Development and validation of early warning score systems for COVID-19 patients.
COVID-19 is a major, urgent, and ongoing threat to global health. Globally more than 24 million have been infected and the disease has claimed more than a million lives as of November 2020. Predicting which patients will need respiratory support is important to guiding individual patient treatment and also to ensuring sufficient resources are available. The ability of six common Early Warning Scores (EWS) to identify respiratory deterioration defined as the need for advanced respiratory support (high-flow nasal oxygen, continuous positive airways pressure, non-invasive ventilation, intubation) within a prediction window of 24 h is evaluated. It is shown that these scores perform sub-optimally at this specific task. Therefore, an alternative EWS based on the Gradient Boosting Trees (GBT) algorithm is developed that is able to predict deterioration within the next 24 h with high AUROC 94% and an accuracy, sensitivity, and specificity of 70%, 96%, 70%, respectively. The GBT model outperformed the best EWS (LDTEWS:NEWS), increasing the AUROC by 14%. Our GBT model makes the prediction based on the current and baseline measures of routinely available vital signs and blood tests.


Distinct genetic architecture underlies the emergence of sleep loss and prey-seeking behavior in the Mexican cavefish.
Sleep is characterized by extended periods of quiescence and reduced responsiveness to sensory stimuli. Animals ranging from insects to mammals adapt to environments with limited food by suppressing sleep and enhancing their response to food cues, yet little is known about the genetic and evolutionary relationship between these processes. The blind Mexican cavefish, Astyanax mexicanus is a powerful model for elucidating the genetic mechanisms underlying behavioral evolution. A. mexicanus comprises an extant ancestral-type surface dwelling morph and at least five independently evolved cave populations. Evolutionary convergence on sleep loss and vibration attraction behavior, which is involved in prey seeking, have been documented in cavefish raising the possibility that enhanced sensory responsiveness underlies changes in sleep. We established a system to study sleep and vibration attraction behavior in adult A. mexicanus and used high coverage quantitative trait loci (QTL) mapping to investigate the functional and evolutionary relationship between these traits. Analysis of surface-cave F2 hybrid fish and an outbred cave population indicates that independent genetic factors underlie changes in sleep/locomotor activity and vibration attraction behavior. High-coverage QTL mapping with genotyping-by-sequencing technology identify two novel QTL intervals that associate with locomotor activity and include the narcolepsy-associated tp53 regulating kinase. These QTLs represent the first genomic localization of locomotor activity in cavefish and are distinct from two QTLs previously identified as associating with vibration attraction behavior. Taken together, these results localize genomic regions underlying sleep/locomotor and sensory changes in cavefish populations and provide evidence that sleep loss evolved independently from enhanced sensory responsiveness.


Nociception and conditioned fear in rats: strains matter.
When using rats in pain research, strain-related differences in outcomes of tests for pain and nociception are acknowledged. However, very little is known about the specific characteristics of these strain differences. In this study four phylogenetically distant inbred rat strains, i.e. Wistar Kyoto (WKY), Fawn Hooded (FH), Brown Norway (BN) and Lewis (LE), were investigated in different tests related to pain and nociception. During Pavlovian fear conditioning, the LE and WKY showed a significantly longer duration of freezing behaviour than the FH and BN. Additionally, differences in c-Fos expression in subregions of the prefrontal cortex and amygdala between rat strains during retrieval and expression of conditioned fear were found. For example, the BN did not show recruitment of the basolateral amygdala, whereas the WKY, FH and LE did. During the hot plate test, the WKY and LE showed a lower thermal threshold compared to the BN and FH. In a follow-up experiment, the two most contrasting strains regarding behaviour during the hot plate test and Pavlovian fear conditioning (i.e. FH and WKY) were selected and the hot plate test, Von Frey test and somatosensory-evoked potential (SEP) were investigated. During the Von Frey test, the WKY showed a lower mechanical threshold compared to the FH. When measuring the SEP, the FH appeared to be less reactive to increasing stimulus intensities when considering both peak amplitudes and latencies. Altogether, the combined results indicate various differences between rat strains in Pavlovian fear conditioning, nociception related behaviours and nociceptive processing. These findings demonstrate the necessity of using multiple rat strains when using tests including noxious stimuli and suggest that the choice of rat strains should be considered. When selecting a strain for a particular study it should be considered how this strain behaves during the tests used in that study.


Implementing an expressive writing study in a cancer clinic.
Patients at a comprehensive cancer center have participated in a weekly writing program for 7 years. Anecdotal evidence following writing in this clinical setting appeared congruent with the results of expressive writing studies conducted in laboratory settings. To move expressive writing research beyond the laboratory, we evaluated the feasibility of engaging a clinical population in a structured expressive writing task while they waited for an appointment in a cancer clinic. Adult leukemia and lymphoma patients (n = 71) completed a baseline assessment, 20-minute writing task, postwriting assessment, and 3-week follow-up; 88% completed the writing task and 56% completed the follow-up. Participants reported positive responses to the writing, and immediately postwriting about half (49.1%) reported that writing resulted in changes in their thoughts about their illness, while 53.8% reported changes in their thoughts at the 3-week follow-up. Reports of changes in thoughts about illness immediately postwriting were significantly associated with better physical quality of life at follow-up, controlling for baseline quality of life. Initial qualitative analyses of the texts identified themes related to experiences of positive change/transformation following a cancer diagnosis. Findings support the feasibility of conducting expressive writing with a clinical population in a nonlaboratory setting. Cancer patients were receptive to expressive writing and reported changes in the way they thought about their illness following writing. These preliminary findings indicate that a single, brief writing exercise is related to cancer patients' reports of improved quality of life.


Alexandrium diversaporum sp. nov., a new non-saxitoxin producing species: Phylogeny, morphology and sxtA genes.
Species of the PST producing planktonic marine dinoflagellate genus Alexandrium have been intensively scrutinised, and it is therefore surprising that new taxa can still be found. Here we report a new species, Alexandrium diversaporum nov. sp., isolated from spherical cysts found at two sites in Tasmania, Australia. This species differs in its morphology from all previously reported Alexandrium species, possessing a unique combination of morphological features: the presence of 2 size classes of thecal pores on the cell surface, a medium cell size, the size and shape of the 6″, 1', 2⁗ and Sp plates, the lack of a ventral pore, a lack of anterior and posterior connecting pores, and a lack of chain formation. We determined the relationship of the two strains to other species of Alexandrium based on an alignment of concatenated SSU-ITS1, 5.8S, ITS2 and partial LSU ribosomal RNA sequences, and found A. diversaporum to be a sister group to Alexandrium leei with high support. A. leei shares several morphological features, including the relative size and shapes of the 6″, 1', 2⁗ and Sp plates and the fact that some strains of A. leei have two size classes of thecal pores. We examined A. diversaporum strains for saxitoxin production and found them to be non-toxic. The species lacked sequences for the domain A4 of sxtA, as has been previously found for non-saxitoxin producing species of Alexandrium.


Multidisciplinary Aortopathy Clinics Should Now Be the Standard of Care in Canada.
Thoracic aortic aneurysm is often undiagnosed and has a very poor prognosis when presented with acute aortic dissection. Early diagnosis, expert medical management, and elective aortic surgery are the cornerstones of improvement of long-term survival in thoracic aortic disease (TAD). International guidelines now recommend the acute and long-term management of patients with TAD to occur within multidisciplinary aortopathy clinics under the care of professionals with specific training and experience. Multidisciplinary "heart teams" are recognized to be more focused on patient-centric care, to facilitate faster clinical decision times with increased adherence to guideline-directed therapy, and to improve knowledge translation and physician and patient satisfaction. The range of differential diagnoses for TAD has expanded rapidly over the past decade. Diagnosis of an index case with a syndromic or nonsyndromic familial TAD allows for preventative care. Effective family screening can save lives by allowing for elective management of thoracic aortic aneurysm rather than emergent care of acute aortic complications. Expert cardiac imaging with access to the full range of required imaging modalities is central to all clinical management decisions. Medical and surgical management of TAD is now provided as personalized care according to patient- and disease-specific factors. Special considerations apply to pregnancy management for women with TAD. Multidisciplinary aortopathy clinics should now be the standard of care for the management of TAD in Canada and we should implement best practice guidelines. With the already established and emerging clinics, the stage is now set to build a Canadian Aortopathy Clinics Trials network.


Low-dose computed tomography coronary angiography with prospective electrocardiogram triggering: feasibility in a large population.
We sought to assess the feasibility of prospective electrocardiogram triggering for achieving low-dose computed tomography coronary angiography (CTCA) in a large population. Prospective electrocardiogram triggering dramatically reduces radiation exposure for CTCA but requires heart rate (HR) control to obtain diagnostic image quality. Its feasibility in daily clinical routine has therefore remained to be elucidated. We evaluated 612 patients consecutively referred for CTCA by 64-slice computed tomography. Intravenous metoprolol (2 to 30 mg) was administered if necessary to achieve a target HR below 65 beats/min. Image quality was assessed on a semiquantitative 4-point scale for each coronary segment. Forty-six (7.5%) patients were deemed ineligible due to irregular heart rhythm (n = 19), insufficient response to metoprolol (n = 21), renal insufficiency (n = 3), or inability to follow breath-hold commands (n = 3). Mean effective radiation dose was 1.8 ± 0.6 mSv with a diagnostic image quality in 96.2% of segments. Finally, low-dose CTCA allowed a firm diagnosis with regard to the presence or absence of coronary artery disease in 527 (86.1%) patients. Intravenous metoprolol to achieve an HR below 65 beats/min was used in 64.4% of patients. Incidence of nondiagnostic segments was inversely related to HR (r = -0.809, p < 0.001). Below an HR cutoff of 62 beats/min, only 1.2% of coronary segments were nondiagnostic. Low-dose CTCA by electrocardiogram triggering is feasible in the vast majority of an every-day population. However, HR control is crucial, as an HR below 62 beats/min favors diagnostic image quality.


F-Actin nucleated on chromosomes coordinates their capture by microtubules in oocyte meiosis.
Capture of each and every chromosome by spindle microtubules is essential to prevent chromosome loss and aneuploidy. In somatic cells, astral microtubules search and capture chromosomes forming lateral attachments to kinetochores. However, this mechanism alone is insufficient in large oocytes. We have previously shown that a contractile F-actin network is additionally required to collect chromosomes scattered in the 70-µm starfish oocyte nucleus. How this F-actin-driven mechanism is coordinated with microtubule capture remained unknown. Here, we show that after nuclear envelope breakdown Arp2/3-nucleated F-actin "patches" form around chromosomes in a Ran-GTP-dependent manner, and we propose that these structures sterically block kinetochore-microtubule attachments. Once F-actin-driven chromosome transport is complete, coordinated disassembly of F-actin patches allows synchronous capture by microtubules. Our observations indicate that this coordination is necessary because early capture of chromosomes by microtubules would interfere with F-actin-driven transport leading to chromosome loss and formation of aneuploid eggs.


Vesicular uptake system for the cation lucigenin in the rat hepatocyte.
The hepatic transport mechanism for the fluorescent bivalent hydrophilic organic cation lucigenin (LU) was characterized employing kinetic and morphological methods. The extraction of LU by the perfused rat liver was 50% and uptake was saturable. LU did not inhibit the carrier-mediated hepatic uptake of the model organic cationic compounds tributylmethyl ammonium (type 1) and vecuronium (type 2) in isolated hepatocytes, whereas the uptake of LU in the perfused liver was not affected by either type of cation or by the cardiac glycoside cymarin, a potent type 2 inhibitor. The cytoskeleton-disrupting agents cytochalasin B and nocodazole, however, significantly lowered hepatic uptake of LU. In the intact liver, LU did not stimulate fluid phase endocytosis, as indicated by a lack of effect on the internalization of horseradish peroxidase. These kinetic data point to adsorptive endocytosis as the most probable uptake mechanism. This was confirmed by the inhibitory effect of neomycin and the polycation poly(L-lysine) on LU uptake. Fluorescence microscopy revealed that LU accumulated in the hepatocytes in discrete vesicular structures. Partial co-localization of rhodamine-dextran and acid phosphatase with LU indicated that part of the LU fluorescence was present in lysosomes, although not all lysosomes contained LU. Taken together, we conclude that we identified a novel vesicular pathway for uptake of organic cations by hepatocytes.


High-order resting-state functional connectivity network for MCI classification.
Brain functional connectivity (FC) network, estimated with resting-state functional magnetic resonance imaging (RS-fMRI) technique, has emerged as a promising approach for accurate diagnosis of neurodegenerative diseases. However, the conventional FC network is essentially low-order in the sense that only the correlations among brain regions (in terms of RS-fMRI time series) are taken into account. The features derived from this type of brain network may fail to serve as an effective disease biomarker. To overcome this drawback, we propose extraction of novel high-order FC correlations that characterize how the low-order correlations between different pairs of brain regions interact with each other. Specifically, for each brain region, a sliding window approach is first performed over the entire RS-fMRI time series to generate multiple short overlapping segments. For each segment, a low-order FC network is constructed, measuring the short-term correlation between brain regions. These low-order networks (obtained from all segments) describe the dynamics of short-term FC along the time, thus also forming the correlation time series for every pair of brain regions. To overcome the curse of dimensionality, we further group the correlation time series into a small number of different clusters according to their intrinsic common patterns. Then, the correlation between the respective mean correlation time series of different clusters is calculated to represent the high-order correlation among different pairs of brain regions. Finally, we design a pattern classifier, by combining features of both low-order and high-order FC networks. Experimental results verify the effectiveness of the high-order FC network on disease diagnosis. Hum Brain Mapp 37:3282-3296, 2016. © 2016 Wiley Periodicals, Inc.


An artificial light source influences mating and oviposition of black soldier flies, Hermetia illucens.
Current methods for mass-rearing black soldier flies, Hermetia illucens (L.) (Diptera: Stratiomyidae), in the laboratory are dependent on sunlight. Quartz-iodine lamps and rare earth lamps were examined as artificial light sources for stimulating H. illucens to mate and lay eggs. Sunlight was used as the control. Adults in the quartz-iodine lamp treatment had a mating rate of 61% of those in the sunlight control. No mating occurred when the rare earth lamp was used as a substitute. Egg hatch for the quartz-iodine lamp and sunlight treatments occurred in approximately 4 days, and the hatch rate was similar between these two treatments. Larval and pupal development under these treatments required approximately 18 and 15 days at 28°C, respectively. Development of methods for mass rearing of H. illucens using artificial light will enable production of this fly throughout the year without investing in greenhouse space or requiring sunlight.


Evaluation of work-related psychosocial factors and regional musculoskeletal pain: results from a EULAR Task Force.
To establish whether review articles provide consistent conclusions on associations between workplace psychosocial factors and musculoskeletal pain and, if differences exist, to explore whether this is related to the methods used. Reviews, reported up to February 2007, that included consideration of workplace psychosocial factors and upper limb, back or knee pain were identified through searches of multiple databases. The specific work-related psychosocial factors considered were job demands, support, job autonomy and job satisfaction. The conclusions of each review on one or more of the psychosocial/musculoskeletal pain associations were extracted. 15 review articles were identified that considered one or more of the regional pain syndromes included in the study. For back pain, the most consistent conclusions (four reviews positive out of six) were with high job demands and low job satisfaction. The studies of upper limb pain were exclusively related to shoulder and/or neck pain, and the most consistent positive conclusions were with high and low job demands (four reviews positive out of six and two reviews positive out of three, respectively). For knee pain, only a single review was identified. For individual reviews of back and upper limb pain, there were marked differences in the number of associations concluded to be positive between reviews. The reasons for reviews coming to different conclusions included that they were often evaluating different bodies of evidence (according to their search criteria, the year when the review was conducted, the role that quality assessment played in whether studies contributed to evidence, and the combination of risk factors addressed in individual studies), but more important was whether the review specified explicit criteria for making conclusions on strength of evidence. These conclusions emphasise the importance of developing standardised methods for conducting such evaluations of existing evidence and the importance of new longitudinal studies for clarifying the temporal relationship between psychosocial factors and musculoskeletal pain in the workplace.


Confined plasmons in nanofabricated single silver particle pairs: experimental observations of strong interparticle interactions.
We report on the optical properties of single isolated silver nanodisks and pairs of disks fabricated by electron beam lithography. By systematically varying the disk size and surface separation and recording elastic scattering spectra in different polarization configurations, we found evidence for extremely strong interparticle interactions. The dipolar surface plasmon resonance for polarization parallel to the dimer axis exhibited a red shift as the interdimer separation was decreased; as expected from previous work, an extremely strong shift was observed. The scattering spectra of single particles and pairs separated by more than one particle radius can be well described by the coupled dipole approximation (CDA), where the particles are approximated as point dipoles using a modified dipole polarizability for oblate spheroids. For smaller particle separations (d < 20 nm), the simple dipole model severely underestimates the particle interaction, indicating the importance of multipolar fields and finite-size effects. The discrete dipole approximation (DDA), which is a finite-element method, describes the experimental results well even at d < 20 nm, including particles that have metallic bridges.


Hair Cortisol and Its Association With Psychological Risk Factors for Psychiatric Disorders: A Pilot Study in Adolescent Twins.
Measuring cortisol in hair is a promising method to assess long-term alterations of the biological stress response system, and hair cortisol concentrations (HCC) may be altered in psychiatric disorders and in subjects suffering from chronic stress. However, the pattern of associations between HCC, chronic stress and mental health require clarification. Our exploratory study: (1) assessed the association between HCC and perceived stress, symptoms of depression and neuroticism, and the trait extraversion (as a control variable); and (2) made use of the twin design to estimate the genetic and environmental covariance between the variables of interest. Hair samples from 109 (74 female) subjects (age range 12-21 years, mean 15.1) including 8 monozygotic (MZ) and 21 dizygotic (DZ) twin pairs were analyzed. Perceived stress was measured with the Perceived Stress Scale and/or the Daily Life and Stressors Scale, neuroticism, and extraversion with the NEO-Five Factor Inventory or the Junior Eysenck Personality Questionnaire, and depressive symptoms with the Somatic and Psychological Health Report. We found a modest positive association between HCC and the three risk factors - perceived stress, symptoms of depression, and neuroticism (r = 0.22-0.33) - but no correlation with extraversion (-0.06). A median split revealed that the associations between HCC and risk factors were stronger (0.47-0.60) in those subjects with HCC >11.36 pg/mg. Furthermore, our results suggest that the genetic effects underlying HCC are largely shared with those that influence perceived stress, depressive symptoms, and neuroticism. These results of our proof of principle study warrant replication in a bigger sample but raise the interesting question of the direction of causation between these variables.


Vasohibins: new transglutaminase-like cysteine proteases possessing a non-canonical Cys-His-Ser catalytic triad.
Vasohibin-1 and Vasohibin-2 regulate angiogenesis, tumour growth and metastasis. Their molecular functions, however, were previously unknown, in large part owing to their perceived lack of homology to proteins of known structure and function. To identify their functional amino acids and domains, their molecular activity and their evolutionary history, we undertook an in-depth analysis of Vasohibin sequences. We find that Vasohibin proteins are previously undetected members of the transglutaminase-like cysteine protease superfamily, and all possess a non-canonical Cys-His-Ser catalytic triad. We further propose a calcium-dependent activation mechanism for Vasohibin proteins. These findings can now be used to design constructs for protein structure determination and to develop enzyme inhibitors as angiogenic regulators to treat metastasis and tumour growth. firstname.lastname@example.com Supplementary data are available at Bioinformatics online.


Tissue Distribution and Visualization of Internalized Human Norovirus in Leafy Greens.
Lettuce has been implicated in human norovirus (HuNoV) outbreaks. The virus is stable on the leaf surface for at least 2 weeks; however, the dynamics of virus internalization have not been fully investigated. The purpose of this study was to assess the internalization and distribution of HuNoV and two surrogate viruses, porcine sapovirus (SaV) and Tulane virus (TV), in lettuce and spinach. Viral inoculations through the roots of seedlings and the petiole of leaves from mature plants were performed, and the viruses were tracked on days 1 and 6 post-root inoculation and at 16 h and 72 h post-petiole inoculation. Confocal microscopy was used to visualize root-internalized HuNoV. In both lettuce and spinach, (i) HuNoV was internalized into the roots and leaves at similar RNA titers, whereas surrogate viruses were more restricted to the roots, (ii) all three viruses were stable inside the roots and leaves for at least 6 days, and (iii) HuNoV disseminated similarly inside the central veins and leaf lamina, whereas surrogate viruses were more restricted to the central veins. Infectious TV, but not SaV, was detectable in all tissues, suggesting that TV has greater stability than SaV. HuNoV was visualized inside the roots' vascular bundle and the leaf mesophyll of both plants. In conclusion, using surrogate viruses may underestimate the level of HuNoV internalization into edible leaves. The internalization of HuNoV through roots and cut leaves and the dissemination into various spinach and lettuce tissues raise concerns of internal contamination through irrigation and/or wash water.IMPORTANCE Human noroviruses are the leading cause of foodborne outbreaks, with lettuce being implicated in the majority of outbreaks. The virus causes acute gastroenteritis in all age groups, with more severe symptoms in children, the elderly, and immunocompromised patients, contributing to over 200,000 deaths worldwide annually. The majority of deaths due to HuNoV occur in the developing world, where limited sanitation exists along with poor wastewater treatment facilities, resulting in the contamination of water resources that are often used for irrigation. Our study confirms the ability of lettuce and spinach to internalize HuNoV from contaminated water through the roots into the edible leaves. Since these leafy greens are consumed with minimal processing that targets only surface pathogens, the internalized HuNoV presents an added risk to consumers. Thus, preventive measures should be in place to limit the contamination of irrigation water. In addition, better processing technologies are needed to inactivate internalized viral pathogens.


The experience of Chinese immigrant women in caring for a terminally ill family member in Australia.
The Chinese community, a heterogeneous, highly visible non-English speaking ethnic group in Australia, remains mostly hidden and underrepresented in palliative care service delivery along with participation in health research despite being the fastest growing such group in the country. There is a lack of Australian research information concerning the impact of migration on the caregiving experience of women carers within the Chinese cultural framework and the Australian palliative care context. This paper aims to explore the influence of Chinese cultural norms and immigration on the experience of immigrant women of Chinese ancestry caring for a terminally ill family member at home in Sydney. This study also seeks to identify factors that may present access barriers to palliative care support services. A qualitative approach was used in this study. Data were collected from semi-structured interviews with five home-based Chinese women carers and were analysed using thematic analysis. Findings identified that the participants found being a carer is a lonely and isolating experience. Sources of isolation and loneliness included social isolation experienced as a solitary carer without meaningful family and social relationships; loss of familiar cultural understandings and family values; and emotional isolators expressed in response to the physical and emotional role commitment and other constraints. The study results suggest the need for palliative care educational programmes designed to help nurses to understand the impact of cultural background within the palliative care context. Results also indicate that health care professionals should provide culturally appropriate and competent palliative care services, sensitive to the diverse socio-cultural influences and individual needs of Chinese migrants.


Heart rate variability to assess ventilatory threshold in ski-mountaineering.
The capacity to predict the heart rate (HR) and speed at the first (VT1) and second (VT2) ventilatory thresholds was evaluated during an incremental ski-mountaineering test using heart rate variability (HRV). Nine skiers performed a field test to exhaustion on an alpine skiing track. VT1 and VT2 were individually determined by visual analysis from gas exchanges (VT1V and VT2V) and time-varying spectral HRV analysis (VT1fH, VT2fH and VT2H). VT1 could not be determined with the HRV methods used. On the contrary, the VT2 was determined in all skiers. No significant difference between HR and speed at VT2H and VT2V was observed (174.3 ± 5.6 vs. 174.3 ± 5.3 bpm, and 6.3 ± 0.9 and 6.3 ± 0.9 km h(-1), respectively). Strong correlations were obtained for HR (r = 0.91) and speed (r = 0.92) at VT2H and VT2V with small limits of agreement (±3.6 bpm for HR). Our results indicated that HRV enables determination of HR and speed at VT2 during a specific ski-mountaineering incremental test. These findings provide practical applications for skiers in order to evaluate and control specific training loads, at least when referring to VT2.


Behavior problems at 5 years of age and maternal mental health in autism and intellectual disability.
We examined child behavior problems and maternal mental health in a British population-representative sample of 5 year-old children with an autism spectrum disorder (ASD), controlling for the presence of an intellectual disability (ID). Behavior problems were significantly higher in children with ASD with/out ID compared to typically developing children, but compared to children with ID only hyperactivity was significantly higher in children with ASD/ID. After controlling for ID and maternal mental health, the presence of ASD significantly increased the odds for hyperactivity, conduct problems and emotional symptoms. Negative maternal outcomes (serious mental illness, psychological distress, and physical health limitations) were not consistently elevated in ASD. The findings highlight the early age at which behavior problems emerge in ASD, and suggest that at this age , there may not be a clear disadvantage for maternal mental health associated with having a child with ASD in the family, over and above that conferred by child behavior problems.


[The effects of probiotics on symptoms of irritable bowel syndrome].
Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) tract disorder that has heterogeneous clinical presentations such as abdominal pain, diarrhea, constipation, and abdominal distension. It is known that several mechanisms are involved in the pathogenesis of IBS. Probiotics may target one or more pathophysiologic pathways in IBS and may improve the symptoms of IBS. However, the results of studies about probiotics on IBS are controversial. Therefore, the aim of this study was to evaluate the effect of probiotics on GI symptoms and intestinal gas volume changes in patients with IBS. Forty patients were randomly allocated to be treated with Medilac DS (Bacillus subtilis, Streptococcus faecium) (n=20) or placebo (n=20) in a double-blind, prospective manner. The change in intestinal gas volume and symptom scores after 4-week treatment were evaluated for the efficacy. There was no significant difference in bloating, frequency of gas expulsion, frequency of defecation, and hardness of stool before and after the treatment. However, the severity of abdominal pain and the frequency of abdominal pain decreased significantly in Medilac DS group (2.4+/-1.3 cm/day --> 1.6+/-1.6 cm/day, 1.7+/-1.3/day --> 1.0+/-1.0/day) (p=0.044, p=0.038), but not in placebo group (2.1+/-2.0 cm/day --> 1.8+/-2.1 cm/day, 1.3+/-1.2/day --> 1.4+/-1.9/day). In both groups, intestinal gas volume at baseline, after 2-week treatment, and after 4-week treatment did not show significant change. Medilac DS was well tolerated without adverse events. Medilac DS is a safe and useful probiotic agent for the treatment of abdominal pain in patients with IBS.


Intrathyroidal parathyroid glands: small, but mighty (a Napoleon phenomenon).
Intrathyroidal parathyroid adenomas (ITPAs) are a rare entity. The aim of this study is to describe the experience of 2 endocrine surgery centers and to distinguish characteristics of intrathyroidal parathyroid adenoma and nonintrathyroidal parathyroid adenomas. We included patients who had undergone operations for primary hyperparathyroidism who had intrathyroidal parathyroid adenomas. Patients with single intrathyroidal parathyroid adenomas were also compared to age- and sex-matched controls with nonintrathyroidal parathyroid adenomas. Of 4,868 patients who underwent parathyroidectomy between January 2002 and June 2011, we identified 53 (1%) patients with intrathyroidal parathyroid adenoma. Sestamibi and ultrasound scans correctly identified the adenoma in 35 (70%) and 11 (61%) cases, respectively. Single adenomas were identified in 44 (83%) patients, double adenomas in 4 (8%) patients, and hyperplasia in 5 (9%) patients. Lobectomy was performed in 17 (32%) patients; enucleation was used in 36 (68%) patients. Cure was achieved in all patients and no patients experienced a recurrence. Patients with single intrathyroidal parathyroid adenomas had significantly smaller glands than patients with nonintrathyroidal parathyroid adenomas (325 ± 47 vs 772 ± 61 mg; P < .0001); however, no significant difference was identified between the groups with regard to demographics, symptoms, preoperative laboratory values, or outcomes. Single intrathyroidal parathyroid adenomas are smaller than nonintrathyroidal parathyroid adenomas, but patients with intrathyroidal parathyroid adenomas present with similar laboratory values and symptoms. Recognition of this rare entity can lead to a successful surgical outcome.


Processing of DNA for nonhomologous end-joining is controlled by kinase activity and XRCC4/ligase IV.
Nonhomologous end-joining (NHEJ) repairs DNA double-strand breaks created by ionizing radiation and V(D)J recombination. To repair the broken ends, NHEJ processes noncompatible ends into a ligatable form but suppresses processing of compatible ends. It is not known how NHEJ controls polymerase and nuclease activities to act exclusively on noncompatible ends. Here, we analyzed processing independently of ligation by using a two-stage assay with extracts that recapitulated the properties of NHEJ in vivo. Processing of noncompatible ends required wortmannin-sensitive kinase activity. Since DNA-dependent protein kinase catalytic subunit (DNA-PKcs) brings the ends together before undergoing activation of its kinase, this suggests that processing occurred after synapsis of the ends. Surprisingly, all polymerase and most nuclease activity required XRCC4/Ligase IV. This suggests a mechanism for how NHEJ suppresses processing to optimize the preservation of DNA sequence.


Formulation and evaluation of diclofenac potassium fast-disintegrating tablets and their clinical application in migraine patients.
The aim of this study was to prepare fast-disintegrating tablets (FDTs) of diclofenac potassium with sufficient integrity as well as a pleasant taste, using two different fillers and binders: Tablettose 70(®) and Di-Pac(®). Tablets were made with direct compression method. Tablet properties such as porosity, hardness, and disintegration time were determined. Diclofenac potassium determinations were carried out using a validated spectrophotometric method for the analysis of drug. Furthermore, in vivo experiments were carried out to compare the analgesic effect and the time to relieve migraine headache between the commercial tablets and FDTs of diclofenac potassium against placebo. Results showed that FDTs of diclofenac potassium with durable structure and desirable taste can be prepared using both fillers and binders but tablets prepared with Di-Pac had a better taste so the tablet formulation containing Di-Pac was chosen for in vivo experiments. Placebo controlled in vivo trial demonstrated that 50 mg diclofenac potassium, administered as a single dose of FDTs or commercial tablets, was effective in relieving the pain and both of them were superior to placebo.


Identification of menaquinones (vitamin K2 homologues) as novel constituents of honey.
Our recent research indicated that honey active macromolecules form colloidal particles that scatter the light and produce elaborate UV spectral profile dominated by double absorption peaks at 240-250 nm. The absorption at 240-250 nm signified the stable honey conformation that supported antibacterial activity and hydrogen peroxide production. Our aim was to identify the bioactive constituent relevant to this absorption. The methodology included activity-guided fractionation of honey through size-exclusion chromatography, solid-phase extraction and UPLC-UV-MS. UV spectral analysis of UPLC peaks revealed compounds with UV λ (max) typical of naphtoquinones. The MS chromatograms showed mass ions differing by [M-68n] indicating a polyisoprene structure and the fragmentation patterns typical for menaquinones. The exact mass measurements of menaquinones using a quadrupole-Orbitrap mass spectrometry confirmed their identification as a series of MK-3 to MK-7 aptimers. Detection of menaquinones, previously unknown constituents of honey, suggests that they might play role in honey redox and antibacterial activities.


Integrative and comparative genomic analysis of HPV-positive and HPV-negative head and neck squamous cell carcinomas.
The genetic differences between human papilloma virus (HPV)-positive and -negative head and neck squamous cell carcinomas (HNSCC) remain largely unknown. To identify differential biology and novel therapeutic targets for both entities, we determined mutations and copy-number aberrations in a large cohort of locoregionally advanced HNSCC. We performed massively parallel sequencing of 617 cancer-associated genes in 120 matched tumor/normal samples (42.5% HPV-positive). Mutations and copy-number aberrations were determined and results validated with a secondary method. The overall mutational burden in HPV-negative and HPV-positive HNSCC was similar with an average of 15.2 versus 14.4 somatic exonic mutations in the targeted cancer-associated genes. HPV-negative tumors showed a mutational spectrum concordant with published lung squamous cell carcinoma analyses with enrichment for mutations in TP53, CDKN2A, MLL2, CUL3, NSD1, PIK3CA, and NOTCH genes. HPV-positive tumors showed unique mutations in DDX3X, FGFR2/3 and aberrations in PIK3CA, KRAS, MLL2/3, and NOTCH1 were enriched in HPV-positive tumors. Currently targetable genomic alterations were identified in FGFR1, DDR2, EGFR, FGFR2/3, EPHA2, and PIK3CA. EGFR, CCND1, and FGFR1 amplifications occurred in HPV-negative tumors, whereas 17.6% of HPV-positive tumors harbored mutations in fibroblast growth factor receptor genes (FGFR2/3), including six recurrent FGFR3 S249C mutations. HPV-positive tumors showed a 5.8% incidence of KRAS mutations, and DNA-repair gene aberrations, including 7.8% BRCA1/2 mutations, were identified. The mutational makeup of HPV-positive and HPV-negative HNSCC differs significantly, including targetable genes. HNSCC harbors multiple therapeutically important genetic aberrations, including frequent aberrations in the FGFR and PI3K pathway genes. See related commentary by Krigsfeld and Chung, p. 495.


Plasmon resonance and the imaging of metal-impregnated neurons with the laser scanning confocal microscope.
The staining of neurons with silver began in the 1800s, but until now the great resolving power of the laser scanning confocal microscope has not been utilized to capture the in-focus and three-dimensional cytoarchitecture of metal-impregnated cells. Here, we demonstrate how spectral confocal microscopy, typically reserved for fluorescent imaging, can be used to visualize metal-labeled tissues. This imaging does not involve the reflectance of metal particles, but rather the excitation of silver (or gold) nanoparticles and their putative surface plasmon resonance. To induce such resonance, silver or gold particles were excited with visible-wavelength laser lines (561 or 640 nm), and the maximal emission signal was collected at a shorter wavelength (i.e., higher energy state). Because the surface plasmon resonances of noble metal nanoparticles offer a superior optical signal and do not photobleach, our novel protocol holds enormous promise of a rebirth and further development of silver- and gold-based cell labeling protocols.


Paradoxes of nitric oxide in the diabetic kidney.
As an important modulator of renal function and morphology, the nitric oxide (NO) system has been extensively studied in the diabetic kidney. However, a number of studies in different experimental and clinical settings have produced often confusing data and contradictory findings. We have reviewed a wide spectrum of findings and issues that have amassed concerning the pathophysiology of the renal NO system in diabetes, pointed out the controversies, and attempted to find some explanation for these discrepancies. Severe diabetes with profound insulinopenia can be viewed as a state of generalized NO deficiency, including in the kidney. However, we have focused our hypotheses and conclusions on the events occurring during moderate glycemic control with some degree of treatment with exogenous insulin, representing more the clinically applicable state of diabetic nephropathy. Available evidence suggests that diabetes triggers mechanisms that in parallel enhance and suppress NO bioavailability in the kidney. We hypothesize that during the early phases of nephropathy, the balance between these two opposing forces is shifted toward NO. This plays a role in the development of characteristic hemodynamic changes and may contribute to consequent structural alterations in glomeruli. Both endothelial (eNOS) and neuronal NO synthase can contribute to altered NO production. These enzymes, particularly eNOS, can be activated by Ca(2+)-independent and alternative routes of activation that may be elusive in traditional methods of investigation. As the duration of exposure to the diabetic milieu increases, factors that suppress NO bioavailability gradually prevail. Increasing accumulations of advanced glycation end products may be one of the culprits in this process. In addition, this balance is continuously modified by actual metabolic control and the degree of insulinopenia.


Inhibition or deletion of soluble epoxide hydrolase prevents hyperglycemia, promotes insulin secretion, and reduces islet apoptosis.
Soluble epoxide hydrolase (sEH) is an enzyme involved in the metabolism of endogenous inflammatory and antiapoptotic mediators. However, the roles of sEH in diabetes and the pancreas are unknown. Our aims were to determine whether sEH is involved in the regulation of hyperglycemia in diabetic mice and to investigate the reasons for the regulation of insulin secretion by sEH deletion or inhibition in islets. We used two separate approaches, targeted disruption of Ephx2 gene [sEH knockout (KO)] and a selective inhibitor of sEH [trans-4-[4-(3-adamantan-1-ylureido)-cyclohexyloxy]-benzoic acid (t-AUCB)], to assess the role of sEH in glucose and insulin homeostasis in streptozotocin (STZ) mice. We also examined the effects of sEH KO or t-AUCB on glucose-stimulated insulin secretion (GSIS) and intracellular calcium levels in islets. Hyperglycemia in STZ mice was prevented by both sEH KO and t-AUCB. In addition, STZ mice with sEH KO had improved glucose tolerance. More important, when insulin levels were assessed by hyperglycemic clamp study, sEH KO was found to promote insulin secretion. In addition, sEH KO and t-AUCB treatment augmented islet GSIS. Islets with sEH KO had a greater intracellular calcium influx when challenged with high glucose or KCl in the presence of diazoxide. Moreover, sEH KO reduced islet cell apoptosis in STZ mice. These results show not only that sEH KO and its inhibition prevent hyperglycemia in diabetes, but also that sEH KO enhances islet GSIS through the amplifying pathway and decreases islet cell apoptosis in diabetes.


Loss of TLR3 aggravates CHIKV replication and pathology due to an altered virus-specific neutralizing antibody response.
RNA-sensing toll-like receptors (TLRs) mediate innate immunity and regulate anti-viral response. We show here that TLR3 regulates host immunity and the loss of TLR3 aggravates pathology in Chikungunya virus (CHIKV) infection. Susceptibility to CHIKV infection is markedly increased in human and mouse fibroblasts with defective TLR3 signaling. Up to 100-fold increase in CHIKV load was observed in Tlr3-/- mice, alongside increased virus dissemination and pro-inflammatory myeloid cells infiltration. Infection in bone marrow chimeric mice showed that TLR3-expressing hematopoietic cells are required for effective CHIKV clearance. CHIKV-specific antibodies from Tlr3-/- mice exhibited significantly lower in vitro neutralization capacity, due to altered virus-neutralizing epitope specificity. Finally, SNP genotyping analysis of CHIKF patients on TLR3 identified SNP rs6552950 to be associated with disease severity and CHIKV-specific neutralizing antibody response. These results demonstrate a key role for TLR3-mediated antibody response to CHIKV infection, virus replication and pathology, providing a basis for future development of immunotherapeutics in vaccine development.


Relationship of deoxynucleotide changes to inhibition of DNA synthesis induced by the antiretroviral agent 3'-azido-3'-deoxythymidine and release of its monophosphate by human lymphoid cells (CCRF-CEM).
The metabolism and cytostatic effects of 3'-azido-3'-deoxythymidine (AZT), one of the most effective agents being used in the treatment of acquired immunodeficiency syndrome, were investigated in the CCRF-CEM line of human T lymphoid cells. The concentration of drug required to inhibit cell growth by 50% (CD50) was significantly lower when the cells were exposed to AZT for 24 hr (CD50 = 50 microM), as compared with 48 or 96 hr (CD50 = 225 and greater than 300 microM, respectively). AZT at 25 microM blocked the progression of cells in S phase for about 12 hr, but this effect was reversed by 24 hr, despite the continued presence of drug in the medium. At this drug concentration, the level of dTTP decreased to about 75% of the control level by 4 hr but rebounded to 30% above normal by 8 hr of drug exposure. dGTP and dATP pool sizes were unchanged, whereas the dCTP pool increased 5-fold. The time course of these biochemical changes indicated that the onset of S phase arrest was not directly related to the decrease in deoxynucleoside triphosphate pools. CCRF-CEM cells incubated with 25 microM AZT accumulated about 0.9 mM 5'-monophosphate (AZTMP) after 4 hr whereas levels of the 5'-di- and 5'-triphosphates (AZTDP and AZTTP) plateaued at about 2 and 5 microM, respectively. After this period, there was a rapid decrease in AZTMP accumulation, to one third its initial level by 24 hr, whereas AZTDP and AZTTP pools decreased to only about 70%. The loss in AZT nucleotide formation with time of drug exposure was associated with a concomitant accumulation of AZTMP in the medium. Cellular excretion of AZTMP was not associated with any detectable cell lysis or leakage of other cellular metabolites. The ability of CCRF-CEM cells to excrete AZTMP may be an important factor limiting the biochemical and biological effects of the drug.


ACTonFood. Acceptance and Commitment Therapy-Based Group Treatment Compared to Cognitive Behavioral Therapy-Based Group Treatment for Weight Loss Maintenance: An Individually Randomized Group Treatment Trial.
The purpose of this Individually Randomized Group Treatment Trial was to compare an Acceptance and Commitment Therapy-based (ACT) group intervention and a Cognitive Behavioral Therapy-based (CBT) group intervention for weight loss maintenance in a sample of adult patients with obesity seeking treatment for weight loss. One hundred and fifty-five adults (BMI: Kg/m2 = 43.8 [6.8]) attending a multidisciplinary rehabilitation program for weight loss were randomized into two conditions: ACT and CBT. Demographical, physical, and clinical data were assessed at the beginning of the program (t0), at discharge (t1), and at 6-month follow-up (t2). The following measures were administered: The Acceptance and Action Questionnaire-II (AAQ-II) and the Clinical Outcome in Routine Evaluation-Outcome Measure (CORE-OM). Generalized linear mixed models were performed to assess differences between groups. Moderation effects for gender and Eating Disorders (ED) have been considered. From baseline to discharge, no significant differences between interventions were found, with the only exception of an improvement in the CORE-OM total score and in the CORE-OM subjective wellbeing subscale for those in the CBT condition. From discharge to follow-up, ACT group participants showed significant results in terms of weight loss maintenance, CORE-OM total score, and CORE-OM and AAQ-II wellbeing, symptoms, and psychological problems subscales. Gender moderated the effects of time and intervention on the CORE-OM subscale reporting the risk for self-harm or harm of others. The presence of an eating disorder moderated the effect of time and intervention on the CORE-OM total score, on the CORE-OM symptoms and psychological problems subscales, and on the AAQ-II. Patients who received the ACT intervention were more likely to achieve a ≥5% weight loss from baseline to follow-up and to maintain the weight loss after discharge. The ACT intervention was thus effective in maintaining weight loss over time.


Epidemiology of candidemia: 3-year results from the emerging infections and the epidemiology of Iowa organisms study.
Bloodstream infections due to Candida species cause significant morbidity and mortality. Surveillance for candidemia is necessary to detect trends in species distribution and antifungal resistance. We performed prospective surveillance for candidemia at 16 hospitals in the State of Iowa from 1 July 1998 through 30 June 2001. Using U.S. Census Bureau and Iowa Hospital Association data to estimate a population denominator, we calculated the annual incidence of candidemia in Iowa to be 6.0 per 100,000 of population. Candida albicans was the most common species detected, but 43% of candidemias were due to species other than C. albicans. Overall, only 3% of Candida species were resistant to fluconazole. However, Candida glabrata was the most commonly isolated species other than C. albicans and demonstrated some resistance to azoles (fluconazole MIC at which 90% of the isolates tested are inhibited, 32 microg/ml; 10% resistant, 10% susceptible dose dependent). C. glabrata was more commonly isolated from older patients (P = 0.02) and caused over 25% of candidemias among persons 65 years of age or older. The investigational triazoles posaconazole, ravuconazole, and voriconazole had excellent in vitro activity overall against Candida species. C. albicans is the most important cause of candidemia and remains highly susceptible to available antifungal agents. However, C. glabrata has emerged as an important and potentially antifungal resistant cause of candidemia, particularly among the elderly.


Viral vectors for production of recombinant proteins in plants.
Global demand for recombinant proteins has steadily accelerated for the last 20 years. These recombinant proteins have a wide range of important applications, including vaccines and therapeutics for human and animal health, industrial enzymes, new materials and components of novel nano-particles for various applications. The majority of recombinant proteins are produced by traditional biological "factories," that is, predominantly mammalian and microbial cell cultures along with yeast and insect cells. However, these traditional technologies cannot satisfy the increasing market demand due to prohibitive capital investment requirements. During the last two decades, plants have been under intensive investigation to provide an alternative system for cost-effective, highly scalable, and safe production of recombinant proteins. Although the genetic engineering of plant viral vectors for heterologous gene expression can be dated back to the early 1980s, recent understanding of plant virology and technical progress in molecular biology have allowed for significant improvements and fine tuning of these vectors. These breakthroughs enable the flourishing of a variety of new viral-based expression systems and their wide application by academic and industry groups. In this review, we describe the principal plant viral-based production strategies and the latest plant viral expression systems, with a particular focus on the variety of proteins produced and their applications. We will summarize the recent progress in the downstream processing of plant materials for efficient extraction and purification of recombinant proteins.


The impact of eurythmy therapy on stress coping strategies and health-related quality of life in healthy, moderately stressed adults.
'Stress' and 'health-related quality of life' (HRQoL) are two important theoretical constructs for modern therapy evaluation with clinical relevance. Eurythmy therapy (EYT) is a mind-body-therapy derived from anthroposophic medicine with promising effects on heart rate variability (HRV), HRQoL and disease scores. The purpose of this study was to investigate the impact of EYT on stress coping strategies (SCS) and HRQoL in a controlled study with moderately stressed participants. 68 healthy, moderately stressed adults (mean age: 42.2; SD: 8.2) performed 10h of EYT in a group setting over a period of six weeks. A non-randomised control group of 22 healthy adults (mean age: 43.6; SD: 13.7) received no intervention and did only complete the questionnaires at the same data points. Outcomes were measured before and after the intervention (AVEM & SF-36). A significant impact on SCS was found in seven AVEM scales (MANOVA, F (1/74)=4.59; p=.04). With regard to changes in risk pattern affiliation (AVEM), 24% of the participants receiving EYT (n=55) changed over time from a risky stress coping pattern to a healthier pattern. Concerning the HRQoL four normally distributed scales of the SF-36 ('vitality', 'social functioning', 'mental health' and 'physical functioning') showed a significant group×time interaction favouring the EYT group (MANOVA, F (1/74)=17.26; p<.001). Statistically and clinically relevant mean differences over time of at least eight scale points were found for 'role physical', 'bodily pain', 'vitality' and 'mental health', and of at least 15 scale points for 'role emotional' and 'social functioning'. A six-week period of EYT training can result in a significant reduction of stress and consequently improve QoL. Because a significant proportion of participants had high levels of stress at baseline the results suggest a health-enhancing benefit of EYT that may have clinical potential for prevention of stress and associated disorders in healthy individuals and possibly in patients with chronic diseases, for example.


Motion-induced blindness and Troxler fading: common and different mechanisms.
Extended stabilization of gaze leads to disappearance of dim visual targets presented peripherally. This phenomenon, known as Troxler fading, is thought to result from neuronal adaptation. Intense targets also disappear intermittently when surrounded by a moving pattern (the "mask"), a phenomenon known as motion-induced blindness (MIB). The similar phenomenology and dynamics of these disappearances may suggest that also MIB is, likewise, solely due to adaptation, which may be amplified by the presence of the mask. Here we directly compared the dependence of both phenomena on target contrast. Observers reported the disappearance and reappearance of a target of varying intensity (contrast levels: 8%-80%). MIB was induced by adding a mask that moved at one of various different speeds. The results revealed a lawful effect of contrast in both MIB and Troxler fading, but with opposite trends. Increasing target contrast increased (doubled) the rate of disappearance events for MIB, but decreased the disappearance rate to half in Troxler fading. The target mean invisible period decreased equally strongly with target contrast in MIB and in Troxler fading. The results suggest that both MIB and Troxler are equally affected by contrast adaptation, but that the rate of MIB is governed by an additional mechanism, possibly involving antagonistic processes between neuronal populations processing target and mask. Our results link MIB to other bi-stable visual phenomena that involve neuronal competition (such as binocular rivalry), which exhibit an analogous dependency on the strength of the competing stimulus components.


Preventing osteoporosis in symptomatic postmenopausal women.
Osteoporosis is a common postmenopausal disease that has a substantial impact on the quality of life of older women and is associated with significant morbidity and mortality. There are various options for preventing osteoporosis in postmenopausal women, and all are associated with differing benefit-risk profiles. Estrogen therapy (in hysterectomized women) and estrogen/progestogen therapy (in nonhysterectomized women) are the most effective treatments available for the relief of vasomotor and urogenital symptoms in postmenopausal women and provide significant protection against osteoporotic fractures. Selective estrogen receptor modulators reduce bone loss and prevent vertebral fractures without endometrial or breast stimulation. Raloxifene, the only selective estrogen receptor modulator approved for osteoporosis prevention and treatment, significantly reduces vertebral but not nonvertebral or hip fractures. Bisphosphonates prevent bone loss and vertebral fractures; however, not all bisphosphonates have been shown to prevent nonvertebral fractures. Selective estrogen receptor modulators and bisphosphonates are not effective for menopausal symptoms. Hormone therapy should be considered as first-line therapy for preventing bone loss and fractures in early postmenopausal women who are symptomatic; other options include selective estrogen receptor modulators and bisphosphonates, especially in older, nonsymptomatic women. Future therapies are likely to include newer selective estrogen receptor modulators, combinations of estrogen with selective estrogen receptor modulators, and denosumab.


Real healthcare reform: focus on primary care access.
Primary care coverage for the uninsured is the first necessary step to reform and can be more cost effective and tolerable than a major system reform. By providing foundational care to the uninsured, more care resources are targeted to those that most need the services, while providing benefits such as increased productivity and reduced inappropriate emergency department utilization. The authors aimed to design a primary care coverage system in the United States for the uninsured using established reimbursement, budgeting, and compliance methods. Providing four primary care visits for acute care, four associated ancillary and four fulfilled pharmaceutical-treatment prescriptions, and one preventive primary care visit per year for nearly 48,000,000 uninsured would cost $36 per month for every working American and legal alien resident. Theoretical and empirical literature was reviewed and the authors applied practical knowledge based on their experience in healthcare systems to develop the Access America Program.


Estimating global, regional, and national daily and cumulative infections with SARS-CoV-2 through Nov 14, 2021: a statistical analysis.
Timely, accurate, and comprehensive estimates of SARS-CoV-2 daily infection rates, cumulative infections, the proportion of the population that has been infected at least once, and the effective reproductive number (Reffective) are essential for understanding the determinants of past infection, current transmission patterns, and a population's susceptibility to future infection with the same variant. Although several studies have estimated cumulative SARS-CoV-2 infections in select locations at specific points in time, all of these analyses have relied on biased data inputs that were not adequately corrected for. In this study, we aimed to provide a novel approach to estimating past SARS-CoV-2 daily infections, cumulative infections, and the proportion of the population infected, for 190 countries and territories from the start of the pandemic to Nov 14, 2021. This approach combines data from reported cases, reported deaths, excess deaths attributable to COVID-19, hospitalisations, and seroprevalence surveys to produce more robust estimates that minimise constituent biases. We produced a comprehensive set of global and location-specific estimates of daily and cumulative SARS-CoV-2 infections through Nov 14, 2021, using data largely from Johns Hopkins University (Baltimore, MD, USA) and national databases for reported cases, hospital admissions, and reported deaths, as well as seroprevalence surveys identified through previous reviews, SeroTracker, and governmental organisations. We corrected these data for known biases such as lags in reporting, accounted for under-reporting of deaths by use of a statistical model of the proportion of excess mortality attributable to SARS-CoV-2, and adjusted seroprevalence surveys for waning antibody sensitivity, vaccinations, and reinfection from SARS-CoV-2 escape variants. We then created an empirical database of infection-detection ratios (IDRs), infection-hospitalisation ratios (IHRs), and infection-fatality ratios (IFRs). To estimate a complete time series for each location, we developed statistical models to predict the IDR, IHR, and IFR by location and day, testing a set of predictors justified through published systematic reviews. Next, we combined three series of estimates of daily infections (cases divided by IDR, hospitalisations divided by IHR, and deaths divided by IFR), into a more robust estimate of daily infections. We then used daily infections to estimate cumulative infections and the cumulative proportion of the population with one or more infections, and we then calculated posterior estimates of cumulative IDR, IHR, and IFR using cumulative infections and the corrected data on reported cases, hospitalisations, and deaths. Finally, we converted daily infections into a historical time series of Reffective by location and day based on assumptions of duration from infection to infectiousness and time an individual spent being infectious. For each of these quantities, we estimated a distribution based on an ensemble framework that captured uncertainty in data sources, model design, and parameter assumptions. Global daily SARS-CoV-2 infections fluctuated between 3 million and 17 million new infections per day between April, 2020, and October, 2021, peaking in mid-April, 2021, primarily as a result of surges in India. Between the start of the pandemic and Nov 14, 2021, there were an estimated 3·80 billion (95% uncertainty interval 3·44-4·08) total SARS-CoV-2 infections and reinfections combined, and an estimated 3·39 billion (3·08-3·63) individuals, or 43·9% (39·9-46·9) of the global population, had been infected one or more times. 1·34 billion (1·20-1·49) of these infections occurred in south Asia, the highest among the seven super-regions, although the sub-Saharan Africa super-region had the highest infection rate (79·3 per 100 population [69·0-86·4]). The high-income super-region had the fewest infections (239 million [226-252]), and southeast Asia, east Asia, and Oceania had the lowest infection rate (13·0 per 100 population [8·4-17·7]). The cumulative proportion of the population ever infected varied greatly between countries and territories, with rates higher than 70% in 40 countries and lower than 20% in 39 countries. There was no discernible relationship between Reffective and total immunity, and even at total immunity levels of 80%, we observed no indication of an abrupt drop in Reffective, indicating that there is not a clear herd immunity threshold observed in the data. COVID-19 has already had a staggering impact on the world up to the beginning of the omicron (B.1.1.529) wave, with over 40% of the global population infected at least once by Nov 14, 2021. The vast differences in cumulative proportion of the population infected across locations could help policy makers identify the transmission-prevention strategies that have been most effective, as well as the populations at greatest risk for future infection. This information might also be useful for targeted transmission-prevention interventions, including vaccine prioritisation. Our statistical approach to estimating SARS-CoV-2 infection allows estimates to be updated and disseminated rapidly on the basis of newly available data, which has and will be crucially important for timely COVID-19 research, science, and policy responses. Bill & Melinda Gates Foundation, J Stanton, T Gillespie, and J and E Nordstrom.


[Factors associated with the burden of metabolic syndrome diseases among Brazilian adults].
This study aimed to identify socio-demographic and behavioral factors associated with the burden of metabolic syndrome diseases, based on data collected in 2007 by the Telephone Survey System for the Surveillance of Risk and Protective Factors for Chronic Non-Communicable Diseases (VIGITEL). The sample included 49,276 adults living in the Brazilian State capitals and Federal District. Metabolic syndrome was defined as the presence of at least two of the following: diabetes, dyslipidemia, high blood pressure, and obesity. Burden of disease showed that 22.7% of the adult population presented at least one of these conditions and 14.2% had two or more. Adjusted prevalence ratios showed that the odds of metabolic syndrome increased after 25 years of age, with insufficient physical activity, and with overweight in both men and women. Public health promotion policies should be encouraged that include modifiable factors with a major impact on the prevention and treatment of metabolic syndrome, as well as clinical diagnosis in populations at risk of metabolic syndrome.


Days spent at home in the last 6 months of life: a quality indicator of end of life care in patients with hematologic malignancies.
Despite advances in the management of hematologic malignancies, a significant proportion of patients die of their disease. We used administrative databases in Ontario, Canada (between 2005 and 2013) to determine the number of days spent at home in the last 6 months of life. We studied the predictors of the median number of days at home (DAH) using quantile regression. For the 11,127 patients with hematologic malignancies who died, the median number of DAH in the last 6 months was 156 days. Patients with acute leukemias (p < .0001), women (p < .0001), and those requiring transfusions (p < .0001) spent the fewest DAH. Patients assessed by palliative care prior to their last 6 months were likely to spend more time at home (p < .0001). Providing additional supports for patients nearing the end of life, including earlier access to palliative care and continued transfusion support, may increase the likelihood that patients can die at home.


An Integrated View of Aristolochic Acid Nephropathy: Update of the Literature.
The term "aristolochic acid nephropathy" (AAN) is used to include any form of toxic interstitial nephropathy that is caused either by ingestion of plants containing aristolochic acids (AA) as part of traditional phytotherapies (formerly known as "Chinese herbs nephropathy"), or by the environmental contaminants in food (Balkan endemic nephropathy). It is frequently associated with urothelial malignancies. Although products containing AA have been banned in most of countries, AAN cases remain regularly reported all over the world. Moreover, AAN incidence is probably highly underestimated given the presence of AA in traditional herbal remedies worldwide and the weak awareness of the disease. During these two past decades, animal models for AAN have been developed to investigate underlying molecular and cellular mechanisms involved in AAN pathogenesis. Indeed, a more-in-depth understanding of these processes is essential to develop therapeutic strategies aimed to reduce the global and underestimated burden of this disease. In this regard, our purpose was to build a broad overview of what is currently known about AAN. To achieve this goal, we aimed to summarize the latest data available about underlying pathophysiological mechanisms leading to AAN development with a particular emphasis on the imbalance between vasoactive factors as well as a focus on the vascular events often not considered in AAN.


Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department.
Nonpharmacologic interventions, such as distraction, have been shown to be powerful adjuncts in reducing pain and anxiety in children with both acute and chronic painful conditions. There are no controlled studies evaluating these interventions as adjuncts to facilitate completion of painful procedures in the pediatric emergency department (ED). We assessed the effectiveness of distraction techniques in reducing the sensory and affective components of pain among pediatric patients undergoing laceration repair in the ED. Eligible children between 6 and 18 years of age (N = 240) presenting to the ED for laceration repair were randomly assigned to an intervention or control arm. Those assigned to the intervention arm were given a choice of age-appropriate distracters during laceration repair. Quantitative measures of pain intensity, situational anxiety, and pain distress (as perceived by the parent) were assessed by using the 7-point Facial Pain Scale, State Trait Anxiety Inventory for Children, and a visual analog scale, respectively, before and after laceration repair. The State Trait Anxiety Inventory for Children was performed in children > or = 10 years of age. There was no difference in mean change in Facial Pain Scale scores between the control and the intervention groups in children < 10 years of age. Multivariate analysis in this same age group showed that the intervention was independently associated with a reduction in pain distress as perceived by parents based on the mean change in visual analog scale scores. In older children, the intervention was independently associated with reduction in situational anxiety but not in pain intensity or in parental perception of pain distress. The use of distraction techniques is effective in reducing situational anxiety in older children and lowering parental perception of pain distress in younger children. This technique may have a role in improving the quality of management of procedural pain in a pediatric ED setting.


Randomized Controlled Trial of Online Expressive Writing to Address Readjustment Difficulties Among U.S. Afghanistan and Iraq War Veterans.
We examined the efficacy of a brief, accessible, nonstigmatizing online intervention-writing expressively about transitioning to civilian life. U.S. Afghanistan and Iraq war veterans with self-reported reintegration difficulty (N = 1,292, 39.3% female, M = 36.87, SD = 9.78 years) were randomly assigned to expressive writing (n = 508), factual control writing (n = 507), or no writing (n = 277). Using intention to treat, generalized linear mixed models demonstrated that 6-months postintervention, veterans who wrote expressively experienced greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually (ds = 0.13 to 0.20; ps < .05) and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all (ds = 0.22 to 0.35; ps ≤ .001). Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (d = 0.17). Relative to both control conditions, expressive writing did not lead to improved life satisfaction. Secondary analyses also found beneficial effects of expressive writing on clinically significant distress, PTSD screening, and employment status. Online expressive writing holds promise for improving health and functioning among veterans experiencing reintegration difficulty, albeit with small effect sizes.


Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes.
Background. Approximately 4 million Americans receive nursing home (NH) care annually. Nursing home residents commonly have risk factors for Clostridium difficile infection (CDI), including advanced age and antibiotic exposures. We estimated national incidence of NH-onset (NHO) CDI and patient outcomes. Methods. We identified NHO-CDI cases from population-based surveillance of 10 geographic areas in the United States. Cases were defined by C difficile-positive stool collected in an NH (or from NH residents in outpatient settings or ≤3 days after hospital admission) without a positive stool in the prior 8 weeks. Medical records were reviewed on a sample of cases. Incidence was estimated using regression models accounting for age and laboratory testing method; sampling weights were applied to estimate hospitalizations, recurrences, and deaths. Results. A total of 3503 NHO-CDI cases were identified. Among 262 sampled cases, median age was 82 years, 76% received antibiotics in the 12 weeks prior to the C difficile-positive specimen, and 57% were discharged from a hospital in the month before specimen collection. After adjusting for age and testing method, the 2012 national estimate for NHO-CDI incidence was 112 800 cases (95% confidence interval [CI], 93 400-131 800); 31 400 (28%) were hospitalized within 7 days after a positive specimen (95% CI, 25 500-37 300), 20 900 (19%) recurred within 14-60 days (95% CI, 14 600-27 100), and 8700 (8%) died within 30 days (95% CI, 6600-10 700). Conclusions. Nursing home onset CDI is associated with substantial morbidity and mortality. Strategies focused on infection prevention in NHs and appropriate antibiotic use in both NHs and acute care settings may decrease the burden of NHO CDI.


Lumbar laminotomy for the intrathecal administration of nusinersen for spinal muscular atrophy: technical note and outcomes.
Nusinersen (Spinraza) is a US Food and Drug Administration-approved intrathecal medication for the treatment of spinal muscular atrophy (SMA). Adult patients with SMA often undergo thoracolumbar fusion to treat neurogenic scoliosis, preventing thecal access. The authors report a laminotomy technique and the ease of intrathecal access in three SMA patients with prior thoracolumbar fusions.Patients were positioned in the lateral decubitus position or prone. Lumbar laminotomy was performed below the conus, between the lateral longitudinal rods, to preserve mechanical stability. Fluoroscopy provided real-time identification of instruments. Hardware was contoured with a carbide drill bit to develop the surgical window. Fiducial screws were placed along the perimeter for demarcation. Sublaminar wire removal caused dural defects that were repaired with a layer of dural substitute onlay and sealant. All patients successfully received nusinersen thecal injections via lumbar puncture by an interventional radiologist. Fluoroscopy time ranged from 6 to 36 seconds. No postoperative pseudomeningoceles, cerebrospinal fluid leaks, or wound complications occurred.For patients with SMA and posterior fusion from prior scoliosis treatment, lumbar laminotomy is an effective method for creating thecal access for the administration of nusinersen.


THUMPD1 bi-allelic variants cause loss of tRNA acetylation and a syndromic neurodevelopmental disorder.
Covalent tRNA modifications play multi-faceted roles in tRNA stability, folding, and recognition, as well as the rate and fidelity of translation, and other cellular processes such as growth, development, and stress responses. Mutations in genes that are known to regulate tRNA modifications lead to a wide array of phenotypes and diseases including numerous cognitive and neurodevelopmental disorders, highlighting the critical role of tRNA modification in human disease. One such gene, THUMPD1, is involved in regulating tRNA N4-acetylcytidine modification (ac4C), and recently was proposed as a candidate gene for autosomal-recessive intellectual disability. Here, we present 13 individuals from 8 families who harbor rare loss-of-function variants in THUMPD1. Common phenotypic findings included global developmental delay, speech delay, moderate to severe intellectual deficiency, behavioral abnormalities such as angry outbursts, facial dysmorphism, and ophthalmological abnormalities. We demonstrate that the bi-allelic variants identified cause loss of function of THUMPD1 and that this defect results in a loss of ac4C modification in small RNAs, and of individually purified tRNA-Ser-CGA. We further corroborate this effect by showing a loss of tRNA acetylation in two CRISPR-Cas9-generated THUMPD1 KO cell lines. In addition, we also show the resultant amino acid substitution that occurs in a missense THUMPD1 allele identified in an individual with compound heterozygous variants results in a marked decrease in THUMPD1 stability and RNA-binding capacity. Taken together, these results suggest that the lack of tRNA acetylation due to THUMPD1 loss of function results in a syndromic form of intellectual disability associated with developmental delay, behavioral abnormalities, hearing loss, and facial dysmorphism.


Identification of heat shock factor binding protein in Plasmodium falciparum.
Heat shock factor binding protein (HSBP) was originally discovered in a yeast two-hybrid screen as an interacting partner of heat shock factor (HSF). It appears to be conserved in all eukaryotes studied so far, with yeast being the only exception. Cell biological analysis of HSBP in mammals suggests its role as a negative regulator of heat shock response as it appears to interact with HSF only during the recovery phase following exposure to heat stress. While the identification of HSF in the malaria parasite is still eluding biologists, this study for the first time, reports the presence of a homologue of HSBP in Plasmodium falciparum. PfHSBP was cloned and purified as his-tag fusion protein. CD (Circular dichroism) spectroscopy was performed to predict the secondary structure. Immunoblots and immunofluorescence approaches were used to study expression and localization of HSBP in P. falciparum. Cellular fractionation was performed to examine subcellular distribution of PfHSBP. Immunoprecipitation was carried out to identify HSBP interacting partner in P. falciparum. PfHSBP is a conserved protein with a high helical content and has a propensity to form homo-oligomers. PfHSBP was cloned, expressed and purified. The in vivo protein expression profile shows maximal expression in trophozoites. The protein was found to exist in oligomeric form as trimer and hexamer. PfHSBP is predominantly localized in the parasite cytosol, however, upon heat shock, it translocates to the nucleus. This study also reports the interaction of PfHSBP with PfHSP70-1 in the cytoplasm of the parasite. This study emphasizes the structural and biochemical conservation of PfHSBP with its mammalian counterpart and highlights its potential role in regulation of heat shock response in the malaria parasite. Analysis of HSBP may be an important step towards identification of the transcription factor regulating the heat shock response in P. falciparum.


Three-dimensional, fine-resolution imaging using laser frequency diversity.
Experimental results obtained using a fine-resolution, three-dimensional imaging method are presented. The method consists of flood illuminating an extended object with a laser beam and recording the scattered light as the laser frequency is varied. An image is recovered by three-dimensional Fourier transformation of the recorded data. For the results presented here, a tunable dye-laser source is used, and the obtained range resolution is 287 microm.


Persistence, bioaccumulation and vertical transfer of pollutants in long-finned pilot whales stranded in Chilean Patagonia.
Long-finned pilot whales (LFPW) are cetaceans with strong social groups often involved in mass strandings worldwide. However, these beachings occur for reasons that are not fully understood. In 2016, 124 LFPW were stranded on the Chilean Patagonian islands, offering a unique opportunity to obtain crucial information on the ecology, biology, and genetics of this population. In addition, we examined whether persistent organic pollutants (POPs) and trace elements (TEs) were responsible for this mass mortality. Stable isotopes (δ13C & δ15N) and genetic analyses were used to reconstruct the trophic ecology, social structure, and kinship of LFPW and compared to POPs and TEs levels found in LFPW. Mitochondrial DNA analyses on 71 individuals identified four maternal lineages within the stranded LFPW. Of these animals, 32 individuals were analyzed for a suite of POPs, TEs, and lipid content in blubber. The highest levels were found for ΣDDXs (6 isomers) (542.46 ± 433.46 ng/g, lw) and for total Hg (2.79 ± 1.91 mg/kg, dw). However, concentrations found in these LFPW were lower than toxicity thresholds and those reported for LFPW stranded in other regions. Evidence was found of ΣDDX, Σ7PCBs, and Cd bioaccumulation and maternal transfer of POPs in mother/offspring groups. Nevertheless, no clear relationship between contaminant concentrations and LFPW mortality was established. Further research is still needed to assess LFPW populations including conservations status and exposure to chemicals in remote areas such as Patagonia.


ICONE: An International Consortium of Neuro Endovascular Centres.
The proliferation of new endovascular devices and therapeutic strategies calls for a prudentand rational evaluation of their clinical benefit. This evaluation must be done in an effective manner and in collaboration with industry. Such research initiative requires organisation a land methodological support to survive and thrive in a competitive environment. We propose the formation of an international consortium, an academic alliance committed to the pursuit of effective neurovascular therapies. Such a consortium would be dedicated to the designand execution of basic science, device developmentand clinical trials. The Consortium is owned and operated by its members. Members are international leaders in neurointerventional research and clinical practice. The Consortium brings competency, knowledge, and expertise to industry as well as to its membership across aspectrum of research initiatives such as: expedited review of clinical trials, protocol development, surveys and systematic reviews; laboratory expertise and support for research design and grant applications to public agencies. Once objectives and protocols are approved, the Consortium provides a stable network of centers capable of timely realization of clinical trials or pre clinical investigations in an optimal environment. The Consortium is a non-profit organization. The potential revenue generated from clientsponsored financial agreements will be redirected to the academic and research objectives of the organization. The Consortium wishes to work inconcert with industry, to support emerging trends in neurovascular therapeutic development. The Consortium is a realistic endeavour optimally structured to promote excellence through scientific appraisal of our treatments, and to accelerate technical progress while maximizing patients' safety and welfare.


HLA-B27 heavy chain homodimers are expressed in HLA-B27 transgenic rodent models of spondyloarthritis and are ligands for paired Ig-like receptors.
HLA-B27 transgenic rats and strains of HLA-B27-transgenic beta(2)-microglobulin (beta(2)m)-deficient mice develop a multisystem inflammatory disease affecting the joints, skin, and bowel with strong similarity to human spondyloarthritis. We show that HLA-B27 transgenic mice and rats express HC10-reactive, beta(2)m-free HLA-B27 homodimers (B27(2)) and multimers, both intracellularly and at the cell surface of leukocytes, including rat dendritic cells. Fluorescent-labeled tetrameric complexes of HLA-B27 homodimers (B27(2) tetramers) bind to populations of lymphocytes, monocytes, and dendritic cells. The murine (and probably rat) paired Ig-like receptors (PIRs) are ligands for B27(2). Thus, B27(2) tetramers stain RBL cells transfected with murine activating PIR-A4 and inhibitory PIR-B receptors. Murine PIR-A and -B can be immunoprecipitated from the RAW264.7 macrophage cell line, and murine PIR-A can be immunoprecipitated from the J774.A1 line using B27(2). B27(2) tetramer staining corresponds to the distribution of PIR expression on lymphoid and myeloid cells and on murine macrophage cell lines. B27(2) can induce TNF-alpha release from the J774.A1 macrophage cell line. The binding of B27(2) to PIR is inhibited by HC10, an mAb that ameliorates arthritis in HLA-B27(+) beta(2)m(-/-) mice. The expression and PIR recognition of B27(2) could explain the pathogenesis of rodent spondyloarthritis.


Genetic variability in parasites and host-parasite interactions.
We have examined genetic variability in parasites in the context of ecological interactions with the host. Recent research on Echinococcus, Giardia and Cryptosporidium has been used to illustrate: (i) the problems that parasite variability and species recognition pose for understanding the complex and often controversial relationship between parasite and host occurrence; (ii) the need for accurate parasite characterization and the application of appropriate molecular techniques to studies on parasite transmission if fundamental questions about zoonotic relationships and risk factors are to be answered; (iii) our lack of understanding about within-host interactions between genetically heterogeneous parasites at the inter- and intraspecific levels, and the significance of such interactions with respect to evolutionary considerations and the clinical outcome of parasite infections. If advances in molecular biology and mathematical ecology are to be realized, we need to give serious consideration to the development of appropriate species concepts and in vivo systems for testing the predictions and assumptions of theoretical models.


Alcoholic beverages and prostate cancer in a prospective US cohort study.
Despite numerous investigations, the correlation between alcohol consumption and prostate cancer risk remains uncertain. This report investigated the association between alcohol use and prostate cancer risk in a prospective cohort study of 294,707 US men aged 50-71 years in 1995-1996. Cox proportional hazards regression models with hazard ratios and 95% confidence intervals were adjusted for characteristics including age, race, body mass index, physical activity, and family history of prostate cancer, as well as testing for prostate-specific antigen and a digital rectal examination. There were 15,327 nonadvanced and 1,900 advanced prostate cancers identified through 2003 and 514 fatal cases through 2005. Risk of nonadvanced prostate cancer was 25% higher for men consuming ≥6 drinks daily (hazard ratio = 1.25, 95% confidence interval: 1.13, 1.37), 19% higher for men consuming 3-<6 drinks daily, and 6% higher for men consuming up to 3 drinks daily, compared with nondrinkers. The association between alcohol consumption and nonadvanced prostate cancer risk did not differ appreciably by age, family history of prostate cancer, smoking status, body mass index, or self-reported prostate-specific antigen testing and digital rectal examination (the latter available for >60% of respondents). The authors observed no association between alcohol intake and advanced prostate cancer and an inverse association with fatal prostate cancer among heavy drinkers. These findings suggest that higher alcohol consumption modestly increases nonadvanced prostate cancer risk.


Weak Epistasis May Drive Adaptation in Recombining Bacteria.
The impact of epistasis on the evolution of multi-locus traits depends on recombination. While sexually reproducing eukaryotes recombine so frequently that epistasis between polymorphisms is not considered to play a large role in short-term adaptation, many bacteria also recombine, some to the degree that their populations are described as "panmictic" or "freely recombining." However, whether this recombination is sufficient to limit the ability of selection to act on epistatic contributions to fitness is unknown. We quantify homologous recombination in five bacterial pathogens and use these parameter estimates in a multilocus model of bacterial evolution with additive and epistatic effects. We find that even for highly recombining species (e.g., Streptococcus pneumoniae or Helicobacter pylori), selection on weak interactions between distant mutations is nearly as efficient as for an asexual species, likely because homologous recombination typically transfers only short segments. However, for strong epistasis, bacterial recombination accelerates selection, with the dynamics dependent on the amount of recombination and the number of loci. Epistasis may thus play an important role in both the short- and long-term adaptive evolution of bacteria, and, unlike in eukaryotes, is not limited to strong effect sizes, closely linked loci, or other conditions that limit the impact of recombination.


Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement.
The Management of Myelomeningocele Study (MOMS) was a multicenter randomized trial comparing the safety and efficacy of prenatal and postnatal closure of myelomeningocele. The trial was stopped early because of the demonstrated efficacy of prenatal surgery, and outcomes on 158 of 183 pregnancies were reported. Here, the authors update the 1-year outcomes for the complete trial, analyze the primary and related outcomes, and evaluate whether specific prerandomization risk factors are associated with prenatal surgery benefit. The primary outcome was a composite of fetal loss or any of the following: infant death, CSF shunt placement, or meeting the prespecified criteria for shunt placement. Primary outcome, actual shunt placement, and shunt revision rates for prenatal versus postnatal repair were compared. The shunt criteria were reassessed to determine which were most concordant with practice, and a new composite outcome was created from the primary outcome by replacing the original criteria for CSF shunt placement with the revised criteria. The authors used logistic regression to estimate whether there were interactions between the type of surgery and known prenatal risk factors (lesion level, gestational age, degree of hindbrain herniation, and ventricle size) for shunt placement, and to determine which factors were associated with shunting among those infants who underwent prenatal surgery. Ninety-one women were randomized to prenatal surgery and 92 to postnatal repair. The primary outcome occurred in 73% of infants in the prenatal surgery group and in 98% in the postnatal group (p < 0.0001). Actual rates of shunt placement were only 44% and 84% in the 2 groups, respectively (p < 0.0001). The authors revised the most commonly met criterion to require overt clinical signs of increased intracranial pressure, defined as split sutures, bulging fontanelle, or sunsetting eyes, in addition to increasing head circumference or hydrocephalus. Using these modified criteria, only 3 patients in each group met criteria but did not receive a shunt. For the revised composite outcome, there was a difference between the prenatal and postnatal surgery groups: 49.5% versus 87.0% (p < 0.0001). There was also a significant reduction in the number of children who had a shunt placed and then required a revision by 1 year of age in the prenatal group (15.4% vs 40.2%, relative risk 0.38 [95% CI 0.22-0.66]). In the prenatal surgery group, 20% of those with ventricle size < 10 mm at initial screening, 45.2% with ventricle size of 10 up to 15 mm, and 79.0% with ventricle size ≥ 15 mm received a shunt, whereas in the postnatal group, 79.4%, 86.0%, and 87.5%, respectively, received a shunt (p = 0.02). Lesion level and degree of hindbrain herniation appeared to have no effect on the eventual need for shunting (p = 0.19 and p = 0.13, respectively). Similar results were obtained for the revised outcome. Larger ventricles at initial screening are associated with an increased need for shunting among those undergoing fetal surgery for myelomeningocele. During prenatal counseling, care should be exercised in recommending prenatal surgery when the ventricles are 15 mm or larger because prenatal surgery does not appear to improve outcome in this group. The revised criteria may be useful as guidelines for treating hydrocephalus in this group.


Utilizing signature-score to identify oncogenic pathways of cholangiocarcinoma.
Extracting maximal information from gene signature sets (GSSs) via microarray-based transcriptional profiling involves assigning function to up and down regulated genes. Here we present a novel sample scoring method called Signature-score (S-score) which can be used to quantify the expression pattern of tumor samples from previously identified gene signature sets. A simulation result demonstrated an improved accuracy and robustness by S-score method comparing with other scoring methods. By applying the S-score method to cholangiocarcinoma (CAC), an aggressive hepatic cancer that arises from bile ducts cells, we identified enriched oncogenic pathways in two large CAC data sets. Thirteen pathways were enriched in CAC compared with normal liver and bile duct. Moreover, using S-score, we were able to dissect correlations between CAC-associated oncogenic pathways and Gene Ontology function. Two major oncogenic clusters and associated functions were identified. Cluster 1, which included beta-catenin and Ras, showed a positive correlation with the cell cycle, while cluster 2, which included TGF-beta, cytokeratin 19 and EpCAM was inversely correlated with immune function. We also used S-score to identify pathways that are differentially expressed in CAC and hepatocellular carcinoma (HCC), the more common subtype of liver cancer. Our results demonstrate the utility and effectiveness of S-score in assigning functional roles to tumor-associated gene signature sets and in identifying potential therapeutic targets for specific liver cancer subtypes.


Traditional food availability and consumption in remote Aboriginal communities in the Northern Territory, Australia.
To explore availability, variety and frequency consumption of traditional foods and their role in alleviating food insecurity in remote Aboriginal Australia. Availability was assessed through repeated semi-structured interviews and consumption via a survey. Quantitative data were described and qualitative data classified. Aboriginal and non-Indigenous key informants (n=30 in 2013; n=19 in 2014) from 20 Northern Territory (NT) communities participated in interviews. Aboriginal primary household shoppers (n=73 in 2014) in five of these communities participated in a survey. Traditional foods were reported to be available year-round in all 20 communities. Most participants (89%) reported consuming a variety of traditional foods at least fortnightly and 71% at least weekly. Seventy-six per cent reported being food insecure, with 40% obtaining traditional food during these times. Traditional food is consumed frequently by Aboriginal people living in remote NT. Implications for public health: Quantifying dietary contribution of traditional food would complement estimated population dietary intake. It would contribute evidence of nutrition transition and differences in intakes across age groups and inform dietary, environmental and social interventions and policy. Designing and conducting assessment of traditional food intake in conjunction with Aboriginal leaders warrants consideration.