Transition metals in control of gene expression.
Metalloproteins play structural and catalytic roles in gene expression. The metalloregulatory proteins are a subclass that exerts metal-responsive control of genes involved in respiration, metabolism, and metal-specific homeostasis or stress-response systems, such as iron uptake and storage, copper efflux, and mercury detoxification. Two allosteric mechanisms for control of gene expression were first discovered in metalloregulatory systems: an iron-responsive translational control mechanism for ferritin production and a mercury-responsive DNA-distortion mechanism for transcriptional control of detoxification genes. These otherwise unrelated mechanisms give rise to a rapid physiological response when metal ion concentrations exceed a dangerous threshold. Molecular recognition in these allosteric metal ion receptors is achieved through atypical coordination geometries, cluster formation, or complexes with prosthetic groups, such as sulfide and heme. Thus, many of the inorganic assemblies that otherwise buttress the structure of biopolymers or catalyze substrate transformation in active sites of enzymes have also been adapted to serve sensor functions in the metalloregulatory proteins. Mechanistic studies of these metal-sensor protein interactions are providing new insights into fundamental aspects of inorganic chemistry, molecular biology, and cellular physiology.


PTEN protects p53 from Mdm2 and sensitizes cancer cells to chemotherapy.
The PTEN tumor suppressor protein inhibits phosphatidylinositol 3-kinase (PI3K)/Akt signaling that promotes translocation of Mdm2 into the nucleus. When restricted to the cytoplasm, Mdm2 is degraded. The ability of PTEN to inhibit the nuclear entry of Mdm2 increases the cellular content and transactivation of the p53 tumor suppressor protein. Retroviral transduction of PTEN into U87MG (PTEN null) glioblastoma cells increases p53 activity and expression of p53 target genes and induces cell cycle arrest. U87MG/PTEN glioblastoma cells are more sensitive than U87MG/PTEN null cells to death induced by etoposide, a chemotherapeutic agent that induces DNA damage. Previously, tumor suppressor proteins have been supposed to act individually to suppress cancers. Our results establish a direct connection between the activities of two major tumor suppressors and show that they act together to respond to stresses and malignancies. PTEN protects p53 from survival signals, permitting p53 to function as a guardian of the genome. By virtue of its capacity to protect p53, PTEN can sensitize tumor cells to chemotherapy that relies on p53 activity. p53 induces PTEN gene expression, and here it is shown that PTEN protects p53, indicating that a positive feedback loop may amplify the cellular response to stress, damage, and cancer.


The abutment duplication technique: a novel protocol for cementable implant-supported restorations.
The purpose of this study was to present a new laboratory technique for cementable implant-supported restorations and to evaluate its efficacy in reducing chair time for both patients and clinicians, while maintaining the precision of an indirect procedure for crown fabrication. The technique consisted of the duplication of the implant portion of a working cast prepared using double-pour or plastic base die systems for single or multiple crowns. For this purpose, a flask previously intended for the production of ceramic inlays and onlays was used. Duplication was obtained using a high-precision addition silicon material and a low-shrinkage polyurethane resin. The duplicated implant abutment was used to finalize the fixed partial denture restorations after the originals were delivered to the patients. Fifty abutments were tested consecutively. The castings (19 single crowns, 31 fixed partial dentures) produced on the original abutments were seated on the duplicate abutments and evaluated by two prosthodontists and two dental technicians using a visual inspection method (laboratory microscope at 163 magnification). Forty-eight restorations were "good" (completely seated, no marginal opening) and 2 were "acceptable" (incomplete seating but amendable), with a 98% success rate. The technique presented demonstrates efficacy and predictability in reducing the number of clinical sessions for delivering precisely fitting cementable implant-supported restorations.


Andrographolide Attenuates Gut-Brain-Axis Associated Pathology in Gulf War Illness by Modulating Bacteriome-Virome Associated Inflammation and Microglia-Neuron Proinflammatory Crosstalk.
Gulf War Illness (GWI) is a chronic multi-symptomatic illness that is associated with fatigue, pain, cognitive deficits, and gastrointestinal disturbances and presents a significant challenge to treat in clinics. Our previous studies show a role of an altered Gut-Brain axis pathology in disease development and symptom persistence in GWI. The present study utilizes a mouse model of GWI to study the role of a labdane diterpenoid andrographolide (AG) to attenuate the Gut-Brain axis-linked pathology. Results showed that AG treatment in mice (100 mg/kg) via oral gavage restored bacteriome alterations, significantly increased probiotic bacteria Akkermansia, Lachnospiraceae, and Bifidobacterium, the genera that are known to aid in preserving gut and immune health. AG also corrected an altered virome with significant decreases in virome families Siphoviridae and Myoviridae known to be associated with gastrointestinal pathology. AG treatment significantly restored tight junction proteins that correlated well with decreased intestinal proinflammatory mediators IL-1β and IL-6 release. AG treatment could restore Claudin-5 levels, crucial for maintaining the BBB integrity. Notably, AG could decrease microglial activation and increase neurotrophic factor BDNF, the key to neurogenesis. Mechanistically, microglial conditioned medium generated from IL-6 stimulation with or without AG in a concentration similar to circulating levels found in the GWI mouse model and co-incubated with neuronal cells in vitro, decreased Tau phosphorylation and neuronal apoptosis. In conclusion, we show that AG treatment mitigated the Gut-Brain-Axis associated pathology in GWI and may be considered as a potential therapeutic avenue for the much-needed bench to bedside strategies in GWI.


Local Translation in Axons: When Membraneless RNP Granules Meet Membrane-Bound Organelles.
Eukaryotic cell compartmentalization relies on long-known membrane-delimited organelles, as well as on more recently discovered membraneless macromolecular condensates. How these two types of organelles interact to regulate cellular functions is still largely unclear. In this review, we highlight how membraneless ribonucleoprotein (RNP) organelles, enriched in RNAs and associated regulatory proteins, cooperate with membrane-bound organelles for tight spatio-temporal control of gene expression in the axons of neuronal cells. Specifically, we present recent evidence that motile membrane-bound organelles are used as vehicles by RNP cargoes, promoting the long-range transport of mRNA molecules to distal axons. As demonstrated by recent work, membrane-bound organelles also promote local protein synthesis, by serving as platforms for the local translation of mRNAs recruited to their outer surface. Furthermore, dynamic and specific association between RNP cargoes and membrane-bound organelles is mediated by bi-partite adapter molecules that interact with both types of organelles selectively, in a regulated-manner. Maintaining such a dynamic interplay is critical, as alterations in this process are linked to neurodegenerative diseases. Together, emerging studies thus point to the coordination of membrane-bound and membraneless organelles as an organizing principle underlying local cellular responses.


A polymorphism in the CDKN1B gene is associated with increased risk of hereditary prostate cancer.
The loss of cell cycle control is believed to be an important mechanism in the promotion of carcinogenesis. CDKN1B (p27) belongs to the Cip/Kip family and functions as an important cell cycle gatekeeper. Several lines of evidence from clinical studies and laboratory experiments demonstrate that CDKN1B is an important tumor suppressor gene in prostate cancer etiology. In addition, a case-control study has shown that the 326T/G (V109G) polymorphism in CDKN1B is associated with advanced prostate cancer. In light of the evidence for linkage between the chromosomal location of the CDKN1B gene (12p13) and prostate cancer susceptibility in several hereditary prostate cancer (HPC) populations, we hypothesized that sequence variants of CDKN1B play a role in HPC. To test this hypothesis, we first resequenced this gene in 96 HPC probands to identify germ-line mutations and sequence variants. We then genotyped the identified sequence variants among all family members of 188 HPC families and tested for their cosegregation with prostate cancer. In total, 10 sequence variants were identified, including three nonsynonymous changes. A family-based test, which is free from the effects of population stratification, revealed a significant association between single nucleotide polymorphism (SNP) -79C/T and prostate cancer (with a nominal P of 0.0005). The C allele of -79C/T was overtransmitted from parents to their affected offspring. Evidence for this association was primarily contributed by affected offspring whose age at diagnosis was <65 years. Together with the previous association study in a sporadic prostate cancer population, our new findings additionally suggest that germ-line variants of this gene play a role in prostate cancer susceptibility.


High-power continuous-wave frequency-doubling in KTiOAsO4.
High-power continuous-wave generation at 533 nm is demonstrated in bulk periodically poled KTiOAsO(4) (KTA) by single-pass frequency doubling of a VBG-locked Yb-doped fiber laser. Absorption characteristic and second harmonic generation (SHG) performance of different KTA samples are studied and compared. The best performing sample catered for 25%-efficient SHG of 13.6 W green light with high spatial beam quality M(2) <1.2.


Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017.
Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories. We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections. Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets. Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact. Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.


Autonomic and Adrenocortical Interactions Predict Mental Health in Late Adolescence: The TRAILS Study.
The present study is informed by the theory of allostatic load to examine how multiple stress responsive biomarkers are related to mental health outcomes. Data are from the TRAILS study, a large prospective population study of 715 Dutch adolescents (50.9 % girls), assessed at 16.3 and 19.1 years. Reactivity measures of the hypothalamic pituitary-adrenal (HPA) axis and autonomic nervous system (ANS) biomarkers (heart rate, HR; respiratory sinus arrhythmia, RSA; and pre-ejection period, PEP) to a social stress task were used to predict concurrent and longitudinal changes in internalizing and externalizing symptoms. Hierarchical linear modeling revealed relatively few single effects for each biomarker with the exception that high HR reactivity predicted concurrent internalizing problems in boys. More interestingly, interactions were found between HPA-axis reactivity and sympathetic and parasympathetic reactivity. Boys with high HPA reactivity and low RSA reactivity had the largest increases in internalizing problems from 16 to 19 years. Youth with low HPA reactivity along with increased ANS activation characterized by both decreases in RSA and decreases in PEP had the most concurrent externalizing problems, consistent with broad theories of hypo-arousal. Youth with high HPA reactivity along with increases in RSA but decreases in PEP also had elevated concurrent externalizing problems, which increased over time, especially within boys. This profile illustrates the utility of examining the parasympathetic and sympathetic components of the ANS which can act in opposition to one another to achieve, overall, stress responsivity. The framework of allostasis and allostatic load is supported in that examination of multiple biomarkers working together in concert was of value in understanding mental health problems concurrently and longitudinally. Findings argue against an additive panel of risk and instead illustrate the dynamic interplay of stress physiology systems.


The AbcA transporter of Staphylococcus aureus affects cell autolysis.
Increased production of penicillin-binding protein PBP 4 is known to increase peptidoglycan cross-linking and contributes to methicillin resistance in Staphylococcus aureus. The pbp4 gene shares a 400-nucleotide intercistronic region with the divergently transcribed abcA gene, encoding an ATP-binding cassette transporter of unknown function. Our study revealed that methicillin stimulated abcA transcription but had no effects on pbp4 transcription. Analysis of abcA expression in mutants defective for global regulators showed that abcA is under the control of agr. Insertional inactivation of abcA by an erythromycin resistance determinant did not influence pbp4 transcription, nor did it alter resistance to methicillin and other cell wall-directed antibiotics. However, abcA mutants showed spontaneous partial lysis on plates containing subinhibitory concentrations of methicillin due to increased spontaneous autolysis. Since the autolytic zymograms of cell extracts were identical in mutants and parental strains, we postulate an indirect role of AbcA in control of autolytic activities and in protection of the cells against methicillin.


Assessment of burnout among health workers and bankers in Aba south local government area, Abia state, South East Nigeria.
To determine the prevalence of burnout among health workers and bankers in Aba South Local Government Area in Abia State. A cross-sectional, descriptive study was carried out in 2013 among health workers and bankers in Aba metropolis. By multistage sampling method, proportionate number of the health workers and bankers were selected. The study instrument was Freudenberger Burnout Scale. A total of 327 health workers and bankers were studied: 253 (77.4%) were health workers while 74 (22.6%) were bankers. The age range was 21 to 59 years, and 229 (70.0%) were females. Most (48.3%) had worked for 5 years or less and had burnout scores within 0-25. There was significant difference between gender ( P = 0.017), level of education ( P = 0.038), and type of occupation ( P = 0.002) to burnout score. Age ( P = 0.956), marital status ( P = 0.461), and years of work ( P = 0.247) did not significantly affect burnout score. Female health workers were significantly more at risk of burning out compared to their male counterparts. Among bankers, however, though females were more at risk, this was not significant. Sex, level of education and type of work were the greatest contributors to burnout score. The prevalence of burnout risk among health workers and bankers is high. More female health workers are at risk of burnout than male health workers. There should be policies aimed at identifying those most at risk and reducing the prevalence.


Predictors of Online Child Sexual Abuse in a U.S. National Sample.
As technology has become increasingly integrated into the everyday lives of young people and social interactions have moved online, so too have the opportunities for child sexual abuse. However, the risk factors for online sexual abuse, and their similarities or differences with those of offline sexual abuse have not been clarified, making it difficult to design prevention strategies. Using a nationally representative online survey panel of young adults ages 18 to 28, the current study sought to identify risk factors for online childhood sexual abuse and compare their relevance and strength in predicting offline sexual abuse. The 2,639 participants, ages 18 to 28, were sampled from the Ipsos KnowledgePanel and were asked questions about 11 different kinds of technology-facilitated online sexual abuse that occurred in childhood, follow-up questions about their dynamics and offenders, and a variety of potential risk factors. Results indicated that: (1) being cisgender female, nonheterosexual, and having parents with less than a high school education emerged as important demographic predictors of online child sexual abuse (OCSA); and (2) early offline sexual abuse was the strongest predictor of OCSA, when considering both its direct and indirect effects through online risky behavior. Findings suggest that prevention programs directed at reducing risk of sexual abuse, in general, are likely to be effective against online sexual abuse, provided they also incorporate efforts to educate youth on the need to avoid risky online behaviors.


European principles of inhibitor management in patients with haemophilia.
In spite of recent major advances in the understanding and treatment of inhibitor development in patients with haemophilia, multidisciplinary management of many of these patients remains suboptimal and highly heterogenous across Europe. Following a series of multidisciplinary meetings and a review of the literature, the European haemophilia community of health professionals and patients jointly defined practical optimum standards for ensuring and harmonizing treatment and care for patients with an inhibitor. Ten complementary principles for the management of inhibitors in haemophilia have been developed, emphasizing the importance and benefits of a centralized, multidisciplinary, expert and holistic approach. This document will serve as a benchmark to improve the multidisciplinary and practical management of patients with inhibitor. Implementation and adherence to each of these principles should have a major positive impact on the management and outcomes of patients developing an inhibitor.


Photoreceptor structure and function in patients with congenital achromatopsia.
To assess photoreceptor structure and function in patients with congenital achromatopsia. Twelve patients were enrolled. All patients underwent a complete ocular examination, spectral-domain optical coherence tomography (SD-OCT), full-field electroretinographic (ERG), and color vision testing. Macular microperimetry (MP; in four patients) and adaptive optics (AO) imaging (in nine patients) were also performed. Blood was drawn for screening of disease-causing genetic mutations. Mean (± SD) age was 30.8 (± 16.6) years. Mean best-corrected visual acuity was 0.85 (± 0.14) logarithm of the minimal angle of resolution (logMAR) units. Seven patients (58.3%) showed either an absent foveal reflex or nonspecific retinal pigment epithelium mottling to mild hypopigmentary changes on fundus examination. Two patients showed an atrophic-appearing macular lesion. On anomaloscopy, only 5 patients matched over the entire range from 0 to 73. SD-OCT examination showed a disruption or loss of the macular inner/outer segments (IS/OS) junction of the photoreceptors in 10 patients (83.3%). Seven of these patients showed an optically empty space at the level of the photoreceptors in the fovea. AO images of the photoreceptor mosaic were highly variable but significantly disrupted from normal. On ERG testing, 10 patients (83.3%) showed evidence of residual cone responses to a single-flash stimulus response. The macular MP testing showed that the overall mean retinal sensitivity was significantly lower than normal (12.0 vs. 16.9 dB, P < 0.0001). The current approach of using high-resolution techniques to assess photoreceptor structure and function in patients with achromatopsia should be useful in guiding selection of patients for future therapeutic trials as well as monitoring therapeutic response in these trials.


Bridging the gap between preclinical and clinical microbicide trials: blind evaluation of candidate gels in murine models of efficacy and safety.
Despite significant protection in preclinical studies, cellulose sulfate (CS) failed to protect women against HIV-1/2 and was associated with a trend toward increased HIV-1 acquisition in one of the clinical trials. These results highlight the need for preclinical tests more predictive of clinical outcomes. The objective of this study was to test coded vaginal gels, including CS, in murine models of safety and efficacy to determine the models' utility for evaluating future products. Four coded formulations, including 6% CS, 2% PRO 2000 and two placebo gels, were administered intravaginally to medroxyprogesterone-treated mice and their ability to prevent genital herpes (efficacy) or to alter the susceptibility to low dose HSV challenge (safety) was determined. Nonoyxnol-9 served as a positive toxicity control. CS and PRO 2000 significantly protected mice from genital herpes following infection with a laboratory or clinical isolate of HSV-2 introduced in buffer (p<0.001). However, protection was reduced when virus was introduced in seminal plasma. Moreover, mice were significantly more susceptible to infection with low doses of HSV-2 when challenged 12 h after the 7th daily dose of CS or nonoxynol-9 (p<0.05). The increased susceptibility was associated with alterations in epithelial architecture. CS prevented genital herpes when present at the time of viral challenge, but increased the rate of infection when gel was applied daily for 7 days with a vaginal wash prior to viral inoculation. The findings presumably reflect altered epithelial architecture, which may have contributed to the trend towards increased HIV observed clinically.


Methods for the comparative evaluation of pharmaceuticals.
POLITICAL BACKGROUND: As a German novelty, the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen; IGWiG) was established in 2004 to, among other tasks, evaluate the benefit of pharmaceuticals. In this context it is of importance that patented pharmaceuticals are only excluded from the reference pricing system if they offer a therapeutic improvement. The institute is commissioned by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) or by the Ministry of Health and Social Security. The German policy objective expressed by the latest health care reform (Gesetz zur Modernisierung der Gesetzlichen Krankenversicherung, GMG) is to base decisions on a scientific assessment of pharmaceuticals in comparison to already available treatments. However, procedures and methods are still to be established. This health technology assessment (HTA) report was commissioned by the German Agency for HTA at the Institute for Medical Documentation and Information (DAHTA@DIMDI). It analysed criteria, procedures, and methods of comparative drug assessment in other EU-/OECD-countries. The research question was the following: How do national public institutions compare medicines in connection with pharmaceutical regulation, i.e. licensing, reimbursement and pricing of drugs? Institutions as well as documents concerning comparative drug evaluation (e.g. regulations, guidelines) were identified through internet, systematic literature, and hand searches. Publications were selected according to pre-defined inclusion and exclusion criteria. Documents were analysed in a qualitative matter following an analytic framework that had been developed in advance. Results were summarised narratively and presented in evidence tables. Currently licensing agencies do not systematically assess a new drug's added value for patients and society. This is why many countries made post-licensing evaluation of pharmaceuticals a requirement for reimbursement or pricing decisions. Typically an explicitly designated drug review body is involved. In all eleven countries included (Austria, Australia, Canada, Switzerland, Finland, France, the Netherlands, Norway, New Zealand, Sweden, and the United Kingdom) a drug's therapeutic benefit in comparison to treatment alternatives is leading the evaluation. A medicine is classified as a therapeutic improvement if it demonstrates an improved benefit-/risk-profile compared to treatment alternatives. However, evidence of superiority to a relevant degree is requested. Health related quality of life is considered as the most appropriate criterion for a drug's added value from patients' perspective. Review bodies in Australia, New Zealand, and the United Kingdom have committed themselves to include this outcome measure whenever possible. Pharmacological or innovative characteristics (e.g. administration route, dosage regime, new acting principle) and other advantages (e.g. taste, appearance) are considered in about half of the countries. However, in most cases these aspects rank as second line criteria for a drug's added value. All countries except France and Switzerland perform a comparative pharmacoeconomic evaluation to analyse costs caused by a drug intervention in relation to its benefit (preferably by cost utility analysis). However, the question if a medicine is cost effective in relation to treatment alternatives is answered in a political and social context. A range of remarkably varying criteria are considered. Countries agree that randomised controlled head-to-head trials (head-to-head RCT) with a high degree of internal and external validity provide the most reliable and least biased evidence of a drug's relative treatment effects (as do systematic reviews and meta-analyses of these RCT). Final outcome parameters reflecting long-term treatment objectives (mortality, morbidity, quality of life) are preferred to surrogate parameters. Following the concept of community effectiveness, drug review institutions also explicitly favour RCT in a "natural" design, i.e. in daily routine and country specific care settings. The countries' requirements for pharmacoeconomic studies are similar despite some methodological inconsistencies, e.g. concerning cost calculation. Outcomes of clinical and pharmacoeconomic analyses are largely determined by the choice of comparator. Selecting an appropriate comparative treatment is therefore crucial. In theory, the best or most cost effective therapy is regarded as appropriate comparator for clinical and economic studies. Pragmatically however, institutions accept that the drug is compared to the treatment of daily routine or to the least expensive therapy. If a pharmaceutical offers several approved indications, in some countries all of them are assessed. Others only evaluate a drug's main indication. Canada is the only country which also considers a medicine's off-label use. It is well known that clinical trials and pharmacoeconomic studies directly comparing a drug with adequate competitors are lacking - in quantitative as well as in qualitative terms. This is specifically the case before or shortly after marketing authorisation. Yet there is the need to support reimbursement or pricing decisions by scientific evidence. In this situation review bodies are often forced to rely on observational studies or on other internally less valid data (including expert and consensus opinions). As a second option they use statistical approaches like indirect adjusted comparisons (in Australia and the United Kingdom) and, commonly, economic modelling. However, there is consensus that results provided by these techniques need to be verified by valid head-to-head comparisons as soon as possible. In the majority of countries reimbursement and pricing decisions are based on systematic and evidence-based evaluation comparing a drug's clinical and economic characteristics to daily treatment routine. However, further evaluation criteria, requirements and specific methodological issues still lack internationally consented standards.


Distinct cytotoxic mechanisms of pristine versus hydroxylated fullerene.
The mechanisms underlying the cytotoxic action of pure fullerene suspension (nano-C60) and water-soluble polyhydroxylated fullerene [C60(OH)n] were investigated. Crystal violet assay for cell viability demonstrated that nano-C60 was at least three orders of magnitude more toxic than C60(OH)n to mouse L929 fibrosarcoma, rat C6 glioma, and U251 human glioma cell lines. Flow cytometry analysis of cells stained with propidium iodide (PI), PI/annexin V-fluorescein isothiocyanate, or the redox-sensitive dye dihydrorhodamine revealed that nano-C60 caused rapid (observable after few hours), reactive oxygen species (ROS)-associated necrosis characterized by cell membrane damage without DNA fragmentation. In contrast, C60(OH)n caused delayed, ROS-independent cell death with characteristics of apoptosis, including DNA fragmentation and loss of cell membrane asymmetry in the absence of increased permeability. Accordingly, the antioxidant N-acetylcysteine protected the cell lines from nano-C60 toxicity, but not C60(OH)n toxicity, while the pan-caspase inhibitor z-VAD-fmk blocked C60(OH)n-induced apoptosis, but not nano-C60-mediated necrosis. Finally, C60(OH)n antagonized, while nano-C60 synergized with, the cytotoxic action of oxidative stress-inducing agents hydrogen peroxide and peroxynitrite donor 3-morpholinosydnonimine. Therefore, unlike polyhydroxylated C60 that exerts mainly antioxidant/cytoprotective and only mild ROS-independent pro-apoptotic activity, pure crystalline C60 seems to be endowed with strong pro-oxidant capacity responsible for the rapid necrotic cell death.


Comparison of ribotyping and multilocus enzyme electrophoresis for subtyping of Listeria monocytogenes isolates.
Ribotyping was compared with multilocus enzyme electrophoresis (MEE) for subtyping 305 Listeria monocytogenes isolates from clinical and nonclinical sources. For ribotyping, EcoRI-restricted genomic DNA fragments of L. monocytogenes strains were separated by agarose gel electrophoresis, and Southern blots were probed with a cloned Escherichia coli rrnB operon (plasmid pKK3535) labeled with digoxigenin. The L. monocytogenes isolates were divided into 28 distinct ribotypes, while MEE analysis divided the same isolates into 78 electrophoretic types (ETs). On the basis of their ribotype profiles, the strains were divided into two subgroups. The ribotype alpha (RT alpha) subgroup contained serotypes 1/2a, 1/2c, and 3a, and the ribotype beta (RT beta) subgroup contained serotypes 1/2b, 3b, 4b, and 4ab. This division is in complete agreement with MEE analysis, which divides the species into two subgroups (ET groups A and B), with the same serotype distribution in each subgroup. Overall, MEE was more discriminating than ribotyping. However, in several instances ribotyping discriminated between isolates within the same ET. Ribotyping was more discriminating for serotypes 1/2a, 1/2c, and 3a (Simpson's Index for Diversity [DI] = 0.81) than for serotypes 1/2b and 4b (DI = 0.76). A substantial proportion (69%) of serotype 1/2b and 4b strains clustered in five ETs and five ribotypes. These data suggest that ribotyping and MEE do not provide adequate discrimination between strains of serotypes 1/2b and 4b. Methods such as pulsed-field gel electrophoresis and random amplified polymorphic DNA analysis should be explored for further discrimination of strains of these serotypes.


Elevated levels of mercapturic acids of acrolein and crotonaldehyde in the urine of Chinese women in Singapore who regularly cook at home.
Lung cancer is unusually common among non-smoking women in Southeastern Asia but the causes of this frequently fatal disease are not well understood. Several epidemiology studies indicate that inhalation of fumes from high temperature Chinese style cooking with a wok may be a cause. Only one previous study investigated uptake of potential toxicants and carcinogens by women who cook with a wok. We enrolled three-hundred twenty-eight non-smoking women from Singapore for this study. Each provided a spot urine sample and answered a questionnaire concerning their cooking habits and other factors. The urine samples were analyzed by liquid chromatography-tandem mass spectrometry for mercapturic acid metabolites of acrolein (3-hydroxypropylmercapturic acid), crotonaldehyde (3-hydroxy-1-methylpropylmercapturic acid), and benzene (S-phenylmercapturic acid), accepted biomarkers of uptake of these toxic and carcinogenic compounds. We observed statistically significant effects of wok cooking frequency on levels of 3-hydroxypropylmercapturic acid and 3-hydroxy-1-methylpropylmercapturic acid, but not S-phenylmercapturic acid. Women who cooked greater than 7 times per week had a geometric mean of 2600 (95% CI, 2189-3090) pmol/mg creatinine 3-hydroxypropylmercapturic acid compared to 1901 (95% CI, 1510-2395) pmol/mg creatinine when cooking less than once per week (P for trend 0.018). The corresponding values for 3-hydroxy-1-methylpropylmercapturic acid were 1167 (95% CI, 1022-1332) and 894 (95% CI, 749-1067) pmol/mg creatinine (P for trend 0.008). We conclude that frequent wok cooking leads to elevated exposure to the toxicants acrolein and crotonaldehyde, but not benzene. Kitchens should be properly ventilated to decrease exposure to potentially toxic and carcinogenic fumes produced during Chinese style wok cooking.


Atypical presentation of congenital yellow nail syndrome in a 2-year-old female.
Yellow nail syndrome (YNS) is a rare clinical entity of unknown etiology that is characterized by a triad of yellow nails, respiratory manifestations, and lymphedema. The condition appears in the mid- to later years of life and only rarely in childhood. We describe a rare case of YNS with an atypical clinical presentation consisting of only yellow and dystrophic nails in a 2-year-old female since birth. A case of congenital YNS with only dystrophic and yellow nails is reported. A 2-year-old female presented with yellow nails since birth. There was no positive family history. Physical examination revealed 20 thickened, dystrophic, yellow nails with onycholysis. There was no evidence of respiratory manifestations or lymphedema. Although rare, YNS can present as a congenital clinical entity and persist after birth. Pediatric patients with YNS show different clinical manifestations than the classic adult patient. The presence of yellow and dystrophic nails in the absence of respiratory and lymphatic manifestations may be the only sign of pathology and warrants close monitoring as progression to more serious complications can occur.


Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns.
To assess the predictive ability of a universal predischarge serum bilirubin measurement to screen for risk of subsequent significant hyperbilirubinemia in the direct Coombs negative healthy term and near-term newborn during the first postnatal week. Total serum bilirubin (TSB) levels were obtained at the time of the routine metabolic screen in all term and near-term newborns cared for in the Pennsylvania Hospital Well Baby Nursery (n = 13 003). Postnatal age (in hours) at the time of TSB measurement was recorded. A percentile-based bilirubin nomogram for the first week was constructed from hour-specific predischarge and postdischarge TSB values of newborns (n = 2840; median BW = 3230 g and median gestational age = 39 weeks) who met classification criteria for healthy newborns (excluding those with a positive direct Coombs test or those requiring phototherapy before age 60 hours) and who were enrolled in a hospital supervised home or outpatient follow-up program. The accuracy of the predischarge TSB as a predictor of subsequent degree of hyperbilirubinemia was determined. The study patients in the nomogram were racially diverse. Nearly 60% were breastfed. Predischarge, 6.1% of the study population (172/2840) had TSB values in the high-risk zone (>/=95th percentile) at 18 to 72 hours; of these, 39.5% (68/172) remained in that zone (likelihood ratio [LR] = 14.08, sensitivity = 54%; specificity = 96.2%, probability = 39.5%). Predischarge, 32.1% of the population (912/2840) had TSB values in the intermediate-risk zone. In a clinically significant minority of these newborns (58/912 or 6.4%), the postdischarge TSB moved into the high-risk zone (LR of this move: 3.2 from the upper-intermediate zone and.48 from the lower-intermediate risk zone). The predischarge TSB in 61.8% of the newborns (1756/2840) was in the low-risk zone (<40th percentile) and there was no measurable risk for significant hyperbilirubinemia (LR = 0, sensitivity = 100%; specificity = 64.7%; probability = 0%). An hour-specific TSB before hospital discharge can predict which newborn is at high, intermediate or low risk for developing clinically significant hyperbilirubinemia (specifically defined as TSB levels >/=95th percentile for age in hours). Risk designation and subsequent increases or decreases of in TSB can be easily monitored on an hour-specific percentile based predictive bilirubin nomogram. A predischarge TSB measured as a universal policy would facilitate targeted intervention and follow-up in a safe, cost-effective manner. In conjunction with bilirubin practice parameter of the American Academy of Pediatrics, it could reduce the potential risk for bilirubin-induced neurologic dysfunction.


Effect of Nd:YAG laser parameters on the penetration depth of a representative Ni-Cr dental casting alloy.
The effects of voltage and laser beam (spot) diameter on the penetration depth during laser beam welding in a representative nickel-chromium (Ni-Cr) dental alloy were the subject of this study. The cast alloy specimens were butted against each other and laser welded at their interface using various voltages (160-390 V) and spot diameters (0.2-1.8 mm) and a constant pulse duration of 10 ms. After welding, the laser beam penetration depths in the alloy were measured. The results were plotted and were statistically analyzed with a two-way ANOVA, employing voltage and spot diameter as the discriminating variables and using Holm-Sidak post hoc method (a = 0.05). The maximum penetration depth was 4.7 mm. The penetration depth increased as the spot diameter decreased at a fixed voltage and increased as the voltage increased at a fixed spot diameter. Varying the parameters of voltage and laser spot diameter significantly affected the depth of penetration of the dental cast Ni-Cr alloy. The penetration depth of laser-welded Ni-Cr dental alloys can be accurately adjusted based on the aforementioned results, leading to successfully joined/repaired dental restorations, saving manufacturing time, reducing final cost, and enhancing the longevity of dental prostheses.


DP4-AI automated NMR data analysis: straight from spectrometer to structure.
A robust system for automatic processing and assignment of raw 13C and 1H NMR data DP4-AI has been developed and integrated into our computational organic molecule structure elucidation workflow. Starting from a molecular structure with undefined stereochemistry or other structural uncertainty, this system allows for completely automated structure elucidation. Methods for NMR peak picking using objective model selection and algorithms for matching the calculated 13C and 1H NMR shifts to peaks in noisy experimental NMR data were developed. DP4-AI achieved a 60-fold increase in processing speed, and near-elimination of the need for scientist time, when rigorously evaluated using a challenging test set of molecules. DP4-AI represents a leap forward in NMR structure elucidation and a step-change in the functionality of DP4. It enables high-throughput analyses of databases and large sets of molecules, which were previously impossible, and paves the way for the discovery of new structural information through machine learning. This new functionality has been coupled with an intuitive GUI and is available as open-source software at https://github.com/KristapsE/DP4-AI.


Analysis of employment data for interventional pulmonary fellowship graduates.
Interventional pulmonology (IP) is a maturing field in the subspecialty of pulmonary medicine. Over the last few years, there has been an increased number of listed IP fellowship training programs in the United States and Canada, causing debate about the employment market for IP fellowship graduates. To analyze employment data of IP fellowship graduates. Interventional pulmonary fellows, during their IP in-service examination, were surveyed on employment position after graduation. The survey occurred in May or June in the years 2012, 2013, and 2014. An IP position was defined as a position encompassing more than 60% of effort directly toward IP. Geographic location and practice structure (i.e., academic, private/hybrid, and existing or initiating IP practice) were collected and analyzed. There was an 88.5% response rate, with 53 IP fellows participating in the survey. The majority of IP fellowship graduates (75%; 39/52) had positions in academic IP practices. All seven IP private practice positions were to create an IP program. One IP graduate was in a non-IP academic position, four were in non-IP private practice, one was in a research position, and one had no known employment. Most IP fellowship graduates were men (77.4%). Most IP positions were filled in states east of the Mississippi River; only 8 of 53 (15.1%) positions were filled in states west of the Mississippi river. Despite speculation about the scarcity of academic jobs after fellowship, recently trained IP fellows are more likely to practice in academic settings and join established practices.


Single-particle light-scattering measurement: photochemical aerosols and atmospheric particulates.
The use of single-particle light-scattering measurements to determine the origin of atmospheric hazes has been explored by measurement of laboratory aerosols, field samples, and computer analysis of the light-scattering data. The refractive index of measured spherical particles 800 nm to 1000 nm in diameter was determined within 2%. For particles of diameter less than 500 nm the measurement of absolute scattering intensity is required for complete analysis. Distinctive nonspherical and absorbing particles were observed both in automotive exhaust and atmospheric samples. Electrostatic suspension of atmospheric particulates is demonstrated to provide a practical approach to optical measurement of single particles. The technique may be used to calibrate optical particle counters or identify particles with unique shape or refractive index.


Globin switches in yolk sac-like primitive and fetal-like definitive red blood cells produced from human embryonic stem cells.
We have previously shown that coculture of human embryonic stem cells (hESCs) for 14 days with immortalized fetal hepatocytes yields CD34(+) cells that can be expanded in serum-free liquid culture into large numbers of megaloblastic nucleated erythroblasts resembling yolk sac-derived cells. We show here that these primitive erythroblasts undergo a switch in hemoglobin (Hb) composition during late terminal erythroid maturation with the basophilic erythroblasts expressing predominantly Hb Gower I (zeta(2)epsilon(2)) and the orthochromatic erythroblasts hemoglobin Gower II (alpha(2)epsilon(2)). This suggests that the switch from Hb Gower I to Hb Gower II, the first hemoglobin switch in humans is a maturation switch not a lineage switch. We also show that extending the coculture of the hESCs with immortalized fetal hepatocytes to 35 days yields CD34(+) cells that differentiate into more developmentally mature, fetal liver-like erythroblasts, that are smaller, express mostly fetal hemoglobin, and can enucleate. We conclude that hESC-derived erythropoiesis closely mimics early human development because the first 2 human hemoglobin switches are recapitulated, and because yolk sac-like and fetal liver-like cells are sequentially produced. Development of a method that yields erythroid cells with an adult phenotype remains necessary, because the most mature cells that can be produced with current systems express less than 2% adult beta-globin mRNA.


Mean focal length of an aberrated lens.
We outline an approach for the calculation of the mean focal length of an aberrated lens and provide closed-form solutions that show that the focal length of the lens is dependent on the presence of defocus, x-astigmatism, and spherical aberration. The results are applicable to Gaussian beams in the presence of arbitrary-sized apertures. The theoretical results are confirmed experimentally, showing excellent agreement. As the final results are in algebraic form, the theory may readily be applied in the laboratory if the aberration coefficients of the lens are known.


Quantitative genetics of plumage color: lifetime effects of early nest environment on a colorful sexual signal.
Phenotypic differences among individuals are often linked to differential survival and mating success. Quantifying the relative influence of genetic and environmental variation on phenotype allows evolutionary biologists to make predictions about the potential for a given trait to respond to selection and various aspects of environmental variation. In particular, the environment individuals experience during early development can have lasting effects on phenotype later in life. Here, we used a natural full-sib/half-sib design as well as within-individual longitudinal analyses to examine genetic and various environmental influences on plumage color. We find that variation in melanin-based plumage color - a trait known to influence mating success in adult North American barn swallows (Hirundo rustica erythrogaster) - is influenced by both genetics and aspects of the developmental environment, including variation due to the maternal phenotype and the nest environment. Within individuals, nestling color is predictive of adult color. Accordingly, these early environmental influences are relevant to the sexually selected plumage color variation in adults. Early environmental conditions appear to have important lifelong implications for individual reproductive performance through sexual signal development in barn swallows. Our results indicate that feather color variation conveys information about developmental conditions and maternal care alleles to potential mates in North American barn swallows. Melanin-based colors are used for sexual signaling in many organisms, and our study suggests that these signals may be more sensitive to environmental variation than previously thought.


Efficacy of cognitive rehabilitation therapies for mild cognitive impairment (MCI) in older adults: working toward a theoretical model and evidence-based interventions.
To evaluate the efficacy of cognitive rehabilitation therapies (CRTs) for mild cognitive impairment (MCI). Our review revealed a need for evidence-based treatments for MCI and a lack of a theoretical rehabilitation model to guide the development and evaluation of these interventions. We have thus proposed a theoretical rehabilitation model of MCI that yields key intervention targets-cognitive compromise, functional compromise, neuropsychiatric symptoms, and modifiable risk and protective factors known to be associated with MCI and dementia. Our model additionally defines specific cognitive rehabilitation approaches that may directly or indirectly target key outcomes-restorative cognitive training, compensatory cognitive training, lifestyle interventions, and psychotherapeutic techniques. Fourteen randomized controlled trials met inclusion criteria and were reviewed. Studies markedly varied in terms of intervention approaches and selected outcome measures and were frequently hampered by design limitations. The bulk of the evidence suggested that CRTs can change targeted behaviors in individuals with MCI and that CRTs are associated with improvements in objective cognitive performance, but the pattern of effects on specific cognitive domains was inconsistent across studies. Other important outcomes (i.e., daily functioning, quality of life, neuropsychiatric symptom severity) were infrequently assessed across studies. Few studies evaluated long-term outcomes or the impact of CRTs on conversion rates from MCI to dementia or normal cognition. Overall, results from trials are promising but inconclusive. Additional well-designed and adequately powered trials are warranted and required before CRTs for MCI can be considered evidence-based.


Comparison of high pressure and nanoscale confinement effects on crystallization of the molecular glass-forming liquid, dimethyl phthalate.
High pressure and nanoscopic confinement are two different strategies commonly employed to modify the physicochemical properties of various materials. Both strategies act mostly by changing the molecular packing. In this work, we performed a comparative study on the effect of compression and confined geometry on crystallization of a molecular liquid. Dielectric spectroscopy was employed to investigate the crystallization of the van der Waals liquid, dimethyl phthalate, in nanoporous alumina of different pore sizes as well as on increased pressure (up to 200 MPa). The analysis of the crystallization kinetics under varying thermodynamic conditions revealed that both strategies affect the crystallization behavior of the sample in very distinct ways. Compression shifts the maximum crystallization rate towards a higher temperature and broadens it. As a result, it is more challenging to avoid crystallization upon cooling the liquid at high pressure. In contrast, when the same material is incorporated into nanopores, crystallization significantly slows down and the maximum rate shifts towards a lower temperature with decreasing pore size. Finally, we show that crystallization in nanoporous alumina is accompanied by pre-crystallization effects upon which a shift of the α-relaxation peak is observed. An equilibration process prior to the initiation of crystallization was detected for the confined material both above and below the glass transition temperature of the interfacial layer, while not in the bulk.


How to grow a mind: statistics, structure, and abstraction.
In coming to understand the world-in learning concepts, acquiring language, and grasping causal relations-our minds make inferences that appear to go far beyond the data available. How do we do it? This review describes recent approaches to reverse-engineering human learning and cognitive development and, in parallel, engineering more humanlike machine learning systems. Computational models that perform probabilistic inference over hierarchies of flexibly structured representations can address some of the deepest questions about the nature and origins of human thought: How does abstract knowledge guide learning and reasoning from sparse data? What forms does our knowledge take, across different domains and tasks? And how is that abstract knowledge itself acquired?


Technology-based interpersonal victimization: predictors of patterns of victimization over time.
The objective of this study was to identify factors that could predict youth's future technology-based interpersonal victimization and the pattern of that future victimization over time. Data from Growing up With Media, a national, longitudinal, online study were analyzed. At baseline, participants (N = 1,018) were 10- to 15-year-old English speakers who had used the Internet at least once in the last 6 months. Twenty-nine percent reported repeat technology-based interpersonal victimization over a 2-year period (re-victimized group); 10% were victims during only Year 1 (desisted victimized group); and 17% reported victimization during only Year 2 (later victimized group). Of the individual risk factors examined, prior technology-based interpersonal victimization and current amount of Internet use had the strongest overall associations with pattern of technology-based interpersonal victimization over the subsequent 2-year period. There was substantial overlap among the individual risk factors. Thus, they could be thought of more simply in terms of four latent risk and three individual risk factors. On average, across these seven risk factors, repeat victims had the greatest average risk score (0.21) and the not victimized group had the lowest (-0.16). Repeat victims were more likely to be female and older and had more prior experience with problem behaviors, substance use, and negative parent-child relationships as compared with the other three groups. Being female, prior experience with problem behavior, prior substance use, and prior negative parent-child relationships were also associated with frequency of technology-based interpersonal victimization in the near (Year 1) and more distant (Year 2) future. Many of these risk factors related to technology-based victimization over time are malleable, suggesting opportunities for effective targeting of future prevention efforts.


Neurophysiological Measures and Alcohol Use Disorder (AUD): Hypothesizing Links between Clinical Severity Index and Molecular Neurobiological Patterns.
In 1987, Cloninger proposed a clinical description and classification of different personality traits genetically defined and independent from each other. Moreover, he elaborated a specific test the TCI to investigate these traits/states. The study of craving in Alcohol Use Disorder (AUD) assumed a greater significance, since ever more data seems to suggest a direct correlation between high levels of craving and a higher risk of relapse in alcoholics. Thus, our study aim is to explore the possible correlations among TCI linked molecular neurobiological pattern (s), craving and alcohol addiction severity measures in a sample of Italian alcoholics. 191 alcoholics were recruited in a Day Hospital (DH) setting at the Alcohol Addiction Program Latium Region Referral Center, Sapienza University of Rome. After 7 days detoxification treatment a psychodiagnostic protocol was administered, including TCI, VAS-C, ASI and SADQ. All patients signed an Institutional Review Board (IRB) approved informed consent. Principally, we detected a significant positive correlation between HA-scale scores and the VAS scale: increasing in HA-scale corresponds to an increase in craving perception for both intensity (r=0.310; p ≤ 0.001) and frequency (r=0.246; p ≤ 0.001). Moreover, perception of dependence severity, measured with SADQ was also found to be significantly associated positively to both HA-scale (r=0.246; p ≤ 0.001) and NS-scale (r=0.224; p ≤ 0.01). While, for character scales, Persistence (r=-0.195; p=.008) and Self-directedness (r=-0.294; p ≤ 0.001) was negatively associated with ASI linked to alcohol problems. Self-directedness was also negatively correlated with ASI linked to family and social problems (r=-0.349; p ≤ 0.001), employment and support problems (r=-0.220; p=0.003) and psychiatric problems (r=-0.358; p ≤ 0.001). Cooperativeness was a negative correlate with Legal Problems (r=-0.173; p=0.019). and Self-Transcendence was positive correlated with Medical Problems (r=0.276; p ≤ 0.001). In view of recent addiction neurobiological theories, such as the "Reward Deficiency Syndrome (RDS)" and the Koob model, our data could suggest that our cohort of patients could possibly be in a particular stage of the course of their addiction history. Thus, if our hypothesis will be confirmed, the TCI-based assessment of alcoholics would allow an optimization of the treatment. Clinicians understanding these newer concepts will be able to translate this information to their patients and potentially enhance clinical outcome (s), because it could suggest a functional hypothesis of neurotransmitter circuits that helps to frame the patient in his/her history of addiction.


A histomorphometric study of cellular layers after hemiepiphyseal stapling on the physeal plate in rabbits.
Epiphyseal stapling has been widely used to correct angular deformity. The mechanism, however, has not been well determined. To determine the effect of temporary hemiepiphyseal stapling on the cellular layers of the physis, a histomorphometric study was performed using immature rabbits. Distal lateral epiphyseal stapling of the right femur was performed on 6-week-old New Zealand white rabbits. Thirty rabbits were randomly assigned to five groups, and six rabbits in each group were analyzed weekly for up to 5 weeks. The distal femur was deformed into the valgus, and the anatomical lateral distal femoral angle decreased with the passage of time. In the sequential histomorphometry of the operated physeal plate, the area ratio of each layer, compared to the control side, decreased every week. The total area of the physeal plate had decreased up to 60 % at the 5th week compared to the area of the 1st week, and the area of the proliferative layer decreased by the greatest amount among the three layers. Our findings suggest that the proliferation of chondrocytes seemed to be more suppressed by the compression of the stapling, thereby slowing the growth rate, although hypertrophy of the chondrocytes was also suppressed.


Trap array configuration influences estimates and precision of black bear density and abundance.
Spatial capture-recapture (SCR) models have advanced our ability to estimate population density for wide ranging animals by explicitly incorporating individual movement. Though these models are more robust to various spatial sampling designs, few studies have empirically tested different large-scale trap configurations using SCR models. We investigated how extent of trap coverage and trap spacing affects precision and accuracy of SCR parameters, implementing models using the R package secr. We tested two trapping scenarios, one spatially extensive and one intensive, using black bear (Ursus americanus) DNA data from hair snare arrays in south-central Missouri, USA. We also examined the influence that adding a second, lower barbed-wire strand to snares had on quantity and spatial distribution of detections. We simulated trapping data to test bias in density estimates of each configuration under a range of density and detection parameter values. Field data showed that using multiple arrays with intensive snare coverage produced more detections of more individuals than extensive coverage. Consequently, density and detection parameters were more precise for the intensive design. Density was estimated as 1.7 bears per 100 km2 and was 5.5 times greater than that under extensive sampling. Abundance was 279 (95% CI = 193-406) bears in the 16,812 km2 study area. Excluding detections from the lower strand resulted in the loss of 35 detections, 14 unique bears, and the largest recorded movement between snares. All simulations showed low bias for density under both configurations. Results demonstrated that in low density populations with non-uniform distribution of population density, optimizing the tradeoff among snare spacing, coverage, and sample size is of critical importance to estimating parameters with high precision and accuracy. With limited resources, allocating available traps to multiple arrays with intensive trap spacing increased the amount of information needed to inform parameters with high precision.


Effects of replicating primary-reflex movements on specific reading difficulties in children: a randomised, double-blind, controlled trial.
Children with specific reading difficulties have problems that extend beyond the range of underlying language-related deficits (eg, they have difficulties with balance and motor control). We investigated the role of persistent primary reflexes (which are closely linked in the earliest months of life to the balance system) in disrupting the development of reading skills. We assessed the efficacy of an intervention programme based on replicating the movements generated by the primary-reflex system during fetal and neonatal life. A randomised, individually matched, double-blind, placebo-controlled design was used and children (aged 8-11 years) with persistent primary reflexes and a poor standard of reading were enrolled into one of three treatment groups: experimental (children were given a specific movement sequence); placebo-control (children were given non-specific movements); and control (no movements). From an initial sample of 98 children, 60 children, 20 in each group were matched on age, sex, verbal intelligence quotient (IQ), reading ability, and persistent asymmetrical tonic neck reflex. For asymmetrical tonic neck-reflex levels there was a significant (group by time) interaction (p<0.001). The experimental group showed a significant decrease in the level of persistent reflex over the course of the study (mean change -1.8 [95% CI -2.4 to -1.2], p<0.001), whereas the changes in the placebo-control and control groups were not significant (-0.2 [-0.9 to 0.6] and -0.4 [-0.9 to 0.2]). This study provides further evidence of a link between reading difficulties and control of movement in children. In particular, our study highlights how the educational functioning of children may be linked to interference from an early neurodevelopmental system (the primary-reflex system). A new approach to the treatment of children with reading difficulties is proposed involving assessment of underlying neurological functioning, and appropriate remediation.


Efficacy of transradial cerebral angiography in the elderly.
Transradial angiography has become popular among many cardiologists as a diagnostic and therapeutic tool. However, transradial cerebral angiography is not utilized to the same extent. The purpose of this study is to present our experience regarding the usefulness of transradial cerebral angiography, especially in elderly patients. Between May 2011 and February 2012, a total of 126 cerebral angiographies were performed via a transradial approach in a single center. Of them, only 47 patients were over 60 years old. In our institution, we shifted the initial access from the right femoral artery to the right radial artery in all patients requiring cerebral angiography in 2011. We did not attempt radial access in 40 cases for variable reasons. The procedural success rate was 92.2%. We have four failures of transradial angiography; two because of loop formations of the radial and brachial artery and two due to multiple puncture failures. All supra-aortic vessels were successfully catheterized. However, the selective catheterization rates of the left side distal vessels were lower, as success rates were 89.7% for the right internal carotid artery and 75% for the left internal carotid artery. Procedure-related vascular complications, such as puncture site hematoma, hand ischemia, pseudoaneurysm, arteriovenous fistula and arterial dissection were not observed in our series. However, intraprocedural thrombosis developed in one patient, which was resolved completely by intraarterial thrombolytic agents. With advancing patient's age, we believe that transradial cerebral angiography is a useful tool to decrease patient's discomfort and more effectively manage the vessel tortuosity.


Changes in medical student attitudes as they progress through a medical course.
To explore the way ethical principles develop during a medical education course for three groups of medical students--in their first year, at the beginning of their penultimate (fifth) year and towards the end of their final (sixth) year. Survey questionnaire administered to medical students in their first, fifth and final (sixth) year. A large medical school in Queensland, Australia. Approximately half the students in each of three years (first, fifth and sixth) provided data on a voluntary basis, a total of 385 students. At the point of entry, minor differences were found between medical students and first year law and psychology students. More striking were differences between male and female medical students, suggesting early socialization had a substantial impact here. Results indicate that substantial changes in attitude have developed by the beginning of fifth year with little change thereafter. Gender difference persisted. Some difference in ethical attitudes were found when groups of different ethnic backgrounds were compared. The impact of a move to a graduate medical course, which gives high priority to ethics within a professional development domain, can now be evaluated.


Herpes simplex virus (HSV)-mediated ICAM-1 gene transfer abrogates tumorigenicity and induces anti-tumor immunity.
Costimulatory and cellular adhesion molecules are thought to be essential components of antigen presentation in the immune response to cancer. The current studies examine gene transfer utilizing herpes viral amplicon vectors (HSV) to direct surface expression of adhesion molecules, and specifically evaluate the potential of a tumor-expressing intercellular adhesion molecule-1 (ICAM-1) to elicit an anti-tumor response. The human ICAM-1 (hICAM1) gene was inserted into an HSV amplicon vector and tested in a transplantable rat hepatocellular carcinoma and in a human colorectal cancer cell line. Cell surface ICAM-1 expression was assessed by flow cytometry. Lymphocyte binding to HSV-hICAM1-transduced cells was compared with that to cells transduced with HSV not carrying the ICAM gene. Tumorigenicity of HSV-hICAM1-transduced tumor cells were tested in syngeneic Buffalo rats. Additionally, immunization with irradiated (10,000 rads) HSV-hICAM1-transduced tumor cells was performed to determine its effect on tumor growth. A 20-min exposure of tumor cells at a multiplicity of infection (MOI) of 1 resulted in high-level cell surface expression of human ICAM in approximately 25% of tumor cells. Transduced rat or human tumor cells exhibited significantly enhanced binding of lymphocytes (p < 0.05). HSV-hICAM1-transduced cells elicited an increase in infiltration by CD4(+) lymphocytes in vivo and exhibited decreased tumorigenicity. Immunization with irradiated HSV-hICAM1-transduced cells protected against growth of subsequent injected parental tumor cells. HSV amplicon-mediated gene transfer is an efficient method for modifying the cell surface expression of adhesion molecules. Increased tumor expression of ICAM-1 represents a promising immune anti-cancer strategy.


Optimized Cas9 expression systems for highly efficient Arabidopsis genome editing facilitate isolation of complex alleles in a single generation.
Genetic resources for the model plant Arabidopsis comprise mutant lines defective in almost any single gene in reference accession Columbia. However, gene redundancy and/or close linkage often render it extremely laborious or even impossible to isolate a desired line lacking a specific function or set of genes from segregating populations. Therefore, we here evaluated strategies and efficiencies for the inactivation of multiple genes by Cas9-based nucleases and multiplexing. In first attempts, we succeeded in isolating a mutant line carrying a 70 kb deletion, which occurred at a frequency of ~ 1.6% in the T2 generation, through PCR-based screening of numerous individuals. However, we failed to isolate a line lacking Lhcb1 genes, which are present in five copies organized at two loci in the Arabidopsis genome. To improve efficiency of our Cas9-based nuclease system, regulatory sequences controlling Cas9 expression levels and timing were systematically compared. Indeed, use of DD45 and RPS5a promoters improved efficiency of our genome editing system by approximately 25-30-fold in comparison to the previous ubiquitin promoter. Using an optimized genome editing system with RPS5a promoter-driven Cas9, putatively quintuple mutant lines lacking detectable amounts of Lhcb1 protein represented approximately 30% of T1 transformants. These results show how improved genome editing systems facilitate the isolation of complex mutant alleles, previously considered impossible to generate, at high frequency even in a single (T1) generation.


Development of PDMS microbioreactor with well-defined and homogenous culture environment for chondrocyte 3-D culture.
Perfusion cell culture is believed to provide a stable culture environment due to the continuous supply of nutrients and removal of waste. However, the culture scales used in most cases were large, where the culture conditions can not be regarded as homogenous because of chemical gradients. To improve this, the concept of miniaturization is applied to 3-D cell culture. In this study, a simple perfusion microbioreactor was developed based on mass transport simulation to find out the reasonable culture scales with relatively lower chemical gradients. Besides, PDMS surface was treated with surfactant solution to reduce non-specific serum protein adsorption, which keeps the culture conditions steady. Chondrocyte 3-D culture using the proposed microbioreactors was compared with similar perfusion culture with a larger culture scale. Results showed that surfactant-treated PDMS surface could reduce serum protein adsorption by 85% over the native one. Also, microbioreactors were proved to provide a stable culture environment (e.g. pH) over the culture period. Cell culture scale of 200 microm thick culture construct was justified to have relatively lower chemical gradients than the larger scale perfusion culture. As a whole, the proposed culture system is capable of providing a well-defined and homogenous culture environment.


Duplex imaging of the renal arteries with contrast enhancement.
Duplex ultrasound evaluation of the renal arteries is a technically challenging procedure. Its accuracy is significantly influenced by operator expertise and patient factors, such as overlying bowel gas and obesity. Intravenous microbubble contrast agents enhance vascular reflective acoustic signals and may improve ultrasound diagnostic accuracy. The clinical usefulness of such a contrast agent in the renal vasculature was examined prospectively. A total of 22 patients (16 males and 6 females) with mean age of 63 +/-3 years with suspected abdominal vascular disease were studied prospectively. A complete color flow duplex imaging study of the renal vasculature was performed. This was then followed by an identical examination during which an ultrasound contrast agent (Definity, DuPont Pharmaceutical) was infused intravenously at a rate of 2 to 4 mL/min. In addition to imaging of the vessels, the peak systolic velocity and Doppler waveforms of the aorta and renal arteries were examined. These results were independently compared to results with contrast angiography. A mean of 67 mL of contrast was used per patient. Of the total of 43 renal arteries examined, the accuracy for the detection of occlusions was 75% (3 of 4) for both standard and contrast-enhanced duplex ultrasound. The accuracy for the detection of hemodynamically significant stenosis was 50% (6 of 12) for standard and 75% (9 of 12) for contrast-enhanced duplex ultrasound. Visualization of normal or minimally diseased arteries was 94% (30 of 32) for standard and 97% (31 of 32) for contrast-enhanced ultrasound. Although overall accuracy was not enhanced by the infusion of ultrasound contrast, 5 of 7 arteries not visualized by color flow duplex were detected following the infusion of contrast agent, resulting in an additional 10% (5 of 48) of vessels visualized. Peak systolic velocities were increased by an average of 10% in normal or minimally diseased vessels and 12% in stenotic vessels following contrast administration but these differences were not statistically significant. Contrast-enhanced duplex imaging of the renal arteries is safe but not routinely required when performed by an experienced sonographer. However, it may increase visualization and accuracy in patients with stenoses or when the vessels are not initially visualized. Although increased velocities are seen when contrast agent is used, this does not appear to necessitate different Doppler criteria at this time.


Psychedelic therapy for smoking cessation: Qualitative analysis of participant accounts.
Recent pilot trials suggest feasibility and potential efficacy of psychedelic-facilitated addiction treatment interventions. Fifteen participants completed a psilocybin-facilitated smoking cessation pilot study between 2009 and 2015. The aims of this study were as follows: (1) to identify perceived mechanisms of change leading to smoking cessation in the pilot study; (2) to identify key themes in participant experiences and long-term outcomes to better understand the therapeutic process. Participants were invited to a retrospective follow-up interview an average of 30 months after initial psilocybin sessions. Semi-structured interviews were conducted with 12 of the 15 participants. Data were analysed using thematic analysis. Participants reported gaining vivid insights into self-identity and reasons for smoking from their psilocybin sessions. Experiences of interconnectedness, awe, and curiosity persisted beyond the duration of acute drug effects. Participants emphasised that the content of psilocybin experiences overshadowed any short-term withdrawal symptoms. Preparatory counselling, strong rapport with the study team, and a sense of momentum once engaged in the study treatment were perceived as vital additional factors in achieving abstinence. In addition, participants reported a range of persisting positive changes beyond smoking cessation, including increased aesthetic appreciation, altruism, and pro-social behaviour. The findings highlight the value of qualitative research in the psychopharmacological investigation of psychedelics. They describe perceived connections between drug- and non-drug factors, and provide suggestions for future research trial design and clinical applications.


Gender disparities in stress test utilization in chest pain unit patients based upon the ordering physician's gender.
Physicians' gender may impact test utilization in the diagnosis of acute cardiovascular disease. We sought to determine if physician gender affected stress test utilization by patient gender in a low-risk chest pain observation unit. This was a retrospective consecutive cohort study of patients admitted to a chest pain unit in a large volume academic urban emergency department (ED). Inclusion criteria were age>18, American Heart Association low-to-intermediate risk, electrocardiogram nondiagnostic for acute coronary syndrome, and negative initial troponin I. Exclusion criteria were age>75 with a history of coronary artery disease, active comorbid medical problems, or inability to obtain stress testing in the ED for any reason. T-tests were used for univariate comparisons and logistic regression was used to estimate odds ratios (ORs) for receiving testing based on physician gender, controlling for race, insurance, and Thrombolysis In Myocardial Infarction (TIMI) score. Three thousand eight hundred and seventy-three index visits were enrolled during a 2.5-year period. Mean age was 53±20, 55% (95% CI, 53-56%) were female. There was no difference in overall stress utilization based upon physician gender (P=0.28). However, after controlling for other variables, male physicians had significantly lower odds of stress testing female patients (ORM, 0.82; 95% CI, 0.68-0.99), whereas no difference was found in female physicians (ORF, 0.80; 95% CI, 0.57-1.14). Male physicians appear less likely to utilize stress testing in female patients even after controlling for objective clinical variables, including TIMI score. Although adverse outcomes are uncommon in this patient cohort, further investigation into provider-specific practice patterns based on patient gender is necessary.


Reactive Carbonyl Species Mediate ABA Signaling in Guard Cells.
Drought is responsible for a massive reduction in crop yields. In response to drought, plants synthesize the hormone ABA, which induces stomatal closure, thus reducing water loss. In guard cells, ABA triggers production of reactive oxygen species (ROS), which is mediated by NAD(P)H oxidases. The production of ROS is a key factor for ABA-induced stomatal closure, but it remains to be clarified how the production of ROS is transduced into downstream signaling components in guard cells. We investigated roles of reactive carbonyl species (RCS) in ABA-induced stomatal closure using transgenic tobacco (Nicotiana tabacum) overexpressing Arabidopsis 2-alkenal reductase (AER-OE), which scavenges RCS. ABA and hydrogen peroxide (H2O2) induced accumulation of RCS including acrolein and 4-hydroxy-(E)-2-nonenal in wild-type tobacco but not in AER-OE. Stomatal closure and RCS accumulation in response to ABA and H2O2 were inhibited in AER-OE unlike in the wild type, while ABA-induced H2O2 production in guard cells was observed in AER-OE as well as in the wild type. Moreover, ABA inhibited inward-rectifying K+ channels in wild-type guard cells but not in AER-OE guard cells. These results suggest that RCS is involved in ABA-induced stomatal closure and functions downstream of H2O2 production in the ABA signaling pathway in guard cells.


Cloning of fish zinc-finger genes related to Krox-20 and Krox-24.
Southern hybridization suggests that the zebrafish genome contains multiple zinc-finger genes related to the putative mouse developmental genes, Krox-20 and Krox-24. The polymerase chain reaction was employed to amplify and clone the zinc-finger regions of genes related to Krox-20, from two fish species and, for comparison, mouse, hamster and fox. DNA sequence analyses suggest that the genes cloned include the guppy homologue of Krox-20 and the zebrafish homologue of Krox-24, and that these genes diverged prior to the separation of the lineages leading to teleosts and to mammals.


Effectiveness and cost-effectiveness of a fully self-guided internet-based intervention for sub-clinical social anxiety symptoms: Protocol for a randomised controlled trial.
This paper describes the protocol for a large-scale pragmatic, randomised controlled trial and economic evaluation to investigate the effectiveness and cost-effectiveness of the self-directed E-Couch social anxiety module versus a waiting list control condition, for reducing sub-clinical social anxiety symptoms in the general population. Community-based adults (aged 18+) with social anxiety symptoms that do not meet the criteria for social anxiety disorder recruited via a direct-to-consumer advertisement on national websites. Intervention is the self-guided E-Couch social anxiety module. Control group participants are placed on a waiting list to receive the intervention at the end of the trial. Both groups receive email and text message reminders. The primary outcome will be change in self-reported social anxiety score using the Social Phobia Inventory (SPIN). Secondary outcomes will be the changes in the following self-report measures: Brief Fear of Negative Evaluation scale (BFNE-S); depression (CES-D); mental wellbeing (SWEMWEBS); health status (SF36); use of health services; safety events; and adherence, retention, and attrition rates. All measures will be administered at baseline, 6 weeks, and 3, 6 and 12 months. A mixed effects model will be used to analyse the effect of the intervention on the primary and secondary outcomes (intention to treat analysis). Secondary analyses will explore moderators and mediators of effect. A prospective economic evaluation, conducted from a NHS and social care perspective, will provide estimates of cost utility and cost-effectiveness. An interview study will be conducted with 20 participants to explore issues including acceptability, adherence, retention and attrition. NCT02451878 and ISRCTN15819951.


A radiation hybrid breakpoint map of the acute myeloid leukemia (AML) and limb-girdle muscular dystrophy 1A (LGMD1A) regions of chromosome 5q31 localizing 122 expressed sequences.
We have constructed a high-resolution map of a 6-Mb interval of human chromosome 5, band q31, incorporating 175 sequence tagged sites, of which 33 are genetic polymorphisms and 122 are nonredundant expressed sequences. The map was assembled initially as a YAC contig, incorporating data from radiation hybrid maps. To improve resolution and to identify errors in the databases, a radiation hybrid breakpoint map was developed for the interval, which included hybrids from both Stanford G3 and GeneBridge 4 panels. This novel approach facilitated the integration of one RH panel with another and enabled the identification and localization of new, previously unmapped ESTs from the radiation hybrid databases. ESTs were assembled into overlapping transcription units and ordered with respect to polymorphic markers in the region, resulting in a comprehensive map that incorporates markers from multiple different types of maps. This map of 5q31 will facilitate gene discovery efforts for several disorders, including limb-girdle muscular dystrophy type 1A and the genes deleted in acute myeloid leukemias and myelodysplasia. The study demonstrates the utility of a radiation hybrid breakpoint panel for correction of map errors and for the efficient identification of new transcript units in a large genomic interval.


Oral bisphosphonates: early endosseous dental implant success and crestal bone changes. A retrospective study.
The purpose of this retrospective chart-review study was to compare the early success rate and the crestal bone changes of dental implants in patients taking oral bisphosphonates at the time of implant placement to those of patients who had never taken bisphosphonates. A retrospective chart review of 100 women (153 implants) taking oral bisphosphonates at the time of implant placement (test group) and 100 women (132 implants) who had never taken bisphosphonates (control group) was performed to examine overall implant success at the time of stage-two surgery. Radiographic images, which were available for 73 patients in each group and were taken at the time of implant placement and at stage-two surgery, were analyzed to assess and compare crestal bone changes around the implants. There was no significant difference between groups in the success rates of dental implants at stage-two surgery (test 93.5%, control 95.5%). The change in crestal bone height was statistically significant from the time of placement to stage-two surgery within both groups but was not significantly different between groups (means ± standard deviations: test, 0.66 ± 0.70 mm; control: 0.80 ± 0.65 mm). In this study, the use of oral bisphosphonates at the time of implant placement and during healing did not affect early implant success rates or crestal bone changes up to the time of stage-two surgery. In addition, the implant location and the duration of drug therapy at the time of placement were not significant factors in the success rate or bony changes. These conclusions must be viewed in the context of the limitations of the retrospective study design and should be confirmed in longer, more rigorously designed studies.


Variation in readmission by hospital after colorectal cancer surgery.
Hospital readmission after colorectal surgery is common, with reported 30-day readmission rates ranging from 10% to 14%. Readmission has become a major hospital quality metric, but it is unclear whether there is much difference in readmission among hospitals after appropriate risk adjustment. To assess the variability in risk-adjusted readmission rates among hospitals after colorectal surgery. We performed a hierarchical multivariable logistic regression analysis of observational data obtained from the Surveillance, Epidemiology, and End Results-Medicare linked database, a nationally representative cancer registry. We studied 44,822 patients who underwent colorectal resection for cancer at 1401 US hospitals from January 1, 1997, through December 31, 2002. Variation in risk-adjusted 30-day readmission among hospitals. The median age of the study patients was 78 years (interquartile range [IQR], 72-83 years). The overall 30-day readmission rate was 12.3% (n = 5502). Looking at hospitals that performed at least 5 operations annually, we found marked variation in raw readmission rates, with a range of 0% to 41.2% (IQR, 9.5%-14.8%). However, after adjusting for patient characteristics, comorbidities, and operation types in a hierarchical model, no significant variability was found in readmission rates among hospitals, with a range of 11.3% to 13.2% (IQR, 12.1%-12.4%). Furthermore, the 95% CI for hospital-specific readmission overlapped the overall mean at every hospital. Little risk-adjusted variation exists in hospital readmission rates after colorectal surgery. The use of readmission rates as a high-stakes quality measure for payment adjustment or public reporting across surgical specialties should proceed cautiously and must include appropriate risk adjustment.


Circadian rhythms and attention deficit hyperactivity disorder: The what, the when and the why.
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental condition characterised by impulsivity, inattention and hyperactivity. Aside from these core psychopathologies, sleep disturbances are found to be highly comorbid with ADHD, and indeed dysregulated sleep may contribute to some of the symptoms of the disorder. It is not clear how sleep disturbances come to be so common in ADHD, but one putative mechanism is through the circadian timekeeping system. This system underpins the generation of near 24-hour rhythms in a host of physiological, behavioural and psychological parameters, and is a key determinant of the sleep/wake cycle. In this paper we review the evidence for sleep and circadian rhythm disturbance in ADHD, examine the possible mechanistic links between these factors and the disorder and discuss future directions through which the circadian clock can be targetted for ADHD symptom relief.


Granivory of invasive, naturalized, and native plants in communities differentially susceptible to invasion.
Seed predation is an important biotic filter that can influence abundance and spatial distributions of native species through differential effects on recruitment. This filter may also influence the relative abundance of nonnative plants within habitats and the communities' susceptibility to invasion via differences in granivore identity, abundance, and food preference. We evaluated the effect of postdispersal seed predators on the establishment of invasive, naturalized, and native species within and between adjacent forest and steppe communities of eastern Washington, USA that differ in severity of plant invasion. Seed removal from trays placed within guild-specific exclosures revealed that small mammals were the dominant seed predators in both forest and steppe. Seeds of invasive species (Bromus tectorum, Cirsium arvense) were removed significantly less than the seeds of native (Pseudoroegneria spicata, Balsamorhiza sagittata) and naturalized (Secale cereale, Centaurea cyanus) species. Seed predation limited seedling emergence and establishment in both communities in the absence of competition in a pattern reflecting natural plant abundance: S. cereale was most suppressed, B. tectorum was least suppressed, and P. spicata was suppressed at an intermediate level. Furthermore, seed predation reduced the residual seed bank for all species. Seed mass correlated with seed removal rates in the forest and their subsequent effects on plant recruitment; larger seeds were removed at higher rates than smaller seeds. Our vegetation surveys indicate higher densities and canopy cover of nonnative species occur in the steppe compared with the forest understory, suggesting the steppe may be more susceptible to invasion. Seed predation alone, however, did not result in significant differences in establishment for any species between these communities, presumably due to similar total small-mammal abundance between communities. Consequently, preferential seed predation by small mammals predicts plant establishment for our test species within these communities but not between them. Accumulating evidence suggests that seed predation can be an important biotic filter affecting plant establishment via differences in consumer preferences and abundance with important ramifications for plant invasions and in situ community assembly.


Use of leverage to improve adherence to psychiatric treatment in the community.
A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage-money (representative payee or money handler), housing, criminal justice, and outpatient commitment-was assessed. Logistic regression was used to examine associations between clinical and demographic characteristics and receipt of different types of leverage. Ninety-minute interviews were conducted with approximately 200 adult outpatients at each of five sites in five states in different regions of the United States. The percentage of patients who experienced at least one form of leverage varied from 44 to 59 percent across sites. A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, and longer lasting psychopathology; a pattern of multiple hospital readmissions; and intensive outpatient service use. Use of money as leverage ranged from 7 to 19 percent of patients; outpatient commitment, 12 to 20 percent; criminal sanction, 15 to 30 percent; and housing, 23 to 40 percent. Debates on current policy emphasize only one form of leverage, outpatient commitment, which is much too narrow a focus. Attempts to leverage treatment adherence are ubiquitous in serving traditional public-sector patients. Research on the outcomes associated with the use of leverage is critical to understanding the effectiveness of the psychiatric treatment system.