Hemorrhage due to diffuse erosive gastritis.
Of 796 patients admitted with upper gastrointestinal bleeding during a five-year period, 156 (20%) had erosive gastritis. Vigorous nonoperative treatment stopped bleeding in 117 (75%); emergency operation was required in 39 (25%). In 24 of these 39 patients (group A), subtotal gastric resection with truncal vagotomy was performed. In the remaining 15 patients (group B), the operation was limited to pyloroplasty, truncal vagotomy, and multiple suture ligation. These patients were, on the average, 20 years older than the patients in group A, and 12 had life-threatening preoperative problems. (Only four of the group A patients had life-threatening preoperative problems.) The operative mortality in group A was 42%, with rebleeding occurring 33%. In group B, only 17% rebled and the operative mortality was 45%. Survival in the two groups was similar, even though those patients in group B were more critically ill. The less radical procedure may often be the best choice in the high-risk and elderly patients who bleed massively and in whom immediate salvage of life is the main issue.


Using video modeling to teach complex social sequences to children with autism.
This study comprised of two experiments was designed to teach complex social sequences to children with autism. Experimental control was achieved by collecting data using means of within-system design methodology. Across a number of conditions children were taken to a room to view one of the four short videos of two people engaging in a simple sequence of activities. Then, each child's behavior was assessed in the same room. Results showed that this video modeling procedure enhanced the social initiation skills of all children. It also facilitated reciprocal play engagement and imitative responding of a sequence of behaviors, in which social initiation was not included. These behavior changes generalized across peers and maintained after a 1- and 2-month follow-up period.


Flagellin Glycoproteomics of the Periodontitis Associated Pathogen Selenomonas sputigena Reveals Previously Not Described O-glycans and Rhamnose Fragment Rearrangement Occurring on the Glycopeptides.
Flagellated, Gram-negative, anaerobic, crescent-shaped Selenomonas species are colonizers of the digestive system, where they act at the interface between health and disease. Selenomonas sputigena is also considered a potential human periodontal pathogen, but information on its virulence factors and underlying pathogenicity mechanisms is scarce. Here we provide the first report of a Selenomonas glycoprotein, showing that S. sputigena produces a diversely and heavily O-glycosylated flagellin C9LY14 as a major cellular protein, which carries various hitherto undescribed rhamnose- and N-acetylglucosamine linked O-glycans in the range from mono- to hexasaccharides. A comprehensive glycomic and glycoproteomic assessment revealed extensive glycan macro- and microheterogeneity identified from 22 unique glycopeptide species. From the multiple sites of glycosylation, five were unambiguously identified on the 437-amino acid C9LY14 protein (Thr149, Ser182, Thr199, Thr259, and Ser334), the only flagellin protein identified. The O-glycans additionally showed modifications by methylation and putative acetylation. Some O-glycans carried hitherto undescribed residues/modifications as determined by their respective m/z values, reflecting the high diversity of native S. sputigena flagellin. We also found that monosaccharide rearrangement occurred during collision-induced dissociation (CID) of protonated glycopeptide ions. This effect resulted in pseudo Y1-glycopeptide fragment ions that indicated the presence of additional glycosylation sites on a single glycopeptide. CID oxonium ions and electron transfer dissociation, however, confirmed that just a single site was glycosylated, showing that glycan-to-peptide rearrangement can occur on glycopeptides and that this effect is influenced by the molecular nature of the glycan moiety. This effect was most pronounced with disaccharides. This study is the first report on O-linked flagellin glycosylation in a Selenomonas species, revealing that C9LY14 is one of the most heavily glycosylated flagellins described to date. This study contributes to our understanding of the largely under-investigated surface properties of oral bacteria. The data have been deposited to the ProteomeXchange with identifier PXD005859.


Analysis of Histone Modifications by Mass Spectrometry.
Histone N termini undergo diverse post-translational modifications that significantly extend the information potential of the genetic code. Moreover, these modifications mark specific chromatin regions, modulating epigenetic control, lineage commitment, and overall function of chromosomes. It is widely accepted that histone modifications affect chromatin function, but the exact mechanisms by which modifications on histone tails and specific combinations of modifications are generated, and how they cross-talk with one another, are still enigmatic. Mass spectrometry is the gold-standard method for analyzing histone modifications, as it allows the quantification of modifications and combinations. This unit describes how high-resolution mass spectrometry can be used to study histone post-translational modifications. © 2018 by John Wiley & Sons, Inc.


Real-time estimation of TP load in a Mississippi Delta stream using a dynamic data driven application system.
Elevated phosphorus (P) in surface waters can cause eutrophication of aquatic ecosystems and can impair water for drinking, industry, agriculture, and recreation. Currently, no effort has been devoted to estimating real-time variation and load of total P (TP) in surface waters due to the lack of suitable and/or cost-effective wireless sensors. However, when considering human health, drinking water supply, and rapidly developing events such as algal blooms, the availability of timely P information is very critical. In this study, we developed a new approach in the form of a dynamic data driven application system (DDDAS) for monitoring the real-time variation and load of TP in surface water. This DDDAS consisted of the following three major components: (1) a User Control that interacts with Schedule Run to implement the DDDAS with starting and ending times; (2) a Schedule Run that activates the Hydstra model; and (3) a Hydstra model that downloads the real-time data from a US Geological Survey (USGS) website that is updated every 15 min with data from USGS monitoring stations, predicts real-time variation and load of TP, graphs the variables in real-time on a computer screen, and sends email alerts when the TP exceeds a certain value. The DDDAS was applied to monitor real-time variation and load of TP for 30 days in Deer Creek, a stream located east of Leland, Mississippi, USA. Results showed that the TP concentrations in the stream ranged from 0.24 to 0.48 mg L(-1) with an average of 0.30 mg L(-1) for a 30-day monitoring period, whereas the cumulative load of TP from the stream was about 2.8 kg for the same monitoring period. Our study suggests that the DDDAS developed in this study was useful for estimating the real-time variation and load of TP in surface water ecosystems.


The Schottky-Mott Rule Expanded for Two-Dimensional Semiconductors: Influence of Substrate Dielectric Screening.
A comprehensive understanding of the energy level alignment mechanisms between two-dimensional (2D) semiconductors and electrodes is currently lacking, but it is a prerequisite for tailoring the interface electronic properties to the requirements of device applications. Here, we use angle-resolved direct and inverse photoelectron spectroscopy to unravel the key factors that determine the level alignment at interfaces between a monolayer of the prototypical 2D semiconductor MoS2 and conductor, semiconductor, and insulator substrates. For substrate work function (Φsub) values below 4.5 eV we find that Fermi level pinning occurs, involving electron transfer to native MoS2 gap states below the conduction band. For Φsub above 4.5 eV, vacuum level alignment prevails but the charge injection barriers do not strictly follow the changes of Φsub as expected from the Schottky-Mott rule. Notably, even the trends of the injection barriers for holes and electrons are different. This is caused by the band gap renormalization of monolayer MoS2 by dielectric screening, which depends on the dielectric constant (εr) of the substrate. Based on these observations, we introduce an expanded Schottky-Mott rule that accounts for band gap renormalization by εr -dependent screening and show that it can accurately predict charge injection barriers for monolayer MoS2. It is proposed that the formalism of the expanded Schottky-Mott rule should be universally applicable for 2D semiconductors, provided that material-specific experimental benchmark data are available.


Cortisol, Chromogranin A, and Pupillary Responses Evoked by Speech Recognition Tasks in Normally Hearing and Hard-of-Hearing Listeners: A Pilot Study.
Pupillometry is one method that has been used to measure processing load expended during speech understanding. Notably, speech perception (in noise) tasks can evoke a pupil response. It is not known if there is concurrent activation of the sympathetic nervous system as indexed by salivary cortisol and chromogranin A (CgA) and whether such activation differs between normally hearing (NH) and hard-of-hearing (HH) adults. Ten NH and 10 adults with mild-to-moderate hearing loss (mean age 52 years) participated. Two speech perception tests were administered in random order: one in quiet targeting 100% correct performance and one in noise targeting 50% correct performance. Pupil responses and salivary samples for cortisol and CgA analyses were collected four times: before testing, after the two speech perception tests, and at the end of the session. Participants rated their perceived accuracy, effort, and motivation. Effects were examined using repeated-measures analyses of variance. Correlations between outcomes were calculated. HH listeners had smaller peak pupil dilations (PPDs) than NH listeners in the speech in noise condition only. No group or condition effects were observed for the cortisol data, but HH listeners tended to have higher cortisol levels across conditions. CgA levels were larger at the pretesting time than at the three other test times. Hearing impairment did not affect CgA. Self-rated motivation correlated most often with cortisol or PPD values. The three physiological indicators of cognitive load and stress (PPD, cortisol, and CgA) are not equally affected by speech testing or hearing impairment. Each of them seem to capture a different dimension of sympathetic nervous system activity.


Rapid and robust phylotyping of spa t003, a dominant MRSA clone in Luxembourg and other European countries.
spa typing is a common genotyping tool for methicillin-resistant Staphylococcus aureus (MRSA) in Europe. Given the high prevalence of dominant clones, spa-typing is proving to be limited in its ability to distinguish outbreak isolates from background isolates. New molecular tools need to be employed to improve subtyping of dominant local MRSA strains (e.g., spa type t003). Phylogenetically critical, or canonical, SNPs (can-SNPs) were identified as subtyping targets through sequence analysis of 40 MRSA whole genomes from Luxembourg. Real-time PCR assays were designed around target SNPs and validated using a repository of 240 previously sub-typed and epidemiologically characterized Luxembourg MRSA isolates, including 153 community and hospital isolates, 69 isolates from long term care (LTC) facilities, and 21 prospectively analyzed MRSA isolates. Selected isolates were also analyzed by whole genome SNP typing (WGST) for comparison to the SNP assays and other subtyping techniques. Fourteen real-time PCR assays were developed and validated, including two assays to determine presence of spa t003 or t008. The other twelve assays successfully provided a high degree of resolution within the t003 subtype. WGST analysis of the LTC facility isolates provided greater resolution than other subtyping tools, identifying clusters indicative of ongoing transmission within LTC facilities. canSNP-based PCR assays are useful for local level MRSA phylotyping, especially in the presence of one or more dominant clones. The assays designed here can be easily adapted for investigating t003 MRSA strains in other regions in Western Europe. WGST provides substantially better resolution than other typing methods.


Hormonal modulation of ESR1 mutant metastasis.
Estrogen receptor alpha gene (ESR1) mutations occur frequently in ER-positive metastatic breast cancer, and confer clinical resistance to aromatase inhibitors. Expression of the ESR1 Y537S mutation induced an epithelial-mesenchymal transition (EMT) with cells exhibiting enhanced migration and invasion potential in vitro. When small subpopulations of Y537S ESR1 mutant cells were injected along with WT parental cells, tumor growth was enhanced with mutant cells becoming the predominant population in distant metastases. Y537S mutant primary xenograft tumors were resistant to the antiestrogen tamoxifen (Tam) as well as to estradiol (E2) withdrawal. Y537S ESR1 mutant primary tumors metastasized efficiently in the absence of E2; however, Tam treatment significantly inhibited metastasis to distant sites. We identified a nine-gene expression signature, which predicted clinical outcomes of ER-positive breast cancer patients, as well as breast cancer metastasis to the lung. Androgen receptor (AR) protein levels were increased in mutant models, and the AR agonist dihydrotestosterone significantly inhibited estrogen-regulated gene expression, EMT, and distant metastasis in vivo, suggesting that AR may play a role in distant metastatic progression of ESR1 mutant tumors.


Profiling of diurnal patterns of metabolite and transcript abundance in potato (Solanum tuberosum) leaves.
Diurnal changes in carbohydrates and a broad range of primary metabolites were analysed through a diurnal period in potato leaves (Solanum tuberosum cv. Desiree) using an established gas chromatography-mass spectrometry based metabolic profiling protocol alongside conventional spectrophotometric technologies. In tandem, we profiled transcript levels using both a custom array containing approximately 2,500 cDNA clones predominantly representing transcripts involved in primary metabolism and commercially available arrays containing approximately 12,000 cDNA clones that gave coverage of transcript levels over a broader functional range. The levels of many metabolites and transcripts varied during the diurnal period with 56 significant differences observed in the metabolite contents and 832 significant differences recorded in transcript levels. Whilst a large number of the differences would be expected from what has been known previously, several novel changes were observed in these experiments. Notably, qualitative comparison of the combined data sets obtained from the parallel analysis of transcripts and metabolites suggests relatively few changes in gene expression strongly correlate with changes in metabolite levels during a diurnal cycle. Furthermore, these changes appear to be confined to the central metabolic pathways. However, principal component analysis of the metabolic profiles obtained here revealed that metabolite patterns change progressively through a diurnal period suggesting the operation of mechanisms for tight temporal regulation of metabolite composition.


NEDDylation regulates E2F-1-dependent transcription.
The ubiquitin-like molecule NEDD8 modifies cullin-RING ubiquitin E3 ligases. NEDD8 has been shown to have a few additional substrates, but the extent to which this modification targets non-cullins and the functional significance of such modifications remain unclear. Here, we demonstrate that the cell-cycle-regulating transcription factor E2F-1 is a substrate for NEDD8 post-translational modification. NEDDylation results in decreased E2F-1 stability, lower transcriptional activity and slower cell growth. The lysine residues in E2F-1 targeted for NEDDylation can also be methylated, pointing to a possible interplay between these modifications. These results identify a new mode of E2F-1 regulation and highlight the emerging role of NEDD8 in regulating transcription factor stability and function.


Functional characterization of a 13-bp deletion (c.-1522_-1510del13) in the promoter of the von Willebrand factor gene in type 1 von Willebrand disease.
We have studied the effect of a 13-bp deletion in the promoter of the von Willebrand factor (VWF) gene in a patient with type 1 von Willebrand disease. The index case has a VWF:Ag of 0.49 IU/mL and is heterozygous for the deletion. The deletion is located 48 bp 5' of the transcription start site, and in silico analysis, electrophoretic mobility shift assays, and chromatin immunoprecipitation studies all predict aberrant binding of Ets transcription factors to the site of the deletion. Transduction of reporter gene constructs into blood outgrowth endothelial cells showed a 50.5% reduction in expression with the mutant promoter (n = 16, P < .001). A similar 40% loss of transactivation was documented in transduced HepG2 cells. A similar marked reduction of transgene expression was shown in the livers of mice injected with the mutant promoter construct (n = 8, P = .003). Finally, in studies of BOEC mRNA, the index case showed a 4.6-fold reduction of expression of the VWF transcript associated with the deletion mutation. These studies show that the 13-bp deletion mutation alters the binding of Ets (and possibly GATA) proteins to the VWF promoter and significantly reduces VWF expression, thus playing a central pathogenic role in the type 1 von Willebrand disease phenotype in the index case.


Improving diffusion-weighted imaging of post-mortem human brains: SSFP at 7 T.
Post-mortem diffusion imaging of whole, human brains has potential to provide data for validation or high-resolution anatomical investigations. Previous work has demonstrated improvements in data acquired with diffusion-weighted steady-state free precession (DW-SSFP) compared with conventional diffusion-weighted spin echo at 3T. This is due to the ability of DW-SSFP to overcome signal-to-noise and diffusion contrast losses brought about by tissue fixation related decreases in T2 and ADC. In this work, data of four post-mortem human brains were acquired at 3T and 7 T, using DW-SSFP with similar effective b-values (b(eff)~5150 s/mm(2)) for inter-field strength comparisons; in addition, DW-SSFP data were acquired at 7 T with higher b(eff) (~8550 s/mm(2)) for intra-field strength comparisons. Results demonstrate that both datasets acquired at 7 T had higher SNR and diffusion contrast than data acquired at 3T, and data acquired at higher b(eff) had improved diffusion contrast than at lower b(eff) at 7 T. These results translate to improved estimates of secondary fiber orientations leading to higher fidelity tractography results compared with data acquired at 3T. Specifically, tractography streamlines of cortical projections originating from the corpus callosum, corticospinal tract, and superior longitudinal fasciculus were more successful at crossing the centrum semiovale and projected closer to the cortex. Results suggest that DW-SSFP at 7 T is a preferential method for acquiring diffusion-weighted data of post-mortem human brain, specifically where the primary region of interest involves crossing white matter tracts.


Influences of the heme-lysine crosslink in cytochrome P460 over redox catalysis and nitric oxide sensitivity.
Ammonia (NH3)-oxidizing bacteria (AOB) derive total energy for life from the multi-electron oxidation of NH3 to nitrite (NO2-). One obligate intermediate of this metabolism is hydroxylamine (NH2OH), which can be oxidized to the potent greenhouse agent nitrous oxide (N2O) by the AOB enzyme cytochrome (cyt) P460. We have now spectroscopically characterized a 6-coordinate (6c) {FeNO}7 intermediate on the NH2OH oxidation pathway of cyt P460. This species has two fates: it can either be oxidized to the {FeNO}6 that then undergoes attack by NH2OH to ultimately generate N2O, or it can lose its axial His ligand, thus generating a stable, off-pathway 5-coordinate (5c) {FeNO}7 species. We show that the wild type (WT) cyt P460 exhibits a slow nitric oxide (NO)-independent conversion (kHis-off = 2.90 × 10-3 s-1), whereas a cross-link-deficient Lys70Tyr cyt P460 mutant protein underwent His dissociation via both a NO-independent (kHis-off = 3.8 × 10-4 s-1) and a NO-dependent pathway [kHis-off(NO) = 790 M-1 s-1]. Eyring analyses of the NO-independent pathways for these two proteins revealed a significantly larger (ca. 27 cal mol-1 K-1) activation entropy (ΔS‡) in the cross-link-deficient mutant. Our results suggest that the Lys-heme cross-link confers rigidity to the positioning of the heme P460 cofactor to avoid the fast NO-dependent His dissociation pathway and subsequent formation of the off-pathway 5c {FeNO}7 species. The relevance of these findings to NO signaling proteins such as heme-nitric oxide/oxygen binding (H-NOX) is also discussed.


Hypoglycemic Syndrome without Hyperinsulinemia. A Diagnostic Challenge.
The most common cause of organic fasting hypoglycemia in adults is the presence of an insulin-producing pancreatic adenoma, but when high insulin levels are not found, the differential diagnosis is challenging. Misdiagnosis can lead to an unnecessary pancreatectomy. Insulin concentrations may be low in some cases despite a clinical history suggestive of insulinoma. In these cases, a proinsulinoma should be suspected, although the rarity of this condition requires an extensive workup before reaching a final diagnosis. We describe an unusual case of a 38-year-old man with a severe hypoglycemic syndrome due to a proinsulin-secreting pancreatic adenoma. Insulin was measured by the specific assay and suppressed under the lower detection limit during fasting hypoglycemia. Serum proinsulin and C-peptide levels were abnormally elevated, and further tests revealed an islet cell tumor. The tumor was surgically removed, relieving the fasting hypoglycemia. Histopathological study showed a conventional well-differentiated neuroendocrine tumor with high immunoreactivity against proinsulin and with lesser intensity against insulin. Interestingly, GS-9A8 antibody clone used for immunostaining proinsulin did not cross-react with human insulin or C-peptide, providing an unbiased picture of proinsulin secretion. The resolution of symptoms, the fall of proinsulin concentrations after tumor removal and the histopathology study confirmed the diagnosis of proinsulinoma.


An antifungal agent inhibits an aminoacyl-tRNA synthetase by trapping tRNA in the editing site.
Aminoacyl-transfer RNA (tRNA) synthetases, which catalyze the attachment of the correct amino acid to its corresponding tRNA during translation of the genetic code, are proven antimicrobial drug targets. We show that the broad-spectrum antifungal 5-fluoro-1,3-dihydro-1-hydroxy-2,1-benzoxaborole (AN2690), in development for the treatment of onychomycosis, inhibits yeast cytoplasmic leucyl-tRNA synthetase by formation of a stable tRNA(Leu)-AN2690 adduct in the editing site of the enzyme. Adduct formation is mediated through the boron atom of AN2690 and the 2'- and 3'-oxygen atoms of tRNA's3'-terminal adenosine. The trapping of enzyme-bound tRNA(Leu) in the editing site prevents catalytic turnover, thus inhibiting synthesis of leucyl-tRNA(Leu) and consequentially blocking protein synthesis. This result establishes the editing site as a bona fide target for aminoacyl-tRNA synthetase inhibitors.


Nuclear magnetic resonance structure of the prohead RNA E-loop hairpin.
The Bacillus subtilis phage phi29 packaging motor requires prohead RNA for genome encapsidation. The nuclear magnetic resonance structure of the prohead RNA E-loop hairpin, r(5'AUUGAGUU), is presented and compared to predictions from MC-SYM. The prohead RNA E-loop hairpins contain sequences similar to rRNA hairpins. Comparison of predicted and experimentally determined prohead and ribosomal hairpin structures reveals that sequence similarity is a stronger determinant of hairpin structural similarity than grouping similar types of RNA. All the hairpins contain a U-turn motif but differ in the first noncanonical pair and backbone orientation. These structures provide benchmarks for further improvements in RNA structure predictions from sequence.


UV-B Robertson-Berger meter characterization and field calibration.
The New Zealand Meteorological Service has used a Robertson-Berger meter (RB meter) to monitor solar UV-B radiation for the past decade. The radiometric properties of the instrument have been analyzed and agree with the standard values published by Berger. A detailed theoretical treatment of the RB meter response that fully accounts for its cosine response is presented. Field measurements made with the RB meter and with a double monochromator spectral radiometer were used to validate the theoretical model and to derive a calibration for the RB meter. Only cloud-free data were considered so that the downward radiation field at the surface could be modeled as the sum of direct solar and isotropic diffuse components. The imperfect cosine responses of both instruments were modeled. A RB meter count was found to equate to 0.25 +/- 0.02 Jm(-2) referenced to 300-nm radiation at vertical incidence.


The Dutch Oxford Cognitive Screen (OCS-NL): psychometric properties in Flemish stroke survivors.
The Oxford Cognitive Screen is a stroke-specific screen to evaluate attention, executive functions, memory, praxis, language, and numeric cognition. It was originally validated in England for acute stroke patients. In this study, we examined the psychometric properties of the Dutch OCS (OCS-NL). A total of 193 (99 acute stroke unit, 94 rehabilitation unit) patients were included in our study. A subset of patients (n = 128) completed a retest with the parallel version of the OCS-NL. First, we did not find evidence for a difference in prevalence of impairment between patients in the acute stroke versus rehabilitation unit on all but one of the subtests. For praxis, we observed a 14% lower prevalence of impairment in the rehabilitation than the acute stroke unit. Second, the parallel-form reliability ranged from weak to excellent across subtests. Third, in stroke patients below age 60, the OCS-NL had a 92% sensitivity relative to the MoCA, while the MoCA had a 55% sensitivity relative to the OCS-NL. Last, although left-hemispheric stroke patients performed worse on almost all MoCA subdomains, they performed similarly to right-hemispheric stroke patients on non-language domains on the OCS-NL. Our results suggest that the OCS-NL is a reliable cognitive screen that can be used in acute stroke and rehabilitation units. The OCS-NL may be more sensitive to detect cognitive impairment in young stroke patients and less likely to underestimate cognitive abilities in left-hemispheric stroke patients than the MoCA.


A new class of chiral materials hosting magnetic skyrmions beyond room temperature.
Skyrmions, topologically protected vortex-like nanometric spin textures in magnets, have been attracting increasing attention for emergent electromagnetic responses and possible technological applications for spintronics. In particular, metallic magnets with chiral and cubic/tetragonal crystal structure may have high potential to host skyrmions that can be driven by low electrical current excitation. However, experimental observations of skyrmions have been limited to below room temperature for the metallic chiral magnets, specifically for the MnSi-type B20 compounds. Towards technological applications, transcending this limitation is crucial. Here we demonstrate the formation of skyrmions with unique spin helicity both at and above room temperature in a family of cubic chiral magnets: β-Mn-type Co-Zn-Mn alloys with a different chiral space group from that of B20 compounds. Lorentz transmission electron microscopy, magnetization and small-angle neutron scattering measurements unambiguously reveal formation of a skyrmion crystal under application of a magnetic field in both thin-plate and bulk forms.


Compliance Index, a Marker of Peripheral Arterial Stiffness, may Predict Renal Function Decline in Patients with Chronic Kidney Disease.
Compliance index derived from digital volume pulse (CI-DVP), measuring the relationship between volume and pressure changes in fingertip, is a surrogate marker of peripheral arterial stiffness. This study investigated if CI-DVP can predict renal function deterioration, cardiovascular events and mortality in patients with chronic kidney disease (CKD). In this prospective observational study, 149 CKD patients were included for final analysis. CI-DVP and brachial-ankle pulse wave velocity (baPWV) were measured, decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope. Composite renal and cardiovascular outcomes were evaluated, including ≥50% eGFR decline, start of renal replacement therapy, and major adverse events. Patients in CKD stages 3b to 5 had higher baPWV and lower CI-DVP values than those in patients with CKD stages 1 to 3a. Stepwise multivariate linear regression analysis showed that lower CI-DVP (p =0.0001) and greater proteinuria (p =0.0023) were independent determinants of higher eGFR decline rate. Multivariate Cox regression analysis revealed that CI-DVP (HR 0.68, 95% CI 0.46-1.00), baseline eGFR (HR 0.96, 95% CI 0.94-0.98) and serum albumin (HR 0.17, 95% CI 0.07-0.42) were independent predictors for composite renal and cardiovascular outcomes. Compliance index, CI-DVP, was significantly associated with renal function decline in patients with CKD. A higher CI-DVP may have independent prognostic value in slower renal function decline and better composite renal and cardiovascular outcomes in CKD patients.


The Impact of Aerosol Particle Mixing State on the Hygroscopicity of Sea Spray Aerosol.
Aerosol particles influence global climate by determining cloud droplet number concentrations, brightness, and lifetime. Primary aerosol particles, such as those produced from breaking waves in the ocean, display large particle-particle variability in chemical composition, morphology, and physical phase state, all of which affect the ability of individual particles to accommodate water and grow into cloud droplets. Despite such diversity in molecular composition, there is a paucity of methods available to assess how particle-particle variability in chemistry translates to corresponding differences in aerosol hygroscopicity. Here, an approach has been developed that allows for characterization of the distribution of aerosol hygroscopicity within a chemically complex population of atmospheric particles. This methodology, when applied to the interpretation of nascent sea spray aerosol, provides a quantitative framework for connecting results obtained using molecular mimics generated in the laboratory with chemically complex ambient aerosol. We show that nascent sea spray aerosol, generated in situ in the Atlantic Ocean, displays a broad distribution of particle hygroscopicities, indicative of a correspondingly broad distribution of particle chemical compositions. Molecular mimics of sea spray aerosol organic material were used in the laboratory to assess the volume fractions and molecular functionality required to suppress sea spray aerosol hygroscopicity to the extent indicated by field observations. We show that proper accounting for the distribution and diversity in particle hygroscopicity and composition are important to the assessment of particle impacts on clouds and global climate.


Oestrogenicity of paper and cardboard extracts used as food containers.
Bisphenol-A (BPA), dibutyl phthalate (DBP), and di-2-ethylhexyl phthalate (DEHP), which are common chemical residues in food-packaging materials, were investigated in paper and cardboard containers used for take-away food. The oestrogenicity of aqueous extracts was tested in E-Screen bioassay and analysis carried out by high-performance liquid chromatography (HPLC) and gas chromatography-mass spectrometry (GC/MS). Oestrogenicity was demonstrated in 90% of extracts (geometric mean [GM] = 11.97 pM oestradiol equivalents g(-1)). DEHP, DBP, and BPA (GM = 341.74, 37.59, and 2.38 ng g(-1) of material) were present in 77.50, 67.50, and 47.50% of samples, respectively. In bivariate analyses, no significant association was found between the levels of these chemicals and oestrogenicity in cardboard/paper extracts. A close-to-significant association was found between oestrogenicity and DBP (beta = 1.25; p = 0.06) in paper extracts, which reached statistical significance in multivariate analysis (beta = 1.61; p = 0.03). Paper and cardboard used in food packaging may contribute to the inadvertent exposure of consumers to endocrine-disrupting chemicals.


How pain management for children with cerebral palsy in South African schools complies with up-to-date knowledge.
Pain in children with cerebral palsy (CP) has its sources in musculoskeletal problems that can influence learning in a school setting. Best pain management is essential for these children, but school staff may not keep up to date with the latest developments and interventions. Therefore, staff's perceptions of beneficial strategies may not comply with contemporary scientific knowledge about effective evidence-based interventions. This study investigated how pain management intervention for children with CP in South African schools complied with international scientific knowledge about evidence-based interventions. The intention was to provide support for an update of knowledge on both individual level (i.e. professionals) and system level (i.e. decision makers). Five focus groups were conducted with staff members at five schools for children with special educational needs in South Africa. Manifest and latent content analyses of professional statements identified interventions reported as beneficial and related them to higher and lower levels of intervention evidence as reported at the time of data collection. Most treatment strategies concerned motor functioning that fell within the framework of physiotherapists and occupational therapists. Access to orthopaedic expertise was limited, waiting times were long and medication for spasticity treatment was not offered. A discrepancy between published evidence and clinical practice for pain management in children with CP in South African school settings was noted. Suggestions for improved early intervention to identify children's hips at risk through surveillance programmes; and orthopaedic management are proposed to prevent deformities and unnecessary suffering in South African children with CP.


Creating equal opportunities: the social accountability of medical education.
As new developments in medical education move inexorably forward, medical schools are being encouraged to revisit their curricula to ensure quality graduates and match their outcomes against defined standards. These standards may eventually be transferred into global accreditation standards, which allow 'safe passage' of graduates from one country to another [Educational Commission for Foreign Medical Graduates (ECFMG) 2010. Requiring medical school accreditation for ECFMG certification--moving accreditation forward. Available from: http://www.ecfmg.org/accreditation/rationale.pdf]. Gaining much attention is the important standard of social accountability--ensuring that graduates' competencies are shaped by the health and social needs of the local, national and even international communities in which they will serve. But, in today's 'global village', if medical schools address the needs of their immediate community, who should address the needs of the wider global community? Should medical educators and their associations be looking beyond national borders into a world of very unequal opportunities in terms of human and financial resources; a world in which distant countries and populations are very quickly affected by medical and social disasters; a world in which the global playing field of medical education is far from level? With medical schools striving to produce fit-for-purpose graduates who will hopefully address the health needs of their country, is it now time for the medical education fraternity to extend their roles of social accountability to level this unlevel playing field? We believe so: the time has come for the profession to embrace a global accountability model and those responsible for all aspects of healthcare professional development to recognise their place within the wider global community.


The need for consistent nomenclature and assessment of growth phases in diauxic cultures of Saccharomyces cerevisiae.
The need for consistent nomenclature and accurate assessment of late growth phases in diauxic yeast cultures is highlighted by the substantial variation of stress tolerance in Saccharomyces cerevisiae after the exhaustion of the initial fermentable carbon source. At present, a wide variety of assessment methods and confused terminology exists in the literature, leading to difficulties in the interpretation and comparison of published results. A method based on the depletion of ethanol accumulated during the respiro-fermentative growth phase is suggested as suitable for assessing subsequent growth phases and reporting results. Consistent application of nomenclature for growth phases is recommended to assist the interpretation of published experimental results. It is suggested that the phases of growth in diauxic batch culture should be referred to using the terms (1) initial lag phase, (2) respiro-fermentative phase, (3) diauxic lag phase, (4) respiratory phase, (5) stationary phase, and (6) death phase.


Serial analysis of gene expression in Plasmodium falciparum reveals the global expression profile of erythrocytic stages and the presence of anti-sense transcripts in the malarial parasite.
Serial analysis of gene expression (SAGE) was applied to the malarial parasite Plasmodium falciparum to characterize the comprehensive transcriptional profile of erythrocytic stages. A SAGE library of approximately 8335 tags representing 4866 different genes was generated from 3D7 strain parasites. Basic local alignment search tool analysis of high abundance SAGE tags revealed that a majority (88%) corresponded to 3D7 sequence, and despite the low complexity of the genome, 70% of these highly abundant tags matched unique loci. Characterization of these suggested the major metabolic pathways that are used by the organism under normal culture conditions. Furthermore several tags expressed at high abundance (30% of tags matching to unique loci of the 3D7 genome) were derived from previously uncharacterized open reading frames, demonstrating the use of SAGE in genome annotation. The open platform "profiling" nature of SAGE also lead to the important discovery of a novel transcriptional phenomenon in the malarial pathogen: a significant number of highly abundant tags that were derived from annotated genes (17%) corresponded to antisense transcripts. These SAGE data were validated by two independent means, strand specific reverse transcription-polymerase chain reaction and Northern analysis, where antisense messages were detected in both asexual and sexual stages. This finding has implications for transcriptional regulation of Plasmodium gene expression.


Cancer survival in New Zealand: ethnic, social and geographical inequalities.
This study investigated the combined effects of ethnicity, deprivation and geographical access to health services on the likelihood of survival from a range of common cancers in New Zealand. Individual cancer registry records of 99,062 cases of melanoma, colorectal, lung, breast and prostate cancers diagnosed in the period 1994-2004 were supplemented with small area information on social deprivation and estimates of travel time to the nearest primary care and cancer centre. Logistic regression was used to identify the variables associated with advanced extent of the disease at diagnosis. Adverse influences on survival were investigated using Cox proportional hazards models. Controlling for age and gender, Māori and Pacific peoples' ethnicity was strongly associated with poorer survival, partly because ethnicity was also linked to the likelihood of advanced disease at diagnosis. Living in a deprived area was related to later stage presentation and poorer survival of people with melanoma, but there was no other evidence that living in a deprived area or in a remote location were associated with later stage presentation. Some disease-specific trends in survival were observed. Colorectal and lung cancers were more likely to be fatal for people living in deprived areas, survival from prostate cancer was poor for men living remote from primary care, and people with colorectal, breast and prostate cancers had adverse survival chances if they lived distant from a cancer centre.


CT-guided biopsies: quality, complications and impact on treatment: a retrospective initial quality control.
To retrospectively evaluate the quality and complications of CT-guided biopsies and their impact on treatment. A total of 265 CT-guided interventions performed during a 6-month period were extracted by digital database query. These included 127 CT-guided biopsies, which were classified by patient age, organ/body area, histopathological biopsy diagnosis, complications, and performing physician. In 51 % of cases (65 / 127), CT-guided biopsies led to a malignant diagnosis and a change in the patient's treatment. Retrospectively, complications were to be expected in a range of 12 - 26 %, given a 95 % confidence interval. In terms of organ/body area, most complications occurred in lung biopsies (23 / 56; 41 %). 80 % of CT-guided biopsies were performed without complications. 2 of the 11 physicians performed 66 % of all biopsies (84 / 127) and had significantly fewer complications than the others. Patient age was a statistically significant factor for complications (p < 0.018) as well as for a malignant biopsy diagnosis (p < 0.009). Our initial quality control assessment suggests that frequent use of CT-guided biopsy by the performing physician rather than the general level of experience is associated with fewer complications for patients. Age is a significant factor for complications of CT-guided biopsies, thus leading to an increased risk/benefit ratio. As expected, age also significantly increases the risk of a malignant biopsy result. Complications and malignant biopsy results were not significantly associated. CT-guided biopsies triggered a change in treatment in over 50 % of cases.


Correlating multiallelic copy number polymorphisms with disease susceptibility.
The human genome contains a significant amount of sequence variation, from single nucleotide polymorphisms to large stretches of DNA that may be present in a range of different copies between individuals. Several such regions are variable in >1% of the population (referred to as copy number polymorphisms or CNPs), and many studies have looked for associations between the copy number of genes within multiallelic CNPs and disease susceptibility. Associations have indeed been described for several genes, including the β-defensins (DEFB4, DEFB103, DEFB104), chemokine ligand 3 like 1 (CCL3L1), Fc gamma receptor 3B (FCGR3B), and complement component C4 (C4). However, follow-up replication in independent cohorts has failed to reproduce a number of these associations. It is clear that replicated associations such as those between C4 and systemic lupus erythematosus, and β-defensin and psoriasis, have used robust genotyping methodologies. Technical issues associated with genotyping sequences of high identity may therefore account for failure to replicate other associations. Here, we compare and contrast the most popular approaches that have been used to genotype CNPs, describe how they have been applied in different situations, and discuss potential reasons for the difficulty in reproducibly linking multiallelic CNPs to complex diseases.


Update on Treatment of Acute Ischemic Stroke.
The article "Update on Treatment of Acute Ischemic Stroke" by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as "Treatment of Acute Ischemic Stroke" and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief. PURPOSE OF REVIEWThis article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.RECENT FINDINGSIn addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.SUMMARYTimely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.


Oncolytic adenoviruses - selective retargeting to tumor cells.
Virotherapy is an approach for the treatment of cancer, in which the replicating virus itself is the anticancer agent. Virotherapy exploits the lytic property of virus replication to kill tumor cells. As this approach relies on viral replication, the virus can self-amplify and spread in the tumor from an initial infection of only a few cells. The success of this approach is fundamentally based on the ability to deliver the replication-competent viral genome to target cells with a requisite level of efficiency. With virotherapy, while a number of transcriptional retargeting strategies have been utilized to restrict viral replication to tumor cells, this review will focus primarily on transductional retargeting strategies, whereby oncolytic viruses can be designed to selectively infect tumor cells. Using the adenoviral vector paradigm, there are three broad strategies useful for viral retargeting. One strategy uses heterologous retargeting ligands that are bispecific in that they bind both to the viral vector as well as to a cell surface target. A second strategy uses genetically modified viral vectors in which a cellular retargeting ligand is incorporated. A third strategy involves the construction of chimeric recombinant vectors, in which a capsid protein from one virus is exchanged for that of another. These transductional retargeting strategies have the potential for reducing deleterious side effects, and increasing the therapeutic index of virotherapeutic agents.


Occupational social class, educational level, smoking and body mass index, and cause-specific mortality in men and women: a prospective study in the European Prospective Investigation of Cancer and Nutrition in Norfolk (EPIC-Norfolk) cohort.
To investigate the independent associations between occupational and educational based measures of socioeconomic status (SES) and cause-specific mortality, and the extent to which potentially modifiable risk factors smoking and body mass index (BMI) explain such relationships. Prospective population study of 22,486 men and women aged 39-79 years living in the general community in Norfolk, United Kingdom, recruited using general practice age-sex registers in 1993-1997 and followed up for total mortality using death certification to 2006. In men a strong inverse relationship was found between social class and all cause, cardiovascular and cancer mortality, with relative risk of social class V compared to I of 2.21 for all cause mortality (95% CI 1.54-3.17, P < 0.001). This was attenuated but not abolished after adjusting for modifiable risk factors, smoking and BMI, with relative risk of social class V compared to I for all cause mortality of 1.92 (95% CI 1.34-2.77, P < 0.001). A similar, but smaller effect was seen in women. Educational status was not associated with mortality independently of social class. Social class and education are not necessarily interchangeable measures of SES. Some but not all of the socioeconomic differential in mortality can be explained by potentially modifiable risk factors smoking and BMI. Further understanding of the mechanisms underlying the association of each socioeconomic indicator with specific health outcomes is needed if we are to reduce inequalities in health.


Effect of vitamin D supplementation on glycaemic control and insulin resistance: a systematic review and meta-analysis.
To systematically review the evidence for the effect of vitamin D supplementation on glycaemia, insulin resistance, progression to diabetes and complications of diabetes. Systematic review and meta-analysis. We searched databases including MEDLINE, EMBASE and the Cochrane Library for randomized controlled trials comparing vitamin D or analogues with placebo. We extracted data on fasting glucose, glycaemic control, insulin resistance, insulin/C-peptide levels, micro- and macrovascular outcomes and progression from non-diabetes to diabetes. Studies were assessed independently by two reviewers according to a pre-specified protocol. Fifteen trials were included in the systematic review. Trial reporting was of moderate, variable quality. Combining all studies, no significant improvement was seen in fasting glucose, HbA(1c) or insulin resistance in those treated with vitamin D compared with placebo. For patients with diabetes or impaired glucose tolerance, meta-analysis showed a small effect on fasting glucose (-0.32 mmol/l, 95%CI -0.57 to -0.07) and a small improvement in insulin resistance (standard mean difference -0.25, 95%CI -0.48 to -0.03). No effect was seen on glycated haemoglobin in patients with diabetes and no differences were seen for any outcome in patients with normal fasting glucose. Insufficient data were available to draw conclusions regarding micro- or macrovascular events; two trials failed to show a reduction in new cases of diabetes in patients treated with vitamin D. There is currently insufficient evidence of beneficial effect to recommend vitamin D supplementation as a means of improving glycaemia or insulin resistance in patients with diabetes, normal fasting glucose or impaired glucose tolerance.


[A case of paraneoplastic cerebellar degeneration with resting tremor].
A 65-year-old woman was operated for gastric adenocarcinoma in 1989. Six years later, peritonitis carcinomatosa, swelling of periaortic lymphnodes and high serum CA-125 were discovered. She received chemotherapy with 5-FU and cisplatin resulting in reduction of ascites. In September, 1998, the swelling of left supraclavicular lymphnodes and the elevation of serum CA-125 reappeared. Pathological diagnosis of supraclavicular lymphnodes was adenocarcinoma. Serum CA-125 was normalized by chemotherapy using cisplatin, farumorubicin and endoxan. However, unsteadiness appeared since December 10, 1998 followed by dysarthria and involuntary movement of neck and upper limbs. These symptoms progressed subacutely. The physical examination on admission revealed swelling of left suraclavicular lymphnodes, nystagmus on lateral gaze, saccadic eye movement on smooth pursuit and severe cerebellar ataxia. In addition, resting tremor of 3-4 Hz was observed at right hand, left wrist and neck which tended to increase amplitude by calculation. Similar movements were seen in the left first toe, though the frequency was lower. Brain MRI revealed mild cerebellar atrophy. She was diagnosed as paraneoplastic cerebellar degeneration (PCD) by serum anti Yo antibody and clinical course. The study of HLA showed positive link to A4 without A24. The primary focus of adenocarcinoma in cervical lymphnodes was suggested to be ovary rather than stomach due to the pattern of immunostaining for cytokeratin, CEA and CA125, although no carcinoma was found in ovarium clinically. The feature of this case is a PCD with resting tremor of frequency of 3-4 Hz and negative link to HLA-A24 in Japanese.


Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking.
To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.


Building blocks of the nexin-dynein regulatory complex in Chlamydomonas flagella.
The directional flow generated by motile cilia and flagella is critical for many processes, including human development and organ function. Normal beating requires the control and coordination of thousands of dynein motors, and the nexin-dynein regulatory complex (N-DRC) has been identified as an important regulatory node for orchestrating dynein activity. The nexin link appears to be critical for the transformation of dynein-driven, linear microtubule sliding to flagellar bending, yet the molecular composition and mechanism of the N-DRC remain largely unknown. Here, we used proteomics with special attention to protein phosphorylation to analyze the composition of the N-DRC and to determine which subunits may be important for signal transduction. Two-dimensional electrophoresis and MALDI-TOF mass spectrometry of WT and mutant flagellar axonemes from Chlamydomonas identified 12 N-DRC-associated proteins, including all seven previously observed N-DRC components. Sequence and PCR analyses identified the mutation responsible for the phenotype of the sup-pf-4 strain, and biochemical comparison with a radial spoke mutant revealed two components that may link the N-DRC and the radial spokes. Phosphoproteomics revealed eight proteins with phosphorylated isoforms for which the isoform patterns changed with the genotype as well as two components that may play pivotal roles in N-DRC function through their phosphorylation status. These data were assembled into a model of the N-DRC that explains aspects of its regulatory function.


Neural correlates of evidence accumulation during value-based decisions revealed via simultaneous EEG-fMRI.
Current computational accounts posit that, in simple binary choices, humans accumulate evidence in favour of the different alternatives before committing to a decision. Neural correlates of this accumulating activity have been found during perceptual decisions in parietal and prefrontal cortex; however the source of such activity in value-based choices remains unknown. Here we use simultaneous EEG-fMRI and computational modelling to identify EEG signals reflecting an accumulation process and demonstrate that the within- and across-trial variability in these signals explains fMRI responses in posterior-medial frontal cortex. Consistent with its role in integrating the evidence prior to reaching a decision, this region also exhibits task-dependent coupling with the ventromedial prefrontal cortex and the striatum, brain areas known to encode the subjective value of the decision alternatives. These results further endorse the proposition of an evidence accumulation process during value-based decisions in humans and implicate the posterior-medial frontal cortex in this process.


Tear physiology in dry eye associated with chronic GVHD.
The purpose of this study was to compare tear physiology characteristics of chronic GVHD (cGVHD)-associated dry eye to dry eye caused by Sjogren's syndrome (SS), a extreme form of aqueous-deficient dry eye, and meibomian gland dysfunction (MGD), the major cause of evaporative dry eye. Tear turnover rate, evaporation and osmolarity along with meibomian gland dropout and lipid layer interferometric patterns were assessed in the right eyes of 12 patients with dry eye associated with cGVHD, 12 age-matched patients with SS and 12 age-sex matched subjects with MGD. In cGVHD, the decrease in tear turnover rate was similar (P=0.33), but the number of non-functioning meibomian glands was significantly higher (P<0.01) than in SS. Tear evaporation rate in cGVHD dry eye was found to be similar to that in MGD (P=0.36) and significantly higher than in SS (P<0.01). The lipid layer was most unstable in cGVHD compared with other groups. There was no variation in tear volume across all groups. Although statistical significance was not detected, the mean tear osmolarity (333.51±14.67mOsm/L) was highest in cGVHD. Major aspects of tear physiology were severely impaired in cGVHD-associated dry eye.


Bridging the Gap Between the Classroom and the Clerkship: A Clinical Reasoning Curriculum for Third-Year Medical Students.
Clinical reasoning is the complex cognitive process that drives the diagnosis of disease and treatment of patients. There is a national call for medical educators to develop clinical reasoning curricula in undergraduate medical education. To address this need, we developed a longitudinal clinical reasoning curriculum for internal medicine clerkship students. We delivered six 1-hour sessions to approximately 40 students over the 15-week combined medicine-surgery clerkship at Penn State College of Medicine. We developed the content using previous work in clinical reasoning, including the American College of Physicians' Teaching Medicine Series book Teaching Clinical Reasoning. Students applied a clinical reasoning diagnostic framework to written cases during each workshop. Each session followed a scaffold approach and built upon previously learned clinical reasoning skills. We administered a pre- and postsurvey to assess students' baseline knowledge of clinical reasoning concepts and perceived confidence in performing clinical reasoning skills. Students also provided open-ended responses regarding the effectiveness of the curriculum. The curriculum was well received by students and led to increased perceived knowledge of clinical reasoning concepts and increased confidence in applying clinical reasoning skills. Students commented on the usefulness of practicing clinical reasoning in a controlled environment while utilizing a framework that could be deliberately applied to patient care. The longitudinal clinical reasoning curriculum was effective in reinforcing key concepts of clinical reasoning and allowed for deliberate practice in a controlled environment. The curriculum is generalizable to students in both the preclinical and clinical years.


Signatures of natural selection are not uniform across genes of innate immune system, but purifying selection is the dominant signature.
We tested the opposing views concerning evolution of genes of the innate immune system that (i) being evolutionary ancient, the system may have been highly optimized by natural selection and therefore should be under purifying selection, and (ii) the system may be plastic and continuing to evolve under balancing selection. We have resequenced 12 important innate-immunity genes (CAMP, DEFA4, DEFA5, DEFA6, DEFB1, MBL2, and TLRs 1, 2, 4, 5, 6, and 9) in healthy volunteers (n = 171) recruited from a region of India with high microbial load. We have compared these data with those of European-Americans (EUR) and African-Americans (AFR). We have found that most of the human haplotypes are many mutational steps away from the ancestral (chimpanzee) haplotypes, indicating that humans may have had to adapt to new pathogens. The haplotype structures in India are significantly different from those of EUR and AFR populations, indicating local adaptation to pathogens. In these genes, there is (i) generally an excess of rare variants, (ii) high, but variable, degrees of extended haplotype homozygosity, (iii) low tolerance to nonsynonymous changes, (iv) essentially one or a few high-frequency haplotypes, with star-like phylogenies of other infrequent haplotypes radiating from the modal haplotypes. Purifying selection is the most parsimonious explanation operating on these innate immunity genes. This genetic surveillance system recognizes motifs in pathogens that are perhaps conserved across a broad range of pathogens. Hence, functional constraints are imposed on mutations that diminish the ablility of these proteins to detect pathogens.


Evaluation of putative renal cell carcinoma markers PAX-2, PAX-8, and hKIM-1 in germ cell tumors: a tissue microarray study of 100 cases.
In a subset of cases, metastatic renal cell carcinoma can demonstrate significant morphologic overlap with germ cell neoplasms, making accurate diagnosis challenging. In such cases, immunohistochemistry is often used as an adjunct diagnostic tool. Expression of the putative renal cell carcinoma markers PAX-2, PAX-8, and hKIM-1 has been reported in a small series of certain germ cell tumors, raising doubt about their specificity for renal cell carcinoma. To further characterize these markers, we evaluated PAX-2, PAX-8, and hKIM-1 staining in 100 germ cell tumors using tissue microarrays. PAX-2 and PAX-8 staining was identified in 50% and 25% of yolk sac tumors (respectively), with hKIM-1 staining identified in 48% of embryonal carcinomas and 50% of yolk sac tumors. All other germ tumor cells (notably including 62 seminomas) were negative for all 3 markers, in contrast to prior reports of PAX-8 reactivity in seminoma. This study indicates that PAX-2, PAX-8, and hKIM-1 should be used cautiously in distinguishing renal cell carcinoma from nonseminomatous germ cell neoplasia and also adds to the growing list of nonrenal tumors that express these 3 markers.


Surgical technique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge.
Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis. An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability. A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores. As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort. This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation. Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.


Towards better triage of infants suspected of cow's milk allergy: development of a preliminary multivariable diagnostic index.
The double-blind placebo-controlled food challenge (DBPCFC) is currently the gold standard to diagnose cow's milk allergy (CMA). However, DBPCFCs are burdensome, expensive and require specialised facilities. For primary care physicians, selective and consistent referral to DBPCFC of infants suspected of CMA may be difficult. The objective of this study was to assess the predictive value of clinical parameters for a positive DBPCFC in infants suspected of CMA. Clinical data from 124 infants suspected of CMA that had undergone a DBPCFC were collected. Out of a total of 23 parameters, nine candidate predictors were selected on clinical grounds. We used bootstrapped logistic regression analysis to find a more parsimonious and practical model. The prevalence of a positive DBPCFC was 34.7 % (95 % CI from 27 to 43). A well-calibrated diagnostic model containing as predictors abdominal cramps, inconsolable crying and the objective SCORAD index discriminated moderately well between infants with and without a positive DBPCFC. The area under the ROC curve was 0.68 (95 % CI from 0.58 to 0.78). The fifth and 95th percentiles of the positive DBPCFC predictive probability distribution were 17 and 73 % (17 and 59 % after correction for over-optimism). We conclude that a diagnostic model with three clinical parameters may be used for better referral of children suspected of CMA and the decision to either initially perform an open food challenge or directly perform a DBPCFC. Large prospective studies are needed to validate these findings and provide additional precision.


Quantitation of dihydropyrimidine dehydrogenase expression by real-time reverse transcription polymerase chain reaction.
Several recent studies have reported a correlation between intratumor dihydropyrimidine dehydrogenase (DPD) messenger RNA (mRNA) levels and sensitivity to 5-fluorouracil (5-FU). However, significant tissue requirements and labor-intensive methodology have limited the large-scale studies necessary for statistical validation. In addition, the semiquantitative results obtained by these methods further limit their application. We have developed a real-time reverse transcription-PCR (RT-PCR) assay, based on TaqMan fluorescence methodology, capable of rapid and accurate quantitation of DPD mRNA levels in biopsy-sized tissue samples. Results obtained with this approach indicate a linear dynamic range of 10(8)-10(3) DPD mRNA copies, with an intra-assay variation of <5%. We evaluated the data using three different methods (absolute standard curve, relative standard curve, and comparative C(T)) and show them to be equivalent. This RT-PCR assay was validated by quantitative comparison to Northern blot analysis in five tissues. In addition, analysis of 18 colorectal tumor and liver tissue specimens demonstrated a significant correlation (r(2) = 0.90) between DPD enzyme activity and mRNA levels. This method provides the first high-throughput, reproducible, and sensitive technique capable of determining DPD mRNA expression levels in nanogram amounts of total RNA.


DNA sequence evolution of the amylase multigene family in Drosophila pseudoobscura.
The alpha-Amylase locus in Drosophila pseudoobscura is a multigene family of one, two or three copies on the third chromosome. The nucleotide sequences of the three Amylase genes from a single chromosome of D. pseudoobscura are presented. The three Amylase genes differ at about 0.5% of their nucleotides. Each gene has a putative intron of 71 (Amy1) or 81 (Amy2 and Amy3) bp. In contrast, Drosophila melanogaster Amylase genes do not have an intron. The functional Amy1 gene of D. pseudoobscura differs from the Amy-p1 gene of D. melanogaster at an estimated 13.3% of the 1482 nucleotides in the coding region. The estimated rate of synonymous substitutions is 0.398 +/- 0.043, and the estimated rate of nonsynonymous substitutions is 0.068 +/- 0.008. From the sequence data we infer that Amy2 and Amy3 are more closely related to each other than either is to Amy1. From the pattern of nucleotide substitutions we reason that there is selection against synonymous substitutions within the Amy1 sequence; that there is selection against nonsynonymous substitutions within the Amy2 sequence, or that Amy2 has recently undergone a gene conversion with Amy1; and that Amy3 is nonfunctional and subject to random genetic drift.


Hsp72 overexpression accelerates the recovery from caerulein-induced pancreatitis.
Heat shock protein (Hsp) 72 is a molecular chaperone which is upregulated in response to a variety of stress situations and has a general cytoprotective function. Increased Hsp72 levels were implicated in protection from acute pancreatitis; a hypothesis which was not tested in a transgenic mouse model yet. To analyze the role of Hsp72 during acute pancreatitis, well-characterized transgenic animals overexpressing rat Hsp72 (Hsp72 mice) under the control of the ß-actin promoter were subjected to caerulein- and L-arginine-induced acute pancreatitis. The severity of experimental pancreatitis was determined via serum lipase levels, morphometric evaluation and quantification of pancreatic edema/inflammation. Hsp72 mice displayed ∼100-times Hsp72 overexpression, but no changes in the remaining chaperones. Robust Hsp72 signal was observed in pancreatic acini, but not in islets or ductal cells. In both models, elevated Hsp72 did not protect from development of acute pancreatitis and the pancreatitis-associated lung injury, but accelerated recovery from caerulein-induced tissue injury (lower lipase levels, edema, inflammation and necrosis 36 h after caerulein administration). The observed protective function of Hsp72 in caerulein-induced pancreatitis is likely due to an attenuated NF-κB signalling. Hsp72 overexpression accelerates the recovery from acute pancreatitis and may represent a potential treatment strategy.


Do consumers' preferences for improved provision of malaria treatment services differ by their socio-economic status and geographic location? A study in southeast Nigeria.
Improvement of utilization of malaria treatment services will depend on provision of treatment services that different population groups of consumers prefer and would want to use. Treatment of malaria in Nigeria is still problematic and this contributes to worsening burden of the disease in the country. Therefore this study explores the socio-economic and geographic differences in consumers' preferences for improved treatment of malaria in Southeast Nigeria and how the results can be used to improve the deployment of malaria treatment services. This study was undertaken in Anambra state, Southeast Nigeria in three rural and three urban areas. A total of 2,250 randomly selected householders were interviewed using a pre tested interviewer administered questionnaire. Preferences were elicited using both a rating scale and ranking of different treatment provision sources by the respondents. A socio-economic status (SES) index was used to examine for SES differences, whilst urban-rural comparison was used to examine for geographic differences, in preferences. The most preferred source of provision of malaria treatment services was public hospitals (30.5%), training of mothers (19%) and treatment in Primary healthcare centres (18.1%). Traditional healers (4.8%) and patent medicine dealers (4.2%) were the least preferred strategies for improving malaria treatment. Some of the preferences differed by SES and by a lesser extent, the geographic location of the respondents. Preferences for provision of improved malaria treatment services were influenced by SES and by geographic location. There should be re-invigoration of public facilities for appropriate diagnosis and treatment of malaria, in addition to improving the financial and geographic accessibility of such facilities. Training of mothers should be encouraged but home management will not work if the quality of services of patent medicine dealers and pharmacy shops where drugs for home management are purchased are not improved. Therefore, there is the need for a holistic improvement of malaria treatment services.


Risk stratification for readmission after major hepatectomy: development of a readmission risk score.
Hospital readmission is becoming a quality measure, despite poor understanding of the risks of readmission. This study examines readmission risk factors after major hepatectomy and develops a predictive model. A retrospective review was performed on patients who had undergone major hepatectomy at 1 of 3 academic centers between the years 2000 and 2012. Clinicopathologic and perioperative data were analyzed for risk factors of 90-day readmission using logistic regression. A readmission risk score was developed and validated in a separate validation set to determine its predictive value. Of 1,184 hepatectomies performed, 17.3% of patients were readmitted within 90 days. Factors associated with readmission include operative blood loss (odds ratio [OR] = 1.00; 95% CI, 1.000-1.001), any postoperative complication (OR = 4.3; 95% CI, 1.8-10.4), a major postoperative complication (OR = 5.7; 95% CI, 3.2-10.2), postoperative pulmonary embolism (OR = 12.2; 95% CI, 1.9-78.4), no postoperative blood transfusion (OR = 3.3; 95% CI, 1.7-6.2), surgical site infection (OR = 5.3; 95% CI, 2.9-10.0), and post-hepatectomy hyperbilirubinemia (OR = 1.1; 95% CI, 1.1-1.2). A scoring system based on these risk factors accurately predicted readmission in the validation cohort. A score of >20 points had a positive predictive value of 30.8% and negative predictive value of 95.6%, and a score >50 had a positive predictive value of 50.9% and negative predictive value of 87.7%. This risk score accurately stratifies readmission risk. The risk of hospital readmission within 90 days after major hepatectomy is high and is reliably predicted with a novel scoring system.


Tailoring your heart failure project for success in rural areas.
The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model. An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge. Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted. The IPC was effective in decreasing HF readmissions. These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF.


Exposure to childhood abuse is associated with human sperm DNA methylation.
Offspring of persons exposed to childhood abuse are at higher risk of neurodevelopmental and physical health disparities across the life course. Animal experiments have indicated that paternal environmental stressors can affect sperm DNA methylation and gene expression in an offspring. Childhood abuse has been associated with epigenetic marks in human blood, saliva, and brain tissue, with statistically significant methylation differences ranging widely. However, no studies have examined the association of childhood abuse with DNA methylation in gametes. We examined the association of childhood abuse with DNA methylation in human sperm. Combined physical, emotional, and sexual abuse in childhood was characterized as none, medium, or high. DNA methylation was assayed in 46 sperm samples from 34 men in a longitudinal non-clinical cohort using HumanMethylation450 BeadChips. We performed principal component analysis and examined the correlation of principal components with abuse exposure. Childhood abuse was associated with a component that captured 6.2% of total variance in DNA methylation (p < 0.05). Next, we investigated the regions differentially methylated by abuse exposure. We identified 12 DNA regions differentially methylated by childhood abuse, containing 64 probes and including sites on genes associated with neuronal function (MAPT, CLU), fat cell regulation (PRDM16), and immune function (SDK1). We examined adulthood health behaviors, mental health, and trauma exposure as potential mediators of an association between abuse and DNAm, and found that mental health and trauma exposure partly mediated the association. Finally, we constructed a parsimonious epigenetic marker for childhood abuse using a machine learning approach, which identified three probes that predicted high vs. no childhood abuse in 71% of participants. Our results suggested that childhood abuse is associated with sperm DNA methylation, which may have implications for offspring development. Larger samples are needed to identify with greater confidence specific genomic regions differentially methylated by childhood abuse.


Atrial Fibrillation Detection and Atrial Fibrillation Burden Estimation via Wearables.
Atrial Fibrillation (AF) is an important cardiac rhythm disorder, which if left untreated can lead to serious complications such as a stroke. AF can remain asymptomatic, and it can progressively worsen over time; it is thus a disorder that would benefit from detection and continuous monitoring with a wearable sensor. We develop an AF detection algorithm, deploy it on a smartwatch, and prospectively and comprehensively validate its performance on a real-world population that included patients diagnosed with AF. The algorithm showed a sensitivity of 87.8% and a specificity of 97.4% over every 5-minute segment of PPG evaluated. Furthermore, we introduce novel algorithm blocks and system designs to increase the time of coverage and monitor for AF even during periods of motion noise and other artifacts that would be encountered in daily-living scenarios. An average of 67.8% of the entire duration the patients wore the smartwatch produced a valid decision. Finally, we present the ability of our algorithm to function throughout the day and estimate the AF burden, a first-of-this-kind measure using a wearable sensor, showing 98% correlation with the ground truth and an average error of 6.2%.


Enteric methane emission, milk production, and composition of dairy cows fed 3-nitrooxypropanol.
This study examined the effect of 3-nitrooxypropanol (3-NOP), an investigational substance, on enteric methane emission, milk production, and composition in Holstein dairy cows. Following a 3-wk covariate period, 48 multi- and primiparous cows averaging (± standard deviation) 118 ± 28 d in milk, 43.4 ± 8 kg/d milk yield, and 594 ± 57 kg of body weight were blocked based on days in milk, milk yield, and enteric methane emission and randomly assigned to 1 of 2 treatment groups: (1) control, no 3-NOP, and (2) 3-NOP applied at 60 mg/kg feed dry matter. Inclusion of 3-NOP was through the total mixed ration and fed for 15 consecutive weeks. Cows were housed in a freestall barn equipped with a Calan Broadbent Feeding System (American Calan Inc., Northwood, NH) for monitoring individual dry matter intake and fed ad libitum once daily. Enteric gaseous emissions (methane, carbon dioxide, and hydrogen) were measured using 3 GreenFeed (C-Lock Inc., Rapid City, SD) units. Dry matter intake, cow body weight, and body weight change were not affected by 3-NOP. Compared with the control group, 3-NOP applied at 60 mg/kg feed dry matter decreased daily methane emission, emission yield, and emission intensity by 26, 27, and 29%, respectively. Enteric emission of carbon dioxide was not affected, and hydrogen emission was increased 6-fold by 3-NOP. Administration of 3-NOP had no effect on milk and energy-corrected milk yields and feed efficiency, increased milk fat and milk urea nitrogen concentrations, and increased milk fat yield but had no other effects on milk components. Concentration of C6:0 and C8:0 and the sum of saturated fatty acids in milk fat were increased by 3-NOP. Total trans fatty acids and the sum of polyunsaturated fatty acids were decreased by 3-NOP. In this experiment, 3-NOP decreased enteric methane daily emission, yield, and intensity without affecting dry matter intake and milk yield, but increased milk fat in high-producing dairy cows.


Energy transfer on the MgO surface, monitored by UV-induced H2 chemisorption.
Surface anions on edges (4-coordinated = 4C) and on corners (3-coordinated = 3C) of cubic MgO nanoparticles exhibit UV resonance absorptions around 5.5 and 4.6 eV, respectively. After monochromatic excitation of either site the electron paramagnetic resonance (EPR) spectrum exhibits exclusively signal components related to 3-coordinated O- radicals (O-(3C), electron hole centers), which are perfectly bleached by H(2) addition. The disappearance of the O-(3C) EPR signal components is paralleled by a depletion of the UV resonance absorption of the 3-coordinated O(2-) only and the appearance of one single band in the OH stretching region of the IR spectrum. Obviously the sites of UV excitation and subsequent UV induced surface reaction with H(2) are not the same. This may coherently be explained in terms of mobility of the exciton (O(2-)(4C)* or--after ionization--of the corresponding electron hole O-(4C) along the edge where it was created. Finally the mobile state is trapped at a corner site where the O(3C)H group is formed.


Unravelling the γ-butyrolactone network in Streptomyces coelicolor by computational ensemble modelling.
Antibiotic production is coordinated in the Streptomyces coelicolor population through the use of diffusible signaling molecules of the γ-butyrolactone (GBL) family. The GBL regulatory system involves a small, and not completely defined two-gene network which governs a potentially bi-stable switch between the "on" and "off" states of antibiotic production. The use of this circuit as a tool for synthetic biology has been hampered by a lack of mechanistic understanding of its functionality. We here present the creation and analysis of a versatile and adaptable ensemble model of the Streptomyces GBL system (detailed information on all model mechanisms and parameters is documented in http://www.systemsbiology.ls.manchester.ac.uk/wiki/index.php/Main_Page). We use the model to explore a range of previously proposed mechanistic hypotheses, including transcriptional interference, antisense RNA interactions between the mRNAs of the two genes, and various alternative regulatory activities. Our results suggest that transcriptional interference alone is not sufficient to explain the system's behavior. Instead, antisense RNA interactions seem to be the system's driving force, combined with an aggressive scbR promoter. The computational model can be used to further challenge and refine our understanding of the system's activity and guide future experimentation.


Diurnal variation of human tear meniscus volume measured with tear strip meniscometry self-examination.
Tear secretion is critical for maintenance of healthy ocular surface and vision. Most of normal subjects and dry eye patients feel worsening of ocular dryness in the afternoon, however, diurnal variation of tear meniscus volume has not been directly measured because there was no appropriate method. We used a simple, non-invasive technique, tear strip meniscometry (SM) by self-examination. Previous investigations indicated the values of SM correlated strongly with those of the Schirmer test, tests of tear break up time, and tear meniscus height measurement by anterior optical coherence tomography. The purpose of this study was to capture diurnal variation of aqueous availability at the tear meniscus by measuring wetted length using SM through self-examination. Thirty-six medical personnel (mean age; 35.7 years) participated and SM self-examination was performed using a mirror seven times a day. The strip is applied for 5 seconds to the lateral side of the lower lid tear meniscus without touching the ocular surface. The measured SM value was the highest upon awakening (4.44 ± 3.14 mm) and gradually decreased in the evening; 3.81 ± 3.12 at 9:00, 3.31 ± 2.72* at 12:00, 2.89 ± 1.88* at 15:00, 2.92 ± 1.87* at 18:00, 2.78 ± 1.85* at 21:00, and 2.89 ± 1.75* at bedtime with statistical significance compared to the value upon awakening (*P < 0.05, Dunnett's multiple comparison test). Proportion of number of subjects with low SM value (< 4 mm) to total number of subjects was 52.8% upon awakening and 83.3% at 21:00, and gradually increased toward evening. Our results could identify diurnal variation of tear meniscus volume in the general population.


Impact of Interferon-α Receptor-1 Promoter Polymorphisms on the Transcriptome of the Hepatitis B Virus-Associated Hepatocellular Carcinoma.
Genetic polymorphisms within the promoter of interferon-α receptor type-1 (IFNAR1) have been associated with the susceptibility to and the outcome of chronic hepatitis B virus (HBV) infection. However, the impact of these polymorphisms in the transcriptome of the HBV-associated hepatocellular carcinoma (HCC) remains largely unexplored. Using whole-genome and exome sequencing data from The Cancer Genome Atlas project, we characterized three single-nucleotide polymorphisms (SNPs: -568G/C, -408C/T, -3C/T) and one variable number tandem repeat [VNTR: -77(GT)n] within the IFNAR1 promoter sequence in 49 HCC patients. RNAseq data from 10 genotyped HCC samples were grouped according to their -77VNTR or -3SNP genotype to evaluate the impact of these polymorphisms on the differential expression on the HCC transcriptome. There is a fourfold higher impact of the -77VNTR on the HCC transcriptome compared to the -3SNP (q < 0.1, p < 0.001). The expression of the primary IFNAR1 transcript is not affected by these polymorphisms but a secondary, HCC-specific transcript is expressed only in homozygous -77VNTR ≤8/≤8(GT)n samples (p < 0.05). At the same time, patients carrying at least one -77VNTR >8(GT) allele, presented a strong upregulation of the fibronectin-1 (FN-1) gene, which has been associated with the development of HCC. Gene Ontology and pathway enrichment analysis of the differentially expressed genes revealed a strong disruption of the PI3K-AKT signaling pathway, which can be partially triggered by the extracellular matrix FN-1. The IFNAR-1 promoter polymorphisms are not involved in the expression levels of the main IFNAR-1 transcript. The -77VNTR has a regulatory role on the expression of a secondary, truncated, HCC-specific transcript, which in turn coincides with disruptions in cancer-associated pathways and in FN-1 expression modifications.


Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Surveys.
Maternal mortality rates have decreased globally but remain off track for Millennium Development Goals. Good-quality delivery care is one recognised strategy to address this gap. This study examines the role of the private (non-public) sector in providing delivery care and compares the equity and quality of the sectors. The most recent Demographic and Health Survey (2000-2013) for 57 countries was used to analyse delivery care for most recent birth among >330 000 women. Wealth quintiles were used for equity analysis; skilled birth attendant (SBA) and Caesarean section rates served as proxies for quality of care in cross-sectoral comparisons. The proportion of women who used appropriate delivery care (non-facility with a SBA or facility-based births) varied across regions (49-84%), but wealth-related inequalities were seen in both sectors in all regions. One-fifth of all deliveries occurred in the private sector. Overall, 36% of deliveries with appropriate care occurred in the private sector, ranging from 9% to 46% across regions. The presence of a SBA was comparable between sectors (≥93%) in all regions. In every region, Caesarean section rate was higher in the private compared to public sector. The private sector provided between 13% (Latin America) and 66% (Asia) of Caesarean section deliveries. This study is the most comprehensive assessment to date of coverage, equity and quality indicators of delivery care by sector. The private sector provided a substantial proportion of delivery care in low- and middle-income countries. Further research is necessary to better understand this heterogeneous group of providers and their potential to equitably increase the coverage of good-quality intrapartum care.


Individual differences in nucleus accumbens activity to food and sexual images predict weight gain and sexual behavior.
Failures of self-regulation are common, leading to many of the most vexing problems facing contemporary society, from overeating and obesity to impulsive sexual behavior and STDs. One reason that people may be prone to engaging in unwanted behaviors is heightened sensitivity to cues related to those behaviors; people may overeat because of hyperresponsiveness to food cues, addicts may relapse following exposure to their drug of choice, and some people might engage in impulsive sexual activity because they are easily aroused by erotic stimuli. An open question is the extent to which individual differences in neural cue reactivity relate to actual behavioral outcomes. Here we show that individual differences in human reward-related brain activity in the nucleus accumbens to food and sexual images predict subsequent weight gain and sexual activity 6 months later. These findings suggest that heightened reward responsivity in the brain to food and sexual cues is associated with indulgence in overeating and sexual activity, respectively, and provide evidence for a common neural mechanism associated with appetitive behaviors.


Peptide neurons in the canine small intestine.
The distributions of peptide-containing nerve fibers and cell bodies in the canine small intestine were determined with antibodies raised against seven peptides: enkephalin, gastrin-releasing peptide (GRP), neuropeptide Y, neurotensin, somatostatin, substance P, and vasoactive intestinal peptide (VIP). Immunoreactive nerve cell bodies and fibers were found for each peptide except neurotensin. In the muscle layers there were numerous substance P, VIP, and enkephalin fibers, fewer neuropeptide Y fibers, and very few GRP or somatostatin fibers. The mucosa contained many VIP and substance P fibers, moderate numbers of neuropeptide Y, somatostatin, and GRP fibers and rare enkephalin fibers. Nerve cell bodies reactive for each of the six neural peptides were located in both the myenteric and submucous plexuses. The distributions of nerve cell bodies and processes in the canine small intestine show many similarities with other mammals, for example, in the distributions of VIP, substance P, neuropeptide Y, and somatostatin nerves. There are some major differences, such as the presence in dogs of numerous submucosal nerve cell bodies with enkephalinlike immunoreactivity and of GRP-like immunoreactivity in submucous nerve cell bodies and mucosal fibers.


Rearrangement of the bcr gene in Philadelphia chromosome-negative chronic myeloid leukemia.
We studied the clinical, hematologic, cytogenetic, and molecular biologic features of seven patients with Philadelphia (Ph1) chromosome-negative chronic myeloid leukemia (CML). In five cases the hematologic findings were indistinguishable from those of patients with classical Ph1-positive disease. Myeloid cells were studied by chromosome-banding techniques. One patient had a masked Ph1 chromosome (with translocation t(4;9;22)), one had a deletion involving chromosome 16, and one had a small minority population of 22q- cells without 9q+ but otherwise normal metaphases; metaphases from the other four patients were entirely normal. DNA prepared from the myeloid cells was digested with the restriction enzymes EcoRI, HindIII, BamHI and BglII. Southern analysis using a 0.6-kb fragment of the breakpoint cluster region (bcr) gene showed the presence in each patient's DNA of a germline fragment together with a rearranged fragment or fragments with at least one of the restriction enzymes. We conclude that genomic changes in the bcr gene characteristic of CML can be present in the absence of a Ph1 chromosome.


Role of calcium in secretory and metabolic effects of substrates in the gastric mucosa.
The role of extracellular Ca2+ in the effects and oxidation of metabolic substrates was investigated in the isolated toad gastric mucosa. In the presence of lipoate, the stimulating effect of 10 mM glucose on spontaneous acid secretion was significantly reduced by 76% in Ca2+-free solutions. The inhibition was overcome by addition of 5 mM Ca2+. The increment in respiration induced by glucose was also blocked in the absence of external Ca2+. The effect of 10 mM pyruvate on acid secretion was inhibited by 37% in Ca2+-free solutions. The secretory responses induced by 10 mM butyrate and 10 mM octanoate were not significantly affected by Ca2+-free solutions. The rates of oxidation of [14C]-glucose and [14C]pyruvate were significantly reduced by incubating in Ca2+-free solutions containing 0.1 mM of EGTA. When O2 uptake and glucose oxidation were measured simultaneously in the same preparation, the increment in the rate of glucose oxidation accounted for by 43% of the total increase of respiration observed in the presence of Ca2+. The rates of oxidation of [14C]butyrate and [14C]acetate were not significantly affected by Ca2+-free solutions. The rate of oxidation of [14C]glucose exhibited saturation kinetics versus concentration and was lower in the absence of external Ca2+ under a range of glucose concentrations. Similar results were observed when the experiments were performed in the absence of external potassium to block the acid secretory process. Ca2+ stimulated the rate of glucose oxidation in a dose-dependent manner. The kinetics of 45Ca2+ efflux and 45Ca2+ uptake were not significantly affected by glucose and butyrate.(ABSTRACT TRUNCATED AT 250 WORDS)


Hydrophobic gating in ion channels.
Biological ion channels are nanoscale transmembrane pores. When water and ions are enclosed within the narrow confines of a sub-nanometer hydrophobic pore, they exhibit behavior not evident from macroscopic descriptions. At this nanoscopic level, the unfavorable interaction between the lining of a hydrophobic pore and water may lead to stochastic liquid-vapor transitions. These transient vapor states are "dewetted", i.e. effectively devoid of water molecules within all or part of the pore, thus leading to an energetic barrier to ion conduction. This process, termed "hydrophobic gating", was first observed in molecular dynamics simulations of model nanopores, where the principles underlying hydrophobic gating (i.e., changes in diameter, polarity, or transmembrane voltage) have now been extensively validated. Computational, structural, and functional studies now indicate that biological ion channels may also exploit hydrophobic gating to regulate ion flow within their pores. Here we review the evidence for this process and propose that this unusual behavior of water represents an increasingly important element in understanding the relationship between ion channel structure and function.


Inhibition of Pseudomonas aeruginosa by hyperbaric oxygen. I. Sulfonamide activity enhancement and reversal.
To elucidate an explanation for in vitro sulfonamide enhancement by high-pressure oxygen (HPO) and the reported absence of enhancement with in vivo therapy, Pseudomonas aeruginosa cultures were exposed to selected antifolate antimicrobials in the presence of 1.87 atm absolute of O(2) and compared with non-HPO treated controls. Under these conditions, HPO alone retarded growth. Trimethoprim, a non-sulfonamide which inhibits dihydrofolate reductase, was not bactericidal, nor did HPO enhance existent bacteriostatic activity. The sulfonamide, sulfisozazole, was not bactericidal, but HPO enhanced bacteriostatic activity twofold; bacteriostasis was mitigated in HPO-treated and control cultures by p-aminobenzoate but not by a mixture of compounds involved in folate-mediated "1-C" biosynthesis. Mafenide, a unique sulfonamide, at high concentrations with HPO, was synergistically bactericidal; non-HPO-treated cultures were bacteriostatically inhibited. Bacteriostatic activity of lower mafenide concentrations was also enhanced at least twofold by HPO. These inhibitory effects of mafenide, acting with or without HPO, were mitigated by the above mixture, but not by p-aminobenzoate. This may explain the lack of in vivo HPO-mafenide enhancement in burn-wound sepsis where exudates would contain such a mixture. Lastly, HPO itself was largely bactericidal at 2.87 atm absolute of O(2). This was reversed to various degrees by the above mixture, or its components, or by folic, folinic, or p-aminobenzoic acids. These in vitro interactions suggest HPO per se may act at the same site as some sulfonamides to inhibit folate synthesis (not primarily at the dihydrofolate reductase level), or coenzyme functions of folate, or both.