Inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital.
To evaluate educational level as a contributing factor in handwashing compliance. Observation of hand washing opportunities was performed for approximately 12 weeks before an announced Joint Commission on Accreditation of Healthcare Organizations (JCAHO) visit and for approximately 10 weeks after the visit. Trained observers recorded the date, time, and location of the observation; the type of healthcare worker or hospital employee observed; and the type of hand hygiene opportunity observed. University of Toledo Medical Center, a 319-bed teaching hospital. A total of 2,373 observations were performed. The rate of hand washing compliance among nurses was 91.3% overall. Medical attending physicians had the lowest observed rate of compliance (72.4%; P<.001). Nurses showed statistically significant improvement in their rate of hand hygiene compliance after the JCAHO visit (P = .001), but no improvement was seen for attending physicians (P = .117). The compliance rate in the surgical intensive care unit was more than 90%, greater than that in other hospital units (P = .001). Statistically, the compliance rate was better during the first part of the week (Monday, Tuesday, and Wednesday) than during the latter part of the week (Thursday and Friday) (P = .002), and the compliance rate was better during the 3 PM-11 PM shift, compared with the 7 AM-3 PM shift (P<.001). When evaluated by logistic regression analysis, non-physician healthcare worker status and observation after the JCAHO accreditation visit were associated with an increased rate of hand hygiene compliance. An inverse correlation existed between the level of professional educational and the rate of compliance. Future research initiatives may need to address the different motivating factors for hand hygiene among nurses and physicians to increase compliance.


New molecular targets for antiepileptic drugs: alpha(2)delta, SV2A, and K(v)7/KCNQ/M potassium channels.
Many currently prescribed antiepileptic drugs (AEDs) act via voltage-gated sodium channels, through effects on gamma-aminobutyric acid-mediated inhibition, or via voltage-gated calcium channels. Some newer AEDs do not act via these traditional mechanisms. The molecular targets for several of these nontraditional AEDs have been defined using cellular electrophysiology and molecular approaches. Here, we describe three of these targets: alpha(2)delta, auxiliary subunits of voltage-gated calcium channels through which the gabapentinoids gabapentin and pregabalin exert their anticonvulsant and analgesic actions; SV2A, a ubiquitous synaptic vesicle glycoprotein that may prepare vesicles for fusion and serves as the target for levetiracetam and its analog brivaracetam (which is currently in late-stage clinical development); and K(v)7/KCNQ/M potassium channels that mediate the M-current, which acts a brake on repetitive firing and burst generation and serves as the target for the investigational AEDs retigabine and ICA-105665. Functionally, all of the new targets modulate neurotransmitter output at synapses, focusing attention on presynaptic terminals as critical sites of action for AEDs.


Sample preparation strategies for efficient correlation of 3D SIM and soft X-ray tomography data at cryogenic temperatures.
3D correlative microscopy methods have revolutionized biomedical research, allowing the acquisition of multidimensional information to gain an in-depth understanding of biological systems. With the advent of relevant cryo-preservation methods, correlative imaging of cryogenically preserved samples has led to nanometer resolution imaging (2-50 nm) under harsh imaging regimes such as electron and soft X-ray tomography. These methods have now been combined with conventional and super-resolution fluorescence imaging at cryogenic temperatures to augment information content from a given sample, resulting in the immediate requirement for protocols that facilitate hassle-free, unambiguous cross-correlation between microscopes. We present here sample preparation strategies and a direct comparison of different working fiducialization regimes that facilitate 3D correlation of cryo-structured illumination microscopy and cryo-soft X-ray tomography. Our protocol has been tested at two synchrotron beamlines (B24 at Diamond Light Source in the UK and BL09 Mistral at ALBA in Spain) and has led to the development of a decision aid that facilitates experimental design with the strategic use of markers based on project requirements. This protocol takes between 1.5 h and 3.5 d to complete, depending on the cell populations used (adherent cells may require several days to grow on sample carriers).


A biomechanical study on the effect of premature fusion of the frontosphenoidal suture on orbit asymmetry in unilateral coronal synostosis.
The coronal ring of patients with unilateral coronal synostosis (UCS) presents premature fusion. This study aims to elucidate whether or not the dynamic behavior of the orbit in response to intracranial pressure (ICP) differs between patients in whom the premature fusion exists only in the frontoparietal suture (FPS) and those in whom the premature fusion extends to the frontosphenoidal suture (FSS). A total of 15 UCS patients were included in the present study. Patients in whom premature fusion was seen inside the FPS and those in whom premature fusion extended to the FSS were categorized as FP Only (4.2 +/- 1.4 m/o) and FP + FS groups (4.6 +/- 2.2 m/o), respectively. On the basis of computed tomography (CT) data, computer-aided design models were produced. Pressure of 15 mm Hg was applied to the neurocranium of each skull model to simulate ICP. Using the finite element method, the displacements presented by each model's orbits were calculated. Displacements of the two groups were compared. The orbit demonstrated greater displacement in the FP Only group than in the FP + FS group, suggesting that premature closure of the FSS disturbs growth of the orbit in response to ICP. In performing surgical treatment for UCS, the degree of fusion that the FSS presents should be evaluated carefully. In cases in which the FSS presents premature fusion, it is recommended to release the fusion at an early stage of cranial growth to improve the appearance of the orbital region.


Pre-clinical toxicity & immunobiological evaluation of DNA rabies vaccine & combination rabies vaccine in rhesus monkeys (Macaca mulatta).
Pre-clinical toxicology evaluation of biotechnology products is a challenge to the toxicologist. The present investigation is an attempt to evaluate the safety profile of the first indigenously developed recombinant DNA anti-rabies vaccine [DRV (100 μg)] and combination rabies vaccine [CRV (100 μg DRV and 1.25 IU of cell culture-derived inactivated rabies virus vaccine)], which are intended for clinical use by intramuscular route in Rhesus monkeys. As per the regulatory requirements, the study was designed for acute (single dose - 14 days), sub-chronic (repeat dose - 28 days) and chronic (intended clinical dose - 120 days) toxicity tests using three dose levels, viz. therapeutic, average (2x therapeutic dose) and highest dose (10 x therapeutic dose) exposure in monkeys. The selection of the model i.e. monkey was based on affinity and rapid higher antibody response during the efficacy studies. An attempt was made to evaluate all parameters which included physical, physiological, clinical, haematological and histopathological profiles of all target organs, as well as Tiers I, II, III immunotoxicity parameters. In acute toxicity there was no mortality in spite of exposing the monkeys to 10XDRV. In sub chronic and chronic toxicity studies there were no abnormalities in physical, physiological, neurological, clinical parameters, after administration of test compound in intended and 10 times of clinical dosage schedule of DRV and CRV under the experimental conditions. Clinical chemistry, haematology, organ weights and histopathology studies were essentially unremarkable except the presence of residual DNA in femtogram level at site of injection in animal which received 10X DRV in chronic toxicity study. No Observational Adverse Effects Level (NOAEL) of DRV is 1000 ug/dose (10 times of therapeutic dose) if administered on 0, 4, 7, 14, 28 th day. The information generated by this study not only draws attention to the need for national and international regulatory agencies in formulating guidelines for pre-clinical safety evaluation of biotech products but also facilitates the development of biopharmaceuticals as safe potential therapeutic agents.


Effects of high-concentration influent suspended solids on aerobic granulation in pilot-scale sequencing batch reactors treating real domestic wastewater.
The aim of this study was to investigate the effect of high-influent-concentration suspended solids (SS) on the cultivation, structure and long-term stability of aerobic granular sludge (AGS). Cultivation and long-term stability of AGS were monitored in two pilot-scale sequencing batch reactors fed with raw (R1) and settled (R2) domestic wastewater, representing high and medium SS content, respectively. The real domestic wastewater had high chemical oxygen demand (COD) content (1100 ± 270 mg COD L-1). Aerobic granular sludge was cultivated in 44 days (R1) and 25 days (R2) under the conditions of high settling velocity (18 m h-1) and high organic loading rate (OLR) (2.1-2.4 kg COD m3 day). The AGS in both reactors had similar structural properties during long-term operation and remained structurally and functionally stable during the last five months of operation. Comparative evaluation of the results indicated that the high influent SS content of the real domestic wastewater had a positive influence on maintaining significantly lower SVI30 and relatively lower effluent SS concentration. Moreover, a higher influent SS content resulted in smaller mature granules during the stable period. Microbial community analyses helped to understand the aerobic granular sludge structure and showed that the sludge retention time and OLR affected the granular sludge population. The high influent SS increased biomass detachment from the granular sludge surface and caused wash-out of some bacteria colonizing the exterior of the granular sludge.


Hormone replacement therapy and incidence of acute myocardial infarction. A population-based nested case-control study.
Epidemiological studies suggest a decreased risk of coronary heart disease (CHD) in healthy women taking hormonal replacement therapy (HRT). Whether this effect is shared by oral and transdermal preparations is unknown. We conducted a population-based case-control study nested in a cohort of women 50 to 74 years of age without cardiovascular disease history in the United Kingdom. Among 164 769 women from the General Practice Research Database (January 1, 1991, to December 31, 1995), we identified 1242 first acute myocardial infarctions (AMI) and confirmed 1013 after medical record review. We randomly selected 5000 age-frequency-matched control subjects. AMI incidence was 1.6 per 1000 person-years; 13% and 17% of cases and control subjects used HRT within 6 months before the index date. Risk factor and comorbidity-adjusted OR of AMI for current-recent HRT users compared with nonusers was 0.72 (95% CI 0.59 to 0.89). The OR was similar within 30 days before the index date. The beneficial effect was present after 1 year of use (OR 0. 68; 95% CI 0.53 to 0.86), with no increase in risk within the first year. ORs for unopposed and opposed therapy were 0.52 (95% CI 0.35 to 0.78) and 0.79 (95% CI 0. 59 to 1.08); 79% and 21% used oral and transdermal therapy. The protective effect was present at medium-high doses of estrogens with ORs for oral and transdermal therapy of 0.63 (95% CI 0.46 to 0.86) and 0.62 (95% CI 0.37 to 1.06) and ceased after 2 to 3 years since stopping HRT. Results are consistent with those previously reported in women without CHD who were taking oral HRT and, although based on few users, suggest that transdermal therapy might have similar cardioprotective effects.


A Strategy to Optimize the Generation of Stable Chromobody Cell Lines for Visualization and Quantification of Endogenous Proteins in Living Cells.
Single-domain antibodies have emerged as highly versatile nanoprobes for advanced cellular imaging. For real-time visualization of endogenous antigens, fluorescently labelled nanobodies (chromobodies, CBs) are introduced as DNA-encoded expression constructs in living cells. Commonly, CB expression is driven from strong, constitutively active promoters. However, high expression levels are sometimes accompanied by misfolding and aggregation of those intracellular nanoprobes. Moreover, stable cell lines derived from random genomic insertion of CB-encoding transgenes bear the risk of disturbed cellular processes and inhomogeneous CB signal intensities due to gene positioning effects and epigenetic silencing. In this study we propose a strategy to generate optimized CB expressing cell lines. We demonstrate that expression as ubiquitin fusion increases the fraction of intracellularly functional CBs and identified the elongation factor 1α (EF1-α) promoter as highly suited for constitutive CB expression upon long-term cell line cultivation. Finally, we applied a CRISPR/Cas9-based gene editing approach for targeted insertion of CB expression constructs into the adeno-associated virus integration site 1 (AAVS1) safe harbour locus of human cells. Our results indicate that this combinatorial approach facilitates the generation of fully functional and stable CB cell lines for quantitative live-cell imaging of endogenous antigens.


Sagittal and Frontal Plane Evaluation of the Whole Spine and Clinical Outcomes after Vertebral Fractures.
Although it is known that a change in any level of the spine alters biomechanics, there are not many studies to evaluate the spine as a whole in both sagittal and frontal planes. This prospective cohort study evaluates the morphology and mobility of the entire spine in patients with vertebral fractures. The Treatment Group consisted of 43 patients who underwent percutaneous balloon kyphoplasty or percutaneous balloon kyphoplasty plus fixation. The Control Group consisted of 39 healthy subjects. Spinal Mouse was used for the assessment of the curvatures and the mobility of the spine. Clinical outcomes were evaluated by Visual Analogue Scale and Oswestry Disability Index. The measurements were recorded at 15 days and 3, 6, and 12 months postoperatively. Regarding the curvatures and mobility in sagittal plane, a statistically significant increase appeared early at 3 months, for lumbar curve, spinopelvic angulation, and overall trunk inclination. In the frontal plane, most of the improvements were recorded after 6 months. Patients with osteoporotic fracture showed statistically significant lower mean value than patients with traumatic fracture. Pain and disability index showed early improvements. This study provides a comprehensive and complete picture of the functionality of the spine in patients treated with percutaneous balloon kyphoplasty.


The fate of striatal dopaminergic neurons in Parkinson's disease and Huntington's chorea.
The striatum harbours a population of dopaminergic neurons that is thought to act as a local source of dopamine (DA). This neuronal population increases in size in animal models of Parkinson's disease, where striatal DA levels are low, but its fate in idiopathic Parkinson's disease and Huntington's chorea is poorly known. In this study, we used antibodies raised against the enzyme tyrosine hydroxylase (TH), a faithful marker of dopaminergic neurons, to compare, by means of stereological counting methods, the number of striatal TH+ neurons on post-mortem brain sections from Parkinson's disease patients, Huntington's disease patients and age-matched controls. Propidium iodide nuclear staining was also performed to avoid counting short TH+ axonal segments that bear a large swollen varicosity and resemble small bipolar neurons. In normal subjects, TH+ neurons were scattered throughout the striatum, but they abounded preferentially in the ventral portion of the structure and were more numerous in the putamen than in the caudate nucleus. They displayed a multipolar cell body of medium size (10-20 mum in diameter) that emitted 3-5 smooth dendrites, a typical characteristic of striatal interneurons. These TH+ cells were rarely found in the small TH-poor striosomes, most of them being embedded in the large TH-rich extrastriosomal matrix. The number of striatal TH+ neurons was also found to vary according to an inverse relation with the age of the subjects. In pathological brains, the morphological characteristics of the striatal TH+ neurons were relatively unaltered, but the number of such neurons was markedly reduced compared with controls. The striatum of Parkinson's disease patients was found to contain six times less TH+ neurons than that of controls, whereas the striatum of Huntington's disease patients was largely devoid of such neurons. These findings are at odds with the results obtained in rodent and monkey models of Parkinson's disease, in which the number of striatal TH+ neurons is reported to increase markedly following DA denervation. Since Parkinson's disease patients examined in this study were all treated with l-3,4-dihydroxyphenylalanine to compensate for the loss of striatal DA and that levels of striatal DA are reportedly higher in the striatum of Huntington's disease patients compared with controls, we hypothesize that local DA concentrations exert a negative feedback on the expression of TH phenotype by striatal interneurons. A better knowledge of factors governing the in vivo state of this ectopic neuronal population could open new therapeutic avenues for the treatment of Parkinson's disease and Huntington's chorea.


The direct healthcare costs attributable to West Nile virus illness in Ontario, Canada: a population-based cohort study using laboratory and health administrative data.
West Nile virus (WNV) is a mosquito-borne flavivirus, first detected in the Western Hemisphere in 1999 and spread across North America over the next decade. Though endemic in the most populous areas of North America, few studies have estimated the healthcare costs associated with WNV. The objective of this study was to determine direct healthcare costs attributable to WNV illness in Ontario, Canada. We conducted a cost-of-illness study on incident laboratory confirmed and probable WNV infected subjects identified from the provincial laboratory database from Jan 1, 2002 through Dec 31, 2012. Infected subjects were linked to health administrative data and matched to uninfected subjects. We used phase-of-care methods to calculate costs for 3 phases of illness: acute infection, continuing care, and final care prior to death. Mean 10-day attributable costs were reported in 2014 Canadian dollars, per capita. Sensitivity analysis was conducted to test the impact of WNV neurologic syndromes on healthcare costs. One thousand five hundred fifty-one laboratory confirmed and probable WNV infected subjects were ascertained; 1540 (99.3%) were matched to uninfected subjects. Mean age of WNV infected subjects was 49.1 ± 18.4 years, 50.5% were female. Mean costs attributable to WNV were $1177 (95% CI: $1001, $1352) for acute infection, $180 (95% CI: $122, $238) for continuing care, $11,614 (95% CI: $5916, $17,313) for final care - acute death, and $3199 (95% CI: $1770, $4627) for final care - late death. Expected 1-year costs were $13,648, adjusted for survival. Three hundred seventeen infected subjects were diagnosed with at least one neurologic syndrome and greatest healthcare costs in acute infection were associated with encephalitis ($4710, 95% CI: $3770, $5650). WNV is associated with increased healthcare resource utilization across all phases of care. High-quality studies are needed to understand the health system impact of vector-borne diseases and evaluate the cost effectiveness of novel WNV interventions.


Tomato Spotted Wilt Virus NSs Protein Supports Infection and Systemic Movement of a Potyvirus and Is a Symptom Determinant.
Plant viruses are inducers and targets of antiviral RNA silencing. To condition susceptibility, most plant viruses encode silencing suppressor proteins that interfere with antiviral RNA silencing. The NSs protein is an RNA silencing suppressor in orthotospoviruses, such as the tomato spotted wilt virus (TSWV). The mechanism of RNA silencing suppression by NSs and its role in virus infection and movement are poorly understood. Here, we cloned and tagged TSWV NSs and expressed it from a GFP-tagged turnip mosaic virus (TuMV-GFP) carrying either a wild-type or suppressor-deficient (AS9) helper component proteinase (HC-Pro). When expressed in cis, NSs restored pathogenicity and promoted systemic infection of suppressor-deficient TuMV-AS9-GFP in Nicotiana benthamiana and Arabidopsis thaliana. Inactivating mutations were introduced in NSs RNA-binding domain one. A genetic analysis with active and suppressor-deficient NSs, in combination with wild-type and mutant plants lacking essential components of the RNA silencing machinery, showed that the NSs insert is stable when expressed from a potyvirus. NSs can functionally replace potyviral HC-Pro, condition virus susceptibility, and promote systemic infection and symptom development by suppressing antiviral RNA silencing through a mechanism that partially overlaps that of potyviral HC-Pro. The results presented provide new insight into the mechanism of silencing suppression by NSs and its effect on virus infection.


Enucleation in consort with immunologic impairment promotes metastasis of intraocular melanomas in mice.
A series of investigations was employed to determine if metastases of intraocular melanomas could be induced by experimental manipulations. Syngeneic B16F10 melanoma cells transplanted intracamerally into C57BL/6 mice produced progressively growing intraocular tumors, yet formed only occasional pulmonary metastases. Neither enucleation nor mechanical manipulation of the melanoma-containing eye promoted a significant increase in the incidence of metastases. Likewise, immunologic impairment in the form of natural killer cell deficiency, T-lymphocyte deficiency, or gamma-irradiation-induced lymphopenia failed to produce spontaneous metastases in intraocular melanoma-bearing mice. However, enucleation in consort with immune impairment (T-cell deficiency) produced a sharp increase in the incidence and number of pulmonary metastases in intraocular melanoma-bearing mice. Further studies showed that external pressure to the tumor-containing globe (without enucleation) produced extensive metastases in athymic, nude mice. By contrast, atraumatic enucleation of rapidly frozen eyes prevented metastasis of intraocular melanomas in similar hosts. Collectively, the results indicate that induction of distant metastases in hosts harboring intraocular melanomas requires two simultaneous processes: (1) mechanical manipulation of the melanoma-containing eye, and (2) concomitant impairment of T-cell-dependent immune processes. The data strongly suggest that mechanical manipulation of melanoma-containing eyes produces intravascular showers of melanoma cells that are rejected by T-cell-dependent immune processes in the immunocompetent host. In the absence of these normal T-cell-dependent immune mechanisms, enucleation-induced showers of blood-borne melanoma cells gain a foothold in the lung and form progressive metastases.


Abnormally decreased HbA1c can be assessed with erythrocyte creatine in patients with a shortened erythrocyte age.
To investigate whether erythrocyte creatine can serve as a corrective index for HbA1c in patients with a shortened mean age of erythrocytes. HbA1c and creatine in density-fractionated erythrocytes from 18 normal subjects were measured. HbA1c and erythrocyte creatine in the whole blood of 43 patients with liver cirrhosis (LC), 14 patients with hemolytic anemia (HA), 38 other patients with high reticulocyte counts (HRC) (>2.2%), and 59 normal subjects were also measured. The patients in this study all had normal blood glucose levels. A correction formula derived from the linear regression equation for the correlation between HbA1c and erythrocyte creatine was used to correct the patients' HbA1c values. Among density-fractionated erythrocytes, the young cells exhibited low HbA1c and high creatine values. With progressively increasing density, HbA1c gradually increased and creatine gradually decreased. In the whole blood samples, the HbA1c values were significantly lower (P < 0.001) in LC, HA, and HRC patients than in normal subjects. By contrast, the erythrocyte creatine values were significantly higher (P < 0.001) in LC, HA, and HRC patients than in normal subjects. A linear correlation between HbA1c (y) and erythrocyte creatine (x) was observed (y=-0.224x + 5.00; n=154; r=-0.70; P < 0.001). Based on the regression equation, a correction formula was obtained. Low HbA1c values (<4.3%) were found in 24 of the 43 LC patients, 12 of the 14 HA patients, and 20 of the 38 HRC patients. After correction of the HbA1c values, 15 of the 24 LC patients, 9 of the 12 HA patients, and 16 of the 20 HRC patients had HbA1c values within the normal range. HbA1c decreased in inverse proportion to the increase in erythrocyte creatine because of a shortened mean age of erythrocytes. The abnormally decreased HbA1c value could be assessed with erythrocyte creatine.


SU-E-T-471: Beam Properties of an In-Room Proton Therapy Accelerator.
To quantify basic beam properties of the first gantry-mounted proton therapy accelerator, situated in the treatment room and delivering beam to the patient without any intermediate bending magnets. Monte Carlo simulations for prototype beamlines of the Mevion S250TM proton therapy system were performed using MCNPX. For each configuration, open profiles in air were determined at 3 different positions for 3 range settings (216 profiles). Similarly, half-beam-blocked profiles were determined for the same settings (216 profiles). Additionally, beam axis fluence profiles in air were determined for 3 range settings (72 profiles). Finally, Bragg peak depth-dose curves in water were determined for 3 range settings (72 profiles). Using these 576 profiles, several beamline parameters were determined for each proton range and configuration, including virtual SAD, effective source size, and effective SAD. Additionally, Bortfeld's analytic approximation of the Bragg curve was fit to each depth-dose curve to determine R0, σ and ε. The 72 values determined for each parameter were compared within each configuration and across all configurations. Within any configuration, the change in range was too small (=2.5 cm) to have a large effect on any of the extracted parameters. Comparing parameters among configurations revealed smooth trends. These parameters were then fit as a function of range. The simplicity of this system results in beams with greater similarity among configurations as compared to other proton therapy systems. Because a beam with fixed initial energy is degraded only by tissue-equivalent materials, range straggling and beam divergence are nearly constant across all beamline configurations. Beam parameters change smoothly as functions of proton range, with no major discontinuities between configurations. This suggests that the entire machine may be fully and accurately characterized in a treatment planning system by fewer measurements than would normally be required.


Prevalence and risk factors for intestinal parasites in food handlers, southern Brazil.
In this study, the prevalence and risk factors for enteroparasites were determined in food handlers from Maringá, Paraná State, southern Brazil. Fecal and subungual materials of 150 street food vendors were analyzed by the methods of Lutz, Faust, and Mello, respectively. A questionnaire on hygiene and sanitary conditions of the workplace and of domicile was applied. The prevalence of enteroparasites was 28%, and the protozoa infection was more expressive (21.3%) than by helminths (6.7%), but without significant difference (p > 0.05). Entamoeba coli was the most frequent species occurring in 15.3%, while the prevalence of protozoa pathogenic was low (Giardia lamblia: 2.7% and Entamoeba histolytica: 0.7%). The subungual material presented negative results. The presence of pets in domiciles has increased twice the risk of infection. The working conditions of the majority of street food vendors were inappropriate. The results highlight the need for more rigorous programs of continuing education, parasitological examination every six months, and health surveillance. In this way, the quality of the service provided to the population can be improved and the transmission of food-borne diseases can be prevented.


[Socioeconomic inequalities in mortality in the Basque Country [Spain]].
To describe socioeconomic inequalities in mortality in the Basque Country, using mortality and socioeconomic data by census sections. Mortality and population data were obtained from the Basque Institute of Statistics. Socioeconomic characteristics of the census sections were assigned to each death and a deprivation index combining information from four socioeconomic indicators was computed. Age-adjusted mortality rates by sex, age group (0-64 > or = 65) and cause of death were calculated for each quintile of the deprivation index. Poisson regression models were fitted to estimate age-adjusted rate ratios and excess mortality attributable to inequalities. Mortality showed a gradient according to the deprivation index in men and women. Mortality was greater in the most deprived sections. Mortality inequalities were observed in men younger than 65 years. A total of 9.3% of deaths in men and 4.9% of those in women were attributable to socioeconomic inequalities. The relative importance of the cause of death differed according to the inequality measure used. Lifestyle-related causes of death were notable. This study illustrates the potential utility of census section socioeconomic indicators both to describe socioeconomic inequalities in mortality and to identify priorities for interventions.


Coordinating Tissue Regeneration Through Transforming Growth Factor-β Activated Kinase 1 Inactivation and Reactivation.
Aberrant wound healing presents as inappropriate or insufficient tissue formation. Using a model of musculoskeletal injury, we demonstrate that loss of transforming growth factor-β activated kinase 1 (TAK1) signaling reduces inappropriate tissue formation (heterotopic ossification) through reduced cellular differentiation. Upon identifying increased proliferation with loss of TAK1 signaling, we considered a regenerative approach to address insufficient tissue production through coordinated inactivation of TAK1 to promote cellular proliferation, followed by reactivation to elicit differentiation and extracellular matrix production. Although the current regenerative medicine paradigm is centered on the effects of drug treatment ("drug on"), the impact of drug withdrawal ("drug off") implicit in these regimens is unknown. Because current TAK1 inhibitors are unable to phenocopy genetic Tak1 loss, we introduce the dual-inducible COmbinational Sequential Inversion ENgineering (COSIEN) mouse model. The COSIEN mouse model, which allows us to study the response to targeted drug treatment ("drug on") and subsequent withdrawal ("drug off") through genetic modification, was used here to inactivate and reactivate Tak1 with the purpose of augmenting tissue regeneration in a calvarial defect model. Our study reveals the importance of both the "drug on" (Cre-mediated inactivation) and "drug off" (Flp-mediated reactivation) states during regenerative therapy using a mouse model with broad utility to study targeted therapies for disease. Stem Cells 2019;37:766-778.


The effect of seniority and education on departmental dictation utilization.
Electronic medical records (EMR) are considered the best solution to improved dissemination of health information for patients. The associated transcription caused a significant cost increase in an academic pediatric center. An educational campaign was implemented to achieve cost-effective transcriptions without compromising the number of EMR transcriptions. We analyzed the effect of seniority on transcription times over a 4-month period. We also compared the dictation volume before and 4 months after educational interventions. This study was performed in a pediatric academic center with both inpatient and outpatient transcription utilization analyzed. All clinicians providing pediatric care and utilizing the hospital-based transcription over the study time period were analyzed. Interventions included targeted education about efficiencies in transcription, time-based dictation costs, avoidance of lengthy pauses and unnecessary detail, shortening of total transcriptions, superfluous phrases as well as structured templates. Level of training by postgraduate year of training and seniority within faculty were measured for impact on dictation time and effect of education to improve times. Learners in year one had an average dictation time of 7.5 ± 2.2 minutes, which decreased with seniority to an average of 4.1 ± 2.2 minutes for senior faculty (0.0007, ANOVA). After educational initiatives were implemented, there was progressive decline in dictation utilization. The total dictation time decreased from 8,750 minutes per month in August 2009 to 4,296 minutes in December of 2009 (p = 0.0045, unpaired t-test). We identified a substantial need for education in dictation utilization and demonstrated that relatively simple interventions can result in substantial costs savings.


Study of feasibility and effectiveness of ASHA-Soft (Online Payment and Performance Monitoring System) in Rajasthan.
ASHA-Soft is the pioneer e-Health program which was launched to manage online payment and for monitoring performance of ASHA workers in Rajasthan. There is a paucity of studies which documents the feasibility and effectiveness of this program with aim to assess the feasibility and effectiveness of ASHA-Soft program. Study was conducted in Jodhpur using quantitative and qualitative method. Primary and secondary data approach was used to assess feasibility and effectiveness of ASHA-Soft. Purposive sampling was done to recruit 150 ASHA workers having experience of more than 5 years to capture the perception before and after implementation of ASHA-Soft. Qualitative data was also obtained from ASHA workers and key stakeholders. To assess the effectiveness secondary data was obtained from various sources was analyzed. Mean age of participants were 35.51+ 6.7 years. Most of ASHAs agreed that ASHA-Soft mediated timely payment (68%) and payment according to their performance (81%). It also increased their motivational level (96%).There were no significant difference in different work experience of ASHAs and perception towards ASHA-Soft regarding timely payment (p=0.99), improving quality of life (p=0.66) and motivation level (p=0.40). This program has provided standard online procedure of online payment and monitoring for ASHAs. Incentives received by ASHAs increased to 77%, performance increased by 7% and 9% for maternal health and child health respectively within one year of its initial implementation. Study finding demonstrate that ASHA-Soft program is acceptable to the users and is effective in terms of meeting organizational requirement.


A political history of medicare and prescription drug coverage.
This article examines the history of efforts to add prescription drug coverage to the Medicare program. It identifies several important patterns in policymaking over four decades. First, prescription drug coverage has usually been tied to the fate of broader proposals for Medicare reform. Second, action has been hampered by divided government, federal budget deficits, and ideological conflict between those seeking to expand the traditional Medicare program and those preferring a greater role for private health care companies. Third, the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 reflect earlier missed opportunities. Policymakers concluded from past episodes that participation in the new program should be voluntary, with Medicare beneficiaries and taxpayers sharing the costs. They ignored lessons from past episodes, however, about the need to match expanded benefits with adequate mechanisms for cost containment. Based on several new circumstances in 2003, the article demonstrates why there was a historic opportunity to add a Medicare prescription drug benefit and identify challenges to implementing an effective policy.


Genetic testing and economic evaluations: a systematic review of the literature.
To identify those studies in which economic analysis of predictive genetic and pharmacogenetic testing programs have been carried out. Since the Italian National Prevention Plan 2014-2018 foresees the implementation of genetic testing for inherited breast cancer, special attention was given to the cost-effectiveness of BRCA1/2 testing programs. A systematic review of primary economic evaluations (EEs) of predictive genetic and pharmacogenetic testing programs and an overview of previously published systematic reviews of economic evaluations (ERs) was performed. Overall 128 EEs and 11 ERs were identified. The methodological quality of both EEs and ERs was good on average. Both predictive genetic and pharmacogenetic testing programs were mainly concerned with oncological diseases. Seventeen percent of genetic testing programs are cost-saving, while a further 44% of cost/QALY ratios fall under the commonly used threshold of €37,000 per QALY. For BRCA1/2 testing, only cascade genetic screening programs, targeted to close relatives of carriers, show clear evidence of cost-effectiveness. Despite some limitations, EEs and ERs are powerful tools that provide indications to policy-makers on which genetic testing programs might be introduced into health care systems and public health practice.


E-cadherin phosphorylation by protein kinase D1/protein kinase C{mu} is associated with altered cellular aggregation and motility in prostate cancer.
The cadherin family of transmembrane glycoproteins plays a critical role in cell-to-cell adhesion and cadherin dysregulation is strongly associated with cancer metastasis and progression. In this study, we report a novel interaction between protein kinase D1 [PKD1; formerly known as protein kinase C mu (PKCmu)] and E-cadherin. PKD1 is a serine/threonine-specific kinase known to play a role in multiple cellular processes including apoptosis, cytoskeleton remodeling, and invasion. Our study shows that PKD1 colocalizes with E-cadherin at cell junctions in LNCaP prostate cancer cells and coimmunoprecipitates with E-cadherin from lysates of LNCaP cells. In vitro kinase assays have shown that PKD1 phosphorylates E-cadherin. Inhibition of PKD1 activity by the selective inhibitor Gö6976 in LNCaP cells resulted in decreased cellular aggregation and overexpression of PKD1 in C4-2 prostate cancer cells increased cellular aggregation and decreased cellular motility. We also validated the PKD1 and E-cadherin colocalization in human prostate cancer tissue by confocal laser scanning microscopy. Our study has identified E-cadherin as a novel substrate of PKD1, and phosphorylation of E-cadherin by PKD1 is associated with increased cellular aggregation and decreased cellular motility in prostate cancer. Because both E-cadherin and PKD1 are known to be dysregulated in prostate cancer, our study identified an important protein-protein interaction influencing the signal transduction system associated with cell adhesion in prostate cancer.


Utility of MLH1 methylation analysis in the clinical evaluation of Lynch Syndrome in women with endometrial cancer.
Clinical screening criteria, such as young age of endometrial cancer diagnosis and family history of signature cancers, have traditionally been used to identify women with Lynch Syndrome, which is caused by mutation of a DNA mismatch repair gene. Immunohistochemistry and microsatellite instability analysis have evolved as important screening tools to evaluate endometrial cancer patients for Lynch Syndrome. A complicating factor is that 15-20% of sporadic endometrial cancers have immunohistochemical loss of the DNA mismatch repair protein MLH1 and high levels of microsatellite instability due to methylation of MLH1. The PCR-based MLH1 methylation assay potentially resolves this issue, yet many clinical laboratories do not perform this assay. The objective of this study was to determine if clinical and pathologic features help to distinguish sporadic endometrial carcinomas with MLH1 loss secondary to MLH1 methylation from Lynch Syndrome-associated endometrial carcinomas with MLH1 loss and absence of MLH1 methylation. Of 337 endometrial carcinomas examined, 54 had immunohistochemical loss of MLH1. 40/54 had MLH1 methylation and were designated as sporadic, while 14/54 lacked MLH1 methylation and were designated as Lynch Syndrome. Diabetes and deep myometrial invasion were associated with Lynch Syndrome; no other clinical or pathological variable distinguished the 2 groups. Combining Society of Gynecologic Oncology screening criteria with these 2 features accurately captured all Lynch Syndrome cases, but with low specificity. In summary, no single clinical/pathologic feature or screening criteria tool accurately identified all Lynch Syndrome-associated endometrial carcinomas, highlighting the importance of the MLH1 methylation assay in the clinical evaluation of these patients.


Perceptual learning of oriented gratings as revealed by classification images.
Classification image analysis is a psychophysical technique in which noise components of stimuli are analyzed to produce an image that reveals critical features of a task. Here we use classification images to gain greater understanding of perceptual learning. To achieve reasonable classification images within a single session, we developed an efficient classification image procedure that employed designer noise and a low-dimensional stimulus space. Subjects were trained across ten sessions to detect the orientation of a grating masked in noise, with an eleventh, test, session conducted using a stimulus orthogonal to the trained stimulus. As with standard perceptual learning studies, subjects showed improvements in performance metrics of accuracy, threshold, and reaction times. The clarity of the classification images and their correlation to an ideal target also improved across training sessions in an orientation-specific manner. Furthermore, image-based analyses revealed aspects of performance that could not be observed with standard performance metrics. Subjects with threshold improvements learned to use pixels across a wider area of the image, and, apposed to subjects without threshold improvements, showed improvements in both the bright and dark parts of the image. We conclude that classification image analysis is an important complement to traditional metrics of perceptual learning.


Influence of hypertension, left ventricular hypertrophy, and left ventricular systolic dysfunction on plasma N terminal proBNP.
To examine the relation between plasma concentration of the N terminal of the precursor of brain natriuretic peptide (NT proBNP), left ventricular hypertrophy (LVH), and left ventricular systolic dysfunction (LVSD) in patients with a history of hypertension. Prospective study. Teaching hospital based study. NT proBNP concentrations were determined in five groups of individuals. Group 1: 15 echocardiographic normal controls; group 2: 22 patients with hypertension, normal left ventricular systolic function, and no LVH; group 3: 24 patients with hypertension, normal left ventricular systolic function, and LVH; group 4: 13 patients with history of hypertension, no history of ischaemic heart disease, and left ventricular wall motion index (WMI) between 1.9-1.3; and group 5:17 patients with a history of hypertension, no history of ischaemic heart disease, and WMI < 1.2. Median (range) NT proBNP concentrations (in fmol/ml) for groups 1-5, respectively, were: 129.4 (53.6-159.7), 147.4 (54.3-730. 5), 137.1 (35.8-403.9), 356.7 (124.4-934.4), and 493.5 (248.9-909). Mean log NT proBNP differed among all five groups (p < 0.0001), and between groups 4 and 5 versus groups 1-3 (p < 0.0001), and group 4 versus group 5 (p = 0.02) only. The results suggest that the presence of hypertension with or without LVH (and normal left ventricular systolic function) does not affect NT proBNP concentrations. Moreover, there is a significant rise in NT proBNP only when LVSD develops in hypertension. Thus, NT proBNP remains a useful diagnostic aid for LVSD, even in hypertensive patients.


Pharmacokinetics of cannabidiol in dogs.
Cannabidiol (CBD) is one of the major nonpsychoactive cannabinoids produced by Cannabis sativa L. Recent studies have shown that CBD has a high protective index, comparable to that of phenobarbital and phenytoin. Because CBD has been reported to possess both anticonvulsant and antiepileptic activity, its pharmacokinetics were studied in dogs after the administration of two iv doses (45 and 90 mg) and one oral dose (180 mg) to dogs. After iv administration, CBD was rapidly distributed, followed by a prolonged elimination. It has a terminal half-life of 9 hr. CBD plasma levels declined in a triphasic fashion. The total body clearance of CBD was 17 liters/hr (after the 45-mg dose) and 16 liters/hr (after the 90-mg dose). This clearance value, after its normalization to blood clearance using mathematical equations, approaches the value of the hepatic blood flow; the extraction ratio in the liver is 0.74. CBD was observed to have a large volume of distribution, approximately 100 liters. In the dose range of 45 to 90 mg, the increase in the AUC was proportional to the dose, a fact that indicates that the pharmacokinetic profile of CBD in this dose range was not dose dependent. In three of the six dogs studied, CBD could not be detected in the plasma after oral administration. In the other three, the oral bioavailability ranged from 13 to 19%. The results of this study show that CBD is barely absorbed after oral administration to dogs. This low bioavailability may be due to a first pass effect.


Time-varying coefficient models for the analysis of air pollution and health outcome data.
In this article a time-varying coefficient model is developed to examine the relationship between adverse health and short-term (acute) exposure to air pollution. This model allows the relative risk to evolve over time, which may be due to an interaction with temperature, or from a change in the composition of pollutants, such as particulate matter, over time. The model produces a smooth estimate of these time-varying effects, which are not constrained to follow a fixed parametric form set by the investigator. Instead, the shape is estimated from the data using penalized natural cubic splines. Poisson regression models, using both quasi-likelihood and Bayesian techniques, are developed, with estimation performed using an iteratively re-weighted least squares procedure and Markov chain Monte Carlo simulation, respectively. The efficacy of the methods to estimate different types of time-varying effects are assessed via a simulation study, and the models are then applied to data from four cities that were part of the National Morbidity, Mortality, and Air Pollution Study.


Zinc pyrithione induces cellular stress signaling and apoptosis in Hep-2 cervical tumor cells: the role of mitochondria and lysosomes.
Increased intracellular free zinc concentrations are associated with activation of several stress signaling pathways, specific organelle injury and final cell death. In the present work we examined the involvement of mitochondria and lysosomes and their crosstalk in free zinc-induced cell demise. We report that treatment of cervical tumor Hep-2 cells with zinc pyrithione leads to an early appearance of cytoplasmic zinc-specific foci with corresponding accumulation of zinc first in mitochondria and later in lysosomes. Concomitant with these changes, upregulation of expression of metallothionein II A gene as well as the increased abundance of its protein occurs. Moreover, zinc activates p53 and its dependent genes including Puma and Bax and they contribute to an observed loss of mitochondrial membrane potential and activation of apoptosis. Conversely, lysosomal membrane permeabilization and its promoted cleavage of Bid occurs in a delayed manner in treated cells and their effect on decrease of mitochondrial membrane potential is limited. The use of specific inhibitors as well as siRNA technology suggest a crucial role of MT-IIA in trafficking of free zinc into mitochondria or lysosomes and regulation of apoptotic or necrotic cell demise.


Height and Breast Cancer Risk: Evidence From Prospective Studies and Mendelian Randomization.
Epidemiological studies have linked adult height with breast cancer risk in women. However, the magnitude of the association, particularly by subtypes of breast cancer, has not been established. Furthermore, the mechanisms of the association remain unclear. We performed a meta-analysis to investigate associations between height and breast cancer risk using data from 159 prospective cohorts totaling 5216302 women, including 113178 events. In a consortium with individual-level data from 46325 case patients and 42482 control patients, we conducted a Mendelian randomization analysis using a genetic score that comprised 168 height-associated variants as an instrument. This association was further evaluated in a second consortium using summary statistics data from 16003 case patients and 41335 control patients. The pooled relative risk of breast cancer was 1.17 (95% confidence interval [CI] = 1.15 to 1.19) per 10cm increase in height in the meta-analysis of prospective studies. In Mendelian randomization analysis, the odds ratio of breast cancer per 10cm increase in genetically predicted height was 1.22 (95% CI = 1.13 to 1.32) in the first consortium and 1.21 (95% CI = 1.05 to 1.39) in the second consortium. The association was found in both premenopausal and postmenopausal women but restricted to hormone receptor-positive breast cancer. Analyses of height-associated variants identified eight new loci associated with breast cancer risk after adjusting for multiple comparisons, including three loci at 1q21.2, DNAJC27, and CCDC91 at genome-wide significance level P < 5×10(-8). Our study provides strong evidence that adult height is a risk factor for breast cancer in women and certain genetic factors and biological pathways affecting adult height have an important role in the etiology of breast cancer.


Outcome at age 4 years in offspring of women with maternal phenylketonuria: the Maternal PKU Collaborative Study.
Untreated maternal phenylketonuria (PKU) increases risk for developmental problems in offspring. The extent to which this risk is reduced by maternal dietary therapy at various stages of pregnancy is not known. To determine whether dietary treatment during pregnancy of women with PKU affects developmental outcomes of offspring. The Maternal PKU Collaborative Study, an ongoing, longitudinal prospective study begun in 1984. A total of 78 metabolic clinics and obstetrical offices in the United States, Canada, and Germany. A total of 253 children of women with PKU (n = 149), with untreated mild hyperphenylalaninemia (n = 33), or without known metabolic problems (comparison group; n = 71) were followed up to age 4 years. Women with PKU were offered a low-phenylalanine diet prior to or during pregnancy with the aim of maintaining metabolic control (plasma phenylalanine < or =10 mg/dL [< or =605 micromol/L]). Women with mild hyperphenylalaninemia, who had plasma phenylalanine levels of no more than 10 mg/dL (605 micromol/L) on a normal diet, were not treated. Children's scores on cognitive and behavioral assessments (McCarthy Scales of Children's Abilities, Test of Language Development, Achenbach Child Behavior Checklist, Vineland Adaptive Behavior Scales, and Home Observation for Measurement of the Environment), compared by maternal metabolic status at 0 to 10 weeks', 10 to 20 weeks', and after 20 weeks' gestation. Scores on the McCarthy General Cognitive Index decreased as weeks to metabolic control increased (r = -0.58; P<.001). Offspring of women who had metabolic control prior to pregnancy had a mean (SD) score of 99 (13). Forty-seven percent of offspring whose mothers did not have metabolic control by 20 weeks' gestation had a General Cognitive Index score 2 SDs below the norm. Overall, 30% of children born to mothers with PKU had social and behavioral problems. Our data suggest that delayed development in offspring of women with PKU is associated with lack of maternal metabolic control prior to or early in pregnancy. Treatment at any time during pregnancy may reduce the severity of delay.


Bacterial load and inflammatory response in sputum of alpha-1 antitrypsin deficiency patients with COPD.
Airway inflammation may drive the progression of chronic obstructive pulmonary disease (COPD) associated with alpha-1 antitrypsin deficiency (AATD), but the relationship between airway microbiota and inflammation has not been investigated. We studied 21 non-treated AATD (AATD-noT) patients, 20 AATD-COPD patients under augmentation therapy (AATD-AT), 20 cigarette smoke-associated COPD patients, 20 control healthy smokers (CS) and 21 non-smokers (CON) with normal lung function. We quantified sputum inflammatory cells and inflammatory markers (IL-27, CCL3, CCL5, CXCL8, LTB4, MPO) by ELISA, total bacterial load (16S) and pathogenic bacteria by qRT-PCR. AATD-AT patients were younger but had similar spirometric and DLCO values compared to cigarette smoke-associated COPD, despite a lower burden of smoking history. Compared to cigarette smoke-associated COPD, AATD-noT and AATD-AT patients had lower sputum neutrophil levels (p=0.0446, p=0.0135), total bacterial load (16S) (p=0.0081, p=0.0223), M. catarrhalis (p=0.0115, p=0.0127) and S. pneumoniae (p=0.0013, p=0.0001). Sputum IL-27 was significantly elevated in CS and cigarette smoke-associated COPD. AATD-AT, but not AATD-noT patients, had IL-27 sputum levels (pg/ml) significantly lower than COPD (p=0.0297) and these positively correlated with FEV1% predicted values (r=0.578, p=0.0307). Compared to cigarette smoke-associated COPD, AATD-AT (COPD) patients have a distinct airway inflammatory and microbiological profile. The decreased sputum bacterial load and IL-27 levels in AATD-AT patients suggests that augmentation therapy play a role in these changes.


Legal Aspects of Concussion: The Ever-Evolving Standard of Care.
Today, when an athlete is catastrophically injured while playing a sport, litigation often follows. The likelihood of litigation is even greater in the event of a head injury, especially when the athlete can allege that a prior concussion somehow contributed to the current injury. Whether the potential defendants in these lawsuits, such as schools, coaches, athletic trainers, and other health care professionals, actually face legal liability depends on whether they are deemed to have conformed to the standard of care. The standard of care is a legal term, defined as acting as a reasonable professional in that position or industry would have under the circumstances based on then-existing knowledge. In this article, we examine the standard of care with regard to concussion management and treatment in the context of some of the most notable lawsuits in recent years.


Soluble TNF receptors and kidney dysfunction in the elderly.
The importance of TNF-α and its soluble receptors (sTNFR1 and sTNFR2) in the development of kidney disease is being unraveled. Yet, community-based data regarding the role of sTNFRs are lacking. We assessed serum sTNFRs and aspects of kidney damage cross-sectionally in two independent community-based cohorts of elderly participants: Prospective Investigation of the Vasculature in Uppsala Seniors (n=815; mean age, 75 years; 51% women) and Uppsala Longitudinal Study of Adult Men (n=778; mean age, 78 years). Serum sTNFR1 correlated substantially with different aspects of kidney pathology in the Uppsala Longitudinal Study of Adult Men cohort (R=-0.52 for estimated GFR, R=0.22 for urinary albumin-to-creatinine ratio, and R=0.17 for urinary kidney injury molecule-1; P<0.001 for all), with similar correlations in the Prospective Investigation of the Vasculature in Uppsala Seniors cohort. These associations remained significant after adjustment for age, sex, inflammatory markers, and cardiovascular risk factors and were also evident in participants without diabetes. Serum sTNFR2 was associated with all three markers in the Prospective Investigation of the Vasculature in Uppsala Seniors cohort (P<0.001 for all). Our findings from two independent community-based cohorts confirm and extend results of previous studies supporting circulating sTNFRs as relevant biomarkers for kidney damage and dysfunction in elderly individuals, even in the absence of diabetes.


Stoichiometry of the α-complementation reaction of Escherichia coli β-galactosidase as revealed through single-molecule studies.
The α-complementation reaction of β-galactosidase was studied at single-molecule resolution using arrays of femtoliter-sized wells. Single molecules of the complementation species were observed to be stable for long periods of time, demonstrating that the α-complementation reaction is irreversible. By directly counting the number of active molecules formed in the complementation reaction when different concentrations of enzyme acceptor (EA) and enzyme donor (ED) are used, we deduce that the EA:ED ratio in the complementation species is 4:1.


Using tDCS to facilitate motor learning in speech production: The role of timing.
There exists debate regarding the extent to which transcranial direct current stimulation (tDCS) can affect or enhance human behavior. Here, we examined a previously unexplored domain: speech motor learning. We investigated whether speech motor learning in unimpaired participants can be enhanced using a single-session tDCS experiment, and investigated whether the timing of tDCS relative to a behavioral task affected performance. Participants (N = 80) performed a twenty minute learning task with nonwords containing non-native consonant clusters (e.g., GDEEVOO), and were assigned to groups receiving either sham or active tDCS either immediately before or during the task. Both accuracy and properties of errors were examined throughout the course of the practice task, and then practice was compared to a retention period 30 min later (R1) and two days later (R2). For cluster and whole-(non)word accuracy measures, acquisition was observed for all groups during the practice session. Compared to the beginning of practice, the tDCS-Before group showed significantly greater improvement than both the sham group and the tDCS-During group at R1. An effect was also observed for vowel duration in errors (/gdivu/ → [gədivu]), with the tDCS-Before group showing significant shortening of vowel errors throughout practice. Overall, the findings suggest that tDCS can improve speech motor learning, and that the improvement may be greater when tDCS is applied immediately before practice, warranting further exploration of this new domain for tDCS research.


Biliary strictures: classification based on the principles of surgical treatment.
The classification of biliary strictures used at Hopital Paul Brousse is based on the lowest level at which healthy biliary mucosa is available for anastomosis. The classification is intended to help the surgeon choose the appropriate technique for the repair. Type I strictures, with a common duct stump longer than 2 cm, can be repaired without opening the left duct and without lowering the hilar plate. Type II strictures, with a stump shorter than 2 cm, require opening the left duct for a satisfactory anastomosis. Lowering the hilar plate is not always necessary but may improve the exposure. Type III lesions, in which only the ceiling of the biliary confluence is intact, require lowering the hilar plate and anastomosis on the left ductal system. There is no need to open the right duct if the communication between the ducts is wide. With type IV lesions the biliary confluence is interrupted and requires either reconstruction or two or more anastomoses. Type V lesions are strictures of the hepatic duct associated with a stricture on a separate right branch, and the branch must be included in the repair. Although this classification is intended for established strictures, it is commonly used to describe acute bile duct injuries. The surgeon must be aware, however, that the established stricture is generally one level higher than the level of the injury at the original operation.


Shape and function of the Bicoid morphogen gradient in dipteran species with different sized embryos.
The Bicoid morphogen evolved approximately 150 MYA from a Hox3 duplication and is only found in higher dipterans. A major difference between dipteran species, however, is the size of the embryo, which varies up to 5-fold. Although the expression of developmental factors scale with egg length, it remains unknown how this scaling is achieved. To test whether scaling is accounted for by the properties of Bicoid, we expressed eGFP fused to the coding region of bicoid from three dipteran species in transgenic Drosophila embryos using the Drosophila bicoid cis-regulatory and mRNA localization sequences. In such embryos, we find that Lucilia sericata and Calliphora vicina Bicoid produce gradients very similar to the endogenous Drosophila gradient and much shorter than what they would have produced in their own respective species. The common shape of the Drosophila, Lucilia and Calliphora Bicoid gradients appears to be a conserved feature of the Bicoid protein. Surprisingly, despite their similar distributions, we find that Bicoid from Lucilia and Calliphora do not rescue Drosophila bicoid mutants, suggesting that that Bicoid proteins have evolved species-specific functional amino acid differences. We also found that maternal expression and anteriorly localization of proteins other than Bcd does not necessarily give rise to a gradient; eGFP produced a uniform protein distribution. However, a shallow gradient was observed using eGFP-NLS, suggesting nuclear localization may be necessary but not sufficient for gradient formation.


Particle sizing with a fast polar nephelometer.
We reported previously the design of a polar nephelometer that uses a rotational confocal imaging setup to enable fast scanning of the scattering phase function within a field of view of 55 degrees . The full dynamic range of the detection system can be used by increasing the signal-to-noise ratio by means of averaging successive scans. The calibration of the angular response of the instrument is achieved by obtaining the transfer function of the optical detection system using Rayleigh scatterers. Accurate particle sizing of individual polystyrene spheres (ranging from 1.5 to 9 micro m in diameter) in aqueous suspension is achieved by maximizing a correlation coefficient between precalculated tables of Mie phase functions and data obtained from the polar nephelometer. Good correlation is achieved between experimental and theoretical data, proving the functioning of the instrument as a fast and convenient particle sizer.


Sustained increase in the excitability of myelinated peripheral axons to depolarizing current is mediated by Nav1.6.
Changes in the excitability of peripheral myelinated axons in response to long-lasting subthreshold depolarizing or hyperpolarizing currents (threshold electrotonus) are used as a complementary electrophysiological parameter in the study of peripheral nerve diseases in people. However, the contribution made by various axonal ion channels to specific components of threshold electrotonus remains incompletely understood. In this study, we have recorded threshold electrotonus responses from isolated nerve segments of sural nerve from control and Scn8amed mice, which lack functional Nav1.6 voltage-gated sodium channel. In med mice, the increase in axonal excitability produced by application of subthreshold depolarizing currents for 100-200ms was not sustained. In contrast, there was no difference in threshold electrotonus responses to subthreshold hyperpolarizing current application between Scn8amed and control mice. These data reveal the specific functional role of an identified subtype of voltage-gated sodium channel (Nav1.6) in mediating the depolarizing threshold electrotonus response of peripheral myelinated nerve fibers.


The Relationship Between Lifetime Out-of-pocket Medical Expenditures, Dementia, and Socioeconomic Status in the U.S.
Dementia is one of the most expensive medical conditions. The costs are borne by families, by private insurance and by society via public programs such as Medicaid in the U.S.. There is extensive research on the relationship between dementia and annual medical spending. This paper, instead, estimates cumulative lifetime medical expenditures that can be attributed to the onset of dementia using a nationally representative longitudinal survey from the U.S., the Health and Retirement Study. The lifetime expenditures are estimated by summing any out-of-pocket medical spending reported in the panel from age 65 to death. Censored cases are imputed using a non-parametric matching algorithm called splicing. For example, survivors to the most recent wave are matched to similar individuals from older cohorts who are observed at the relevant ages all the way through death. We find that those who live with dementia for at least half a year pay, on average, $38,540 more out of pocket from age 65 to death when controlling for length of life, demographics, lifetime earnings and comorbidities. The costs of dementia are almost exclusively due to spending on nursing homes. Spending on drugs, doctor visits or hospitals, is not significantly related to dementia. The lifetime costs of dementia are significantly larger for white and rich individuals, perhaps because they use higher quality nursing homes and because they have more financial resources to spend down before becoming eligible for Medicaid support.


Who comes back? Characteristics and predictors of return to emergency department services for pediatric mental health care.
The objective of this study was to investigate predictors of emergency department (ED) return visits for pediatric mental health care. The authors hypothesized that through the identification of clinical and health system variables that predict return ED visits, which children and adolescents would benefit from targeted interventions for persistent mental health needs could be determined. Data on 16,154 presentations by 12,589 pediatric patients (<or=17 years old) were examined from 2002 to 2006, using the Ambulatory Care Classification System (ACCS), a provincewide database for Alberta, Canada. Multivariable logistic regressions identified predictors, while survival analyses estimated time to ED return. In the multivariable analysis, there were four patient factors significantly associated with ED return. Male sex (odds ratio [OR] = 0.78; 99% confidence interval [CI] = 0.69 to 0.89) was associated with a lower rate of return, as was child age. The likelihood of ED return increased with age. Children <or=5 years (OR = 0.26; 99% CI = 0.14 to 0.46) and between ages 6 and 12 (OR = 0.64; 99% CI = 0.51 to 0.79) were less likely to return, compared to 13- to 17-year-olds. Patients with families receiving full assistance for covering government health care premiums were more likely to return compared to those with no assistance (OR = 1.59; 99% CI = 1.33 to 1.91). Patients were more likely to return if their initial presentation was for a mood disorder (OR = 1.72; 99% CI = 1.46 to 2.01) or psychotic-related illness (OR = 2.53; 99% CI = 1.80 to 3.56). There were two modest health care system predictors in the model. The likelihood of return decreased for patients triaged as nonurgent (OR = 0.62; 99% CI = 0.45 to 0.87) versus those triaged as urgent (level 3 acuity) and increased for patients with visits to general (vs. pediatric) EDs (OR = 1.25; 99% CI = 1.03 to 1.52). ED region (urban vs. rural) did not predict return. Within 72 hours of discharge, 6.1 and 8.7% of patients diagnosed with a mood disorder and psychotic-related illness, respectively, returned to the ED. Throughout the study period, 28.5 and 36.6% of these diagnostic populations, respectively, returned to the ED. Among children and adolescents who accessed the ED for mental health concerns, being female, older in age, in receipt of social assistance, and having an initial visit for a mood disorder or psychotic-related illness were associated with return for further care. How patient presentations were triaged and whether visits were made to a pediatric or general ED also affected the likelihood of return.


Cyclin-mediated inhibition of muscle gene expression via a mechanism that is independent of pRB hyperphosphorylation.
It was recently demonstrated that ectopic expression of cyclin D1 inhibits skeletal muscle differentiation and, conversely, that expression of cyclin-dependent kinase (cdk) inhibitors facilitates activation of this differentiation program (S. S. Rao, C. Chu, and D. S. Kohtz, Mol. Cell. Biol. 14:5259-5267, 1994; S. S. Rao and D. S. Kohtz, J. Biol. Chem. 270:4093-4100, 1995; S. X. Skapek, J. Rhee, D. B. Spicer, and A. B. Lassar, Science 267:1022-1024, 1995). Here we demonstrate that cyclin D1 inhibits muscle gene expression without affecting MyoD DNA binding activity. Ectopic expression of cyclin D1 inhibits muscle gene activation by both MyoD and myogenin, including a mutated form of myogenin in which two potential inhibitory cdk phosphorylation sites are absent. Because the retinoblastoma gene product, pRB, is a known target for cyclin D1-cdk phosphorylation, we determined whether cyclin D1-mediated inhibition of myogenesis was due to hyperphosphorylation of pRB. In pRB-deficient fibroblasts, the ability of MyoD to activate the expression of muscle-specific genes requires coexpression of ectopic pRB (B. G. Novitch, G. J. Mulligan, T. Jacks, and A. B. Lassar, J. Cell Biol., 135:441-456, 1996). In these cells, the expression of cyclins A and E can lead to pRB hyperphosphorylation and can inhibit muscle gene expression. The negative effects of cyclins A or E on muscle gene expression are, however, reversed by the presence of a mutated form of pRB which cannot be hyperphosphorylated. In contrast, cyclin D1 can inhibit muscle gene expression in the presence of the nonhyperphosphorylatable form of pRB. On the basis of these results we propose that G1 cyclin-cdk activity blocks the initiation of skeletal muscle differentiation by two distinct mechanisms: one that is dependent on pRB hyperphosphorylation and one that is independent of pRB hyperphosphorylation.


Technical Note: Insertion of digital lesions in the projection domain for dual-source, dual-energy CT.
To compare algorithms performing material decomposition and classification in dual-energy CT, it is desirable to know the ground truth of the lesion to be analyzed in real patient data. In this work, we developed and validated a framework to insert digital lesions of arbitrary chemical composition into patient projection data acquired on a dual-source, dual-energy CT system. A model that takes into account beam-hardening effects was developed to predict the CT number of objects with known chemical composition. The model utilizes information about the x-ray energy spectra, the patient/phantom attenuation, and the x-ray detector energy response. The beam-hardening model was validated on samples of iodine (I) and calcium (Ca) for a second-generation dual-source, dual-energy CT scanner for all tube potentials available and a wide range of patient sizes. The seven most prevalent mineral components of renal stones were modeled and digital stones were created with CT numbers computed for each patient/phantom size and x-ray energy spectra using the developed beam-hardening model. Each digital stone was inserted in the dual-energy projection data of a water phantom scanned on a dual-source scanner and reconstructed with the routine algorithms in use in our practice. The geometry of the forward projection for dual-energy data was validated by comparing CT number accuracy and high-contrast resolution of simulated dual-energy CT data of the ACR phantom with experimentally acquired data. The beam-hardening model and forward projection method accurately predicted the CT number of I and Ca over a wide range of tube potentials and phantom sizes. The images reconstructed after the insertion of digital kidney stones were consistent with the images reconstructed from the scanner, and the CT number ratios for different kidney stone types were consistent with data in the literature. A sample application of the proposed tool was also demonstrated. A framework was developed and validated for the creation of digital objects of known mineral composition, and for inserting the digital objects into projection data from a commercial dual-source, dual-energy CT scanner. Among other applications, it will allow a systematic investigation of the impact of scan and reconstruction parameters on kidney stone dual-energy properties under rigorously controlled conditions.


Effects of electronic decision support on high-tech diagnostic imaging orders and patients.
To evaluate the effects of providing appropriateness criteria through guideline-based electronic health record (EHR) decision support for high-tech diagnostic imaging (HTDI) procedures. Chart audits were performed on a random sample of adult primary care orders for 3 HTDI procedures (computed tomography [CT] and magnetic resonance imaging [MRI] of the head, and MRI of the lumbar spine) before and after implementation of an EHR decision support system. Level of appropriateness, abnormal findings, and apparent effects on patient care. A total of 299 eligible audits were performed. Decision support was associated with a 20% to 36% drop in spine MRI and head CT orders, but head MRI order volume was unaffected. Combined results for the 3 procedures showed that a larger proportion of studies ordered after implementing decision support (89.2% vs 79.5%, P = .02) fit appropriateness criteria, and more postimplementation studies had A ratings (highest utility rating) (81.8% vs 70%, P = .04). However, there were no differences in the proportion of tests with positive findings (42/132 vs 28/120, P = .16 among procedures that met definite criteria) or the proportion with a likely impact on patients (6.6% vs 10.8%, P = .07). These data support the feasibility of using chart audits to assess the relationship between appropriateness criteria and HTDI orders. Although introduction of EHR clinical decision support for diagnostic imaging orders was associated with reduced volume and increased appropriateness of orders, there was little apparent impact on either findings or patients.


The effect of fennel (Foeniculum Vulgare) seed oil emulsion in infantile colic: a randomized, placebo-controlled study.
Despite its benign, natural course, colic is a significant problem in infants and imparts a psychological, emotional, and physical burden to parents. Dicyclomine hydrochloride is the only pharmacological treatment for infantile colic that has been consistently effective. Unfortunately, 5% of infants treated with dicyclomine hydrochloride develop serious side effects, including death. Fennel seed oil has been shown to reduce intestinal spasms and increase motility of the small intestine. However, there have not been any clinical studies of its effectiveness. To determine the effectiveness of fennel seed oil emulsion in infantile colic. Randomized placebo-controlled trial. Two large multi-specialty clinics. 125 infants, 2 to 12 weeks of age, who met definition of colic. Fennel seed oil emulsion compared with placebo. Relief of colic symptoms, which was defined as decrease of cumulative crying to less than 9 hours per week. The use of fennel oil emulsion eliminated colic, according to the Wessel criteria, in 65% (40/62) of infants in the treatment group, which was significantly better than 23.7% (14/59) of infants in the control group (P < 0.01). There was a significant improvement of colic in the treatment group compared with the control group [Absolute Risk Reduction (ARR) = 41% (95% CI 25 to 57), Number Needed to Treat (NNT) = 2 (95% CI 2 to 4)]. Side effects were not reported for infants in either group during the trial. Our study suggests that fennel seed oil emulsion is superior to placebo in decreasing intensity of infantile colic.


Sex ratio strategies and the evolution of cue use.
Quantitative tests of sex allocation theory have often indicated that organism strategies deviate from model predictions. In pollinating fig wasps, Lipporrhopalum tentacularis, whole fig (brood) sex ratios are generally more female-biased than predicted by local mate competition (LMC) theory where females (foundresses) use density as a cue to assess potential LMC. We use microsatellite markers to investigate foundress sex ratios in L. tentacularis and show that they actually use their clutch size as a cue, with strategies closely approximating the predictions of a new model we develop of these conditions. We then provide evidence that the use of clutch size as a cue is common among species experiencing LMC, and given the other predictions of our model argue that this is because their ecologies mean it provides sufficiently accurate information about potential LMC that the use of other more costly cues has not evolved. We further argue that the use of these more costly cues by other species is due to the effect that ecological differences have on cue accuracy. This implies that deviations from earlier theoretical predictions often indicate that the cues used to assess environmental conditions differ from those assumed by models, rather than limits on the ability of natural selection to produce "perfect" organisms.


Assessing the capacity to make everyday decisions: a guide for clinicians and an agenda for future research.
Assessing the capacity of patients to make decisions about their functional problems has substantial ethical, clinical, and financial implications. The growing population of older adults with cognitive impairment either in the community or in long-term care and medical facilities increase the importance of adequately assessing this capacity. This review examines the current approaches to making this assessment, demonstrates how they are incomplete, and considers potential approaches for improving these evaluations. Future research should develop and validate methods to identify patients with impaired capacity to make everyday decisions. These data will supplement functional, cognitive, and medical assessments.


SAPA tool: finding protein regions by combination of amino acid composition, scaled profiles, patterns and rules.
Functional modules within protein sequences are often extracted by consensus sequence patterns representing a linear motif; however, other functional regions may only be described by combined features such as amino acid composition, profiles of amino acid properties and randomly distributed short sequence motifs. If only a small number of functional examples are well characterized, the researcher needs a tool to extract similar sequences for further investigation. We provide the web application 'SAPA tool', which allows the user to search with combined properties, ranks the extracted target regions by an integrated score, estimates false discovery rates by using decoy sequences and provides them as a sequence file or spreadsheet. Source code, user manual and the web application implemented in Perl, HTML, CSS and JavaScript and running on Apache are freely available at http://sapa-tool.uio.no/sapa/


In vitro activity of a new semisynthetic echinocandin, LY-303366, against systemic isolates of Candida species, Cryptococcus neoformans, Blastomyces dermatitidis, and Aspergillus species.
The in vitro activities of LY-303366, a new semisynthetic echinocandin, and comparators amphotericin B, 5-fluorocytosine, fluconazole, and ketoconazole against 205 systemic isolates of Candida species, Cryptococcus neoformans, Blastomyces dermatitidis, and Aspergillus species were determined. LY-303366 had MICs of < or = 0.32 microg/ml for all Candida albicans (n = 99), Candida glabrata (n = 18), and Candida tropicalis (n = 10) isolates tested. LY-303366 was also active against Aspergillus species (minimum effective concentration at which 90% of the isolates are inhibited, 0.02 microg/ml) (n = 20), was less active against Candida parapsilosis (MIC at which 90% of the isolates are inhibited [MIC90], 5.12 microg/ml) (n = 10), and was inactive against C. neoformans (MIC90, >10.24 microg/ml) (n = 15) and B. dermatitidis (MIC90, 16 microg/ml) (n = 29).


Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses' hand washing.
Critically ill patients are at marked risk of hospital-acquired infections, which increase patients' morbidity and mortality. Registered nurses are the main health care providers of physical care, including hygiene to reduce and prevent hospital-acquired infections, for hospitalized critically ill patients. To investigate a new patient hand hygiene protocol designed to reduce hospital-acquired infection rates and improve nurses' hand-washing compliance in an intensive care unit. A preexperimental study design was used to compare 12-month rates of 2 common hospital-acquired infections, central catheter-associated bloodstream infection and catheter-associated urinary tract infection, and nurses' hand-washing compliance measured before and during use of the protocol. Reductions in 12-month infection rates were reported for both types of infections, but neither reduction was statistically significant. Mean 12-month nurse hand-washing compliance also improved, but not significantly. A hand hygiene protocol for patients in the intensive care unit was associated with reductions in hospital-acquired infections and improvements in nurses' hand-washing compliance. Prevention of such infections requires continuous quality improvement efforts to monitor lasting effectiveness as well as investigation of strategies to eliminate these infections.


Urinary risk factors for recurrent calcium stone formation in Thai stone formers.
To survey the urinary risk factors associated with recurrent calcium stone and the contribution of renal tubular acidosis to the prevalence of recurrent calcium stone formation in Thai recurrent stone formers. There were 86 consecutive recurrent calcium stone formers. Three-day dietary record, serum biochemical parameters, first morning urine pH, and two 24-hour urine collections were obtainedfrom each subject. Urinary risk factors for calcium stone formation were determined from the average of the 2-day urine collection. Normal controls were 34 subjects matched for aged, sex, and weight, and without a history of renal stone formation. Seven patients (8.1%) were diagnosed as incomplete renal tubular acidosis (iRTA). Among the 79 idiopathic calcium stone formers (ISF), 69.6%, 15.2%, 10.1%, 7.2% and 1.3% of patients were hypocitraturia, hypercalciuria, low urinary volume, hyperuricosuria and hyperoxaluria, respectively. The common combinations of risk factors were hypocitraturia plus low urine output (8.9%) or plus hypercalciuria (7.6%). There were significant differences between ISF and normal controls in urinary oxalate excretion (0.16 +/- 0.01 vs 0.12 +/- 0.01, p < 0.05), urinary calcium/citrate ratio (4.49 +/- 0.50 vs 2.83 +/- 0.34, p < 0.01) and ion activity product for calcium oxalate stone (0. 46 +/- 0.03 vs 0. 33 +/- 0.03, p < 0. 05). Urinary citrate in ISF varied directly with net alkaline absorption (r = 0.34, p < 0.005) and urinary potassium (r = 0.54, p < 0.001). There were significant correlations between urinary calcium excretion and both sodium excretion (r = 0.42, p < 0.001) and urea excretion (r = 0.41, p < 0.001) in ISE There were seven (8.1%) with incomplete renal tubular acidosis. Patients with iRTA tended to have less urinary citrate and higher calcium/citrate ratio than did ISF, but hypercalciuria was uncommon. Hypocitraturia was the most common urinary risk factor found in Thai recurrent idiopathic calcium stone formers followed by hypercalciuria and low urinary volume. Almost one-fourth of the stone formers had multiple risk factors. Hypocitraturia might result from low potassium and low alkaline intake. iRTA was common among recurrent calcium stone formers. Determination of morning urine pH should be a part of the investigations for urinary risk factors to avoid overlooking the diagnosis of iRTA.


Implementation of the Pharmacists' Patient Care Process in a Medicinal Chemistry Course.
Objective. To implement the Pharmacists' Patient Care Process (PPCP) in a medicinal chemistry course. Methods. Doctor of Pharmacy students in a medicinal chemistry course were challenged to apply the PPCP in a lesson on cholinesterase inhibitors and NMDA receptor antagonist in the treatment of Alzheimer's disease. A clinical faculty member with expertise in the topic reviewed the clinical information provided to ensure applicability to patient care. A pre- and post-course survey was administered to assess students' understanding of the PPCP and the effectiveness of the strategies used. Students' pre- and post-course responses were analyzed, and qualitative themes were identified. Results. Of the 141 students enrolled in the course, 96% and 97% completed the pre- and post-course surveys, respectively. Students' post-course responses were higher than pre-course answers to the question that they knew all the steps of the PPCP (96% vs 66%, respectively). Ninety one percent in the post-course survey compared to 62% in the pre-course survey listed the PPCP steps correctly. In addition, more than 90% of the students indicated that the strategies used in the class helped them understand and relate to the PPCP. Qualitative responses revealed themes with positive responses related to the course, course activities, PPCP goals and curriculum design based on the implementation of the PPCP. Conclusion. The introduction of the PPCP as a framework for all pharmacy practitioners is a worthy endeavor. Purposeful strategies to introduce the PPCP in a medicinal course were positively received by students. Formalized efforts to implement the PPCP in clinical, social and administrative, and science courses are critical to introduce the PPCP as a framework for all future pharmacy practitioners.


Nut consumption and weight gain in a Mediterranean cohort: The SUN study.
To assess the association, in a Mediterranean population, between nut consumption and risk of weight gain (at least 5 kg) or the risk of becoming overweight/obese. The Seguimiento Universidad de Navarra project is a prospective cohort of 8865 adult men and women who completed a follow-up questionnaire after a median of 28 months. Dietary habits were assessed with a previously validated semiquantitative food-frequency questionnaire. Nine hundred thirty-seven participants reported a weight gain of > or =5 kg at follow-up. After adjusting for age, sex, smoking, leisure time physical activity, and other known risk factors for obesity, participants who ate nuts two or more times per week had a significantly lower risk of weight gain (odds ratio: 0.69; 95% confidence interval: 0.53 to 0.90, p for trend = 0.006) than those who never or almost never ate nuts. Participants with little nut consumption (never/almost never) gained an average of 424 grams (95% confidence interval: 102 to 746) more than frequent nut eaters. Nut consumption was not significantly associated with incident overweight/obesity in the cohort. Frequent nut consumption was associated with a reduced risk of weight gain (5 kg or more). These results support the recommendation of nut consumption as an important component of a cardioprotective diet and also allay fears of possible weight gain.


Electrostatic potential and electroosmotic flow in a cylindrical capillary filled with symmetric electrolyte: analytic solutions in thin double layer approximation.
The electrostatic potential in a capillary filled with electrolyte is derived by solving the nonlinear Poisson-Boltzmann equation using the method of matched asymptotic expansions. This approach allows obtaining an analytical result for arbitrary high wall potential if the double layer thickness is smaller than the capillary radius. The derived expression for the electrostatic potential is compared to numerical solutions of the Poisson-Boltzmann equation and it is shown that the agreement is excellent for capillaries with radii greater or equal to four times the electrical double layer thickness. The knowledge of the electrostatic potential distribution inside the capillary enables the derivation of the electroosmotic velocity flow profile in an analytical form. The obtained results are applicable to capillaries with radii ranging from nanometers to micrometers depending on the ionic strength of the solution.


Anemia on admission predicts short- and long-term outcomes in patients with acute ischemic stroke.
It is still debatable whether anemia predicts stroke outcome. To describe the characteristics of patients with acute ischemic stroke (AIS) and anemia and identify whether hemoglobin status on admission is a prognostic factor of AIS outcome. All 2439 patients of the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) between January 2003 and June 2011 were selected. Demographics, risk factors, prestroke treatment, clinical, radiological and metabolic variables in patients with and without anemia according to the definition of the World Health Organization were compared. Functional disability and mortality were recorded up to 12 months from admission. Anemic patients (17.5%) were older, had lower body mass index, higher rates of coronary artery disease (CAD), atrial fibrillation, diabetes mellitus and peripheral artery disease. Anemia was associated with more severe stroke manifestations, lower systolic and diastolic blood pressure measurements, worse estimated glomerular filtration rate and elevated C-reactive protein concentrations upon admission and with increased modified Rankin scores during the follow-up. Anemic patients had higher 7-day, 3-month and 12-month mortality, which was associated with hemoglobin status and other factors, including age, CAD, stroke severity, and baseline C-reactive levels. Hemoglobin levels were inversely associated with recurrent stroke and mortality throughout the 12-month follow-up. Anemia is common among AIS patients and is associated with cardiovascular comorbidities. Low hemoglobin status independently predicts short and long-term mortality.


Differentiation of PDX1 gene-modified human umbilical cord mesenchymal stem cells into insulin-producing cells in vitro.
Mesenchymal stem cells (MSCs) have significant advantages over other stem cell types, and greater potential for immediate clinical application. MSCs would be an interesting cellular source for treatment of type 1 diabetes. In this study, MSCs from human umbilical cord were differentiated into functional insulin-producing cells in vitro by introduction of the pancreatic and duodenal homeobox factor 1 (PDX1) and in the presence of induction factors. The expressions of cell surface antigens were detected by flow cytometry. After induction in an adipogenic medium or an osteogenic medium, the cells were observed by Oil Red O staining and alkaline phosphatase staining. Recombinant adenovirus carrying the PDX1 gene was constructed and MSCs were infected by the recombinant adenovirus, then treated with several inducing factors for differentiation into islet β-like cells. The expression of the genes and protein related to islet β-cells was detected by immunocytochemistry, RT-PCR and Western blot analysis. Insulin and C-peptide secretion were assayed. Our results show that the morphology and immunophenotype of MSCs from human umbilical cord were similar to those present in human bone marrow. The MSCs could be induced to differentiate into osteocytes and adipocytes. After induction by recombined adenovirus vector with induction factors, MSCs were aggregated and presented islet-like bodies. Dithizone staining of these cells was positive. The genes' expression related to islet β-cells was found. After induction, insulin and C-peptide secretion in the supernatant were significantly increased. In conclusion, our results demonstrated that PDX1 gene-modified human umbilical cord mesenchymal stem cells could be differentiated into insulin-producing cells in vitro.


Genome-wide scans identify known and novel regions associated with prolificacy and reproduction traits in a sub-Saharan African indigenous sheep (Ovis aries).
Maximizing the number of offspring born per female is a key functionality trait in commercial- and/or subsistence-oriented livestock enterprises. Although the number of offspring born is closely associated with female fertility and reproductive success, the genetic control of these traits remains poorly understood in sub-Saharan Africa livestock. Using selection signature analysis performed on Ovine HD BeadChip data from the prolific Bonga sheep in Ethiopia, 41 candidate regions under selection were identified. The analysis revealed one strong selection signature on a candidate region on chromosome X spanning BMP15, suggesting this to be the primary candidate prolificacy gene in the breed. The analysis also identified several candidate regions spanning genes not reported before in prolific sheep but underlying fertility and reproduction in other species. The genes associated with female reproduction traits included SPOCK1 (age at first oestrus), GPR173 (mediator of ovarian cyclicity), HB-EGF (signalling early pregnancy success) and SMARCAL1 and HMGN3a (regulate gene expression during embryogenesis). The genes involved in male reproduction were FOXJ1 (sperm function and successful fertilization) and NME5 (spermatogenesis). We also observed genes such as PKD2L2, MAGED1 and KDM3B, which have been associated with diverse fertility traits in both sexes of other species. The results confirm the complexity of the genetic mechanisms underlying reproduction while suggesting that prolificacy in the Bonga sheep, and possibly African indigenous sheep is partly under the control of BMP15 while other genes that enhance male and female fertility are essential for reproductive fitness.


HLA has strongest association with IgA nephropathy in genome-wide analysis.
Demographic and family studies support the existence of a genetic contribution to the pathogenesis of IgA nephropathy, but results from genetic association studies of candidate genes are inconsistent. To systematically survey common genetic variation in this disease, we performed a genome-wide analysis in a cohort of patients with IgA nephropathy selected from the UK Glomerulonephritis DNA Bank. We used two groups of controls: parents of affected individuals and previously genotyped, unaffected, ancestry-matched individuals from the 1958 British Birth Cohort and the UK Blood Service. We genotyped 914 affected or family controls for 318,127 single nucleotide polymorphisms (SNPs). Filtering for low genotype call rates and inferred non-European ancestry left 533 genotyped individuals (187 affected children) for the family-based association analysis and 244 cases and 4980 controls for the case-control analysis. A total of 286,200 SNPs with call rates >95% were available for analysis. Genome-wide analysis showed a strong signal of association on chromosome 6p in the region of the MHC (P = 1 × 10(-9)). The two most strongly associated SNPs showed consistent association in both family-based and case-control analyses. HLA imputation analysis showed that the strongest association signal arose from a combination of DQ loci with some support for an independent HLA-B signal. These results suggest that the HLA region contains the strongest common susceptibility alleles that predispose to IgA nephropathy in the European population.


The 6-PACK programme to decrease fall-related injuries in acute hospitals: protocol for a cluster randomised controlled trial.
In-hospital fall-related injuries are a source of personal harm, preventable hospitalisation costs, and access block through increased length of stay. Despite increased fall prevention awareness and activity over the last decade, rates of reported fall-related fractures in hospitals appear not to have decreased. This cluster randomised controlled trial (RCT) aims to determine the efficacy of the 6-PACK programme for preventing fall-related injuries, and its generalisability to other acute hospitals. 24 acute medical and surgical wards from six to eight hospitals throughout Australia will be recruited for the study. Wards will be matched by type and fall-related injury rates, then randomly allocated to the 6-PACK intervention (12 wards) or usual care control group (12 wards). The 6-PACK programme includes a nine-item fall risk assessment and six nursing interventions: 'falls alert' sign; supervision of patients in the bathroom; ensuring patient's walking aids are within reach; establishment of a toileting regime; use of a low-low bed; and use of bed/chair alarm. Intervention wards will be supported by a structured implementation strategy. The primary outcomes are fall and fall-related injury rates 12 months following 6-PACK implementation. This study will involve approximately 16,000 patients, and as such is planned to be the largest hospital fall prevention RCT to be undertaken and the first to be powered for the important outcome of fall-related injuries. If effective, there is potential to implement the programme widely as part of daily patient care in acute hospital wards where fall-related injuries are a problem.