Short-term heart rate turbulence analysis versus variability and baroreceptor sensitivity in patients with dilated cardiomyopathy.
New methods for the analysis of arrhythmias and their hemodynamic consequences have been applied in risk stratification, in particular to patients after myocardial infarction. This study investigates the suitability of short-term heart rate turbulence (HRT) analysis in comparison to heart rate and blood pressure variability as well as baroreceptor sensitivity analyses to characterise the regulatory differences between patients with dilated cardiomyopathy (DCM) and healthy controls. In this study, 30 minutes data of non-invasive continuous blood pressure and ECGs of 37 DCM patients and 167 controls measured under standard resting conditions were analysed. The results show highly significant differences between DCM patients and controls in heart rate and blood pressure variability as well as in baroreceptor sensitivity parameters. Applying a combined heart rate-blood pressure trigger, ventricular premature beats were detected in 24.3% (9) of the DCM patients and 11.3% (19) of the controls. This fact demonstrates the limited applicability of short-term HRT analyses. However, the HRT parameters showed significant differences in this subgroup with ventricular premature beats (turbulence onset: DCM: 1.80+/-2.72, controls: - 4.34+/-3.10, p<0.001; turbulence slope: DCM: 6.75+/-5.50, controls: 21.30+/-17.72, p=0.021). Considering all (including HRT) parameters in the subgroup with ventricular beats, a discrimination rate between DCM patients and controls of 88.0% was obtained (max. 6 parameters). The corresponding value obtained for the total group was 86.3% (without HRT parameters). Comparable classification rates and high correlations between heart rate turbulence and variability and baroreflex parameters point to a more universal applicability of the latter methods.


Suspected Reaction with Cephalosporin May Be a Predictive Factor for β-Lactam Allergy in Children.
Most children diagnosed with β-lactam allergy based only on history are not truly allergic, and mislabeling leads to use of less effective and more costly alternative broader-spectrum antibiotics, significantly increasing drug resistance. To determine the frequency and risk factors of confirmed allergy in patients with β-lactam allergy reported by parents or their doctors and evaluate cross-reactivity between β-lactams in children with confirmed allergy. Sixty-seven children with suspected β-lactam allergy were evaluated via history, sIgE measurements, skin tests, and drug provocation tests over a period of 5 years. β-Lactam allergy was confirmed in 10 (14.9%) patients. Six patients had a positive intradermal test result to one or more of the penicillin skin test materials or ceftriaxone, 4 patients with negative skin test results had positive test results with suspected drugs. Age, gender, time interval between evaluation and the initial reaction, personal history of atopy, parental history of drug allergy, reaction type, and multiple drug allergy history were not significantly different between allergic and tolerant patients. For culprit drugs, there was a significant different between the 2 groups; the rate of confirmed diagnosis was significantly higher for cephalosporins such as ceftriaxone, cefuroxime, and cefprozil (p = 0.03). Three patients with allergy to penicillin tolerated cefuroxime; in 4 patients with selective allergy to ceftriaxone tolerated cephalosporins with a dissimilar side chain (cefadroxil, cefuroxime, cefaclor, and cefdinir). Our study indicates that most patients with a suspected β-lactam allergy tolerated this drug. An appropriate diagnostic allergy workup may prevent the use of less effective and more expensive alternatives.


A recurrent p.Arg92Trp variant in steroidogenic factor-1 (NR5A1) can act as a molecular switch in human sex development.
Cell lineages of the early human gonad commit to one of the two mutually antagonistic organogenetic fates, the testis or the ovary. Some individuals with a 46,XX karyotype develop testes or ovotestes (testicular or ovotesticular disorder of sex development; TDSD/OTDSD), due to the presence of the testis-determining gene, SRY Other rare complex syndromic forms of TDSD/OTDSD are associated with mutations in pro-ovarian genes that repress testis development (e.g. WNT4); however, the genetic cause of the more common non-syndromic forms is unknown. Steroidogenic factor-1 (known as NR5A1) is a key regulator of reproductive development and function. Loss-of-function changes in NR5A1 in 46,XY individuals are associated with a spectrum of phenotypes in humans ranging from a lack of testis formation to male infertility. Mutations in NR5A1 in 46,XX women are associated with primary ovarian insufficiency, which includes a lack of ovary formation, primary and secondary amenorrhoea as well as early menopause. Here, we show that a specific recurrent heterozygous missense mutation (p.Arg92Trp) in the accessory DNA-binding region of NR5A1 is associated with variable degree of testis development in 46,XX children and adults from four unrelated families. Remarkably, in one family a sibling raised as a girl and carrying this NR5A1 mutation was found to have a 46,XY karyotype with partial testicular dysgenesis. These unique findings highlight how a specific variant in a developmental transcription factor can switch organ fate from the ovary to testis in mammals and represents the first missense mutation causing isolated, non-syndromic 46,XX testicular/ovotesticular DSD in humans.


Environmental factors associated with success rates of Australian stock herding dogs.
This study investigated the current management practices associated with stock herding dogs on Australian farms. A parallel goal was to determine whether these practices and the characteristics of the dog handlers were associated with success rates. Success rate refers to the proportion of dogs acquired by the farmer that were retained as working dogs. Data on a total of 4,027 dogs were obtained through The Farm Dog Survey which gathered information from 812 herding dog owners around Australia. Using logistic regression, significant associations were identified between success rate and seven variables: dog breed, housing method, trial participation, age of the dog at acquisition, electric collar use, hypothetical maximum treatment expenditure and the conscientiousness score of the owner's personality. These findings serve as a guide to direct further research into ways of optimising herding dog performance and welfare. They emphasise the importance of not only examining the genetic predispositions of the working dog but also the impact the handler can have on a dog's success in the workplace.


Relationship between body mass index and prognosis of patients presenting with potential acute coronary syndromes.
Studies examining the relationship between obesity and acute coronary syndrome (ACS) have been limited to patients with confirmed diagnoses. The authors sought to determine the relationship between body mass index (BMI) and 30-day cardiovascular events in emergency department (ED) patients with potential ACS. This was a secondary analysis of a prospective cohort study of patients who presented to the ED with potential ACS. Patients were stratified according to their BMI: underweight (BMI < 18.49 kg/m(2) ), normal weight (BMI = 18.5 to 24.99 kg/m(2) ), overweight (BMI = 25 to 29.99 kg/m(2) ), obese (BMI = 30 to 34.99 kg/m(2) ), and very obese (BMI > 35 kg/m(2) ). The primary outcome was acute myocardial infarction (AMI), death, or revascularization within 30 days of presentation. A logistic regression analysis was used to adjust for confounding variables and adjusted odds ratios (aOR) with 95% confidence intervals (CIs) are presented for cardiac events and readmission outcomes. Of the 3,946 patients included in this study, 73 (1.9%) were underweight, 911 (23%) were normal weight, 1,199 (30.4%) were overweight, 872 (22.1%) were obese, and 891 (22.6%) were very obese. Although increased levels of obesity were associated with a greater number of cardiac risk factors, there was no difference in 30-day cardiovascular events between those of normal weight and underweight (aOR = 1.1; 95% CI = 0.4 to 2.7), overweight (aOR = 1.0; 95% CI = 0.7 to 1.4), obese (aOR = 1.2; 95% CI = 0.8 to1.7), or very obese (aOR = 0.8; 95% CI = 0.5 to 1.3). Those who were underweight were more likely to be readmitted within 30 days (aOR = 1.9; 95% CI = 1.0 to 3.7), and those who were very obese were less likely to be readmitted within 30 days (aOR = 0.7; 95% CI = 0.5 to 0.9). Among patients who present to the ED with potential ACS, BMI is not associated with higher risk of cardiovascular outcomes at 30 days.


Improving life expectancy and decreasing the incidence of complications associated with type 2 diabetes: a modelling study of HbA1c targets.
To project the long-term clinical and cost outcomes that accompany predefined improvements in glycaemic control in patients with type 2 diabetes. A peer-reviewed, validated, non-product-specific Markov model of type 2 diabetes was used to project the long-term clinical and cost outcomes associated with three HbA1c reduction scenarios (vs. no reduction): (i) decreasing mean HbA1c from 9.5% to 8.0%; (ii) from 8.0% to 7.0%; and (iii) from 7.0% to 6.5%. A typical baseline US type 2 diabetes cohort derived from National Health and Nutrition Examination Survey data was simulated over a lifetime horizon (35 years). Incidence of diabetes-related complications and costs (2005 USD) were accounted based on published data. Discount rates (3% per annum) were applied to clinical benefits and costs. Sensitivity analyses were performed. Stepwise reductions in HbA1c as an independent variable correlated with delayed time to diabetes-related complications and a reduced cumulative incidence of complications, including cardiovascular, renal and neurologic comorbidities. Related costs also decreased. Reductions in both poorly- (9.5-8.0%) and better-controlled (7.0-6.5%) patients produced incremental gains in undiscounted life expectancy (LE) [1.06 (0.31) and 0.32 (0.34) years [mean (SD)], respectively]. Similar improvement patterns were observed in quality-adjusted life expectancy (QALE). Benefits from sequential reduction scenarios, when aggregated, exhibited the most dramatic effect. Improved glycaemic control was associated with reductions in complication rates and costs, as well as increased LE and QALE among type 2 patients. These data illustrate the long-term importance of reaching normoglycaemia and support intensified HbA1c control as a cornerstone of effective long-term type 2 diabetes management.


Dampness and moulds in relation to respiratory and allergic symptoms in children: results from Phase Two of the International Study of Asthma and Allergies in Childhood (ISAAC Phase Two).
Many studies report that damp housing conditions are associated with respiratory symptoms. Less is known about mechanisms and possible effect modifiers. Studies of dampness in relation to allergic sensitization and eczema are scarce. We study the influence of damp housing conditions world-wide on symptoms and objective outcomes. Cross-sectional studies of 8-12-year-old children in 20 countries used standardized methodology from Phase Two of the International Study of Asthma and Allergies in Childhood (ISAAC). Symptoms of asthma, rhinitis and eczema, plus residential exposure to dampness and moulds, were ascertained by parental questionnaires (n = 46 051). Skin examination, skin prick tests (n = 26 967) and hypertonic saline bronchial challenge (n = 5713) were performed. In subsamples stratified by wheeze (n = 1175), dust was sampled and analysed for house dust mite (HDM) allergens and endotoxin. Current exposure to dampness was more common for wheezy children (pooled odds ratio 1.58, 95% CI 1.40-1.79) and was associated with greater symptom severity among wheezers, irrespective of atopy. A significant (P < 0.01) adverse effect of dampness was also seen for cough and phlegm, rhinitis and reported eczema, but not for examined eczema, nor bronchial hyperresponsiveness. HDM sensitization was more common in damp homes (OR 1.16, 1.03-1.32). HDM-allergen levels were higher in damp homes and were positively associated with HDM-sensitization, but not wheeze. A consistent association of dampness with respiratory and other symptoms was found in both affluent and non-affluent countries, among both atopic and non-atopic children. HDM exposure and sensitization may contribute, but the link seems to be related principally to non-atopic mechanisms.


Calcified atherosclerotic plaque and bone mineral density in type 2 diabetes: the diabetes heart study.
The purpose of the present study was to determine the relationships between atherosclerotic calcified plaque (CP) and bone mineral density (BMD) in subjects with type 2 diabetes mellitus (DM2). CP in the coronary arteries, carotid bifurcation, and abdominal aorta was measured using computed tomography (CT) in 1023 diabetic subjects from 453 families. Trabecular volumetric BMD in thoracic (T-vBMD) and lumbar (L-vBMD) spine was measured with quantitative CT (QCT), while areal BMD (aBMD) in the lumbar spine and hip was measured by dual X-ray absorptiometry (DXA). Correlation coefficients were computed to assess the magnitude of associations and generalized estimating equations (GEE1) were used to make statistical inferences while accounting for familial correlation. Subjects were 53.8% female, 85% European American (EA) and 15% African American (AA). After adjustment for age, significant inverse associations between CP and vBMD persisted in EA men (correlations between -0.11 and -0.16, all p<0.05 with the exception of carotid CP vs. T-vBMD, p=0.076) and in AA women, excluding aortic CP (correlations between -0.16 and -0.25, all p<0.05). Estrogen use in AA but not EA women was consistently associated with an inverse relation between CP and vBMD. Significant inverse relationships between CP and vBMD were observed in EA men and AA women with DM2 after adjusting for age and other covariates. QCT determined vBMD was more strongly related to CP than aBMD by DXA. The relation between CP and BMD in diabetes is influenced by age, sex, and ethnicity, with further effect modification by hormone replacement therapy.


An adaptable stage perfusion incubator for the controlled cultivation of C2C12 myoblasts.
Here we present a stage perfusion incubation system that allows for the cultivation of mammalian cells within PDMS microfluidic devices for long-term microscopic examination and analysis. The custom-built stage perfusion incubator is adaptable to any x-y microscope stage and is enabled for temperature, gas and humidity control as well as equipped with chip and tubing holder. The applied double-layered microfluidic chip allows the predetermined positioning and concentration of cells while the gas permeable PDMS material facilitates pH control via CO2 levels throughout the chip. We demonstrate the functionality of this system by culturing C2C12 murine myoblasts in buffer free medium within its confines for up to 26 hours. We moreover demonstrated the system's compatibility with various chip configurations, other cells lines (HEK-293 cells) and for longer-term culturing. The cost-efficient system are applicable for any type of PDMS-based cell culture system. Detailed technical drawings and specification to reproduce this perfusion incubation system is provided in the ESI.


Evidence against an ecological explanation of the jitter advantage for vection.
Visual-vestibular conflicts have been traditionally used to explain both perceptions of self-motion and experiences of motion sickness. However, sensory conflict theories have been challenged by findings that adding simulated viewpoint jitter to inducing displays enhances (rather than reduces or destroys) visual illusions of self-motion experienced by stationary observers. One possible explanation of this jitter advantage for vection is that jittering optic flows are more ecological than smooth displays. Despite the intuitive appeal of this idea, it has proven difficult to test. Here we compared subjective experiences generated by jittering and smooth radial flows when observers were exposed to either visual-only or multisensory self-motion stimulations. The display jitter (if present) was generated in real-time by updating the virtual computer-graphics camera position to match the observer's tracked head motions when treadmill walking or walking in place, or was a playback of these head motions when standing still. As expected, the (more naturalistic) treadmill walking and the (less naturalistic) walking in place were found to generate very different physical head jitters. However, contrary to the ecological account of the phenomenon, playbacks of treadmill walking and walking in place display jitter both enhanced visually induced illusions of self-motion to a similar degree (compared to smooth displays).


Severe Epstein-Barr virus infection in primary immunodeficiency and the normal host.
Epstein-Barr virus (EBV) infection is ubiquitous in humans, but the majority of infections have an asymptomatic or self-limiting clinical course. Rarely, individuals may develop a pathological EBV infection with a variety of life threatening complications (including haemophagocytosis and malignancy) and others develop asymptomatic chronic EBV viraemia. Although an impaired ability to control EBV infection has long been recognised as a hallmark of severe T-cell immunodeficiency, the advent of next generation sequencing has identified a series of Primary Immunodeficiencies in which EBV-related pathology is the dominant feature. Chronic active EBV infection is defined as chronic EBV viraemia associated with systemic lymphoproliferative disease, in the absence of immunodeficiency. Descriptions of larger cohorts of patients with chronic active EBV in recent years have significantly advanced our understanding of this clinical syndrome. In this review we summarise the current understanding of the pathophysiology and natural history of these diseases and clinical syndromes, and discuss approaches to the investigation and treatment of severe or atypical EBV infection.


Cleavage pattern and development of isolated D blastomeres in bivalves.
Although bivalves develop through spiral cleavage patterns, similar to other lophotrochozoans, the cleavage pattern of D lineage blastomeres is unique, since 2d shows four rounds of stereotypic unequal cleavage before bilateral cleavage of the largest derivative of 2d: 2d(1121) . This unique modification of spiral cleavage is directly associated with the characteristic morphology of bivalves, namely, bilaterally separated shell plates, because the bilateral shell plates are thought to be derived from the bilateral derivatives of 2d(1121) . In this report, to determine whether the unique cleavage pattern of bivalves is regulated depending on the interaction with other cells or by cell autonomous mechanisms, we performed cell isolation experiments and observed subsequent cleavage patterns of isolated blastomeres. When focusing on the largest derivatives of D blastomeres, 8% of isolated D blastomeres followed the cleavage pattern of normal development up to bilateral cleavage. Importantly, the remainder of the partial embryos ended cleavage before that stage, and none of the isolated blastomeres showed abnormal cleavage patterns. We also examined the development of isolated blastomeres and found that isolated D blastomeres could develop shell plates, whereas larvae developed from AB blastomeres never had shell plates. Based on these observations, we concluded that D blastomeres control their unique cleavage pattern through intrinsic mechanisms and develop shell glands autonomously without any cell-cell interaction with other lineages.


Hierarchical competitions subserving multi-attribute choice.
Valuation is a key tenet of decision neuroscience, where it is generally assumed that different attributes of competing options are assimilated into unitary values. Such values are central to current neural models of choice. By contrast, psychological studies emphasize complex interactions between choice and valuation. Principles of neuronal selection also suggest that competitive inhibition may occur in early valuation stages, before option selection. We found that behavior in multi-attribute choice is best explained by a model involving competition at multiple levels of representation. This hierarchical model also explains neural signals in human brain regions previously linked to valuation, including striatum, parietal and prefrontal cortex, where activity represents within-attribute competition, competition between attributes and option selection. This multi-layered inhibition framework challenges the assumption that option values are computed before choice. Instead, our results suggest a canonical competition mechanism throughout all stages of a processing hierarchy, not simply at a final choice stage.


Consensus statement on assessment of waterpipe smoking in epidemiological studies.
Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.


Trade-off between local transmission and long-range dispersal drives infectious disease outbreak size in spatially structured populations.
Transmission of infectious diseases between immobile hosts (e.g., plants, farms) is strongly dependent on the spatial distribution of hosts and the distance-dependent probability of transmission. As the interplay between these factors is poorly understood, we use spatial process and transmission modelling to investigate how epidemic size is shaped by host clustering and spatial range of transmission. We find that for a given degree of clustering and individual-level infectivity, the probability that an epidemic occurs after an introduction is generally higher if transmission is predominantly local. However, local transmission also impedes transfer of the infection to new clusters. A consequence is that the total number of infections is maximal if the range of transmission is intermediate. In highly clustered populations, the infection dynamics is strongly determined by the probability of transmission between clusters of hosts, whereby local clusters act as multiplier of infection. We show that in such populations, a metapopulation model sometimes provides a good approximation of the total epidemic size, using probabilities of local extinction, the final size of infections in local clusters, and probabilities of cluster-to-cluster transmission. As a real-world example we analyse the case of avian influenza transmission between poultry farms in the Netherlands.


Neutrophil Extracellular Traps Profiles in Patients with Incident Systemic Lupus Erythematosus and Lupus Nephritis.
Neutrophil extracellular traps (NET) expose modified antigens for autoantibodies in vasculitis. Little is known about levels and removal pathways of NET in systemic lupus erythematosus (SLE), especially in lupus nephritis (LN). We determined circulating levels and defined NET removal in large subsets of patients with incident SLE (iSLE), some of whom had new-onset nephritis. Serum levels of NET (ELISA), DNase1/DNase1L3 (ELISA), and DNase activity (functional assay) were determined in 216 patients with iSLE [103 had incident LN (iLN)], in 50 patients with other primary glomerulonephritis, and in healthy controls. Ex vivo NET production by neutrophils purified from a random selection of patients was quantified as elastase/DNA release and by immunofluorescence techniques. Serum NET levels were very high in iSLE/iLN compared to all groups of controls and correlated with anti-dsDNA, C3-C4, and proteinuria; iLN had the highest levels. DNase activity was decreased in iLN compared to SLE (20% had one-half DNase activity) despite similar serum levels of DNase1/DNase1L3. In these cases, pretreatment of serum with protein A restored DNase efficiency; 1 patient was homozygous for a c.289_290delAC variant of DNASE1L3. Ex vivo NET production by neutrophils purified from LN, SLE, and normal controls was similar in all cases. Patients with iLN have increased circulating NET and reduced DNase activity, the latter being explained by the presence of inhibitory substances in circulation and/or by rare DNase1L3 mutations. Accumulation of NET derives from a multifactorial mechanism, and is associated and may contribute to disease severity in SLE, in particular to renal lesions. (Clinical trial registration: The Zeus study was registered at ClinicalTrials.gov, study number NCT02403115).


Near-field measurement of amplitude and phase in silicon waveguides with liquid cladding.
Heterodyne near-field scanning optical microscopy (H-NSOM) has proven useful as a tool for characterization of both amplitude and phase of on-chip photonic devices in air, but it has previously been unable to characterize devices with a dielectric overcladding, which is commonly used in practice for such devices. Here we demonstrate H-NSOM of a silicon waveguide with a liquid cladding emulating the solid dielectric. This technique allows characterization of practical devices with realistic refractive index profiles. Fourier analysis is used to estimate the effective refractive index of the mode from the measured data, showing an index shift of 0.08 from air to water cladding, which is seen to correspond well to simulations.


A Rare Case of Pyrethroid Poisoning Presenting as Auditory Hallucination.
Pyrethroid is an insecticide which is widely used for household pests. Even though they are relatively less toxic to humans, reports of accidental poisoning are not uncommon. Cases of anosmia, tremors and arrhythmias after pyrethroid exposure have been reported; however auditory hallucinations have not been presented yet. Herein, we present a case of auditory hallucination in the form of ringing in the ear after exposure to airborne pyrethrin in a 69-year-old male. The significance of this case report is related to the wide use of insecticides containing pyrethrin and highlights the need for physician awareness of this uncommon pathology.


Academic couples: implications for medical school faculty recruitment and retention.
Academic couples constitute 36% of the US professoriate. Universities are in the midst of a major transition in hiring practices to support these and other faculty with working partners. However, less is known about academic couples among medical school faculty and surgical specialties specifically. This study was designed to address this gap. In 2006-2007, the Michelle R Clayman Institute for Gender Research at Stanford University designed and administered the "Managing Academic Careers Survey" to nearly 30,000 full-time faculty across all academic fields at leading research universities nationwide. This study included 2,475 medical school faculty survey respondents at 12 participating institutions. Main outcomes measures were academic partner status; number of journal articles/chapters during career; and applications to other academic position(s) in last 5 years. A total of 73.3% of medical school faculty respondents were in dual-career partnerships (where both partners actively pursue employment) and 32.2% had an academic partner. Sixty-nine percent of academic partners were also in medical schools. Women faculty were more likely than men to have an academic partner. Among surgery faculty, 40% of women had an academic partner, as compared with 29.3% of men. In fully adjusted regression models, faculty with academic partners had higher publication counts than other faculty, and had higher odds of applying to other academic positions. Academic couples constitute one-third of all medical school faculty. They represent a productive and potentially mobile component of the medical faculty workforce. Because women had a higher rate of academic partnering, dual-career academic hiring policies are especially important for recruitment and retention of female faculty in surgical specialties.


A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. Stent Restenosis Study Investigators.
Coronary-stent placement is a new technique in which a balloon-expandable, stainless-steel, slotted tube is implanted at the site of a coronary stenosis. The purpose of this study was to compare the effects of stent placement and standard balloon angioplasty on angiographically detected restenosis and clinical outcomes. We randomly assigned 410 patients with symptomatic coronary disease to elective placement of a Palmaz-Schatz stent or to standard balloon angioplasty. Coronary angiography was performed at base line, immediately after the procedure, and six months later. The patients who underwent stenting had a higher rate of procedural success than those who underwent standard balloon angioplasty (96.1 percent vs. 89.6 percent, P = 0.011), a larger immediate increase in the diameter of the lumen (1.72 +/- 0.46 vs. 1.23 +/- 0.48 mm, P < 0.001), and a larger luminal diameter immediately after the procedure (2.49 +/- 0.43 vs. 1.99 +/- 0.47 mm, P < 0.001). At six months, the patients with stented lesions continued to have a larger luminal diameter (1.74 +/- 0.60 vs. 1.56 +/- 0.65 mm, P = 0.007) and a lower rate of restenosis (31.6 percent vs. 42.1 percent, P = 0.046) than those treated with balloon angioplasty. There were no coronary events (death; myocardial infarction; coronary-artery bypass surgery; vessel closure, including stent thrombosis; or repeated angioplasty) in 80.5 percent of the patients in the stent group and 76.2 percent of those in the angioplasty group (P = 0.16). Revascularization of the original target lesion because of recurrent myocardial ischemia was performed less frequently in the stent group than in the angioplasty group (10.2 percent vs. 15.4 percent, P = 0.06). In selected patients, placement of an intracoronary stent, as compared with balloon angioplasty, results in an improved rate of procedural success, a lower rate of angiographically detected restenosis, a similar rate of clinical events after six months, and a less frequent need for revascularization of the original coronary lesion.


Reassessment of structural characteristics of the d(CGCG)2:actinomycin D complex from complete 1H and 31P NMR.
Complexes formed between Actinomycin D (ActD) and the tetranucleotides d(AGCT)2 and d(CGCG)2 were studied in detail by one and two-dimensional 1H and 31P NMR. The 31P two dimensional chemical exchange experiment, at room temperature on saturated complexes (1:1), showed unambiguously that the asymmetrical phenoxazone ring binds to the unique GC site under the two possible orientations in the d(AGCT)2 tetranucleotide but adopts a single orientation in the d(CGCG)2 tetranucleotide. For the d(CGCG)2:Act D saturated complex, complete assignments of all protons and phosphorus signals of the two-nucleotide strands, as well as of the two cyclic pentapeptide chains has allowed us to study in details the conformational features of the complex from NOE and coupling constants analysis. The tetranucleotide remains in a right-handed duplex, but the sugar puckers are modified for residues at the intercalation site. A uniform C2' endo pucker is observed for residues on the strand facing the quinoid side of the phenoxazone ring while a C2' endo-C3-endo equilibrium about 60% of C2' endo is proposed for the two residues on the strand facing the benzenoid side of the phenoxazone ring. In contrast to previous studies on ActD-DNA interactions, we have been able to measure the 3J phosphorus-proton coupling constants at the intercalation site but also adjacent to it, showing that 31P chemical shifts are not simply related to the backbone conformation. Molecular mechanics calculations, using empirical distances deduced from NOE effects as restrained distances during minimizations, led to a model differing mainly from those previously published by orientation of the N methyl groups of both N-Methyl-Valines.


The existential experience of everyday life with systemic lupus erythematosus.
To explore from the perspective of women the nature of basic existential conditions while living with systemic lupus erythematosus. Systemic lupus erythematosus has an unpredictable disease course and is documented to cause an existential rearrangement of life. The significance of changes in existential conditions and related experiences are unclear in the context of nursing and women with systemic lupus erythematosus. A qualitative design guided by Van Manen's hermeneutic-phenomenological methodology. Individual in-depth interviews with 15 women diagnosed with systemic lupus erythematosus and of various ages, disease durations and severities were undertaken from September 2013 - October 2015. Data were analysed following van Manen's phenomenological approach and using drawing as an interpretive tool. The main existential experience was interpreted as a person "moving with the waves of systemic lupus erythematosus" constituted by the themes "oscillating between presence and absence of systemic lupus erythematosus," "recognizing space and bodily possibilities and limitations" and "being enriched through relationships and activities." When systemic lupus erythematosus was flaring, well-being was threatened and a laborious time to escape the feeling of a setback-in-life persisted long after the disease was medically under control. Daily life with systemic lupus erythematosus is conditioned by a prominent need to be in existential motion, related to the absence and presence of systemic lupus erythematosus. The experience of a setback-in-life by illness might challenge well-being and indicates that periods of disease flares or disturbing symptoms are critical time points to provide support.


Improved detection of artifactual viral minority variants in high-throughput sequencing data.
High-throughput sequencing (HTS) of viral samples provides important information on the presence of viral minority variants. However, detection and accurate quantification is limited by the capacity to distinguish biological from artificial variation. In this study, errors related to the Illumina HiSeq2000 library generation and HTS process were investigated by determining minority variant frequencies in an influenza A/WSN/1933(H1N1) virus reverse-genetics plasmid pool. Errors related to amplification and sequencing were determined using the same plasmid pool, by generation of infectious virus using reverse genetics followed by in duplo reverse-transcriptase PCR (RT-PCR) amplification and HTS in the same sequence run. Results showed that after "best practice" quality control (QC), within the plasmid pool, one minority variant with a frequency >0.5% was identified, while 84 and 139 were identified in the RT-PCR amplified samples, indicating RT-PCR amplification artificially increased variation. Detailed analysis showed that artifactual minority variants could be identified by two major technical characteristics: their predominant presence in a single read orientation and uneven distribution of mismatches over the length of the reads. We demonstrate that by addition of two QC steps 95% of the artifactual minority variants could be identified. When our analysis approach was applied to three clinical samples 68% of the initially identified minority variants were identified as artifacts. Our study clearly demonstrated that, without additional QC steps, overestimation of viral minority variants is very likely to occur, mainly as a consequence of the required RT-PCR amplification step. The improved ability to detect and correct for artifactual minority variants, increases data resolution and could aid both past and future studies incorporating HTS. The source code has been made available through Sourceforge (https://sourceforge.net/projects/mva-ngs).


Milliwatt-level frequency combs in the 8-14 μm range via difference frequency generation from an Er:fiber oscillator.
We report on the generation of mid-infrared (mid-IR) pulses with a maximum average optical power of 4 mW and wide tunability in the 8-14 μm range via difference frequency generation (DFG) in GaSe from an Er:fiber laser oscillator. The DFG process is seeded with self-frequency shifted Raman solitons that are shown to be phase coherent within the whole tuning range, from 1.76 to 1.93 μm. Interference measurements between adjacent pulses at the idler wavelengths attest coherence transfer to the mid-IR.


Simultaneous improvement in productivity, water use, and albedo through crop structural modification.
Spanning 15% of the global ice-free terrestrial surface, agricultural lands provide an immense and near-term opportunity to address climate change, food, and water security challenges. Through the computationally informed breeding of canopy structural traits away from those of modern cultivars, we show that solutions exist that increase productivity and water use efficiency, while increasing land-surface reflectivity to offset greenhouse gas warming. Plants have evolved to maximize capture of radiation in the upper leaves, thus shading competitors. While important for survival in the wild, this is suboptimal in monoculture crop fields for maximizing productivity and other biogeophysical services. Crop progenitors evolved over the last 25 million years in an atmosphere with less than half the [CO2] projected for 2050. By altering leaf photosynthetic rates, rising [CO2] and temperature may also alter the optimal canopy form. Here using soybean, the world's most important protein crop, as an example we show by applying optimization routines to a micrometeorological leaf canopy model linked to a steady-state model of photosynthesis, that significant gains in production, water use, and reflectivity are possible with no additional demand on resources. By modifying total canopy leaf area, its vertical profile and angular distribution, and shortwave radiation reflectivity, all traits available in most major crop germplasm collections, increases in productivity (7%) are possible with no change in water use or albedo. Alternatively, improvements in water use (13%) or albedo (34%) can likewise be made with no loss of productivity, under Corn Belt climate conditions.


Influence of Vacuum Cooling on Escherichia coli O157:H7 Infiltration in Fresh Leafy Greens via a Multiphoton-Imaging Approach.
Microbial pathogen infiltration in fresh leafy greens is a significant food safety risk factor. In various postharvest operations, vacuum cooling is a critical process for maintaining the quality of fresh produce. The overall goal of this study was to evaluate the risk of vacuum cooling-induced infiltration of Escherichia coli O157:H7 into lettuce using multiphoton microscopy. Multiphoton imaging was chosen as the method to locate E. coli O157:H7 within an intact lettuce leaf due to its high spatial resolution, low background fluorescence, and near-infrared (NIR) excitation source compared to those of conventional confocal microscopy. The variables vacuum cooling, surface moisture, and leaf side were evaluated in a three-way factorial study with E. coli O157:H7 on lettuce. A total of 188 image stacks were collected. The images were analyzed for E. coli O157:H7 association with stomata and E. coli O157:H7 infiltration. The quantitative imaging data were statistically analyzed using analysis of variance (ANOVA). The results indicate that the low-moisture condition led to an increased risk of microbial association with stomata (P < 0.05). Additionally, the interaction between vacuum cooling levels and moisture levels led to an increased risk of infiltration (P < 0.05). This study also demonstrates the potential of multiphoton imaging for improving sensitivity and resolution of imaging-based measurements of microbial interactions with intact leaf structures, including infiltration.


Identification Exon Skipping Events From High-Throughput RNA Sequencing Data.
The emergence of next-generation high-throughput RNA sequencing (RNA-Seq) provides tremendous opportunities for researchers to analyze alternative splicing on a genome-wide scale. However, accurate identification of alternative splicing events from RNA-Seq data has remained an unresolved challenge in next-generation sequencing (NGS) studies. Identifying exon skipping (ES) events is an essential part in genome-wide alternative splicing event identification. In this paper, we propose a novel method ESFinder, a random forest classifier to identify ES events from RNA-Seq data. ESFinder conducts thorough studies on predicting features and figures out proper features according to their relevance for ES event identification. Experimental results on real human skeletal muscle and brain RNA-Seq data show that ESFinder could effectively predict ES events with high predictive accuracy. The codes of ESFinder are available at http://mlg.hit.edu.cn/ybai/ES/ESFinder.html.


PrEP for key populations in combination HIV prevention in Nairobi: a mathematical modelling study.
The HIV epidemic in the population of Nairobi as a whole is in decline, but a concentrated sub-epidemic persists in key populations. We aimed to identify an optimal portfolio of interventions to reduce HIV incidence for a given budget and to identify the circumstances in which pre-exposure prophylaxis (PrEP) could be used in Nairobi, Kenya. A mathematical model was developed to represent HIV transmission in specific key populations (female sex workers, male sex workers, and men who have sex with men [MSM]) and among the wider population of Nairobi. The scale-up of existing interventions (condom promotion, antiretroviral therapy, and male circumcision) for key populations and the wider population as have occurred in Nairobi is represented. The model includes a detailed representation of a PrEP intervention and is calibrated to prevalence and incidence estimates specific to key populations and the wider population. In the context of a declining epidemic overall but with a large sub-epidemic in MSM and male sex workers, an optimal prevention portfolio for Nairobi should focus on condom promotion for male sex workers and MSM in particular, followed by improved antiretroviral therapy retention, earlier antiretroviral therapy, and male circumcision as the budget allows. PrEP for male sex workers could enter an optimal portfolio at similar levels of spending to when earlier antiretroviral therapy is included; however, PrEP for MSM and female sex workers would be included only at much higher budgets. If PrEP for male sex workers cost as much as US$500, average annual spending on the interventions modelled would need to be less than $3·27 million for PrEP for male sex workers to be excluded from an optimal portfolio. Estimated costs per infection averted when providing PrEP to all female sex workers regardless of their risk of infection, and to high-risk female sex workers only, are $65 160 (95% credible interval [CrI] $43 520-$90 250) and $10 920 (95% CrI $4700-$51 560), respectively. PrEP could be a useful contribution to combination prevention, especially for under-served key populations in Nairobi. An ongoing demonstration project will provide important information regarding practical aspects of implementing PrEP for key populations in this setting. The Bill & Melinda Gates Foundation.


Protocol for a systematic review: understanding the motivations and barriers to uptake and use of female-initiated, primary biomedical HIV prevention technologies in sub-Saharan Africa.
Women in sub-Saharan Africa are disproportionately affected by high rates of HIV, yet relatively few products exist for female-initiated HIV prevention. New antiretroviral (ARV)-based prevention options could present opportunities for women to expand their HIV prevention choices; however, acceptability and adherence play a key role in the effectiveness of these products and implementation is still in early stages. To better understand which HIV prevention options might best serve women in sub-Saharan Africa, how and why, this review will explore qualitative evidence from clinical trials and implementation studies alike using a meta-ethnographic approach to synthesise data and interpret results. This systematic review will use a meta-ethnographic approach to analyse qualitative data extracted from multiple studies featuring actual use of female-initiated technologies for HIV prevention. The search strategy will be applied in seven databases and papers will be selected using strict inclusion and exclusion criteria. The review will closely follow the guidance set forth by preferred reporting items for systematic reviews and meta-analyses (PRISMA) and Centre for Reviews Dissemination (CRD) where the guidance applies to qualitative data. Two reviewers will review all papers during the paper selection phase, with consultation from a third reviewer to confirm consensus. All papers included in the review will be read and analysed by two reviewers. The final analysis will be conducted by three primary reviewers with additional input from all other authors. With new HIV prevention technologies currently in early implementation phases and still more on the horizon, there is much to learn about how best these products may be delivered. A review such as this could help to inform the real-world implementation of the next wave of new HIV prevention technologies such as ARV-based oral pre-exposure prophylaxis (PrEP).


Receptor subtype discrimination using extensive shape complementary designed interfaces.
To discriminate between closely related members of a protein family that differ at a limited number of spatially distant positions is a challenge for drug discovery. We describe a combined computational design and experimental selection approach for generating binders targeting functional sites with large, shape complementary interfaces to read out subtle sequence differences for subtype-specific antagonism. Repeat proteins are computationally docked against a functionally relevant region of the target protein surface that varies in the different subtypes, and the interface sequences are optimized for affinity and specificity first computationally and then experimentally. We used this approach to generate a series of human Frizzled (Fz) subtype-selective antagonists with extensive shape complementary interaction surfaces considerably larger than those of repeat proteins selected from random libraries. In vivo administration revealed that Wnt-dependent pericentral liver gene expression involves multiple Fz subtypes, while maintenance of the intestinal crypt stem cell compartment involves only a limited subset.


Effect of macrophages and serum of fish susceptible or resistant to epizootic ulcerative syndrome (EUS) on the EUS pathogen, Aphanomyces invadans.
Epizootic ulcerative syndrome (EUS) is one of the most destructive diseases of fresh and brackish water farmed and wild fish in the Asia-Pacific region. The in vitro germination and growth of the propagules of the EUS pathogen, Aphanomyces invadans (= A. piscicida), were assessed in the presence of the head-kidney macrophages, serum, and serum heated to inactivate complement proteins, of three EUS-susceptible and one resistant fish species. The susceptible species were: striped snakehead (Channa striata), giant gourami (Osphronemus gouramy) and silver barb [Barbodes (= Puntius) gonionotus], and the resistant species was Nile tilapia (Oreochromis niloticus). Fish of all species were acclimatised to either low temperature (20 degrees C +/- 1.6) at which EUS is known to occur, or to high temperature (32 degrees C +/- 5.0) at which EUS does not occur, except for giant gouramis which were only studied at low temperature. The respiratory burst of the macrophages was assessed in the presence of A. invadans or the stimulant phorbol myristate acetate (PMA), and compared to that of controls. Anti-A. invadans antibody concentrations were assessed in all species except silver barbs. All assays were carried out at the same temperature, regardless of the temperature that the fish were kept at. Macrophages of all species other than snakeheads inhibited fungal germination at both temperatures, though only silver barb and gourami macrophages could inhibit germling growth. PMA increased the respiratory burst in nearly all cases. The respiratory burst in the presence of A. invadans was consistently lower than that of controls, though the difference was only significant in the case of snakeheads. The respiratory burst of all macrophage treatments was higher at a low temperature. Except in the case of PMA-stimulated macrophages, regressions between respiratory burst and inhibitory action were only found in susceptible species, suggesting that the respiratory burst is important in those species, but is unable to prevent the proliferation of A. invadans. Serum inhibited fungal germination in all cases other than low temperature tilapia, indicating that the EUS resistance of tilapia is not due to the serum. Inhibition of germling growth by serum only occurred in silver barbs and gourami. Heated serum did not inhibit germination in any case except that of high temperature snakehead, and in fact stimulated germination in the case of tilapia. Heating serum did not affect the growth inhibiting activity of silver barbs and gouramis, but it stimulated growth in some groups. At high temperatures snakeheads had high anti-A. invadans antibody concentrations, which may explain the inhibitory activity of their heated serum. A role for complement and antibodies in defence against A. invadans in susceptible species is suggested.


Atopic dermatitis and atopy in non-clinical populations.
A group of 523 individuals from the general population in the Denver, Colorado area responded to an advertisement for subjects with "problem skin" conditions, such as eczema, dry skin, rashes, etc. The subjects completed screening history information and were evaluated for various characteristics during an examination by a dermatologist. Of the entire population, 33% satisfied the criteria for atopic dermatitis. Another group, described as the generic atopy subset, emerged from the classification and constituted 23% of the total. Individuals in this subset typically had either a personal history of atopic disease or a limited family history. They lacked past or present evidence of flexural rash. A third group, totaling 44%, was classified as nonatopic. A relatively large percent of each of the three groups exhibited some clinical signs of dry skin (e.g., scaling, flakiness). This feature is believed to be due, at least in part, to the damaging effects of the cold, dry conditions in Denver, Colorado.


Negotiating the dynamics of uncomfortable knowledge: The case of dual use and synthetic biology.
Institutions need to ignore some knowledge in order to function. This is "uncomfortable knowledge" because it undermines the ability of those institutions to pursue their goals (Rayner, 2012). We identify three bodies of knowledge that are relevant to understandings of the dual use threat posed by synthetic biology but are excluded from related policy discussions. We demonstrate how these "unknown knowns" constitute uncomfortable knowledge because they disrupt the simplified worldview that underpins contemporary discourse on the potential misuse of synthetic biology by malign actors. We describe how these inconvenient truths have been systematically ignored and argue that this is because they are perceived as a threat by organisations involved in the promotion of synthetic biology as well as by those involved in managing biosecurity risks. This has led to a situation where concerns about the biosecurity threat posed by synthetic biology are not only exaggerated, but are, more importantly, misplaced. This, in turn, means that related policies are misdirected and unlikely to have much impact. We focus on the dynamics of discussions about synthetic biology and dual use to demonstrate how the same "knowns" that are denied or dismissed as "unknown knowns" in certain circumstances are sometimes mobilised as "known knowns" by the same category of actors in a different context, when this serves to sustain the goals of the individuals and institutions involved. Based on our own experience, we argue that negotiating the dynamics of uncomfortable knowledge is a difficult, but necessary, component of meaningful transdisciplinary collaborations.


Insights on multimorbidity and associated health service use and costs from three population-based studies of older adults in Ontario with diabetes, dementia and stroke.
Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period. We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs. We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts. Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused.


Effectiveness of Topical Chia Seed Oil on Pruritus of End-stage Renal Disease (ESRD) Patients and Healthy Volunteers.
Several studies have been performed to evaluate the efficacy of dietary n-3 fatty acid for patients with renal dysfunction. While about 40% to 80% of patients with end-stage renal disease (ESRD) complain about pruritus and xerosis, there are few reports on the effects of topical n-3 fatty acid on these symptoms. In order to investigate the possible beneficial effects of topical n-3 fatty acid, oils extracted from chia (Salvia hispanica) seed were formulated into topical products, the effects of which were measured. Five healthy volunteers having xerotic pruritus symptoms and 5 patients with pruritus caused by either ESRD or diabetes were involved in this study. A topical formulation containing 4% chia seed oils were applied for an 8-week duration. Subjective itching symptoms were assessed on a 6-point scale, as were other skin functions, namely transepidermal water loss and skin capacitance. After the 8 weeks of application, significant improvements in skin hydration, lichen simplex chronicus, and prurigo nodularis were observed in all patients. A similar improvement was also observed among healthy volunteers with xerotic pruritus. Improvement of epidermal permeability barrier function and skin hydration, represented by trans-epidermal water loss and skin capacitance, respectively, were also observed. No adverse effects were observed in all the tested patients and volunteers. Chia seed oil can be used as an adjuvant moisturizing agent for pruritic skin, including that of ESRD patients.


Low-level laser therapy in secondary lymphedema after breast cancer: systematic review.
Complex physical therapy is the main treatment for the secondary lymphedema after breast cancer. The low-level laser therapy (LLLT) has been used in order to stimulate lymphangiogenesis, encourage lymphatic motility, and reduce lymphostatic fibrosis. However, these factors could also favor the development of recurrence and metastasis. The objective of this study is to discuss the use of LLLT in the treatment of lymphedema after breast cancer. This study utilized a systematic review on the use of LLLT in the treatment of lymphedema after breast cancer. Evaluating quality of articles was conducted through the PEDro scale. Of the 41 articles identified, four were considered to be of high methodological quality (score ≥ 5). The low-level laser in the axillary region was performed in all studies. The control group was not similar across studies. The results presented showed that there was a reduction in limb volume in the group subjected to low-power laser when compared with other treatments. No studies have evaluated the risk of metastasis or relapse in the irradiated areas. Because no studies have included the complex physical therapy as the comparison group, we cannot claim that laser treatment is the best efficacy or effectiveness in lymphedema treatment after breast cancer. No studies have evaluated the hypothesis that the LLLT can increase the risk of recurrence or metastasis. Therefore, the questions about the safety of this procedure in cancer patients remain.


Patients' expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN).
Understanding patient expectations is a critical component of patient-centered care; however, little is known about which expectation(s) are most important to patients as they relate to their sense of postoperative success. To investigate patient's preoperative expectations of change in symptoms, function, and well-being resulting from surgical intervention and to examine the associations between sociodemographic, lifestyle, health status, and clinical characteristics with patient outcome expectations STUDY DESIGN: Observational cross-sectional study. Preoperative data from the Canadian Spine Outcomes and Research Network national registry of patients of patients (n=4,333) undergoing surgery for degenerative spinal conditions between 2012 and 2017. Patients reported their expectations as a result of the surgery (0 [no change], 1 [somewhat better], 2 [better] or 3 [much better]) for seven items: leg/arm pain, back/neck pain, independence in everyday activities, sporting activities/recreation, general physical capacity, frequency and quality of social contacts, and mental well-being. Patients also reported the single most important change expected. Data on demographic, lifestyles, health status, clinical factors, and reasons for having surgery were also collected. Factor analysis was used to examine the multidimensionality of expectations. Multivariate linear regression was used to examine factors associated with expectations. Over 80% of patients reported expectation for improvements (at least somewhat better) in all items with the exception of social contacts (75.8%). Expectations are multidimensional; a two factor structure emerged indicating two expectation dimensions (pain relief and overall functional well-being). Two expectation scores were calculated corresponding to the two dimensions (0-100), with higher scores reflecting higher expectations. The mean±standard deviation pain relief expectation score was 78.5±24.7 and the mean overall functional well-being expectation score was 69.7±24.4. In multivariate analysis, the variables associated with these dimensions either differed or differed in degree of influence. For example, higher pain and disability scores, thoracolumbar location and diagnosis of spondylolisthesis were associated with higher expectations in both dimensions, while longer disease duration was only associated with lower overall functional well-being expectations. The top three most important expected change items were pain (improvement of leg or arm pain (29.1%)/improvement in back/neck pain (26.0%)), improvement in general capacity/function (21.0%), and improvement of independence in everyday activities (15.9%). Rankings of the most important expected change were similar across sociodemographic, lifestyle, health status, and clinical variables examined. Our findings highlight the need to identify and address specific individual expectations as part of the shared decision-making and presurgery education process.


The "adipose tissue expandability" hypothesis: a potential mechanism for insulin resistance in obese youth.
Obesity has become a major global health challenge of the 21st century, as it is associated with the onset of type 2 diabetes (T2D) and cardiovascular complications, even at a very early age in life. The root causes of pediatric obesity remain incompletely understood. The obesity epidemic together with the relationship of obesity to the growing population burden of chronic disease presents unprecedented research opportunities and challenges. Decades of obesity-related research funded by governments around the world have yielded many important discoveries about both etiological pathways and preventive or therapeutic interventions. Yet, there is a sense that the problem is outpacing these research efforts. Obesity poses a significant risk for the development of cardiovascular disease (CVD) , diabetes and certain cancers thereby shortening life expectancy. Nevertheless, many obese individuals do not develop any of these comorbidities. One hypothesis explaining this dilemma is that total body fat is not the culprit of adverse health in obesity rather the relative proportion of lipids in various fat depots is what determines the metabolic risk. In this review, we describe the role of altered fat partitioning in youth onset obesity and its relation to fatty liver and T2D during adolescence.


In vitro antibiotic susceptibilities of ocular isolates in North and South America. In Vitro Antibiotic Testing Group.
To assess the in vitro susceptibility of ocular bacterial isolates from North and South America to antiinfectives that are commonly used in the treatment of external ocular infection. Ocular isolates (n = 1,291) from 12 laboratories in the United States, Canada, Mexico, and Argentina were tested for their susceptibility to ofloxacin, ciprofloxacin, norfloxacin, gentamicin, tobramycin, chloramphenicol, tetracycline, and erythromycin using both disk-diffusion and broth-dilution methods. When the results from disk-diffusion and broth-dilution testing were combined, the relative overall in vitro efficacy was (in decreasing order): ofloxacin, ciprofloxacin, norfloxacin, gentamicin, chloramphenicol, tobramycin, tetracycline, and erythromycin. Against gram-positive organisms it was: ofloxacin, ciprofloxacin equivalent to chloramphenicol, norfloxacin, tetracycline, gentamicin, and erythromycin equivalent to tobramycin. Against gram-negative organisms it was: ofloxacin equivalent to ciprofloxacin and norfloxacin, gentamicin, tobramycin, chloramphenicol, and tetracycline comparable to erythromycin. The fluoroquinolones ofloxacin, ciprofloxacin, and norfloxacin had higher overall in vitro efficacy than the other antibiotics tested. Of the fluoroquinolones, ofloxacin had the highest in vitro efficacy against gram-positive organisms. All three fluoroquinolones were equivalent in efficacy against gram-negative organisms.


Perceptions of pharmacy students, faculty members, and administrators on the use of technology in the classroom.
To gather and evaluate the perceptions of students, faculty members, and administrators regarding the frequency and appropriateness of classroom technology use. Third-year pharmacy students and faculty members at 6 colleges and schools of pharmacy were surveyed to assess their perceptions about the type, frequency, and appropriateness of using technology in the classroom. Upper-level administrators and information technology professionals were also interviewed to ascertain overall technology goals and identify criteria used to adopt new classroom technologies. Four hundred sixty-six students, 124 faculty members, and 12 administrators participated in the survey. The most frequently used and valued types of classroom technology were course management systems, audience response systems, and lecture capture. Faculty members and students agreed that faculty members appropriately used course management systems and audience response systems. Compared with their counterparts, tech-savvy, and male students reported significantly greater preference for increased use of classroom technology. Eighty-six percent of faculty members reported having changed their teaching methodologies to meet student needs, and 91% of the students agreed that the use of technology met their needs. Pharmacy colleges and schools use a variety of technologies in their teaching methods, which have evolved to meet the needs of the current generation of students. Students are satisfied with the appropriateness of technology, but many exhibit preferences for even greater use of technology in the classroom.


Quality control of a transcriptional regulator by SUMO-targeted degradation.
Slx5 and Slx8 are heterodimeric RING domain-containing proteins that possess SUMO-targeted ubiquitin ligase (STUbL) activity in vitro. Slx5-Slx8 and its orthologs are proposed to target SUMO conjugates for ubiquitin-mediated proteolysis, but the only in vivo substrate identified to date is mammalian PML, and the physiological importance of SUMO-targeted ubiquitylation remains largely unknown. We previously identified mutations in SLX5 and SLX8 by selecting for suppressors of a temperature-sensitive allele of MOT1, which encodes a regulator of TATA-binding protein. Here, we demonstrate that Mot1 is SUMOylated in vivo and that disrupting the Slx5-Slx8 pathway by mutation of the target lysines in Mot1, by deletion of SLX5 or the ubiquitin E2 UBC4, or by inhibition of the proteosome suppresses mot1-301 mutant phenotypes and increases the stability of the Mot1-301 protein. The Mot1-301 mutant protein is targeted for proteolysis by SUMOylation to a much greater extent than wild-type Mot1, suggesting a quality control mechanism. In support of this idea, growth of Saccharomyces cerevisiae in the presence of the arginine analog canavanine results in increased SUMOylation and Slx5-Slx8-mediated degradation of wild-type Mot1. These results therefore demonstrate that Mot1 is an in vivo STUbL target in yeast and suggest a role for SUMO-targeted degradation in protein quality control.


'Double skull' appearance due to calcifications of chronic subdural hematoma and cephalhematoma: a report of two cases.
Chronic subdural hematomas and cephalhematomas are known to become calcified in some patients. We present interesting cases of cephalhematoma in a child and calcified chronic subdural hematoma in an elderly lady with both getting calcified. The first patient was a 7 months male with calcified cephalhematoma who presented with cosmetic deformity of the skull but did not have any neurological deficits. The other patient was a 54-year-old lady with calcified chronic subdural hematoma who presented with one episode of seizure but did not have any neurological deficit. CT scan revealed calcification of the hematoma causing a double skull appearance in both patients.


Dose-specific adverse drug reaction identification in electronic patient records: temporal data mining in an inpatient psychiatric population.
Data collected for medical, filing and administrative purposes in electronic patient records (EPRs) represent a rich source of individualised clinical data, which has great potential for improved detection of patients experiencing adverse drug reactions (ADRs), across all approved drugs and across all indication areas. The aim of this study was to take advantage of techniques for temporal data mining of EPRs in order to detect ADRs in a patient- and dose-specific manner. We used a psychiatric hospital's EPR system to investigate undesired drug effects. Within one workflow the method identified patient-specific adverse events (AEs) and links these to specific drugs and dosages in a temporal manner, based on integration of text mining results and structured data. The structured data contained precise information on drug identity, dosage and strength. When applying the method to the 3,394 patients in the cohort, we identified AEs linked with a drug in 2,402 patients (70.8 %). Of the 43,528 patient-specific drug substances prescribed, 14,736 (33.9 %) were linked with AEs. From these links we identified multiple ADRs (p < 0.05) and found them to occur at similar frequencies, as stated by the manufacturer and in the literature. We showed that drugs displaying similar ADR profiles share targets, and we compared submitted spontaneous AE reports with our findings. For nine of the ten most prescribed antipsychotics in the patient population, larger doses were prescribed to sedated patients than non-sedated patients; five antipsychotics [corrected] exhibited a significant difference (p<0.05). Finally, we present two cases (p < 0.05) identified by the workflow. The method identified the potentially fatal AE QT prolongation caused by methadone, and a non-described likely ADR between levomepromazine and nightmares found among the hundreds of identified novel links between drugs and AEs (p < 0.05). The developed method can be used to extract dose-dependent ADR information from already collected EPR data. Large-scale AE extraction from EPRs may complement or even replace current drug safety monitoring methods in the future, reducing or eliminating manual reporting and enabling much faster ADR detection.


Gentle rocking movements during sleep in the elderly.
Vestibular stimulation in the form of rocking movements could be a promising non-pharmacological intervention for populations with reduced sleep quality, such as the elderly. We hypothesized that rocking movements influence sleep by promoting comfort. We assessed whether gentle rocking movements can facilitate the transition from wake to sleep, increase sleep spindle density and promote deep sleep in elderly people. We assessed self-reported comfort using a pilot protocol including translational movements and movements along a pendulum trajectory with peak linear accelerations between 0.10 and 0.20 m/s2 . We provided whole-night stimulation using the settings rated most comfortable during the pilot study (movements along a pendulum trajectory with peak linear acceleration of 0.15 m/s2 ). Sleep measures (polysomnography) of two baseline and two movement nights were compared. In our sample (n = 19; eight female; mean age: 66.7 years, standard deviation: 3 years), vestibular stimulation using preferred stimulation settings did not improve sleep. A reduction of delta power was observed, suggesting reduced sleep depth during rocking movements. Sleep fragmentation was similar in both conditions. We did not observe a sleep-promoting effect using settings optimized to be comfortable. This finding could imply that comfort is not the underlying mechanism. At frequencies below 0.3 Hz, the otoliths cannot distinguish tilt from translation. Translational movement trajectories, such as used in previous studies reporting positive effects of rocking, could have caused sensory confusion due to a mismatch between vestibular and other sensory information. We propose that this sensory confusion might be essential to the sleep-promoting effect of rocking movements described in other studies.


Hydrogen in drinking water attenuates noise-induced hearing loss in guinea pigs.
It has been shown that molecular hydrogen acts as a therapeutic and preventive antioxidant by selectively reducing the hydroxyl radical, the most cytotoxic of the reactive oxygen species. In the present study, we tested the hypothesis that acoustic damage in guinea pigs can be attenuated by the consumption of molecular hydrogen. Guinea pigs received normal water or hydrogen-rich water for 14 days before they were exposed to 115 dB SPL 4-kHz octave band noise for 3h. Animals in each group underwent measurements for auditory brainstem response (ABR) or distortion-product otoacoustic emissions (DPOAEs) before the treatment (baseline) and immediately, 1, 3, 7, and 14 days after noise exposure. The ABR thresholds at 2 and 4 kHz were significantly better on post-noise days 1, 3, and 14 in hydrogen-treated animals when compared to the normal water-treated controls. Compared to the controls, the hydrogen-treated animals showed greater amplitude of DPOAE input/output growth functions during the recovery process, with statistical significance detected on post-noise days 3 and 7. These findings suggest that hydrogen can facilitate the recovery of hair cell function and attenuate noise-induced temporary hearing loss.


Distribution of glutathione S-transferase isoenzymes in human kidney: basis for possible markers of renal injury.
To determine whether the tissue distribution of glutathione S-transferase (GST) isoenzymes could define the precise nature of renal injury, 13 adult kidneys were studied, using specific antibodies raised against purified isoenzymes. Basic GST stained strongly proximal convoluted tubules and some medullary tubules; acidic GST stained strongly distal convoluted tubules and medullary tubules; neutral GST stained similarly to acidic GST, but weaker, and microsomal GST stained glomerular and interstitial endothelium and collecting ducts deep in the medulla, although there was considerable variation in staining intensity among cases. It is suggested that the measurement of these isoenzymes in serum and urine may help to elucidate the localisation of tissue damage, which may be particularly valuable in patients with cyclosporine toxicity following renal transplantation.


Biomembrane formation after radiofrequency ablation prevents bone cement extravasation during percutaneous vertebroplasty for treating vertebral metastases with posterior margin destruction: An animal study.
We aimed to investigate the feasibility, safety, and efficacy of radiofrequency ablation (RFA) combined with percutaneous vertebroplasty (PVP) for treating VX2 vertebral metastases with posterior margin destruction in a rabbit model. Sixty rabbit models of VX2 vertebral metastases with posterior margin destruction were constructed through computed tomography (CT)-guided percutaneous puncture and randomly divided into four groups of 15 rabbits each: Groups A, RFA+PVP; B, PVP; C, RFA; and D, control. Five rabbits in each group were sacrificed within 24 h of the procedure. Pathological examination and immunohistochemical staining revealed the presence of a biomembrane barrier at the tumor edge; furthermore, bone cement leakage into the spinal canal was observed. The survival time of the remaining rabbits per group was observed, and the differences were analyzed. CT scans of Group A and C rabbits revealed a low-density band around the tumor ablation region. Bone cement leakage rate significantly differed between Groups A and B (20% vs. 100%; P < 0.05). The average postoperative survival times of Group A, B, C, and D rabbits were 16.72 ± 0.93, 7.26 ± 0.75, 7.80 ± 1.30, and 3.84 ± 1.24 days, respectively, showing a significant difference between Group A and the remaining groups (P < 0.05). The biomembrane barrier formed at the tumor edge after RFA can prevent bone cement leakage into the spinal canal, reducing spinal cord injury and prolonging the survival time.


Determination of monomethylarsonous acid, a key arsenic methylation intermediate, in human urine.
In this study we report on the finding of monomethylarsonous acid [MMA(III)] in human urine. This newly identified arsenic species is a key intermediate in the metabolic pathway of arsenic biomethylation, which involves stepwise reduction of pentavalent to trivalent arsenic species followed by oxidative addition of a methyl group. Arsenic speciation was carried out using ion-pair chromatographic separation of arsenic compounds with hydride generation atomic fluorescence spectrometry detection. Speciation of the inorganic arsenite [As(III)], inorganic arsenate [As(V)], monomethylarsonic acid [MMA(V)], dimethylarsinic acid [DMA(V)], and MMA(III) in a urine sample was complete in 5 min. Urine samples collected from humans before and after a single oral administration of 300 mg sodium 2,3-dimercapto-1-propane sulfonate (DMPS) were analyzed for arsenic species. MMA(III) was found in 51 out of 123 urine samples collected from 41 people in inner Mongolia 0-6 hr after the administration of DMPS. MMA(III )in urine samples did not arise from the reduction of MMA(V) by DMPS. DMPS probably assisted the release of MMA(III) that was formed in the body. Along with the presence of MMA(III), there was an increase in the relative concentration of MMA(V) and a decrease in DMA(V) in the urine samples collected after the DMPS ingestion.


Solving minimum distance problems with convex or concave bodies using combinatorial global optimization algorithms.
Determining the minimum distance between convex objects is a problem that has been solved using many different approaches. On the other hand, computing the minimum distance between combinations of convex and concave objects is known to be a more complicated problem. Most methods propose to partition the concave object into convex subobjects and then solve the convex problem between all possible subobject combinations. This can add a large computational expense to the solution of the minimum distance problem. In this paper, an optimization-based approach is used to solve the concave problem without the need for partitioning concave objects into convex pieces. Since the optimization problem is no longer unimodal (i.e., has more than one local minimum point), global optimization techniques are used. Simulated Annealing (SA) and Genetic Algorithms (GAs) are used to solve the concave minimum distance problem. In order to reduce the computational expense, it is proposed to replace the objects' geometry by a set of points on the surface of each body. This reduces the problem to an unconstrained combinatorial optimization problem, where the combination of points (one on the surface of each body) that minimizes the distance will be the solution. Additionally, if the surface points are set as the nodes of a surface mesh, it is possible to accelerate the convergence of the global optimization algorithm by using a hill-climbing local optimization algorithm. Some examples using these novel approaches are presented.


Utopian Hopes or Dystopian Fears? Exploring the Motivational Underpinnings of Moralized Political Engagement.
People are more likely to become politically engaged (e.g., vote, engage in activism) when issues are associated with strong moral convictions. The goal of this research was to understand the underlying motivations that lead to this well-replicated effect. Specifically, to what extent is moralized political engagement motivated by proscriptive concerns (e.g., perceived harms, anticipated regret), prescriptive concerns (e.g., perceived benefits, anticipated pride), or some combination of these processes? And are the motivational pathways between moral conviction and political engagement the same or different for liberals and conservatives? Two studies (combined N = 2,069) found that regardless of political orientation, the association between moral conviction and political engagement was mediated by the perceived benefits of preferred but not the perceived harms of non-preferred policy outcomes, and by both anticipated pride and regret, findings that replicated in two contexts: legalizing same-sex marriage and allowing concealed weapons on college campuses.


Characterisation of chicken Campylobacter jejuni isolates using resolution optimised single nucleotide polymorphisms and binary gene markers.
The principal objective of this study was to determine if Campylobacter jejuni genotyping methods based upon resolution optimised sets of single nucleotide polymorphisms (SNPs) and binary genetic markers were capable of identifying epidemiologically linked clusters of chicken-derived isolates. Eighty-eight C. jejuni isolates of known flaA RFLP type were included in the study. They encompassed three groups of ten isolates that were obtained at the same time and place and possessed the same flaA type. These were regarded as being epidemiologically linked. Twenty-six unlinked C. jejuni flaA type I isolates were included to test the ability of SNP and binary typing to resolve isolates that were not resolved by flaA RFLP. The remaining isolates were of different flaA types. All isolates were typed by real-time PCR interrogation of the resolution optimised sets of SNPs and binary markers. According to each typing method, the three epidemiologically linked clusters were three different clones that were well resolved from the other isolates. The 26 unlinked C. jejuni flaA type I isolates were resolved into 14 SNP-binary types, indicating that flaA typing can be unreliable for revealing epidemiological linkage. Comparison of the data with data from a fully typed set of isolates associated with human infection revealed that abundant lineages in the chicken isolates that were also found in the human isolates belonged to clonal complex (CC) -21 and CC-353, with the usually rare C-353 member ST-524 being especially abundant in the chicken collection. The chicken isolates selected to be diverse according to flaA were also diverse according to SNP and binary typing. It was observed that CC-48 was absent in the chicken isolates, despite being very common in Australian human infection isolates, indicating that this may be a major cause of human disease that is not chicken associated.


Electron nuclear double resonance spectroscopy.
Precise information about the molecular structure, stereochemistry, and environment of paramagnetic species can be obtained by electron nuclear double resonance (ENDOR) spectroscopy. This technique has been applied in a wide range of disciplines to liquid-phase, single-crystal, and powder samples. In some cases-the study of defects in ionic single crystals, for instance-the volume and complexity of data obtained by ENDOR can hinder interpretation. Such difficulties have been overcome by the use of supplemental ENDOR techniques that simplify the assignment of ENDOR lines. The increased use of computers for the automation of instrumentation, the design of experiments, and the analysis of data has made possible the study of a wider range of problems. With these improvements, as well as with the increased sensitivity provided by optically detected ENDOR, it is now feasible to study polycrystalline and amorphous materials, such as thin-film semiconductors and biological samples in vivo.


Detection of SARS-CoV-2 in saliva: implications for specimen transport and storage.
Saliva has recently been proposed as a suitable specimen for the diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Use of saliva as a diagnostic specimen may present opportunities for SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) testing in remote and low-resource settings. Determining the stability of SARS-CoV-2 RNA in saliva over time is an important step in determining optimal storage and transport times. We undertook an in vitro study to assess whether SARS-CoV-2 could be detected in contrived saliva samples. The contrived saliva samples comprised 10 ml pooled saliva spiked with gamma-irradiated SARS-CoV-2 to achieve a concentration of 2.58×104 copies ml SARS-CoV-2, which was subsequently divided into 2 ml aliquots comprising: (i) neat saliva; and a 1 : 1 dilution with (ii) normal saline; (iii) viral transport media, and (iv) liquid Amies medium. Contrived samples were made in quadruplicate, with two samples of each stored at either: (i) room temperature or (ii) 4 °C. SARS-CoV-2 was detected in all SARS-CoV-2 spiked samples at time point 0, day 1, 3 and 7 at both storage temperatures using the N gene RT-PCR assay and time point 0, day 1 and day 7 using the Xpert Xpress SARS-CoV-2 (Cepheid, Sunnyvale, USA) RT-PCR assay. The ability to detect SARS-CoV-2 in saliva over a 1 week period is an important finding that presents further opportunities for saliva testing as a diagnostic specimen for the diagnosis of SARS-CoV-2.


The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012.
The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection. Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712). Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers. The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.


Response inhibition during Differential Reinforcement of Low Rates (DRL) schedules may be sensitive to low-level polychlorinated biphenyl, methylmercury, and lead exposure in children.
Animal studies have shown that exposure to common, low-level environmental contaminants [e.g., polychlorinated biphenyls (PCBs), lead] causes excessive and inappropriate responding on intermittent reinforcement schedules. The Differential Reinforcement of Low Rates task (DRL) has been shown to be especially sensitive to low-level PCB exposure in monkeys. We investigated the relationships between prenatal PCB and postnatal Pb exposure performance on a DRL schedule in children. We predicted that a) prenatal PCB exposure would reduce interresponse times (IRTs) and reinforcements earned, and b) postnatal Pb exposure would reduce IRTs and reinforcements earned. We tested 167 children on a DRL20 (20 sec) reinforcement schedule, and recorded IRTs and the number of reinforced responses across the session. We measured prenatal PCB exposure (cord blood), methylmercury (MeHg) (maternal hair), and postnatal Pb exposure (venous blood), and > 50 potentially confounding variables. Results indicated impaired performance in children exposed to PCBs, MeHg, and Pb. Children prenatally exposed to PCBs responded excessively, with significantly lower IRTs and fewer reinforcers earned across the session. In addition, exposure to either MeHg or Pb predicted statistically significant impairments of a similar magnitude to those for PCBs, and the associated impairments of all three contaminants (PCB, MeHg, and Pb) were statistically independent of one another. These results, taken with animal literature, argue the high sensitivity of DRL performance to low-level PCB, MeHg, and Pb exposure. Future research should employ behavioral tasks in children, such as DRL, that have been demonstrably sensitive to low-level PCB, MeHg, and Pb exposure in animals.


Benign multicystic mesothelioma masquerading as a urachal cyst.
Benign multicystic mesothelioma (BMM) is a benign intra-abdominal lesion that generally occurs in women in their reproductive years. A urachal cyst occurs when the epithelial-lined urachal canal fails to completely obliterate. We report a case of a 38-year-old female presenting with abdominal pain found to have a lesion highly suspicious for a urachal cyst. On pathologic evaluation the lesion was identified as a BMM. This is the first report of BMM presenting as a lesion suspected to be a urachal cyst.


Healing the physician's story: a case study in narrative medicine and end-of-life care.
Telling stories after a loved one's death helps surviving family members to find meaning in the experience and share perceptions about whether the death was consistent with the deceased person's values and preferences. Opportunities for physicians to evaluate the experience of a patient's death and to expose the ethical concerns that care for the dying often raises are rare. Narrative medicine is a theoretical perspective that provides tools to extend the benefits of storytelling and narrative sense-making to physicians. This case study describes narrative writing workshops attended by physicians who care for dying patients. The narratives created revealed the physicians' concerns about ethics and their emotional connection with patients. This case study demonstrates that even one-time reflective writing workshops might create important opportunities for physicians to evaluate their experiences with dying patients and families.


Identification of the putative MAP kinase docking site in the thyroid hormone receptor-beta1 DNA-binding domain: functional consequences of mutations at the docking site.
In CV-1 cells transfected with wild-type (wt) nuclear thyroid hormone receptor TRbeta1 (TR), L-thyroxine (T(4)) causes activation and nuclear translocation of mitogen-activated protein kinase (MAPK, ERK1/2), co-immunoprecipitation of MAPK and TR, and MAPK-dependent serine phosphorylation of TR. In the present studies, we have identified (1) the likely site of TR serine phosphorylation in the TR DNA-binding domain (DBD) by T(4)-activated MAPK, (2) the site of MAPK docking on TR induced by T(4), and (3) functional consequences of TR docking site and serine phosphorylation site mutations on co-repressor and co-activator binding and on transcriptional activation by wt and mutant receptors in T(4)-treated cells. Plasmids containing TR(wt), serine 142-substituted TR (TR(S142A) or TR(S142E)), TR(K128A), TR(R132A), or TR(R133A) were transfected into CV-1 cells, and the cells were treated with 10(-7) M T(4) for 30 min. Activated MAPK was present in nuclear fractions of all T(4)-treated cells and co-immunoprecipitated prominently with TR(wt), TR(S142A), and TR(S142E). TR(K128A) complexing with activated MAPK was minimally detectable, but no association of MAPK with TR(R132A) or TR(R133A) was seen in cells treated with T(4). Serine phosphorylation of TR(wt), but not of any mutants, occurred with T(4). In in vitro phosphorylation studies, constitutively activated MAPK phosphorylated only TR(wt). We concluded that serine 142 of the TR DBD is the likely site of phosphorylation by T(4)-activated MAPK and that the docking site on TR for activated MAPK includes residues 128-133 (KGFFRR), a basic amino acid-enriched motif novel for MAPK substrates. TR mutations in the proposed MAPK docking domain and at residue 142 modulated T(4)-conditioned shedding of co-repressor and recruitment of co-activator proteins by the receptor, and they altered transcriptional activity of TR in a thyroid hormone response element-luciferase reporter assay.


Proteolytic processing of endogenous and recombinant beta 4 integrin subunit.
The alpha 6 beta 4 integrin is a receptor involved in the interaction of epithelial cells with basement membranes. This integrin is unique among the known integrins in that its beta 4 subunit has a large cytoplasmic domain. The function of this cytoplasmic domain is not known. In this paper we show that the beta 4 subunit undergoes proteolytic processing in cultured cells and provide evidence that this also happens in tissues. Immunoprecipitation experiments indicated that the cytoplasmic domain of beta 4 is susceptible to a calcium-dependent protease present in cellular extracts. In vitro assays with purified calpain showed that this enzyme can cleave beta 4 at two distinct sites in the cytoplasmic domain, generating truncated molecules of 165 and 130 kD. Immunoblotting experiments performed on cultured epithelial cells using an antibody to a peptide modeled after the COOH-terminus of the beta 4 subunit showed 70-kD fragments and several fragments of molecular masses between 185 and 115 kD. Similar fragments were detected in CHO cells transfected with the full-length beta 4 cDNA, but not in control transfected cells or in cells transfected with a mutant cDNA lacking the epitope of the cytoplasmic peptide antibody. The sizes of the fragments indicated that both the intracellular and extracellular domains of beta 4 are proteolytically processed. To examine the processing of the beta 4 subunit in epithelial tissues in vivo, human skin frozen sections were stained with antibodies to the ectodomain or the cytoplasmic domain of beta 4. The distinct staining patterns obtained with the two types of antibodies provided evidence that beta 4 is proteolytically processed in vivo in skin. Analogous experiments performed on sections of the cornea suggested that beta 4 is not proteolytically processed at a detectable level in this tissue. Thus, cleavage of the beta 4 subunit occurs in a tissue-specific fashion. These results suggest a potential mechanism of modulating the activities of the alpha 6 beta 4 integrin.


Cloning and characterization of HARP/SMARCAL1: a prokaryotic HepA-related SNF2 helicase protein from human and mouse.
The SNF2 gene family consists of a large group of proteins involved in transcriptional regulation, maintenance of chromosome integrity, and various aspects of DNA repair. We cloned a novel SNF2 family human cDNA, with sequence identity to the Escherichia coli RNA polymerase-binding protein HepA and named the human hepA-related protein (HHARP/SMARCAL1). In addition, the mouse ortholog (Mharp/Smarcal1) was cloned, and the Caenorhabditis elegans ortholog (CEHARP) was identified in the GenBank database. Phylogenetic analysis indicates that the HARP proteins share a high level of sequence similarity to the seven motif helicase core region (SNF2 domain) with identifiable orthologs in other eukaryotic species, except for yeast. Purified His-tagged HARP/SMARCAL1 protein exhibits single-stranded DNA-dependent ATPase activity, consistent with it being a member of the SNF2 family of proteins. Both the human and the mouse genes consist of 17 exons and 16 introns. The human gene maps to chromosome 2q34-q36, and the mouse gene is localized to the syntenic region of chromosome 1 (between markers Gls and Acrg). HARP/SMARCAL1 transcripts are ubiquitously expressed in human and mouse tissues, with testis presenting the highest levels of mRNA expression in humans.