11 exons. Preceding the described ATG initiation site in the mouse a highly conserved region between mouse, chicken and human was detected with a second possible in frame initiation site coding for further 36 amino acids. An alternative splice site adding six nucleotides corresponding to the addition of two amino acids at the end of exon 10 was found. The gene was mapped to chromosome 10q24-->q25 by in situ hybridization, a region frequently deleted in many types of cancer. Fine mapping with a radiation hybrid panel localized the gene in the interval between the markers D10S603 and D10S540.


Paclitaxel and bevacizumab with or without capecitabine as first-line treatment for HER2-negative locally recurrent or metastatic breast cancer: a multicentre, open-label, randomised phase 2 trial.
The addition of bevacizumab to paclitaxel or capecitabine has demonstrated improved progression-free survival (PFS) and objective response rate (ORR) as compared with chemotherapy alone in patients with HER2-negative locally recurrent or metastatic breast cancer (LR/MBC). We evaluated the efficacy and safety of first-line therapy of paclitaxel and bevacizumab with or without capecitabine in patients with HER2-negative LR/MBC. In this multicentre, open-label, randomised phase II trial, women with HER2-negative LR/MBC were randomly assigned in a 1:1 ratio to paclitaxel (90 mg/m2 intravenously [IV] on days 1, 8, and 15) and bevacizumab (10 mg/kg IV on days 1 and 15) every 4 weeks for six cycles, followed by bevacizumab (15 mg/kg IV on day 1) every 3 weeks (AT) or to paclitaxel (90 mg/m2 IV on days 1 and 8), bevacizumab (15 mg/kg IV on day 1) and capecitabine (825 mg/m2 orally twice daily on days 1–14) every 3 weeks for eight cycles, followed by bevacizumab and capecitabine at the same doses every 3 weeks (ATX). The primary end-point was investigator-assessed PFS. Secondary end-points included ORR, duration of response, overall survival (OS) and safety. Exploratory analyses were conducted to evaluate the impact of capecitabine on OS and to validate a novel prognostic model. This trial is registered with EudraCT, number 2006-006058-83. Median PFS was significantly longer in ATX as compared with AT (11.2 months versus 8.4 months; stratified hazard ratio (HR), 0.52; 95% confidence interval (CI), 0.41–0.67; p < 0.0001). The ORR in ATX patients with measurable disease (n = 268) was higher than that in AT (69% versus 51%; p = 0.01). The median duration of response was 6.8 versus 5.4 months for, respectively, ATX and AT (p < 0.0001). Median OS was 24.2 months for ATX and 23.1 months for AT (p = 0.53). The increased rate of grade 3–4 adverse events related to the addition of capecitabine, being hand-foot syndrome (34% versus 0% for AT) and neutropenia (20% versus 12% for AT), generally did not preclude continuation of treatment. Exploratory analyses indicated that (1) patients receiving capecitabine at some line for treatment have significantly improved OS and (2) a prognostic model can classify patients into three risk groups associated with OS. In patients with HER2-negative LR/MBC, addition of capecitabine to paclitaxel and bevacizumab significantly improved PFS, ORR and response duration. This combination was reasonably well tolerated and may be considered of use as first-line treatment in rapidly progressive disease. F. Hoffmann-La Roche Ltd, the Netherlands.


Designing an Excellent Deep-Ultraviolet Birefringent Material for Light Polarization.
Owing to their vital role in creating and controlling polarized light, birefringent materials are used extensively in various advanced optical systems which in turn impact a large, rapidly increasing range of applications in science and technology. Currently, the fairly small birefringence of MgF2 and the low transmittance of α-BaB2O4 (α-BBO) hinder their efficient application for wavelength below 200 nm. For example, deep-ultraviolet (DUV) birefringent materials for light polarization are urgently needed for DUV lithography. Here we demonstrate based on computational and experimental results that parallel chains of corner-connected planar sp2-hybridized BO3 groups found in Ca(BO2)2 effectively produce large birefringence. Ca(BO2)2 achieves three vital "best" properties including the shortest UV cutoff edge, the largest birefringence, and the highest laser-induced damage threshold (LIDT) compared to all the reported borate birefringent materials. On the basis of a Ca(BO2)2 single crystal, a DUV Glan polarizer has been realized and is more efficient than one constructed with commercially available MgF2.


Effects of natural and sexual selection on adaptive population divergence and premating isolation in a damselfly.
The relative strength of different types of directional selection has seldom been compared directly in natural populations. A recent meta-analysis of phenotypic selection studies in natural populations suggested that directional sexual selection may be stronger in magnitude than directional natural selection, although this pattern may have partly been confounded by the different time scales over which selection was estimated. Knowledge about the strength of different types of selection is of general interest for understanding how selective forces affect adaptive population divergence and how they may influence speciation. We studied divergent selection on morphology in parapatric, natural damselfly (Calopteryx splendens) populations. Sexual selection was stronger than natural selection measured on the same traits, irrespective of the time scale over which sexual selection was measured. Visualization of the fitness surfaces indicated that population divergence in overall morphology is more strongly influenced by divergent sexual selection rather than natural selection. Courtship success of experimental immigrant males was lower than that of resident males, indicating incipient sexual isolation between these populations. We conclude that current and strong sexual selection promotes adaptive population divergence in this species and that premating sexual isolation may have arisen as a correlated response to divergent sexual selection. Our results highlight the importance of sexual selection, rather than natural selection in the adaptive radiation of odonates, and supports previous suggestions that divergent sexual selection promotes speciation in this group.


Sleep disturbance and the older worker: findings from the Health and Employment after Fifty study.
Objectives The aim of this study was to characterize the descriptive epidemiology of insomnia in midlife and explore the relative importance of different occupational risk factors for insomnia among older workers. Methods A questionnaire was mailed to all adults aged 50-64 years registered with 24 English general practices. Insomnia was defined as having at least one of four problems with sleep severely in the past three months. Subjects were also asked about employment conditions, feelings concerning work, and their health. Associations were assessed by logistic regression and population attributable fractions (PAF) calculated. Results Analysis was based on 8067 respondents (5470 in paid work), 18.8% of whom reported insomnia. It was more common among women, smokers, obese individuals, those living alone, and those in financial hardship, and less prevalent among the educated, those in South-East England, and those with friendships and leisure-time pursuits. Occupational risk factors included unemployment, shift working, lack of control and support at work, job insecurity, job dissatisfaction and several of its determinants (lacking a sense of achievement, feeling unappreciated, having difficult work colleagues, feeling unfairly criticized). Population burden of insomnia was associated more strongly with difficulties in coping with work demands, job insecurity, difficult colleagues, and lack of friendships at work [population attributable fraction (PAF) 15-33%] than shift work and lack of autonomy or support (PAF 5-7%). It was strongly associated with seven measures of poorer self-assessed health. Conclusions Employment policies aimed at tackling insomnia among older workers may benefit from focusing particularly on job-person fit, job security and relationships in the workplace.


The magnitude and duration of Clostridium difficile infection risk associated with antibiotic therapy: a hospital cohort study.
Antibiotic therapy is the principal risk factor for Clostridium difficile infection (CDI), but little is known about how risks cumulate over the course of therapy and abate after cessation. We prospectively identified CDI cases among adults hospitalized at a tertiary hospital between June 2010 and May 2012. Poisson regression models included covariates for time since admission, age, hospitalization history, disease pressure, and intensive care unit stay. Impacts of antibiotic use through time were modeled using 4 measures: current antibiotic receipt, time since most recent receipt, time since first receipt during a hospitalization, and duration of receipt. Over the 24-month study period, we identified 127 patients with new onset nosocomial CDI (incidence rate per 10,000 patient days [IR] = 5.86). Of the 4 measures, time since most recent receipt was the strongest independent predictor of CDI incidence. Relative to patients with no prior receipt of antibiotics in the last 30 days (IR = 2.95), the incidence rate of CDI was 2.41 times higher (95% confidence interval [CI] 1.41, 4.13) during antibiotic receipt and 2.16 times higher when patients had receipt in the prior 1-5 days (CI 1.17, 4.00). The incidence rates of CDI following 1-3, 4-6 and 7-11 days of antibiotic exposure were 1.60 (CI 0.85, 3.03), 2.27 (CI 1.24, 4.16) and 2.10 (CI 1.12, 3.94) times higher compared to no prior receipt. These findings are consistent with studies showing higher risk associated with longer antibiotic use in hospitalized patients, but suggest that the duration of increased risk is shorter than previously thought.


Ultra high-resolution anterior segment optical coherence tomography in the diagnosis and management of ocular surface squamous neoplasia.
The development of optical coherence tomography (OCT) technology has helped to usher in a new era of in vivo diagnostic imaging of the eye. The utilization of OCT for imaging of the anterior segment and ocular surface has evolved from time-domain devices to spectral-domain devices with greater penetrance and resolution, providing novel images of anterior segment pathology to assist in diagnosis and management of disease. Ocular surface squamous neoplasia (OSSN) is one such pathology that has proven demonstrable by certain anterior segment OCT machines, specifically the newer devices capable of performing ultra high-resolution OCT (UHR-OCT). Distinctive features of OSSN on high resolution OCT allow for diagnosis and differentiation from other ocular surface pathologies. Subtle findings on these images help to characterize the OSSN lesions beyond what is apparent with the clinical examination, providing guidance for clinical management. The purpose of this review is to examine the published literature on the utilization of UHR-OCT for the diagnosis and management of OSSN, as well as to report novel uses of this technology and potential directions for its future development.


Changes in pressure waves after endoscopic intervention in patients with achalasia: A focus on peristaltic recovery of the esophageal body.
We conducted the present study to investigate the recovery of peristalsis of the esophageal body and evaluate the pressure changes observed on manometry before and after endoscopic intervention. Forty-five patients were diagnosed with achalasia, and 36 received endoscopic or surgical treatment. We collected the data of 24 patients who underwent manometry before and after treatment (pneumatic balloon dilatation, n=7; botulinum toxin injection, n=10; peroral endoscopic myotomy, n=7). The lower esophageal sphincter (LES) resting pressure and nadir LES relaxation pressure decreased regardless of the achalasia subtype or type of endoscopic intervention following treatment (p<0.05). Among patients with a nadir LES relaxation pressure of <4 mmHg, 42.9% (6/14) exhibited partial esophageal peristaltic wave recovery. However, no patients with a nadir LES relaxation pressure of >4 mmHg exhibited peristaltic wave recovery (p=0.024). Of the six patients with peristaltic wave recovery, two had type I achalasia (15.4%), three had type II (33.3%), and one had type III (100.0%). The Eckardt score, symptom duration, and type of intervention were not associated with the recovery of peristaltic waves. Our results suggest that normalization of the nadir LES relaxation pressure can be a predictive factor for the recovery of esophageal peristalsis.


Amiloride modulation of carbon dioxide hypersensitivity and thermal nociceptive hypersensitivity induced by interference with early maternal environment.
Early life adversities are risk factors for anxiety disorders and for pain syndromes, which are, in turn, highly comorbid with anxiety disorders. Repeated cross-fostering mouse pups to adoptive lactating females induces epigenetic modification and heightened mRNA-expression of the acid-sensing-ion-channel-1 gene, altered nociception, and hypersensitivity to 6% carbon dioxide air mixtures, a trait marker of specific human anxiety disorders such as, most clearly and prominently, panic disorder. We hypothesized that the acid-sensing ion channel inhibitor amiloride can modulate repeated cross-fostering animals' exaggerated responses to carbon dioxide and nociceptive thermal stimulation. Respiratory carbon dioxide sensitivity was assessed by plethysmography during 6% carbon dioxide air mixture challenges, and nociception was assessed by latency of paw withdrawal to thermal stimulation, in repeated cross-fostering and control animals. To circumvent the blood-brain barrier, prior to testing, amiloride was nebulized in a plethysmograph. Data were analyzed by general linear models. Analyses of tidal volume responses to 6% carbon dioxide of animals pre-treated with nebulized amiloride/saline in a randomized crossover design showed significant modulatory effect of amiloride, and amiloride×repeated cross-fostering interaction. In contrast, repeated cross-fostering animals' responses to 6% carbon dioxide after intraperitoneal amiloride, saline, or no treatment, were no different. Analyses of responses to thermal stimuli showed a significant modulatory effect of nebulized amiloride, and repeated cross-fostering×amiloride interaction. Single-dose nebulized amiloride decreased repeated cross-fostering animals' carbon dioxide sensitivity and nociception indices to levels that were no different from those of control animals. Inasmuch as these results pertain to human anxiety and/or pain hypersensitivity, our findings provide a rationale for studying inhaled amiloride in some anxiety disorders and/or pain syndromes.


Detection of Staphylococcus aureus enterotoxins A to D by real-time fluorescence PCR assay.
Staphylococcus aureus is one of the most significant pathogens causing nosocomial and community-acquired infections. Among the secreted staphylococcal virulence factors, there is a growing list of enterotoxins which can induce gastroenteric syndrome and toxic shock syndrome. Here, we developed a real-time fluorescence PCR assay (TaqMan PCR) for the detection of genes encoding staphylococcal enterotoxins A, B, C1, and D (SEA, SEB, SEC1, and SED) of S. aureus as well as the mecA gene encoding methicillin resistance and the femB gene as a specific genomic marker for S. aureus. SEA to SED were selected because they are the four classically described enterotoxins of S. aureus and because they were detected by latex agglutination. In order to evaluate the reliability of TaqMan PCR, we investigated 93 isolates of S. aureus derived from patients at our hospital over 5 months and compared the results with data obtained by a commercially available reversed passive latex agglutination assay (SET-RPLA) for these isolates. Thirteen enterotoxin genes were detected by TaqMan PCR; however, no proteins expressed by these genes were detected by SET-RPLA. As a result, more isolates of S. aureus (n = 44) were found positive by TaqMan PCR for one or more enterotoxin genes than by SET-RPLA for the respective proteins expressed by these genes (n = 40). We conclude that TaqMan PCR is more sensitive because it offers the possibility for determining enterotoxins on a genotypic basis. Additionally, the assay allows the parallel detection of genes for SEA to SED and methicillin resistance in S. aureus. Furthermore, real-time PCR is well suited for screening large numbers of samples at the same time, allowing rapid, reliable, efficient, and cost-saving routine laboratory diagnosis.


Dealing sensitively with sexuality in a palliative care context.
Sexuality is integral to a person's identity and is encompassed in holistic palliative care. Current directives emphasize psychosocial support that is sensitive to a variety of issues, including sexuality, and offer community nurses the mandate to facilitate expressing sexuality. Nurses fail to address sexuality for a variety of reasons. Appreciating patients' individuality and avoiding making assumptions are some of the requirements to enabling expression of sexuality. Nurses need wisdom and determination to discuss such issues, and it is important that they recognize opportunities and cues as they arise. This article provides an examination of the issues surrounding sexuality outlining an approach that captures' constant attention to details. This guides the 'what', 'how' and 'why' sexuality in palliative care can be addressed. Ethics and safety aspects are briefly discussed and implications for practice suggested. Educating staff and focused education for the patient can positively influence sexuality and individuals' quality of life.


[Tuberculosis in Brazil: construction of a territorially based surveillance system].
To analyze the occurrence of tuberculosis and to identify variables that define situations of collective risk that determine the spatial distribution of the disease, as backing for implementing a territory-based surveillance system for tuberculosis control. This was an ecological study performed in Olinda, a municipality in the metropolitan region of Recife, State of Pernambuco, between 1996 and 2000. The median number of notified tuberculosis cases in each census tract served as the cutoff point for characterizing areas of high and low transmission. A logistic regression model using this response variable allowed odds ratios for some socioeconomic variables from the 2000 demographic census and other covariates related to the transmission of the disease to be estimated. Tuberculosis in Olinda presented high incidence rates during the study period (average of 111 cases per 100,000 inhabitants). Significant associations with the occurrence of tuberculosis were found for the variables of average number of inhabitants per household (OR=2.2; 95% CI: 1.3; 3.6); existence of families with more than one case during the study period (OR=5.1; 95% CI: 2.3; 11.3); and presence of cases of retreatment (OR=6.8; 95% CI: 2.7; 17.1). The census tract where the latter two events occurred accounted for 45% of the total number of cases during the study period, while representing only 28% of the population of Olinda. The two explanatory covariates that were strongly associated with higher incidence rates of the disease are events that need to be carefully monitored at a local level by the tuberculosis surveillance system. Simply by mapping out retreatment cases and households with more than one case, attention could be focused on small areas with high priority for intensive intervention, thus facing up to the tuberculosis problem.


A New Method for Detecting Associations with Rare Copy-Number Variants.
Copy number variants (CNVs) play an important role in the etiology of many diseases such as cancers and psychiatric disorders. Due to a modest marginal effect size or the rarity of the CNVs, collapsing rare CNVs together and collectively evaluating their effect serves as a key approach to evaluating the collective effect of rare CNVs on disease risk. While a plethora of powerful collapsing methods are available for sequence variants (e.g., SNPs) in association analysis, these methods cannot be directly applied to rare CNVs due to the CNV-specific challenges, i.e., the multi-faceted nature of CNV polymorphisms (e.g., CNVs vary in size, type, dosage, and details of gene disruption), and etiological heterogeneity (e.g., heterogeneous effects of duplications and deletions that occur within a locus or in different loci). Existing CNV collapsing analysis methods (a.k.a. the burden test) tend to have suboptimal performance due to the fact that these methods often ignore heterogeneity and evaluate only the marginal effects of a CNV feature. We introduce CCRET, a random effects test for collapsing rare CNVs when searching for disease associations. CCRET is applicable to variants measured on a multi-categorical scale, collectively modeling the effects of multiple CNV features, and is robust to etiological heterogeneity. Multiple confounders can be simultaneously corrected. To evaluate the performance of CCRET, we conducted extensive simulations and analyzed large-scale schizophrenia datasets. We show that CCRET has powerful and robust performance under multiple types of etiological heterogeneity, and has performance comparable to or better than existing methods when there is no heterogeneity.


Molecular docking of intercalators and groove-binders to nucleic acids using Autodock and Surflex.
The molecular docking tools Autodock and Surflex accurately reproduce the crystallographic structures of a collection of small molecule ligands that have been shown to bind nucleic acids. Docking studies were performed with the intercalators daunorubicin and ellipticine and the minor groove binders distamycin and pentamidine. Autodock and Surflex dock daunorubicin and distamycin to their nucleic acid targets within a resolution of approximately 2 A, which is similar to the limit of the crystal structure resolution. However, for the top ranked poses, Autodock and Surflex both dock ellipticine into the correct site but in a different orientation compared to the crystal structure. This appears not only to be partly related to the symmetry of the target nucleic acid, as ellipticine is able to dock from either side of the intercalation site, but also due to the shape of the ligand and docking accuracy. Surflex docks pentamidine in a symmetrically equivalent orientation relative to the crystal structure, while Autodock was able to dock this molecule in the original orientation. In the case of the Surflex docking of pentamidine, the initial rmsd is misleading, given the symmetrical structure of pentamidine. Importantly, the ranking functions of both of these programs are able to return a top pose within approximately 2 A rmsd for daunorubicin, distamycin, and pentamidine and approximately 3 A rmsd for ellipticine compared to their respective crystal structures. Some docking challenges and potential pitfalls are explored, such as the importance of hydrogen treatment on ligands as well as the scoring functions of Autodock and Surflex. Overall for this set of complexes, Surflex is preferred over Autodock for virtual screening, as although the results are comparable, Surflex has significantly faster performance and ease of use under the optimal software conditions tested. These experiments show that molecular docking techniques can be successfully extended to include nucleic acid targets, a finding which has important implications for virtual screening applications and in the design of new small molecules to target therapeutically relevant morphologies of nucleic acids.


Silencing of Dok-7 in Adult Rat Muscle Increases Susceptibility to Passive Transfer Myasthenia Gravis.
Myasthenia gravis (MG) is an autoimmune disease mediated by autoantibodies that target proteins at the neuromuscular junction, primarily the acetylcholine receptor (AChR) and the muscle-specific kinase. Because downstream of kinase 7 (Dok-7) is essential for the full activation of muscle-specific kinase and consequently for dense clustering of AChRs, we hypothesized that reduced levels of Dok-7 increase the susceptibility to passive transfer MG. To test this hypothesis, Dok-7 expression was reduced by transfecting shRNA-coding plasmids into the tibialis anterior muscle of adult rats by in vivo electroporation. Subclinical MG was subsequently induced with a low dose of anti-AChR monoclonal antibody 35. Neuromuscular transmission was significantly impaired in Dok-7-siRNA-electroporated legs compared with the contralateral control legs, which correlated with a reduction of AChR protein levels at the neuromuscular junction (approximately 25%) in Dok-7-siRNA-electroporated muscles, compared with contralateral control muscles. These results suggest that a reduced expression of Dok-7 may play a role in the susceptibility to passive transfer MG, by rendering AChR clusters less resistant to the autoantibody attack.


Analysis of the distribution of organic compounds and drugs between biological tissues in the framework of solute partitioning in aqueous two-phase systems.
Partition coefficients of non-ionic essentially nonpolar compounds between air and rat biological tissues and between blood and other tissues were examined and found to be linearly interrelated according to the previously established equation for partition coefficients of solutes in aqueous two-phase systems: log Kblood-tissue-1 = k0 + k1 log Kblood-tissue-2 + k2 log Kblood-tissue-3, where k0, k1, and k2 are constants. Analysis of partition coefficients of amphiphilic and ionizable drugs between blood and different tissues in rats in vivo showed that the above relationship holds for the blood-tissue partition coefficients of these compounds as well. The data obtained indicate that distribution of organic compounds between different biological tissues may be considered in the framework of solute partitioning in aqueous two-phase systems, and imply that aqueous media in different tissues have different solvent properties, and compound-water interactions in these media may respond to different environments governed by the tissue composition.


Developmental origin and Kit-dependent development of the interstitial cells of cajal in the mammalian small intestine.
Interstitial cells of Cajal (ICCs) form a network of cells between the external longitudinal and circular muscle layers at the level of the Auerbach's plexus in the mammalian small intestine. These cells express the Kit receptor tyrosine kinase and are essential for intestinal pacemaker activity. W mutant mice carrying structural mutations in the Kit gene lack both the network of ICCs and intestinal pacemaker activity. We were interested in the developmental origin of the cells that make up the network of ICCs. In addition, the specific stages of ICC development that require a functional Kit receptor have not been characterized. We show that ICCs originate from mesenchymal progenitor cells that coexpress both Kit and smooth muscle myosin heavy chain, a marker specific for smooth muscle, during embryogenesis. ICC and longitudinal smooth muscle lineages begin to diverge late in gestation. Embryos homozygous for the regulatory Wbanded (Wbd) mutation do not express Kit in these mesenchymal progenitor cells. Nevertheless, Wbd/Wbd mice display a normal network of ICCs and normal smooth muscle layers at postnatal day 5 (p5). Adult Wbd/Wbd mice lack a functional ICC network and intestinal pacemaker activity due to a failure of the ICCs to increase in numbers after p5. These data suggest a common developmental origin of the ICCs and the longitudinal smooth muscle layers in the mammalian small intestine and show that Kit expression is necessary for the postnatal development and proliferation of ICCs but not for the initial cell lineage decision toward an ICC fate during embryogenesis or for smooth muscle development.


Sociodemographic determinants and health outcome variation in individuals with type 1 diabetes mellitus: A register-based study.
Socioeconomic status, origin or demographic attributes shall not determine the quality of healthcare delivery, according to e.g. United Nations and European Union rules. Health equity has been defined as the absence of systematic disparities and unwarranted differences between groups defined by differences in social advantages. A study was performed to investigate whether this was applicable to type 1 diabetes mellitus (T1D) care in a setting with universal, tax-funded healthcare. This retrospective registry-study was based on patient-level data from individuals diagnosed with T1D during 2010-2011 (n = 16,367) in any of seven Swedish county councils (covering ~65% of the Swedish population). Health equity in T1D care was analysed through multivariate regression analyses on absolute HbA1c level at one-year follow-up, one-year change in estimated glomerular filtration rate (eGFR) and one-year change in cardiovascular risk score, using selected sociodemographic dimensions as case-mix factors. Higher educational level was consistently associated with lower levels of HbA1c, and so was being married. Never married was associated with worse eGFR development, and lower educational level was associated with higher cardiovascular risk. Women had higher HbA1c levels than men, and glucose control was significantly worse in patients below the age of 25. Patients' sociodemographic profile was strongly associated with absolute levels of risk factor control in T1D, but also with an increased annual deterioration in eGFR. Whether these systematic differences stem from patient-related problems or healthcare organisational shortcomings is a matter for further research. The results, though, highlight the need for intensified diabetes management education and secondary prevention directed towards T1D patients, taking sociodemographic characteristics into account.


The journey to professional mental health support: a qualitative exploration of the barriers and facilitators impacting military veterans' engagement with mental health treatment.
Background: It is often claimed that military veterans are reticent to seek help for mental disorders, even though delayed treatment may impair recovery and impact the wellbeing of those close to the veteran. Objective: This paper aims to explore the barriers and facilitators to accessing professional mental health support for three groups of veterans who met criteria for a probable mental health disorder and: (1) do not recognize a probable mental disorder; (2) recognize they are affected by a mental disorder but are not seeking professional support; or (3) are currently seeking professional mental health support. Method: Qualitative telephone interviews were conducted with 62 UK military veterans. Thematic analysis identified core themes along an illustrative journey towards professional mental health support. Results: Distinct barriers and facilitators to care were discussed by each group of veterans depicting changes as veterans moved towards accessing professional mental health support. In contrast to much of the literature, stigma was not a commonly reported barrier to care; instead care-seeking decisions centred on a perceived need for treatment, waiting until a crisis event occurred. Whilst the recognition of treatment need represented a pivotal moment, our data identified numerous key steps which had to be surmounted prior to care-seeking. Conclusion: As care-seeking decisions within this sample appeared to centre on a perceived need for treatment future efforts designed to encourage help-seeking in UK military veterans may be best spent targeting the early identification and management of mental health disorders to encourage veterans to seek support before reaching a crisis event.


A case study and state of science review: private versus public healthcare financing.
Medicare is a popular program in Canada that offers universal access to medically-necessary healthcare services for all Canadians through a public insurance plan in each province. In spite of its popularity, healthcare privatization has been debated, often over concerns about wait times for healthcare services. A case report focused on the 2005 Supreme Court's response to the "Chaoulli v. Quebec" challenge of the Quebec law banning the purchase of private health insurance for publicly-insured services is presented, along with findings from a state of science review to determine if there would be any benefit from adopting the United States model of private health insurance. This review reveals private health insurance would have significant negative implications, especially by creating inequity in healthcare access for low-income groups. Further study is needed to determine whether Canada's publicly-funded healthcare system would benefit in any way from increased private financing.


Robust T1-weighted structural brain imaging and morphometry at 7T using MP2RAGE.
To suppress the noise, by sacrificing some of the signal homogeneity for numerical stability, in uniform T1 weighted (T1w) images obtained with the magnetization prepared 2 rapid gradient echoes sequence (MP2RAGE) and to compare the clinical utility of these robust T1w images against the uniform T1w images. 8 healthy subjects (29.0 ± 4.1 years; 6 Male), who provided written consent, underwent two scan sessions within a 24 hour period on a 7T head-only scanner. The uniform and robust T1w image volumes were calculated inline on the scanner. Two experienced radiologists qualitatively rated the images for: general image quality; 7T specific artefacts; and, local structure definition. Voxel-based and volume-based morphometry packages were used to compare the segmentation quality between the uniform and robust images. Statistical differences were evaluated by using a positive sided Wilcoxon rank test. The robust image suppresses background noise inside and outside the skull. The inhomogeneity introduced was ranked as mild. The robust image was significantly ranked higher than the uniform image for both observers (observer 1/2, p-value = 0.0006/0.0004). In particular, an improved delineation of the pituitary gland, cerebellar lobes was observed in the robust versus uniform T1w image. The reproducibility of the segmentation results between repeat scans improved (p-value = 0.0004) from an average volumetric difference across structures of ≈ 6.6% to ≈ 2.4% for the uniform image and robust T1w image respectively. The robust T1w image enables MP2RAGE to produce, clinically familiar T1w images, in addition to T1 maps, which can be readily used in uniform morphometry packages.


Dystonia and Tremor: A Cross-Sectional Study of the Dystonia Coalition Cohort.
To assess the clinical manifestations and predictors of different types of tremors in individuals with different types of isolated dystonia. Clinical manifestations of tremor were assessed in a multicenter, international cross-sectional, cohort study of 2,362 individuals with all types of isolated dystonia (focal, segmental, multifocal, and generalized) recruited through the Dystonia Coalition. Methodical and standardized assessments of all participants in this cohort revealed the overall prevalence of any type of tremor was 53.3%. The prevalence of dystonic tremor varied from 36.9% to 48.4%, depending on criteria used to define it. To identify the factors associated with tremors in dystonia, the data were analyzed by generalized linear modeling and cluster analyses. Generalized linear modeling indicated 2 of the strongest factors associated with tremor included body region affected by dystonia and recruitment center. Tremor was also associated with severity of dystonia and duration of dystonia, but not with sex or race. The cluster analysis distinguished 8 subgroups within the whole cohort; defined largely by body region with dystonia, and secondarily by other clinical characteristics. The large number of cases evaluated by an international team of movement disorder experts facilitated the dissection of several important factors that influence the apparent prevalence and phenomenology of tremor in dystonia. These results are valuable for understanding the many differences reported in prior studies, and for guiding future studies of the nosology of tremor and dystonia.


Cellulose fibres, nanofibrils and microfibrils: The morphological sequence of MFC components from a plant physiology and fibre technology point of view.
During the last decade, major efforts have been made to develop adequate and commercially viable processes for disintegrating cellulose fibres into their structural components. Homogenisation of cellulose fibres has been one of the principal applied procedures. Homogenisation has produced materials which may be inhomogeneous, containing fibres, fibres fragments, fibrillar fines and nanofibrils. The material has been denominated microfibrillated cellulose (MFC). In addition, terms relating to the nano-scale have been given to the MFC material. Several modern and high-tech nano-applications have been envisaged for MFC. However, is MFC a nano-structure? It is concluded that MFC materials may be composed of (1) nanofibrils, (2) fibrillar fines, (3) fibre fragments and (4) fibres. This implies that MFC is not necessarily synonymous with nanofibrils, microfibrils or any other cellulose nano-structure. However, properly produced MFC materials contain nano-structures as a main component, i.e. nanofibrils.


Stepwise evolution of Salmonella Typhimurium ST313 causing bloodstream infection in Africa.
Bloodstream infections caused by nontyphoidal Salmonella are a major public health concern in Africa, causing ~49,600 deaths every year. The most common Salmonella enterica pathovariant associated with invasive nontyphoidal Salmonella disease is Salmonella Typhimurium sequence type (ST)313. It has been proposed that antimicrobial resistance and genome degradation has contributed to the success of ST313 lineages in Africa, but the evolutionary trajectory of such changes was unclear. Here, to define the evolutionary dynamics of ST313, we sub-sampled from two comprehensive collections of Salmonella isolates from African patients with bloodstream infections, spanning 1966 to 2018. The resulting 680 genome sequences led to the discovery of a pan-susceptible ST313 lineage (ST313 L3), which emerged in Malawi in 2016 and is closely related to ST313 variants that cause gastrointestinal disease in the United Kingdom and Brazil. Genomic analysis revealed degradation events in important virulence genes in ST313 L3, which had not occurred in other ST313 lineages. Despite arising only recently in the clinic, ST313 L3 is a phylogenetic intermediate between ST313 L1 and L2, with a characteristic accessory genome. Our in-depth genotypic and phenotypic characterization identifies the crucial loss-of-function genetic events that occurred during the stepwise evolution of invasive S. Typhimurium across Africa.


Predictors of duloxetine adherence and persistence in patients with fibromyalgia.
Adherence to medication for the treatment of fibromyalgia (FM) is predictive of lower overall health-care costs, and thus a lower burden on both patients and providers. The objectives of this study were to examine the predictors of adherence to and persistence with duloxetine therapy among commercially insured FM patients, and to identify subgroups of patients with high duloxetine persistence and adherence. This cross-sectional, retrospective study analyzed medical and pharmacy records over 1 year for patients in the US aged 18-64 years with FM who initiated (no prior 90-day use) duloxetine treatment in 2008. Adherence to duloxetine was measured by medication possession ratio (MPR), with high adherence defined as MPR ≥ 0.8. Persistence was defined as the duration of therapy from the index date to the earliest of: the ending date of the last prescription, the date of the first gap of >15 days between prescriptions, or the end of the study period (12 months). Demographic and clinical predictors of adherence were examined via multiple logistic regression (MLR), and subgroups of duloxetine-persistent and -adherent patients were identified using classification and regression trees (CART). Among 4660 duloxetine patients, 33% achieved high adherence. Factors associated with high adherence from MLR included older age, North Central and Northeast regions, prior venlafaxine, pregabalin, selective serotonin reuptake inhibitor (SSRI), or other antidepressant use, or comorbid dyslipidemia or osteoarthritis (all P < 0.05). CART analysis revealed that patients with prior antidepressant use, aged ≥46, or prior osteoarthritis had higher MPR (all P < 0.05), and patients aged ≥45 with a history of SSRI, venlafaxine, or anticonvulsant use had longer duration of therapy (all P < 0.05). Patients with high adherence to and persistence with duloxetine were significantly older and had prior antidepressant use.


Bilateral ocular anomalies in a South African fur seal (Arctocephalus pusillus pusillus).
A female South African fur seal (Arctocephalus pusillus pusillus) began having obvious clinical ophthalmologic problems by 8 weeks of age. The initial clinical sign was diffuse corneal edema, which progressed to bullae formation and ulcers; the underlying cause of corneal edema and bullous keratopathy was not identified antemortem.An ophthalmological evaluation was performed when the fur seal was approximately 6 months of age, but due to the diffuse corneal edema, intraocular structures could not be easily evaluated. An underlying infectious etiology was suspected; therefore,appropriate diagnostics were pursued, but did not identify a cause. Initial improvement was noted, but the fur seal then became blind and eventually became very painful.Due to decreased quality of life and aggressive behavior, the fur seal was euthanized.Histopathological diagnoses were persistent tunica vasculosa lentis and persistent hyperplastic primary vitreous with bilateral hypermature resorbed cataracts and retinal detachments with rosette formation.


Placental expression of CD100, CD72 and CD45 is dysregulated in human miscarriage.
The etiology of miscarriage is often multifactorial. One major cause, immunological rejection of the fetus, has not been clearly elucidated. Our aim was to establish whether the semaphorin CD100, its natural receptor CD72, and the glycoprotein CD45, implicated in immune mechanisms, are involved in pregnancy loss by examining their placental expression with real-time PCR, immunohistochemistry and western blotting techniques. Placenta tissue from 72 Caucasian women undergoing surgical uterine evacuation due to early spontaneous pregnancy loss between the 8(th) and 12(th) week of gestation was divided into four groups based on miscarriage number. Gestational age-matched placentas from 18 healthy women without a history of miscarriage undergoing voluntary pregnancy termination were the control group. Placenta from 6 Caesarean deliveries performed at 38-40 weeks of gestation was also studied. CD100, CD72 and CD45 were expressed in placenta and exhibited different mRNA and protein levels in normal pregnancy and miscarriage. In particular, protein levels were highly dysregulated around 10 weeks of gestation in first and second miscarriage placentas. The CD100 soluble form was produced and immediately shed from placental tissue in all samples. Fetal CD100, CD72 and CD45 seem to play a role in miscarriage. The present data support the involvement of the fetal immune system in pregnancy maintenance as well as failure.


Baseline sensorimotor GABA levels shape neuroplastic processes induced by motor learning in older adults.
Previous research in young adults has demonstrated that both motor learning and transcranial direct current stimulation (tDCS) trigger decreases in the levels of gamma-aminobutyric acid (GABA) in the sensorimotor cortex, and these decreases are linked to greater learning. Less is known about the role of GABA in motor learning in healthy older adults, a knowledge gap that is surprising given the established aging-related reductions in sensorimotor GABA. Here, we examined the effects of motor learning and subsequent tDCS on sensorimotor GABA levels and resting-state functional connectivity in the brains of healthy older participants. Thirty-six older men and women completed a motor sequence learning task before receiving anodal or sham tDCS to the sensorimotor cortex. GABA-edited magnetic resonance spectroscopy of the sensorimotor cortex and resting-state (RS) functional magnetic resonance imaging data were acquired before and after learning/stimulation. At the group level, neither learning nor anodal tDCS significantly modulated GABA levels or RS connectivity among task-relevant regions. However, changes in GABA levels from the baseline to post-learning session were significantly related to motor learning magnitude, age, and baseline GABA. Moreover, the change in functional connectivity between task-relevant regions, including bilateral motor cortices, was correlated with baseline GABA levels. These data collectively indicate that motor learning-related decreases in sensorimotor GABA levels and increases in functional connectivity are limited to those older adults with higher baseline GABA levels and who learn the most. Post-learning tDCS exerted no influence on GABA levels, functional connectivity or the relationships among these variables in older adults.


Relationship between isoelectric point of native and chemically modified insulin and liposomal fusion.
Native insulin causes fusion of negatively charged liposomes in the pH range from 3.0 to 5.5. In marked contrast, insulin with all three amino groups succinylated did not show fusion ability at any pH. On the other hand, insulin amidated with glycine methyl ester with all six carboxyl groups blocked shifted its activity to higher pH, showing a pH range of activity from 3.0 to 7.4. When the carboxyl groups were recovered by hydrolysis of methoxyl groups from glycine methyl ester-treated insulin, the protein obtained (glycyl-insulin with six free carboxyl groups) behaved as native insulin. A good correlation between the isoelectric point values of insulin and its derivatives and their fusion properties was found.


Clinical and genetic mapping of X chromosome in the X-linked dominant inherited Alport's syndrome.
To study the hereditary mode and clinical characteristics and detect mutations of gene COL4A5 encoding type IV collagen a5 chain among family members of an X-linked dominant inherited Alport's syndrome (AS) family of China, we studied all of 38 family members of whom 2 volunteers underwent renal biopsy. Genomic DNA from all members of the AS family was characterized. All of 51 exons of COL4A5 gene were amplified by polymerase chain reaction (PCR) with the primers synthesized according to the published flanking intervening sequences. PCR products were further analyzed by agarose gel electrophoresis and single strand conformation polymorphism (SSCP) analysis. The study subjects revealing polymorphism by SSCP analysis were directly sequenced. Suspected exons were analyzed with reverse sequencing. Six males and 9 females of the family were diagnosed to have AS by clinical manifestations, family history and/or renal biopsy. Four patients died of end-stage renal disease (ESRD), and 1 patient received kidney transplantation. In the rest of the family members renal function remained normal, however, 22 (58%) revealed hematuria, 11/22 (59%) of them also had proteinuria. The hearing loss was detected in 6 (16%) and ocular lesion in 20 (53%) of family members. By PCR-SSCP analysis, 17 PCR products were identified with different mobility of single strand DNA in volunteers and 9 suspected mutations were revealed with DNA sequencing analysis, but all of which could not be proven by bidirectional sequencing analysis. We conclude that the incidence of hematuria and ophthalmopathy is higher in the X-linked dominant inherited AS in this Chinese family, while some patients have isolated hematuria. Bidirectional sequence analysis should be taken to identify mutations of certain genes. No mutations were found on the region of exons of gene COL4A5.


The effect of bilayer composition on calcium ion transport facilitated by fluid shear stress.
Passive calcium ion permeability across liposome bilayers is increased during exposure to fluid shear forces attainable in the mammalian vasculature. In this study, liposomes prepared from three different lipid mixtures (phosphatidylcholine alone; phosphatidylcholine and cholesterol; a mixture of anionic and cationic phospholipids plus cholesterol) are exposed to uniform shear stress in a rotational viscometer. Liposome permeability to calcium ion is estimated from continuous measurement of free intraliposome calcium ion concentration using a fluorescence technique. Calcium ion permeability in the absence of fluid force and susceptibility to shear-induced permeability modulation are positively correlated with estimated bilayer compressibility. Fluid shear forces are presumed to influence bilayer packing and modulate defect formation in proportion to bilayer compressibility. Bilayer defects produced by fluid forces may increase liposome permeability.


The research, policy and practice interface: reflections on using applied social research to promote equity in health in Malawi.
The case for research to promote equity in health in resource poor contexts such as Malawi is compelling. In Malawi, nearly half of all the people with tuberculosis cannot afford to access free tuberculosis services. In this scenario, there is a clear need to understand the multiple barriers poor women and men face in accessing services and pilot interventions to address these in a way that engages policy makers, practitioners and communities. This paper provides a critical reflection on our experience as applied social researchers working at the REACH (Research for Equity and Community Health) Trust in Malawi. Our work largely uses qualitative research methodologies as a tool for applied social research to explore the equity dimensions of health services in the country. We argue that a key strength of qualitative research methods and analysis is the ability to bring the perceptions and experiences of marginalised groups to policy makers and practitioners. The focus of this paper is two-fold. The first focus lies in synthesising the opportunities and challenges we have encountered in promoting the use of applied social research, and in particular qualitative research methods, on TB and HIV in Malawi. The second focus is on documenting and reflecting on our experiences of using applied social research to promote gender equity in TB/HIV policy and practice in Malawi. In this paper, we reflect on the strategic frameworks we have used in the Malawian context to try and bring the voices of poor women and men to policy makers and practitioners and hence intensify the research to policy and practice interface.


Hyperglycemia and Phosphatidylinositol 3-Kinase/Protein Kinase B/Mammalian Target of Rapamycin (PI3K/AKT/mTOR) Inhibitors in Phase I Trials: Incidence, Predictive Factors, and Management.
Dysregulation of the phosphatidylinositol 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/AKT/mTOR) pathway is implicated in human cancer growth and progression. Agents targeting this pathway are associated with hyperglycemia due to interaction with the insulin-glucose regulatory axis. Identifying the predictive factors for hyperglycemia in patients treated with these agents may help direct future management. Clinical characteristics and outcomes of patients treated consecutively with PI3K, AKT, or mTOR inhibitors in the Drug Development Unit, The Royal Marsden (RM) National Health Service (NHS) Foundation Trust, between 2007 and 2012 were recorded. Baseline variables and their association with grade 3 hyperglycemia (Common Terminology Criteria for Adverse Events, version 3.0) were analyzed by using the chi-square test and Fisher exact test for categorical variables and binary logistic regression for continuous variables. A total of 341 patients were treated in 12 phase I trials of PI3K/AKT/mTOR inhibitors, and 298 patients (87.4%) developed hyperglycemia. Hyperglycemia was grade 1 in 217 (72.8%) and grade 2 in 61 (20.5%) patients, respectively. Grade ≥3 hyperglycemia was seen in 6.7% of patients (n = 20). According to the chi-square test, age <65 years (p = .03), history of diabetes (p = .003), and treatment with AKT and dual PI3K/mTOR inhibitors (p < .0005) predicted the occurrence of grade 3 hyperglycemia. Of 24 patients requiring intervention, 20 received metformin, 2 dietary advice, 1 insulin, and 1 both metformin and insulin. One patient required dose reduction. There were no permanent drug discontinuations, and no hyperglycemia-related dose-limiting toxicities were observed; thus, the recommended phase II dose was not affected by the hyperglycemia observed in our cohort. Hyperglycemia is common in patients treated with PI3K/AKT/mTOR inhibitors; however, it is manageable with conventional treatment. Predictive factors of age, history of diabetes, and administration of AKT and dual PI3K/mTOR inhibitors warrant prospective validation. This study reviewed the clinical data of 341 patients treated in 12 phase I trials of agents targeting phosphatidylinositol3-kinase (PI3), protein kinase B (AKT), and mammalian target of rapamycin (mTOR), as well as dual inhibitors. Hyperglycemia was evident in 87.4% of patients but was ≥grade 3 in just 6.7%. Age <65 years, history of diabetes, and treatment with AKT and dual PI3K/mTOR inhibitors were each associated with grade 3 hyperglycemia. Management of patients was uncomplicated, and no permanent drug discontinuations were necessary. Despite the small study size, these findings support continued caution about enrolling patients with a history of diabetes into such trials. However, clinicians may be reassured, pending prospective validation of these results, that significant hyperglycemia is not frequent and, when it occurs, is manageable.


Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey.
As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.


Neural responses in parietal and occipital areas in response to visual events are modulated by prior multisensory stimuli.
The effect of multi-modal vs uni-modal prior stimuli on the subsequent processing of a simple flash stimulus was studied in the context of the audio-visual 'flash-beep' illusion, in which the number of flashes a person sees is influenced by accompanying beep stimuli. EEG recordings were made while combinations of simple visual and audio-visual stimuli were presented. The experiments found that the electric field strength related to a flash stimulus was stronger when it was preceded by a multi-modal flash/beep stimulus, compared to when it was preceded by another uni-modal flash stimulus. This difference was found to be significant in two distinct timeframes--an early timeframe, from 130-160 ms, and a late timeframe, from 300-320 ms. Source localisation analysis found that the increased activity in the early interval was localised to an area centred on the inferior and superior parietal lobes, whereas the later increase was associated with stronger activity in an area centred on primary and secondary visual cortex, in the occipital lobe. The results suggest that processing of a visual stimulus can be affected by the presence of an immediately prior multisensory event. Relatively long-lasting interactions generated by the initial auditory and visual stimuli altered the processing of a subsequent visual stimulus.