Causes of death in renal transplant recipients with functioning allograft.
The survival of transplant recipients is significantly lower than age-matched controls in the general population. The aim of this study was to analyze the trends in mortality of renal allograft recipients at our centre. We retrospectively analyzed data from all patients who were transplanted between October 1988 and June 2010 and were followed at our center. Patients were considered to have death with graft function (DWGF) if death was not preceded by return to dialysis or re-transplantation. The study included 98 renal allograft recipients (male : female - 7.99 : 1). The mean recipient and donor ages were 35.06 ± 11.84 (range: 15-69) and 41.17 ± 10.44 (range: 22-60) years, respectively. Basic kidney diseases were CGN (chronic glomerulonephritis) (60.20%), CIN (chronic interstitial nephritis) (15.31%), DN (diabetic nephropathy) (8.16%), ADPKD (autosomal dominant polycystic kidney disease) (2.04%) and others (14.29%). They were followed up for a mean 79.91 ± 60.05 patient-months. Mortality occurred in 25 (25.51%) patients (male : female - 4 : 1). Causes of death were sepsis/infection (36%), coronary artery disease (28%), CVA (8%), failed graft (4%), and rest unknown (24%). DWGF was 88% of total death and contributed to 78.57% of total graft loss. Overall patient survival at 1, 5, 10, and 15 years were 90.8%, 80.2%, 65.6%, and 59.1%, respectively (Kaplan-Meier analysis). Those who died exhibited significant differences in recipient's age (median 40 years vs 31 years, P=0.007), pretransplantation hypertension (HTN) (100% vs 65.75%, P<0.001), post-transplant infection (76% vs 42.47%, P=0.005), coronary artery disease (28% vs 1.37%, P<0.001), and serum creatinine at last follow up (median 2.3mg/dL vs 1.56mg/dL, P=0.003). Cardiovascular disease, in addition to infection, is an important cause of death during the first 15 years following renal transplantation even in nondiabetic recipients. Death with functioning graft is of concern.


The coupling hypothesis: why genome scans may fail to map local adaptation genes.
Genomic scans of multiple populations often reveal marker loci with greatly increased differentiation between populations. Often this differentiation coincides in space with contrasts in ecological factors, forming a genetic-environment association (GEA). GEAs imply a role for local adaptation, and so it is tempting to conclude that the strongly differentiated markers are themselves under ecologically based divergent selection, or are closely linked to loci under such selection. Here, we highlight an alternative and neglected explanation: intrinsic (i.e. environment-independent) pre- or post-zygotic genetic incompatibilities rather than local adaptation can be responsible for increased differentiation. Intrinsic genetic incompatibilities create endogenous barriers to gene flow, also known as tension zones, whose location can shift over time. However, tension zones have a tendency to become trapped by, and therefore to coincide with, exogenous barriers due to ecological selection. This coupling of endogenous and exogenous barriers can occur easily in spatially subdivided populations, even if the loci involved are unlinked. The result is that local adaptation explains where genetic breaks are positioned, but not necessarily their existence, which can be best explained by endogenous incompatibilities. More precisely, we show that (i) the coupling of endogenous and exogenous barriers can easily occur even when ecological selection is weak; (ii) when environmental heterogeneity is fine-grained, GEAs can emerge at incompatibility loci, but only locally, in places where habitats and gene pools are sufficiently intermingled to maintain linkage disequilibria between genetic incompatibilities, local-adaptation genes and neutral loci. Furthermore, the association between the locally adapted and intrinsically incompatible alleles (i.e. the sign of linkage disequilibrium between endogenous and exogenous loci) is arbitrary and can form in either direction. Reviewing results from the literature, we find that many predictions of our model are supported, including endogenous genetic barriers that coincide with environmental boundaries, local GEA in mosaic hybrid zones, and inverted or modified GEAs at distant locations. We argue that endogenous genetic barriers are often more likely than local adaptation to explain the majority of Fst-outlying loci observed in genome scan approaches - even when these are correlated to environmental variables.


Noonan syndrome.
Noonan Syndrome (NS) is characterised by short stature, typical facial dysmorphology and congenital heart defects. The incidence of NS is estimated to be between 1:1000 and 1:2500 live births. The main facial features of NS are hypertelorism with down-slanting palpebral fissures, ptosis and low-set posteriorly rotated ears with a thickened helix. The cardiovascular defects most commonly associated with this condition are pulmonary stenosis and hypertrophic cardiomyopathy. Other associated features are webbed neck, chest deformity, mild intellectual deficit, cryptorchidism, poor feeding in infancy, bleeding tendency and lymphatic dysplasias. The syndrome is transmitted as an autosomal dominant trait. In approximately 50% of cases, the disease is caused by missense mutations in the PTPN11 gene on chromosome 12, resulting in a gain of function of the non-receptor protein tyrosine phosphatase SHP-2 protein. Recently, mutations in the KRAS gene have been identified in a small proportion of patients with NS. A DNA test for mutation analysis can be carried out on blood, chorionic villi and amniotic fluid samples. NS should be considered in all foetuses with polyhydramnion, pleural effusions, oedema and increased nuchal fluid with a normal karyotype. With special care and counselling, the majority of children with NS will grow up and function normally in the adult world. Management should address feeding problems in early childhood, evaluation of cardiac function and assessment of growth and motor development. Physiotherapy and/or speech therapy should be offered if indicated. A complete eye examination and hearing evaluation should be performed during the first few years of schooling. Preoperative coagulation studies are indicated. Signs and symptoms lessen with age and most adults with NS do not require special medical care.


Longitudinal cohort study of the epidemiology of malaria infections in an area of intense malaria transmission II. Descriptive epidemiology of malaria infection and disease among children.
A large-scale longitudinal cohort project was initiated in western Kenya in June 1992. Between June 1992 and July 1994, 1,848 children less than 15 years of age were monitored prospectively for a mean of 236 days. During this period, 12,035 blood smears were examined for malaria and only 34% were found to be negative. Parasite prevalence (all species) decreased with age (from a high of 83% among children 1-4 years old to 60% among children 10-14 years old). Even more dramatic decreases were noted in the prevalence of high density falciparum infection (from 37% among children 12-23 months old to < 1% among 10-14-year-old children) and in clinical malaria (20% to 0.3% in the same age groups). Children < 1 year of age accounted for 55% of all cases of anemia detected. Anemia was consistently associated with high density infection in children < 10 years of age (20% to 210% increased risk relative to aparasitemic children). These results demonstrate the relationship between high-density malaria infection and two clinical manifestations of malarial illness.


Intersegmental coordination elicited by unexpected multidirectional slipping-like perturbations resembles that adopted during steady locomotion.
This study aimed at testing the hypothesis that reactive biomechanical responses elicited by unexpected slipping-like perturbations delivered during steady walking are characterized by an intersegmental coordination strategy resembling that adopted during unperturbed walking. Fifteen healthy subjects were asked to manage multidirectional slipping-like perturbations delivered while they walked steadily. The planar covariation law of elevation angles related to lower limb segments was the main observed variable related to unperturbed and perturbed strides. Principal component analysis was used to verify whether elevation angles covaried, both before and after the onset of the perturbation, and, if so, the orientation of the related planes of covariation was compared. Results revealed that the planar covariation law of the unperturbed limb after onset of the perturbation was systematically similar to that seen during steady walking. This occurred despite differences in range of motion and intersubject variability of both elevation and joint angles. The analysis strongly corroborates the hypothesis that the planar covariation law emerges from the interaction between spinal neural networks and limb mechanical oscillators. In particular, fast and stereotyped reactive strategies may result from the interaction among activities of downstream neural networks encrypting well-trained motor schemes, such as those related to walking, limb dynamics, and sensory motor information gathered during the perturbation. In addition, our results allowed us to speculate that rehabilitative treatment based on unexpected perturbations and relying on the plasticity of the central nervous system may also be effective in eliciting unimpaired intralimb coordination in neurological patients.


Healing from childhood sexual abuse: a theoretical model.
Childhood sexual abuse is a prevalent social and health care problem. The processes by which individuals heal from childhood sexual abuse are not clearly understood. The purpose of this study was to develop a theoretical model to describe how adults heal from childhood sexual abuse. Community recruitment for an ongoing broader project on sexual violence throughout the lifespan, referred to as the Sexual Violence Study, yielded a subsample of 48 women and 47 men who had experienced childhood sexual abuse. During semistructured, open-ended interviews, they were asked to describe their experiences with healing from childhood sexual abuse and other victimization throughout their lives. Constructivist grounded theory methods were used with these data to develop constructs and hypotheses about healing. For the Sexual Violence Study, frameworks were developed to describe the participants' life patterns, parenting experiences, disclosures about sexual violence, spirituality, and altruism. Several analytic techniques were used to synthesize the findings of these frameworks to develop an overarching theoretical model that describes healing from childhood sexual abuse. The model includes four stages of healing, five domains of functioning, and six enabling factors that facilitate movement from one stage to the next. The findings indicate that healing is a complex and dynamic trajectory. The model can be used to alert clinicians to a variety of processes and enabling factors that facilitate healing in several domains and to guide discussions on important issues related to healing from childhood sexual abuse.


Nicotine replacement therapy: patterns of use after a quit attempt among methadone-maintained smokers.
To determine the association between daily smoking and use of nicotine replacement therapy (NRT), and to determine predictors of greater NRT use among methadone-maintained smokers. Assignment to free nicotine patch (8 to 12 weeks) plus either (1) a baseline-tailored brief motivational intervention, a quit date behavioral skills counseling session, and a relapse prevention follow-up session (max), or (2) brief advice using NCI's 4 A's model (min). Five methadone maintenance treatment centers. Of the 383 methadone-maintained smokers enrolled, 309 (80.6%) set a specific quit date (received NRT) and were located for assessments. Participants were 51.8% male, 78.6% Caucasian, and smoked 26.6 (SD=12.2) cigarettes/day. Use of NRT and smoking behaviors during the 180-day follow-up period assessed by the Timeline follow-back method. On the day following their quit day, 86.4% of participants used NRT. The percentage of participants using NRT was 52.3%, 27.1%, and 10.4% on day 30, day 60, and day 90, respectively. Participants used NRT on 44.1% of the days through the 90 days of the treatment protocol. The estimated odds of smoking abstinence was 7.1 (P<.001) times higher on days when NRT was used than on days when NRT was not used, and cigarettes/day was also significantly lower on NRT days (14.93 vs 4.65; P<.001). Nicotine replacement therapy use was inconsistent following an initial quit attempt among methadone-maintained smokers. On days when NRT was used, individuals were likely to smoke at reduced levels or not at all.


Remodeling of the sarcomeric cytoskeleton in cardiac ventricular myocytes during heart failure and after cardiac resynchronization therapy.
Sarcomeres are the basic contractile units of cardiac myocytes. Recent studies demonstrated remodeling of sarcomeric proteins in several diseases, including genetic defects and heart failure. Here we investigated remodeling of sarcomeric α-actinin in two models of heart failure, synchronous (SHF) and dyssynchronous heart failure (DHF), as well as a model of cardiac resynchronization therapy (CRT). We applied three-dimensional confocal microscopy and quantitative methods of image analysis to study isolated cells from our animal models. 3D Fourier analysis revealed a decrease of the spatial regularity of the α-actinin distribution in both SHF and DHF versus control cells. The spatial regularity of α-actinin in DHF cells was reduced when compared with SHF cells. The spatial regularity of α-actinin was partially restored after CRT. We found longitudinal depositions of α-actinin in SHF, DHF and CRT cells. These depositions spanned adjacent Z-disks and exhibited a lower density of α-actinin than in the Z-disk. Differences in the occurrence of depositions between the SHF, CRT and DHF models versus control were significant. Also, CRT cells exhibited a higher occurrence of depositions versus SHF, but not DHF cells. Other sarcomeric proteins did not accumulate in the depositions to the same extent as α-actinin. We did not find differences in the expression of α-actinin protein and its encoding gene in our animal models. In summary, our studies indicate that HF is associated with two different types of remodeling of α-actinin and only one of those was reversed after CRT. We suggest that these results can guide us to an understanding of remodeling of structures and function associated with sarcomeres.


The influence of dye structure on charge recombination in dye-sensitized solar cells.
Replacing the nonyl groups on the solar cell dye Ru(4,4'-carboxylic acid-2,2'-bipyridine)(4,4'-dinonyl-2,2'-bipyridine)(NCS)(2) (Z-907) with amino groups results in a marked decrease in solar cell performance. This is despite the fact that the amino derivative (Z-960) has more favourable light absorption characteristics than Z-907 when used with thick nanocrystalline TiO(2) layers. Electron transfer to the electrolyte from the exposed fluorine-doped tin oxide (FTO) substrate is particularly fast in cells employing the Z-960 dye if a compact TiO(2) blocking layer is not used. The kinetics of electron transfer from the nanocrystalline TiO(2) layer in DSCs employing Z-960 are comparable to those of bare TiO(2) and ca. 2 to 5 times faster than for cells employing Z-907. The faster charge recombination in cells employing Z-960 lowers open-circuit photovoltage and results in very significant charge collection losses that lower short-circuit photocurrent. Voltammetric measurements show that surface modification of FTO electrodes with Z-960 results in slightly more facile charge transfer to acceptor species in triiodide/iodide electrolytes in the dark. A simpler molecule, p-aminobenzoic acid, more dramatically catalyses this charge transfer reaction. Conversely, chemical modification of FTO electrodes with Z-907 or p-toluic acid retards charge transfer kinetics. Similar results are obtained for nanocrystalline TiO(2) electrodes modified with these benzoic acid derivatives. These results strongly imply that surface adsorbed molecules bearing amino groups, including dye molecules, can catalyse charge recombination in dye-sensitized solar cells.


[Validation of an instrument for measuring the effects of oral health on the quality of life of older adults in Mexico].
Translate, culturally adapt, and validate a new Spanish version of the Oral Health Impact Profile (OHIP) for older persons in Mexico City, Mexico. A validation study of the new version of OHIP-Mx-49 was carried out through interviews and clinical examinations of people aged 60 or older in the southern area of Mexico City. The following variables were analyzed: sociodemographic (age, sex, marital status, level of schooling, and whether the subject lived alone), clinical (current number of teeth, coronal and root caries, dental hygiene, and the use of removable prostheses and dentures), and self-perception (of the need for dental and general health care). The OHIP-Mx-49 value was calculated as the sum of the scores in seven dimensions: functional limitation, pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The internal consistency (Cronbach's alpha coefficient), replicability (intraclass correlation coefficient), and convergent and discriminant validity (Mann-Whitney and Kruskal-Wallis tests) were assessed. Of the 131 people interviewed (average age: 73.8 +/- 8.3 years), 77.9% were women. High internal consistency values were obtained for the OHIP-Mx-49 (0.96) and the dimensions (0.79-0.86), and replicability in the instrument (0.877) and all the dimensions except social disability (0.176). The average OHIP-Mx-49 score was 37.1 +/- 35.3; higher scores were observed in people with 1-9 teeth (P = 0.02), people who did not have coronal caries (P = 0.02), and people who perceived a need for dental care (P = 0.01). The OHIP-Mx-49 is a reliable and valid instrument that can be used with older Mexicans.


On the structures, spin states, and optical properties of titanium, platinum, and iron azacalixphyrins: a DFT study.
Azacalixphyrins (ACP) constitute a new class of macrocycles isoelectronic and isostructural to porphyrins. Herein, we report the first theoretical investigation of the properties of the ACP macrocycles metallated at their centre by titanium, platinum, and iron ions. We considered both the original phenyl-type ACP and new pyridyl-type forms. Our results indicate that the metallation greatly impacts the global structure of the macrocycle through pseudo Jahn-Teller effects, giving rise to a possible conformational transition between D2d and S4 structures. Such an effect could not be found in the metal-free ACPs. In addition, we find that, in contrast to the purely singlet platinum ACPs, and the purely triplet iron ACPs, several spin states are energetically close in the titanium ACPs, especially when weak field ligands are bound in axial positions to the metallic centre. According to TD-DFT calculations, metallation also tunes the optical properties. In particular, the absorption band in the near infrared region undergoes a hypsochromic shift of ca. 100-200 nm when going from the D2d to the S4 structures. We quantify how the addition of electroactive ligands in the axial position can increase or tune down these spectral changes. This contribution therefore supports the development of ACP coordination complexes.


Analysis of multiple sarcoma expression datasets: implications for classification, oncogenic pathway activation and chemotherapy resistance.
Diagnosis of soft tissue sarcomas (STS) is challenging. Many remain unclassified (not-otherwise-specified, NOS) or grouped in controversial categories such as malignant fibrous histiocytoma (MFH), with unclear therapeutic value. We analyzed several independent microarray datasets, to identify a predictor, use it to classify unclassifiable sarcomas, and assess oncogenic pathway activation and chemotherapy response. We analyzed 5 independent datasets (325 tumor arrays). We developed and validated a predictor, which was used to reclassify MFH and NOS sarcomas. The molecular "match" between MFH and their predicted subtypes was assessed using genome-wide hierarchical clustering and Subclass-Mapping. Findings were validated in 15 paraffin samples profiled on the DASL platform. Bayesian models of oncogenic pathway activation and chemotherapy response were applied to individual STS samples. A 170-gene predictor was developed and independently validated (80-85% accuracy in all datasets). Most MFH and NOS tumors were reclassified as leiomyosarcomas, liposarcomas and fibrosarcomas. "Molecular match" between MFH and their predicted STS subtypes was confirmed both within and across datasets. This classification revealed previously unrecognized tissue differentiation lines (adipocyte, fibroblastic, smooth-muscle) and was reproduced in paraffin specimens. Different sarcoma subtypes demonstrated distinct oncogenic pathway activation patterns, and reclassified MFH tumors shared oncogenic pathway activation patterns with their predicted subtypes. These patterns were associated with predicted resistance to chemotherapeutic agents commonly used in sarcomas. STS profiling can aid in diagnosis through a predictor tracking distinct tissue differentiation in unclassified tumors, and in therapeutic management via oncogenic pathway activation and chemotherapy response assessment.


Distinct activation thresholds of human conventional and innate-like memory T cells.
Conventional memory CD8+ T cells and mucosal-associated invariant T cells (MAIT cells) are found in blood, liver, and mucosal tissues and have similar effector potential following activation, specifically expression of IFN-γ and granzyme B. To better understand each subset's unique contributions to immunity and pathology, we interrogated inflammation- and TCR-driven activation requirements using human memory CD8+ T and MAIT cells isolated from blood and mucosal tissue biopsies in ex vivo functional assays and single cell gene expression experiments. We found that MAIT cells had a robust IFN-γ and granzyme B response to inflammatory signals but limited responsiveness when stimulated directly via their TCR. Importantly, this is not due to an overall hyporesponsiveness to TCR signals. When delivered together, TCR and inflammatory signals synergize to elicit potent effector function in MAIT cells. This unique control of effector function allows MAIT cells to respond to the same TCR signal in a dichotomous and situation-specific manner. We propose that this could serve to prevent responses to antigen in noninflamed healthy mucosal tissue, while maintaining responsiveness and great sensitivity to inflammation-eliciting infections. We discuss the implications of these findings in context of inflammation-inducing damage to tissues such as BM transplant conditioning or HIV infection.


The effects of add-on non-invasive brain stimulation in fibromyalgia: a meta-analysis and meta-regression of randomized controlled trials.
The effects of non-invasive brain stimulation (NBS), including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (TDCS), in treating FM remain inconclusive. The aim of this study was to investigate present evidence of using NBS as an add-on treatment in treating FM. We conducted a database search of the Medline, Embase, PsycINFO and Cochrane Library electronic databases, from inception to July 2015, to analyse randomized controlled trials of NBS in treating FM. A total of 16 studies were included in the current meta-analysis. The pooled mean effect sizes of the 16 included studies revealed significant favourable effects of NBS. The weighted mean effect size in reducing pain, depression, fatigue, sleep disturbance and tender points and improving general health/function were 0.667 (95% CI 0.446, 0.889), 0.322 (95% CI 0.140, 0.504), 0.511 (95% CI 0.247, 0.774), 0.682 (95% CI 0.350, 1.014), 0.867 (95% CI 0.310, 1.425) and 0.473 (95% CI 0.285, 0.661), respectively. rTMS stimulation yielded a greater effect size compared with that of TDCS (effect size 0.698 and 0.568, respectively; P < 0.0001). The primary motor cortex (M1) stimulation yielded a subtle greater effect size in pain reduction compared with that of the dorsolateral prefrontal cortex (effect size 0.709 and 0.693, respectively; P < 0.0001). No linear relationships were found between the effect sizes and treatment regimens and dose. Most of reported adverse effects were minor. Both rTMS and TDCS may be feasible and safe modalities for treating FM. The general effects of rTMS and TDCS are compatible in FM patients. M1 stimulation may be better in pain reduction and the dorsolateral prefrontal cortex may be better in depression improvement.


Physicians criticizing physicians to patients.
Teamwork is critical to providing excellent healthcare, and effective communication is essential for teamwork. Physicians often discuss patient referrals from other physicians, including referrals from outside their primary institution. Sharing conflicting information or negative judgments of other physicians to patients may be unprofessional. Poor teamwork within healthcare systems has been associated with patient mortality and lower staff well-being. This analysis explored how physicians talk to patients with advanced cancer about care rendered by other physicians. Standardized patients (SPs) portraying advanced lung cancer attended covertly recorded visits with consenting oncologists and family physicians. Twenty community-based oncologists and 19 family physicians had encounters with SPs. Physician comments about care by other physicians were extracted from transcriptions and analyzed qualitatively. These comments were categorized as Supportive or Critical. We also examined whether there were differences between physicians who provide supportive comments and those who provided critical comments. Fourteen of the 34 encounters (41 %) included in this analysis contained a total of 42 comments about the patient's previous care. Twelve of 42 comments (29 %) were coded as Supportive, twenty-eight (67 %) as Critical, and two (4 %) as Neutral. Supportive comments attributed positive qualities to another physician or their care. Critical comments included one specialty criticizing another and general lack of trust in physicians. This study described comments by physicians criticizing other physicians to patients. This behavior may affect patient satisfaction and quality of care. Healthcare system policies and training should discourage this behavior.


The exchange of blood-borne amino acids in the leg during abdominal surgical trauma: effects of glucose infusion.
The exchange of plasma amino acids and glucose, lactate, glycerol and 3-hydroxybutyrate in the leg was studied in otherwise healthy patients undergoing elective cholecystectomy. Seven patients were given a constant intravenous infusion of glucose at a rate of 1.1 mmol/min throughout the study. Seven other patients who received normal saline only served as a control group. Measurement of leg blood flow and arterio-femoral venous differences of amino acids and other energy metabolites were made on four occasions: (I) before surgery, (II) 10 min after skin incision, (III) at the end of surgery, and (IV) 30 min after the end of anaesthesia. The release of amino acids from the leg was comparable in the two groups before and during the early part of surgery. At the end of surgery the release of several individual amino acids, as well as the total release of amino acids, from the leg was higher in the patients given glucose infusion compared with the control patients. The infusion of glucose prevented the intraoperative rise in arterial levels and uptake of 3-hydroxybutyrate in the leg. A high release of amino acids at the end of surgery was thus associated with low arterial levels of 3-hydroxybutyrate while the reverse pattern was seen in the control patients. These effects of glucose infusion were qualitatively different from those seen in uninjured postabsorptive man.


Desmoglein 3-specific CD4+ T cells induce pemphigus vulgaris and interface dermatitis in mice.
Pemphigus vulgaris (PV) is a severe autoimmune disease involving blistering of the skin and mucous membranes. It is caused by autoantibodies against desmoglein 3 (Dsg3), an adhesion molecule critical for maintaining epithelial integrity in the skin, oral mucosa, and esophagus. Knowing the antigen targeted by the autoantibodies renders PV a valuable model of autoimmunity. Recently, a role for Dsg3-specific CD4+ T helper cells in autoantibody production was demonstrated in a mouse model of PV, but whether these cells exert cytotoxicity in the tissues is unclear. Here, we analyzed 3 Dsg3-specific TCRs using transgenic mice and retrovirus induction. Dsg3-specific transgenic (Dsg3H1) T cells underwent deletion in the presence of Dsg3 in vivo. Dsg3H1 T cells that developed in the absence of Dsg3 elicited a severe pemphigus-like phenotype when cotransferred into immunodeficient mice with B cells from Dsg3-/- mice. Strikingly, in addition to humoral responses, T cell infiltration of Dsg3-expressing tissues led to interface dermatitis, a distinct form of T cell-mediated autoimmunity that causes keratinocyte apoptosis and is seen in various inflammatory/autoimmune skin diseases, including paraneoplastic pemphigus. The use of retrovirally generated Dsg3-specific T cells revealed that interface dermatitis occurred in an IFN-γ- and TCR avidity-dependent manner. This model of autoimmunity demonstrates that T cells specific for a physiological skin-associated autoantigen are capable of inducing interface dermatitis and should provide a valuable tool for further exploring the immunopathophysiology of T cell-mediated skin diseases.


Amino-termini isoforms of the Slack K+ channel, regulated by alternative promoters, differentially modulate rhythmic firing and adaptation.
The rates of activation and unitary properties of Na+-activated K+ (K(Na)) currents have been found to vary substantially in different types of neurones. One class of K(Na) channels is encoded by the Slack gene. We have now determined that alternative RNA splicing gives rise to at least five different transcripts for Slack, which produce Slack channels that differ in their predicted cytoplasmic amino-termini and in their kinetic properties. Two of these, termed Slack-A channels, contain an amino-terminus domain closely resembling that of another class of K(Na) channels encoded by the Slick gene. Neuronal expression of Slack-A channels and of the previously described Slack isoform, now called Slack-B, are driven by independent promoters. Slack-A mRNAs were enriched in the brainstem and olfactory bulb and detected at significant levels in four different brain regions. When expressed in CHO cells, Slack-A channels activate rapidly upon depolarization and, in single channel recordings in Xenopus oocytes, are characterized by multiple subconductance states with only brief transient openings to the fully open state. In contrast, Slack-B channels activate slowly over hundreds of milliseconds, with openings to the fully open state that are approximately 6-fold longer than those for Slack-A channels. In numerical simulations, neurones in which outward currents are dominated by a Slack-A-like conductance adapt very rapidly to repeated or maintained stimulation over a wide range of stimulus strengths. In contrast, Slack-B currents promote rhythmic firing during maintained stimulation, and allow adaptation rate to vary with stimulus strength. Using an antibody that recognizes all amino-termini isoforms of Slack, Slack immunoreactivity is present at locations that have no Slack-B-specific staining, including olfactory bulb glomeruli and the dendrites of hippocampal neurones, suggesting that Slack channels with alternate amino-termini such as Slack-A channels are present at these locations. Our data suggest that alternative promoters of the Slack gene differentially modulate the properties of neurones.


Feasibility of community level interventions for pre-eclampsia: perspectives, knowledge and task-sharing from Nigeria, Mozambique, Pakistan and India.
Hypertensive disorders of pregnancy (HDP), particularly pre-eclampsia and eclampsia, remain one of the leading causes of maternal mortality and are contributory in many foetal/newborn deaths. This editorial discusses a supplement of seven papers which provide the results of the first round of the CLIP (Community Level Interventions for Pre-eclampsia) Feasibility Studies. These studies report a number of enablers and barriers in each setting, which have informed the implementation of a cluster-randomized trial (cRCT) aimed at reducing pre-eclampsia-related, and all-cause, maternal and perinatal mortality and major morbidity using community-based identification and treatment of pre-eclampsia in selected geographies of Nigeria, Mozambique, Pakistan and India. This supplement unpacks the diverse community perspectives on determinants of maternal health, variant health worker knowledge and routine management of HDP, and viability of task sharing for preeclampsia identification and management in select settings. These studies demonstrate the need for strategies to improve health worker knowledge and routine management of HDP and consideration of expanding the role of community health workers to reach the most remote women and families with health education and access to health services.


Piezo1 integration of vascular architecture with physiological force.
The mechanisms by which physical forces regulate endothelial cells to determine the complexities of vascular structure and function are enigmatic. Studies of sensory neurons have suggested Piezo proteins as subunits of Ca(2+)-permeable non-selective cationic channels for detection of noxious mechanical impact. Here we show Piezo1 (Fam38a) channels as sensors of frictional force (shear stress) and determinants of vascular structure in both development and adult physiology. Global or endothelial-specific disruption of mouse Piezo1 profoundly disturbed the developing vasculature and was embryonic lethal within days of the heart beating. Haploinsufficiency was not lethal but endothelial abnormality was detected in mature vessels. The importance of Piezo1 channels as sensors of blood flow was shown by Piezo1 dependence of shear-stress-evoked ionic current and calcium influx in endothelial cells and the ability of exogenous Piezo1 to confer sensitivity to shear stress on otherwise resistant cells. Downstream of this calcium influx there was protease activation and spatial reorganization of endothelial cells to the polarity of the applied force. The data suggest that Piezo1 channels function as pivotal integrators in vascular biology.


Effect of extraction time on content, composition and sensory perception of proanthocyanidins in wine-like medium and during industrial fermentation of Cabernet Sauvignon.
The research objectives focused on the extraction of grape tannins during extended maceration. Skins and seeds were extracted separately in a wine-like medium. In parallel, the same grapes were fermented in industrial tanks. The content and structural characteristics of extractable proanthocyanidins (PAs) were determined spectrophotometrically and using UHPLC-DAD-MS/MS, respectively. Skin, seed extracts and fermented wines were characterized in chemical and sensorial terms after different extraction durations. The extraction of high molecular-weight PAs (HMWPs) from seeds increased for up to 20 days, whereas low molecular-weight PAs (LMWPs) reached a plateau earlier. The extraction of HMWPs and LMWPs from skins reached a maximum at the first sampling. Sensory evaluation confirmed greater astringency and bitterness of seed extracts with increasing time. Neither seed nor skin extracts differed statistically in terms of the mean degree of polymerization (mDP) and percentage of galloylation (%G) on different extraction days (except for seeds at the first sampling). During industrial maceration, HMWPs and LMWPs increased up to 12.7% alcohol (9 days of maceration); thereafter, the increase was not significant, whereas the mDP, %G and percentage of prodelphinidins did not significantly change after 11.4% alcohol. There were positive correlations with the wine astringency and PA content. Looking at both simulated and industrial maceration, it can be concluded that, with a longer maceration time, the increase in HMWP content was more evident than PA structural changes. The increasing content of tannins from seeds played an important role in the greater astringency and bitterness of Cabernet Sauvignon macerated at length. © 2019 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.


Effects of dietary fern (Adiantum capillus-veneris) leaves powder on serum and mucus antioxidant defence, immunological responses, antimicrobial activity and growth performance of common carp (Cyprinus carpio) juveniles.
A 56-day research was performed to examine the influence of graded levels (0 (control), 0.5, 1 and 2%) of Fern (Adiantum capillus-veneris) leaves powder (FLP) in diet on immune competence and growth of common carp (Cyprinus carpio, initial weight = 20 g). The serum total immunoglobulins content and lysozyme activity in the 1 and 2% FLP groups remarkably increased compared to the other groups (P < 0.05). The skin mucosal lysozyme activity enhanced with increasing dietary FLP level in a dose-response manner. Fish fed on the FLP-supplemented diets had higher skin-mucosal superoxide dismutase activity than the control (P < 0.05). However, serum antioxidant enzymes were not affected by dietary fern (P > 0.05). The serum bactericidal activity against human and fish pathogens increased with enhancing the FLP level in diet against Staphylococcus aureus, Escherichia coli (EHEC ATCC 43895), Escherichia coli (CI), Pseudomonas aeruginosa, Klebsiella pneumonia and Aeromonas hydrophila. The serum antibacterial activity against Yersinia ruckeri in the 2% FLP group was higher than the other treatments. Furthermore, the serum bactericidal activity against P. aeruginosa (ATCC 27853) only observed in fish fed on the 1 and 2% FLP-supplemented diets. The skin mucosal bactericidal activity and inhibitory effects increased with enhancing the FLP level in diet against E. coli, K. pneumonia, Y. ruckeri and A. hydrophila in a dose response manner. Moreover, the skin mucosal bactericidal activity against S. aureus only observed in fish fed on 1 and 2% FLP-supplemented diets. The weight gain values in the 1 and 2% FLP groups were higher than the other treatments (P < 0.05). Feed conversion ratio (FCR) improved with increasing FLP level in diet in a dose-response manner (P < 0.05). By considering serum and mucosal bactericidal activities against different pathogenic bacteria, the supplementation of 2% FLP in diet is recommended for C. carpio during grow-out phase.


Levels of mental distress over 18 years after entering treatment for substance use disorders: A longitudinal cohort study.
The aims were to investigate whether baseline characteristics and problematic substance use were related to change in mental distress over time in patients with substance use disorders during an 18-year period. This was a prospective, longitudinal study of patients followed for 18 years after entering specialised treatment for substance use disorders. A sample of 291 patients was recruited in 1997 and 1998. Mental distress was measured using the Hopkins Symptom Checklist 25 at baseline, and at six and 18 years. Lifetime psychiatric disorders and substance use disorders at baseline were measured using the Composite International Diagnostic Interview, while personality disorders were measured using the Millon Clinical Multiaxial Inventory II. At the six- and 18-year follow-ups, substance use was measured using the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test. Linear mixed model was estimated to assess the overall level of mental distress over 18 years for participants with complete data at baseline (n = 232). In an adjusted model, problematic substance use assessed simultaneously with mental distress, having lifetime affective, anxiety and personality disorder at baseline were associated with greater levels of mental distress over the 18-year period. The change in mental distress from baseline to the six-year, but not to the 18-year, follow-up was significantly larger among females than among males. The results suggests a reciprocal relationship over time between substance use and mental health problems. Also, there seems to be an additive effect between ongoing problematic substance use and lifetime mental disorders on greater levels of mental distress. This addresses the importance of integrated treatment for both substance use disorders and mental disorders to improve the long-term course for patients with these comorbid disorders.


Weight maintenance and relapse in obesity: a qualitative study.
To investigate, among women with obesity who have lost weight, the psychological factors associated with successfully maintaining the new lower weight, as opposed to weight regain. Qualitative research methods (in-depth individual interviews and group interviews) were used to assess the characteristics of successful weight maintainers, as compared with weight regainers and healthy-weight women. In all, 76 females were recruited from the community, comprising 28 formerly obese women who had lost weight and maintained their new lower weight for at least 1 y; 28 obese women who had lost weight but regained the weight that they had lost; and 20 women with a stable weight in the healthy range. Certain psychological factors were identified which characterised the regainers but not the maintainers. These factors were: failure to achieve weight goals and dissatisfaction with the weight achieved; the tendency to evaluate self-worth in terms of weight and shape; a lack of vigilance with regard to weight control; a dichotomous (black-and-white) thinking style; and the tendency to use eating to regulate mood. The results suggest that psychological factors may provide some explanation as to why many people with obesity regain weight following successful weight loss. The factors identified in this study need to be examined further using prospective designs.


Early-onset type 2 diabetes in Mexico.
This review summarizes the clinical, metabolic and genetic characteristics of early-onset type 2 diabetes in Mexico. Early-onset type 2 diabetes is both a clinical challenge and a public health problem. It is calculated that almost 300,000 Mexican diabetics are diagnosed between the ages of 20 and 40. The large Mexican family structure and the high prevalence of the disease provide a unique opportunity to identify the genes and the metabolic abnormalities involved in this form of the disease. In a hospital-based population, our group found that insulin deficiency was the main defect in this form of diabetes. Mutations in the NHF-1 alpha or HNF-4 alpha genes or autoimmunity to the beta cell were found in a small proportion of cases, leaving unexplained the majority of cases. Also discussed are the epidemiologic and therapeutic implications of early-onset type 2 diabetes, and the possible role of genetic testing for prevention.


The Neuronal Kinesin UNC-104/KIF1A Is a Key Regulator of Synaptic Aging and Insulin Signaling-Regulated Memory.
Aging is the greatest risk factor for a number of neurodegenerative diseases, such as Alzheimer's and Parkinson's disease. Furthermore, normal aging is associated with a decline in sensory, motor, and cognitive functions. Emerging evidence suggests that synapse alterations, rather than neuronal cell death, are the causes of neuronal dysfunctions in normal aging and in early stages of neurodegenerative diseases. However, little is known about the mechanisms underlying age-related synaptic decline. Here, we uncover a surprising role of the anterograde molecular motor UNC-104/KIF1A as a key regulator of neural circuit deterioration in aging C. elegans. Through analyses of synapse protein localization, synaptic transmission, and animal behaviors, we find that reduced function of UNC-104 accelerates motor circuit dysfunction with age, whereas upregulation of UNC-104 significantly improves motor function at advanced ages and also mildly extends lifespan. In addition, UNC-104-overexpressing animals outperform wild-type controls in associative learning and memory tests. Further genetic analyses suggest that UNC-104 functions downstream of the DAF-2-signaling pathway and is regulated by the FOXO transcription factor DAF-16, which contributes to the effects of DAF-2 in neuronal aging. Together, our cellular, electrophysiological, and behavioral analyses highlight the importance of axonal transport in the maintenance of synaptic structural integrity and function during aging and raise the possibility of targeting kinesins to slow age-related neural circuit dysfunction.


Point-of-Care Airway Ultrasonography Prior to an Emergency Cricothyroidotomy: Case Report.
The use of ultrasonography in acute and critical care medicine is becoming increasingly common. However, use of an airway ultrasound as an adjunct to determine the type of intervention needed and assess complications is not common practice. We report a 56-year-old male who presented to the Emergency Department of the Sungai Buloh Hospital, Selangor, Malaysia, in 2015 with hoarseness, stridor and impending respiratory failure. A point-of-care ultrasound performed to assess the neck and vocal cords indicated a heterogeneous echogenic mass in the larynx, thus ruling out a cricothyroidotomy. The patient was therefore referred for an emergency tracheostomy. This case highlights the importance of point-of-care airway ultrasonography in the assessment of patients with stridor. This imaging technique not only helps to detect the cause of the stridor, but also to determine the feasibility of a cricothyroidotomy in emergency cases.


Individualised axitinib regimen for patients with metastatic renal cell carcinoma after treatment with checkpoint inhibitors: a multicentre, single-arm, phase 2 study.
Checkpoint inhibitor therapy is a standard of care for patients with metastatic renal cell carcinoma. Treatment options after checkpoint inhibitor therapy include vascular endothelial growth factor receptor (VEGF-R) tyrosine kinase inhibitors, although no prospective data regarding their use in this setting exist. Axitinib is a VEGF-R inhibitor with clinical data supporting increased activity with dose titration. We aimed to investigate the activity of dose titrated axitinib in patients with metastatic renal cell carcinoma who were previously treated with checkpoint inhibitor. We did a multicentre, phase 2 trial of axitinib given on an individualised dosing algorithm. Patients at least 18 years of age with histologically or cytologically confirmed locally recurrent or metastatic renal cell carcinoma with clear cell histology, a Karnofsky Performance Status of 70% or more, and measurable disease who received checkpoint inhibitor therapy as the most recent treatment were eligible. There was no limit on number of previous therapies received. Patients received oral axitinib at a starting dose of 5 mg twice daily with dose titration every 14 days in 1 mg increments (ie, 5 mg twice daily to 6 mg twice daily, up to 10 mg twice daily maximum dose) if there was no axitinib-related grade 2 or higher mucositis, diarrhoea, hand-foot syndrome, or fatigue. If one or more of these grade 2 adverse events occurred, axitinib was withheld for 3 days before the same dose was resumed. Dose reductions were made if recurrent grade 2 adverse events despite treatment breaks or grade 3-4 adverse events occurred. The primary outcome was progression-free survival. Analyses were done per protocol in all patients who received at least one dose of axitinib. Recruitment has been completed and the trial is ongoing. This trial is registered with ClincalTrials.gov, number NCT02579811. Between Jan 5, 2016 and Feb 21, 2018, 40 patients were enrolled and received at least one dose of study treatment. With a median follow-up of 8·7 months (IQR 3·7-14·2), the median progression-free survival was 8·8 months (95% CI 5·7-16·6). Fatigue (83%) and hypertension (75%) were the most common all-grade adverse events. The most common grade 3 adverse event was hypertension (24 patients [60%]). There was one (3%) grade 4 adverse event (elevated lipase) and no treatment-related deaths occurred. Serious adverse events that were likely related to therapy occurred in eight (20%) patients; the most common were dehydration (n=4) and diarrhoea (n=2). Individualised axitinib dosing in patients with metastatic renal cell inoma previously treated with checkpoint inhibitors did not meet the prespecified threshold for progression free survival, but these data show that this individualised titration scheme is feasible and has robust clinical activity. These prospective results warrant consideration of axitinib in this setting. Pfizer.


Predictors of Rapid Aortic Root Dilation and Referral for Aortic Surgery in Marfan Syndrome.
Few data exist regarding predictors of rapid aortic root dilation and referral for aortic surgery in Marfan syndrome (MFS). To identify independent predictors of the rate of aortic root (AoR) dilation and referral for aortic surgery, we investigated the data from the Pediatric Heart Network randomized trial of atenolol versus losartan in young patients with MFS. Data were analyzed from the echocardiograms at 0, 12, 24, and 36 months read in the core laboratory of 608 trial subjects, aged 6 months to 25 years, who met original Ghent criteria and had an AoR z-score (AoRz) > 3. Repeated measures linear and logistic regressions were used to determine multivariable predictors of AoR dilation. Receiver operator characteristic curves were used to determine cut-points in AoR dilation predicting referral for aortic surgery. Multivariable analysis showed rapid AoR dilation as defined by change in AoRz/year > 90th percentile was associated with older age, higher sinotubular junction z-score, and atenolol use (R2 = 0.01) or by change in AoR diameter (AoRd)/year > 90th percentile with higher sinotubular junction z-score and non-white race (R2 = 0.02). Referral for aortic root surgery was associated with higher AoRd, higher ascending aorta z-score, and higher sinotubular junction diameter:ascending aorta diameter ratio (R2 = 0.17). Change in AoRz of 0.72 SD units/year had 42% sensitivity and 92% specificity and change in AoRd of 0.34 cm/year had 38% sensitivity and 95% specificity for predicting referral for aortic surgery. In this cohort of young patients with MFS, no new robust predictors of rapid AoR dilation or referral for aortic root surgery were identified. Further investigation may determine whether generalized proximal aortic dilation and effacement of the sinotubular junction will allow for better risk stratification. Rate of AoR dilation cut-points had high specificity, but low sensitivity for predicting referral for aortic surgery, limiting their clinical use. Clinical Trial Number ClinicalTrials.gov number, NCT00429364.


Donaldson v. Van de Kamp: cryonics, assisted suicide, and the challenges of medical science.
In recent years, advances in medical science have left the legal community with a wide array of social, ethical, and legal problems previously unimaginable. Historically, legislative and judicial responses to these advances lagged behind the rapid pace of such developments. The gap between the scientist's question, "Can we do it?," and the lawyer's question, "Should/may we do it?'" is most evident in the field of cryonics, with its technique of cryonic, or cryogenic, suspension. In cryonic suspension, a legally dead but biologically viable person is preserved at an extremely low temperature until advances in medical science make it possible to revive the person and implement an effective cure. The terminally ill patient who wishes to benefit from such treatment is faced with the dilemma that present life must be ceased with hope of future recovery. As a result, the process challenges our traditional notions of death and the prospects of immortality while raising a host of concomitant legal dilemmas. Some facets of this dilemma are exemplified by Donaldson v. Van de Kamp. In Donaldson, Thomas A. Donaldson sought the declaration of a constitutional right to premortem cryonic suspension of his body and the assistance of others in achieving that state. Donaldson, a forty-six-year-old mathematician and computer software scientist, suffers from a malignant brain tumor that was diagnosed by his physicians in 1988. This tumor is inoperable and continues to grow and invade his brain tissue. Donaldson's condition will gradually deteriorate into a persistent vegetative state and will ultimately result in death. Physicians predict his probable death by August 1993. Donaldson petitioned the California courts, seeking a declaration that he had a constitutional right to achieve cryonic suspension before his natural death. His doctors believe that if Donaldson waits until his natural death to be suspended, future reanimation will be futile because the tumor will have destroyed his brain. In addition, Donaldson's doctors sought an injunction against criminal prosecution for their participation in the suspension, because Donaldson, once suspended, would be considered "dead" under California law. Donaldson and his doctors built their novel argument upon the recent right-to-die cases in which the courts recognized a patient's right to have life-sustaining medical treatment withdrawn. Donaldson argued that his right to privacy and self-determination is paramount to any state interest in maintaining life. Thus, according to Donaldson, balancing the state's reasons to end--or "interrupt," as cryonics enthusiasts would have it--his own life was not necessary. The trial court dismissed the complaint for failure to state a cause of action, and Donaldson appealed to the California Court of Appeals. Because the cryonic process would necessarily involve physician-assisted death, or the aiding, advising, or encouraging of another to commit suicide, the appellate court affirmed the ruling of the trial court, holding that Donaldson did not have a constitutional right to assisted death. Additionally, in light of Donaldson's First Amendment challenge to the statute, the court upheld the criminal statute prohibiting the aiding, advising, or encouraging of another to commit suicide. This Note briefly discusses the process of cryonic suspension and explores the holding of Donaldson in light of the underlying rationale of the California right-to-die cases. Considering the contradictory state and individual interests balanced in the right-to-die cases, this Note concludes that, under a similar balancing test, premortem cryonic suspension could be permitted under certain circumstances; however, the right to premortem cryonic suspension may be more effectively recognized through legislation.


Economic inequalities in maternal health care: prenatal care and skilled birth attendance in India, 1992-2006.
The use of maternal health care is limited in India despite several programmatic efforts for its improvement since the late 1980's. The use of maternal health care is typically patterned on socioeconomic and cultural contours. However, there is no clear perspective about how socioeconomic differences over time have contributed towards the use of maternal health care in India. Using data from three rounds of National Family Health Survey (NFHS) conducted during 1992-2006, we analyse the trends and patterns in utilization of prenatal care (PNC) in first trimester with four or more antenatal care visits and skilled birth attendance (SBA) among poor and nonpoor mothers, disaggregated by area of residence in India and three contrasting provinces, namely, Uttar Pradesh, Maharashtra and Tamil Nadu. In addition, we investigate the relative contribution of public and private health facilities in meeting the demand for SBA, especially among poor mothers. We also examine the role of salient socioeconomic, demographic and cultural factors in influencing aforementioned outcomes. Bivariate analyses, concentration curve and concentration index, logistic regression and multinomial logistic regression models are used to understand the trends, patterns and predictors of the two outcome variables. Results indicate sluggish progress in utilization of PNC and SBA in India and selected provinces during 1992-2006. Enormous inequalities in utilization of PNC and SBA were observed largely to the disadvantage of the poor. Multivariate analysis suggests growing inequalities in utilization of the two outcomes across different economic groups. The use of PNC and SBA remains disproportionately lower among poor mothers in India irrespective of area of residence and province. Despite several governmental efforts to increase access and coverage of delivery services to poor, it is clear that the poor (a) do not use SBA and (b) even if they had SBA, they were more likely to use the private providers.


A Refined Open State of the Glycine Receptor Obtained via Molecular Dynamics Simulations.
Pentameric ligand-gated ion channels are key players in mediating fast neurotransmission. Glycine receptors are chloride-selective members of this receptor family that mediate inhibitory synaptic transmission and are implicated in neurological disorders including autism and hyperekplexia. They have been structurally characterized by both X-ray crystallography and cryoelectron microscopy (cryo-EM) studies, with the latter giving rise to what was proposed as a possible open state. However, recent work has questioned the physiological relevance of this open state structure, since it rapidly collapses in molecular dynamics simulations. Here, we show that the collapse can be avoided by a careful equilibration protocol that reconciles the more problematic regions of the original density map and gives a stable open state that shows frequent selective chloride permeation. The protocol developed in this work provides a means to refine open-like structures of the whole pentameric ligand-gated ion channel superfamily and reconciles the previous issues with the cryo-EM structure.


Inhibitory effects of repeating color and shape: inhibition of return or repetition blindness?
There is a current debate regarding whether attention is influenced by stimulus attributes other than location. The present article replicates and extends previous findings that repeating the nonspatial attribute of color leads to a delay in target detection (M. B. Law, J. Pratt, & R. A. Abrams, 1995). Repetition disadvantage effects were found for the stimulus attributes of both color and shape, as well as for location. However, the nonspatial repetition disadvantage disappeared if the stimuli were presented in peripheral locations (Experiments 3a, 3b, and 4) or the cue was presented for 50 ms (Experiment 6). Moreover, the magnitude of the repetition disadvantage tended to decline as the cue-target stimulus-onset asynchrony increased (Experiments 5a, 5b, and 6). These results suggest that a repetition blindness mechanism may underlie the repetition disadvantage effects of nonspatial features, rather than an inhibition of return mechanism.


Criteria for evaluation of novel markers of cardiovascular risk: a scientific statement from the American Heart Association.
There is increasing interest in utilizing novel markers of cardiovascular disease risk, and consequently, there is a need to assess the value of their use. This scientific statement reviews current concepts of risk evaluation and proposes standards for the critical appraisal of risk assessment methods. An adequate evaluation of a novel risk marker requires a sound research design, a representative at-risk population, and an adequate number of outcome events. Studies of a novel marker should report the degree to which it adds to the prognostic information provided by standard risk markers. No single statistical measure provides all the information needed to assess a novel marker, so measures of both discrimination and accuracy should be reported. The clinical value of a marker should be assessed by its effect on patient management and outcomes. In general, a novel risk marker should be evaluated in several phases, including initial proof of concept, prospective validation in independent populations, documentation of incremental information when added to standard risk markers, assessment of effects on patient management and outcomes, and ultimately, cost-effectiveness.


Classical and non-classical redox reactions of Pd(II) complexes containing redox-active ligands.
Reactivity studies of a Pd(II)-verdazyl complex reveal novel ligand-centred reduction processes which trigger pseudo-reductive elimination at Pd. Reaction of the complex with water induces a ligand-centred redox disproportionation. The reduced verdazyl ligands can also be reversibly protonated.


Targeting effect of microRNA on CD133 and its impact analysis on proliferation and invasion of glioma cells.
MiR-200b, a member of the microRNA-200 family, has been identified to be capable of suppressing glioma cell growth through targeting CREB1 or CD133. However, whether miR-200b affects the biological behavior (proliferation, invasion, and migration) of glioma cells is poorly understood. The aim of this study was to evaluate the effect of miR-200b on the biological behavior of glioma cells in vitro. MiRNA-200b mimics, miRNA-200b inhibitor, and mimic control were transfected into conventionally cultured glioma U251 cells, followed by measuring the expression of miR-200b and CD133 in transfected cells by RT-PCR; effect of miR-200b on CD133 mRNA 3'-UTR luciferase activity by luciferase reporter assay; proliferation activity of transfected U251 cells by MTT method; and changes in U251 cell invasion and migration by Transwell method after transfection. Compared to that in the miRNA-200b inhibitor, mimic control, and blank control groups, miRNA-200b expression was significantly increased and CD133 mRNA expression was significantly decreased in the mimic miRNA-200b group in a time-dependent manner (P < 0.05). Meanwhile, dual luciferase reporter assay showed that miR-200b could inhibit CD133 activity through binding to the 3'-UTR of CD133 mRNA (P < 0.05). Furthermore, the proliferation activity and invasion and migration abilities of U251 cells transfected with miRNA-200b mimic were significantly decreased (P < 0.05). In conclusion, overexpression of miR-200b inhibited the proliferation, invasion, and migration of glioma cells possibly through targeting CD133.


Characterization of the juvenile green turtle (Chelonia mydas) microbiome throughout an ontogenetic shift from pelagic to neritic habitats.
The gut microbiome of herbivorous animals consists of organisms that efficiently digest the structural carbohydrates of ingested plant material. Green turtles (Chelonia mydas) provide an interesting model of change in these microbial communities because they undergo a pronounced shift from a surface-pelagic distribution and omnivorous diet to a neritic distribution and herbivorous diet. As an alternative to direct sampling of the gut, we investigated the cloacal microbiomes of juvenile green turtles before and after recruitment to neritic waters to observe any changes in their microbial community structure. Cloacal swabs were taken from individual turtles for analysis of the 16S rRNA gene sequences using Illumina sequencing. One fecal sample was also obtained, allowing for a preliminary comparison with the bacterial community of the cloaca. We found significant variation in the juvenile green turtle bacterial communities between pelagic and neritic habitats, suggesting that environmental and dietary factors support different bacterial communities in green turtles from these habitats. This is the first study to characterize the cloacal microbiome of green turtles in the context of their ontogenetic shifts, which could provide valuable insight into the origins of their gut bacteria and how the microbial community supports their shift to herbivory.


In vivo imaging of macrophages during the early-stages of abdominal aortic aneurysm using high resolution MRI in ApoE mice.
Angiotensin II (ANG II) promotes vascular inflammation and induces abdominal aortic aneurysm (AAA) in hyperlipidemic apolipoprotein E knock-out (apoE(-/-)) mice. The aim of the present study was to detect macrophage activities in an ANG II-induced early-stage AAA model using superparamagnetic iron oxide (SPIO) as a marker. Twenty-six male apoE(-/-) mice received saline or ANG II (1000 or 500 ng/kg/min) infusion for 14 days. All animals underwent MRI scanning following administration of SPIO with the exception of three mice in the 1000 ng ANG II group, which were scanned without SPIO administration. MR imaging was performed using black-blood T2 to proton density -weighted multi-spin multi-echo sequence. In vivo MRI measurement of SPIO uptake and abdominal aortic diameter were obtained. Prussian blue, CD68,α-SMC and MAC3 immunohistological stains were used for the detection of SPIO, macrophages and smooth muscle cells. ANG II infusion with 1000 ng/kg/min induced AAA in all of the apoE(-/-) mice. ANG II infusion exhibited significantly higher degrees of SPIO uptake, which was detected using MRI as a distinct loss of signal intensity. The contrast-to-noise ratio value decreased in proportion to an increase in the number of iron-laden macrophages in the aneurysm. The aneurysmal vessel wall in both groups of ANG II treated mice contained more iron-positive macrophages than saline-treated mice. However, the presence of cells capable of phagocytosing haemosiderin in mural thrombi also induced low-signal-intensities via MRI imaging. SPIO is taken up by macrophages in the shoulder and the outer layer of AAA. This alters the MRI signaling properties and can be used in imaging inflammation associated with AAA. It is important to compare images of the aorta before and after SPIO injection.


A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas.
Several randomized control trials (RCTs) have compared somatostatin and its analogues versus a control group in patients with enterocutaneous fistulas (ECF). This study meta-analyzes the literature and establishes whether it shows a beneficial effect on ECF closure. We searched MEDLINE, EMBASE, CINAHL, Cochrane, and PubMed databases according to PRISMA guidelines. Seventy-nine articles were screened. Nine RCTs met the inclusion criteria. Statistical analyses were performed using Review Manager 5.1. Somatostatin analogues versus control. Number of fistula closed: A significant number of ECF closed in the somatostatin analogue group compared to control group, P = 0.002.Time to closure: ECF closed significantly faster with somatostatin analogues compared to controls, P < 0.0001.Mortality: No significant difference between somatostatin analogues and controls, P = 0.68.Somatostatin versus control. Number of fistula closed: A significant number of ECF closed with somatostatin as compared to control, P = 0.04.Time to closure: ECF closed significantly faster with somatostatin than controls, P < 0.00001.Mortality: No significant difference between somatostatin and controls, P = 0.63 Somatostatin and octreotide increase the likelihood of fistula closure. Both are beneficial in reducing the time to fistula closure. Neither has an effect on mortality. The risk ratio (RR) for somatostatin was higher than the RR for analogues. This may suggest that somatostatin could be better than analogues in relation to the number of fistulas closed and time to closure. Further studies are required to corroborate these apparent findings.


Cloning and characterization of a human electrogenic Na+-HCO-3 cotransporter isoform (hhNBC).
Our group recently cloned the electrogenic Na+-HCO-3 cotransporter (NBC) from salamander kidney and later from mammalian kidney. Here we report cloning an NBC isoform (hhNBC) from a human heart cDNA library. hhNBC is identical to human renal NBC (hkNBC), except for the amino terminus, where the first 85 amino acids in hhNBC replace the first 41 amino acids of hkNBC. About 50% of the amino acid residues in this unique amino terminus are charged, compared with approximately 22% for the corresponding 41 residues in hkNBC. Northern blot analysis, with the use of the unique 5' fragment of hhNBC as a probe, shows strong expression in pancreas and expression in heart and brain, although at much lower levels. In Xenopus oocytes expressing hhNBC, adding 1.5% CO2/10 mM HCO-3 hyperpolarizes the membrane and causes a rapid fall in intracellular pH (pHi), followed by a pHi recovery. Subsequent removal of Na+ causes a depolarization and a reduced rate of pHi recovery. Removal of Cl- from the bath does not affect the pHi recovery. The stilbene derivative DIDS (200 microM) greatly reduces the hyperpolarization caused by adding CO2/HCO-3. In oocytes expressing hkNBC, the effects of adding CO2/HCO-3 and then removing Na+ were similar to those observed in oocytes expressing hhNBC. We conclude that hhNBC is an electrogenic Na+-HCO-3 cotransporter and that hkNBC is also electrogenic.


Sympathetic denervation of the upper limb improves forearm exercise performance and skeletal muscle bioenergetics.
Sympathetic activation may limit exercise performance by restraining muscle blood flow or by negatively affecting skeletal muscle metabolic behavior. To test this hypothesis, we studied the effect of thoracoscopic sympathetic trunkotomy (TST) on forearm exercise duration, blood flow, and muscle bioenergetics in 13 patients with idiopathic palmar hyperhidrosis. Heart rate and beat-by-beat mean arterial pressure were recorded at rest and during right and left rhythmic handgrip before and 4 to 7 weeks after right TST. Forearm blood flow was measured bilaterally at rest and on the right during exercise. Right forearm muscle phosphocreatine content and intracellular pH were assessed by (31)phosphorus magnetic resonance spectroscopy. After right TST, exercise duration increased from 8.9+/-1.4 to 13.4+/-1.8 minutes (P<0.0001) with the right forearm and from 5.7+/-0.4 to 7.6+/-0.9 minutes (P<0.05) with the left (P<0.05 for the interaction between treatment and side). Right forearm blood flow at rest was 66% higher (P<0.01) after right TST, but this difference decreased as the exercise progressed. After right TST, a significant reduction occurred in muscle acidification and phosphocreatine depletion during ipsilateral forearm exercise. This was associated with a significantly reduced mean arterial pressure response to right handgrip, whereas the pressor response to left handgrip did not change. Sympathetic denervation of the upper limb significantly improves forearm skeletal muscle bioenergetics and exercise performance in patients with idiopathic palmar hyperhidrosis.


Influence of a low dose of dietary soybean on bone properties and mineral status in young rats.
The aim of this study was to evaluate effects of dietary supplementation with genistein, daidzein stachyose, and raw or cooked soybean on mineral content, optical density, and mechanical properties of bones in growing rats. The experiment was performed on 70 male young Wistar rats (4 weeks old at the start of the experiment) divided into seven groups. Genistein, daidzein, or stachyose were administered by gavage. Raw or cooked soybean was added directly to the diet (1%) The experiment lasted 28 days. Femurs were removed postmortem and kept until analysis at -20°C. Mineral content in bones was determined by atomic absorption flame spectrometry, and inductively coupled plasma atomic emission spectrometry. Optical density was analyzed with a KODAK 1D 3.5 system. Mechanical properties were tested using INSTRON 4301 equipment. Genistein increased mineral content in bones of growing rats. Biological action of genistein and daidzein on the mineralization of bone tissues in growing rats was different. Addition of stachyose (1.9 mg/day/rat) did not affect bone tissues, nor did the addition of raw or cooked soybean. None of the studied biologically active substances: genistein (0.26 mg/day/rat), daidzein (0.104 mg/day/rat), stachyose (1.9 mg/day/rat), or soybean had an effect on bone optical density.


The output of the tRNA modification pathways controlled by the Escherichia coli MnmEG and MnmC enzymes depends on the growth conditions and the tRNA species.
In Escherichia coli, the MnmEG complex modifies transfer RNAs (tRNAs) decoding NNA/NNG codons. MnmEG catalyzes two different modification reactions, which add an aminomethyl (nm) or carboxymethylaminomethyl (cmnm) group to position 5 of the anticodon wobble uridine using ammonium or glycine, respectively. In tRNA(cmnm5s2UUG)(Gln) and tRNA(cmnm5UmAA)(Leu), however, cmnm(5) appears as the final modification, whereas in the remaining tRNAs, the MnmEG products are converted into 5-methylaminomethyl (mnm(5)) through the two-domain, bi-functional enzyme MnmC. MnmC(o) transforms cmnm(5) into nm(5), whereas MnmC(m) converts nm(5) into mnm(5), thus producing an atypical network of modification pathways. We investigate the activities and tRNA specificity of MnmEG and the MnmC domains, the ability of tRNAs to follow the ammonium or glycine pathway and the effect of mnmC mutations on growth. We demonstrate that the two MnmC domains function independently of each other and that tRNA(cmnm5s2UUG)(Gln) and tRNA(cmnm5UmAA)(Leu), are substrates for MnmC(m), but not MnmC(o). Synthesis of mnm(5)s(2)U by MnmEG-MnmC in vivo avoids build-up of intermediates in tRNA(mnm5s2UUU)(Lys). We also show that MnmEG can modify all the tRNAs via the ammonium pathway. Strikingly, the net output of the MnmEG pathways in vivo depends on growth conditions and tRNA species. Loss of any MnmC activity has a biological cost under specific conditions.


Probing the nanoscale light emission properties of a CVD-grown MoS2 monolayer by tip-enhanced photoluminescence.
Two-dimensional transition metal dichalcogenides are gaining increasing interest due to their promising optical properties. In particular, molybdenum disulfide (MoS2) which displays a band-gap change from indirect at 1.29 eV for bulk materials to direct at 1.8 eV for the material monolayer. This particular effect can lead to a strong light interaction which can pave the way for a new approach to the next generation of visible light emitting devices. In this work we show the nanoscale variation of light emission properties by tip-enhanced photoluminescence microscopy and spectroscopy in the MoS2 monolayer, grown by chemical vapour deposition. The variations of the light emission properties are due to different effects depending on the shape of the MoS2 single layer, for instance, a different concentration of point defect in an irregularly shaped flake and the presence of a nanoscale terrace in a triangular monolayer. Simultaneously, atomic force microscopy reveals indeed the presence of a nanometric terrace, composed of an additional layer of MoS2, and tip-enhanced PL intensity imaging shows a localized intensity decrease.


Monitoring of petroleum hydrocarbon degradative potential of indigenous microorganisms in ozonated soil.
This study was performed to investigate the petroleum hydrocarbon (PH) degradative potential of indigenous microorganisms in ozonated soil to better develop combined pre-ozonation/bioremediation technology. Diesel-contaminated soils were ozonated for 0-900 min. PH and microbial concentrations in the soils decreased with increased ozonation time. The greatest reduction of total PH (TPH, 47.6%) and aromatics (11.3%) was observed in 900-min ozonated soil. The number of total viable heterotrophic bacteria decreased by three orders of magnitude in the soil. Ozonated soils were incubated for 9 weeks for bioremediation. The number of microorganisms in the soils increased during the incubation period, as monitored by culture- and nonculture-based methods. The soils showed additional PH-removal during incubation, supporting the presence of PH-degraders in the soils. The highest removal (25.4%) of TPH was observed during the incubation of 180-min ozonated soil during the incubation while a negligible removal was shown in 900-min ozonated soil. This negligible removal could be explained by the existence of relatively few or undetected PH-degraders in 900-min ozonated soil. After a 9-week incubation of the ozonated soils, 180-min ozonated soil showed the lowest TPH concentration, suggesting that appropriate ozonation and indigenous microorganisms survived ozonation could enhance remediation of PH-contaminated soil. Microbial community composition in 9-week incubated soils revealed a slight difference between 900-min ozonated and unozonated soils, as analyzed by whole cell hybridization. Taken together, this study provided insight into indigenous microbial potential to degrade PH in ozonated soils.


Profile of aerobic bacteria and their antibiotic sensitivity in chronic suppurative otitis media in Al-Ramadi Teaching Hospital, Ramadi City, Iraq.
Chronic suppurative otitis media (CSOM) is a common otological problem in daily clinical practice. It is crucial to know the bacterial pathogens and their antimicrobial susceptibilities in patients with CSOM to achieve a good clinical outcome. To identify the aerobic bacterial pathogens and their antibiotic sensitivities in subjects with CSOM in Al-Ramadi Teaching Hospital. A cross-sectional, descriptive study included 102 subjects with a clinical diagnosis of CSOM (aural discharge >2 weeks, eardrum perforation, and conductive deafness). Purulent discharge was obtained from the middle ear with sterile swabs and cultured for bacterial microorganisms. The sensitivity of the isolated agents to antimicrobials was evaluated by a culture and sensitivity method. SPSS version 22 was used for statistical analysis of the data. Differences were considered statistically significant at p < 0.05. Out of 3634 outpatient subjects, 102 (2.8%) presented with active CSOM. The age range of the patients was 1-70 years (mean 28.90 ± 19.8). There were 58 females (56.9%). Out of 117 ear swab specimens, 107 (91.5%) yielded positive cultures. The majority (101, 94.4%) of the specimens yielded a single organism. There was a high statistically significant difference (p < 0.001) between gram-positive (n = 77, 68.1%) and gram-negative pathogens (n = 36, 31.9%). Pseudomonas aeruginosa in 65 (57.5%) cases and Staphylococcus aureus in 19 (16.8%) cases were the two most commonly isolated organisms. The drugs imipenem (93.8%), amikacin (86.1%), azteronam (83.1%), and ciprofloxacin (81.5%) were effective against P. aeruginosa (p < 0.001). Amikacin (100%), imipenem (94.7%), ciprofloxacin (68.4%), and gentamicin (63.1%) were the most effective antibiotics against Staph. aureus (p < 0.001). The prevalence rate of active CSOM was 2.8%. Ciprofloxacin showed high effectiveness against the two most common isolated pathogens (P. aeruginosa and Staph. aureus); therefore, it could be used as empirical therapy for active CSOM cases.


Adipocyte-derived collagen VI affects early mammary tumor progression in vivo, demonstrating a critical interaction in the tumor/stroma microenvironment.
The interactions of transformed cells with the surrounding stromal cells are of importance for tumor progression and metastasis. The relevance of adipocyte-derived factors to breast cancer cell survival and growth is well established. However, it remains unknown which specific adipocyte-derived factors are most critical in this process. Collagen VI is abundantly expressed in adipocytes. Collagen(-/-) mice in the background of the mouse mammary tumor virus/polyoma virus middle T oncogene (MMTV-PyMT) mammary cancer model demonstrate dramatically reduced rates of early hyperplasia and primary tumor growth. Collagen VI promotes its growth-stimulatory and pro-survival effects in part by signaling through the NG2/chondroitin sulfate proteoglycan receptor expressed on the surface of malignant ductal epithelial cells to sequentially activate Akt and beta-catenin and stabilize cyclin D1. Levels of the carboxyterminal domain of collagen VIalpha3, a proteolytic product of the full-length molecule, are dramatically upregulated in murine and human breast cancer lesions. The same fragment exerts potent growth-stimulatory effects on MCF-7 cells in vitro. Therefore, adipocytes play a vital role in defining the ECM environment for normal and tumor-derived ductal epithelial cells and contribute significantly to tumor growth at early stages through secretion and processing of collagen VI.


Making sense of ambiguity: evaluation in internal reliability and face validity of the SF 36 questionnaire in women presenting with menorrhagia.
To determine the face validity and internal reliability of the short form 36 (SF 36) health survey questionnaire in women presenting with menorrhagia. Postal survey of women recruited by their general practitioners followed by interviews of a selected subsample. 348 women who had consulted their general practitioner with excessive menstrual bleeding and completed questionnaires after treatment. 49 women selected from this group were interviewed in depth about their health status, and requested to complete the SF 36 questionnaire. Subjective accounts of functioning and wellbeing as measured by the eight scales of the SF 36 questionnaire. Data from the postal survey indicated that the ¿general health perceptions¿ and ¿mental health¿ scales of the SF 36 questionnaire had lower internal reliability coefficients than documented elsewhere. In the follow up interviews several questions on the SF 36 questionnaire were commented on as inappropriate or difficult to answer for patients with heavy menstrual bleeding. Some questions on the SF 36 questionnaire were difficult to answer for this group of patients. Such problems can adversely effect the validity of the measure. It is suggested that comments of patients upon measures such as the SF 36 questionnaire could both determine the appropriateness of such measures for given studies and influence questionnaire design.


When Respecting Autonomy Is Harmful: A Clinically Useful Approach to the Nocebo Effect.
Nocebo effects occur when an adverse effect on the patient arises from the patient's own negative expectations. In accordance with informed consent, providers often disclose information that results in unintended adverse outcomes for the patient. While this may adhere to the principle of autonomy, it violates the doctrine of "primum non nocere," given that side-effect disclosure may cause those side effects. In this article we build off previous work, particularly by Wells and Kaptchuk ( 2012 ) and by Cohen ( 2013 ), to suggest ethical guidelines that permit nondisclosure in the case when a nocebo effect is likely to occur on of the basis of nonmaleficence. We accept that that autonomy vis-à-vis informed consent must be forestalled, but salvage much of its role by elaborating a practical clinical approach to postencounter follow-up. In doing so, we reconcile a clinically practicable process of determining conditions of disclosure with long-standing ethical commitments to patients.


Plasma coenzyme Q10 levels and postmenopausal breast cancer risk: the multiethnic cohort study.
Coenzyme Q10 (CoQ10) is a component of the mitochondrial electron transport chain and is considered an important cellular antioxidant. Decreased circulating CoQ10 levels have been reported in women with breast cancer, but evidence is limited. We examined the association of plasma CoQ10 levels with postmenopausal breast cancer risk using prospectively collected blood samples. Prediagnostic plasma levels of total CoQ10 were measured among 160 incident postmenopausal breast cancer cases and 289 controls in the Multiethnic Cohort Study. Cases and controls were individually matched on age, sex, ethnicity, study location (Hawaii or California), hormone replacement therapy use, date and time of specimen collection, and hours of fasting. Logistic regression was used to compute odds ratios and 95% confidence intervals. Plasma CoQ10 levels were positively associated with breast cancer risk, overall (P = 0.04). The association was stronger after women diagnosed within 1 year of blood draw were excluded to eliminate possible preclinical cases (odds ratio for the highest versus the lowest tertile, 2.26; 95% confidence interval, 1.22-4.19; P for trend = 0.01). Higher CoQ10 levels in postmenopausal women may be associated with increased breast cancer risk. A potential role for CoQ10 in the development and progression of breast cancer has been postulated, but epidemiologic evidence is lacking. Findings from this prospective cohort study add to the limited literature, indicating the potential positive association of circulating CoQ10 with postmenopausal breast cancer risk.


The utility of superficial abdominal reflex in the initial diagnosis of scoliosis: a retrospective review of clinical characteristics of scoliosis with syringomyelia.
With increasing use of magnetic resonance imaging (MRI), underlying syringomyelia is increasingly found in patients with presumed idiopathic scoliosis. To determine the indications for MRI in the differential diagnosis of scoliosis, several clinical characteristics of syringomyelia have been reported. Neurological signs, particularly abnormal superficial abdominal reflex (SAR), are important in establishing the initial diagnosis of scoliosis. However, the prevalence of abnormal SAR in patients with scoliosis and the sensitivity of this sign in predicting syringomyelia are not well known. We aimed to determine the diagnostic utility of SAR and other characteristics of syringomyelia in patients with scoliosis. We reviewed the medical records of 93 patients with scoliosis, 90 of whom underwent corrective surgery. All patients underwent MRI to determine the presence of syringomyelia. Mean age at surgery was 12.5 years. Abnormal SAR was defined as unilateral or bilateral absence or hyporeflexia of SAR. We calculated indices of diagnostic utility of abnormal SAR for non-idiopathic scoliosis and for syringomyelia. Abnormal SAR, left thoracic curve pattern, gender, and curve flexibility were compared between scoliosis with syringomyelia and idiopathic scoliosis. Logistic regression analysis was performed with the existence of syringomyelia as the dependent variable and curve flexibility as the independent variable. Abnormal SAR was observed in 20 patients (prevalence 22%). All 6 patients with myopathic scoliosis displayed bilateral absence of SAR. The sensitivity of abnormal SAR for non-idiopathic scoliosis was 38%, with 96% specificity, 90% PPV (positive predictive value), and 60% NPV (negative predictive value). Syringomyelia was identified in 9 of the 93 patients (9.7%); 8 of these had abnormal SAR. The sensitivity of abnormal SAR for syringomyelia in presumed idiopathic scoliosis was 89%, with 95% specificity, 80% PPV, and 98% NPV. Gender, abnormal neurological findings, and curve flexibility differed significantly between patients with syringomyelia and those with idiopathic scoliosis (P < 0.05). In the logistic regression model, the area under the receiver operating characteristic (ROC) curve was 0.79 and the cut-off value of curve flexibility for syringomyelia was 50% (P = 0.08). Abnormal SAR was a useful indicator not only for syringomyelia, but also for myogenic scoliosis.


Comparison of 8 scores for predicting symptomatic intracerebral hemorrhage after IV thrombolysis.
Intracerebral hemorrhage is a feared complication of IV thrombolytic (rt-PA) therapy. In recent years, at least 8 clinical scores have been proposed to predict either adverse outcome or symptomatic intracerebral hemorrhage (sICH) in patients undergoing rt-PA therapy. The purpose of this study was to evaluate the ability of these 8 scores to predict sICH in an independent clinical dataset. Clinical data was analyzed from consecutive patients (n = 210) receiving IV rt-PA therapy from January 2009 to December 2013 at Yale-New Haven Hospital. Eight scores were calculated for each patient: Stroke-TPI, DRAGON, SPAN-100, ASTRAL, PRS, HAT, SEDAN, and SITS-ICH. sICH was defined according to the NINDS study criteria. Univariate logistic regression was performed using each score as an independent variable and sICH as the dependent variable. Goodness of fit was tested by Receiver operating characteristic (ROC) analysis and by Hosmer-Lemeshow statistics. sICH occurred in 12 patients (5.71 %) after IV rt-PA treatment. Only 4 scores predicted sICH with good accuracy (ROC area >0.7): DRAGON 0.76 (0.63, 0.89); Stroke-TPI 0.74 (0.61, 0.87); ASTRAL 0.72 (0.59, 0.86); and HAT 0.70 (0.55, 0.85), with odds ratios as follows: Stroke-TPI, 1.91 (1.26, 2.90); HAT, 1.67 (1.06, 2.62); DRAGON, 1.66 (1.21, 2.30); and ASTRAL, 1.10 (1.03, 1.16). Three scores showed good agreement with sICH: DRAGON, Stroke-TPI, and HAT with odds ratios substantially greater than 1. Stroke-TPI and HAT additionally benefited from low computational complexity and therefore performed best overall. Our results demonstrate the utility of clinical scores as predictors of sICH in acute ischemic stroke patients undergoing IV thrombolytic therapy.


Neisseria meningitidis recruits factor H using protein mimicry of host carbohydrates.
The complement system is an essential component of the innate and acquired immune system, and consists of a series of proteolytic cascades that are initiated by the presence of microorganisms. In health, activation of complement is precisely controlled through membrane-bound and soluble plasma-regulatory proteins including complement factor H (fH; ref. 2), a 155 kDa protein composed of 20 domains (termed complement control protein repeats). Many pathogens have evolved the ability to avoid immune-killing by recruiting host complement regulators and several pathogens have adapted to avoid complement-mediated killing by sequestering fH to their surface. Here we present the structure of a complement regulator in complex with its pathogen surface-protein ligand. This reveals how the important human pathogen Neisseria meningitidis subverts immune responses by mimicking the host, using protein instead of charged-carbohydrate chemistry to recruit the host complement regulator, fH. The structure also indicates the molecular basis of the host-specificity of the interaction between fH and the meningococcus, and informs attempts to develop novel therapeutics and vaccines.


Out-of-Pocket Spending for Hospitalizations Among Nonelderly Adults.
Patients' out-of-pocket spending for major health care expenses, such as inpatient care, may result in substantial financial distress. Limited contemporary data exist on out-of-pocket spending among nonelderly adults. To evaluate out-of-pocket spending associated with hospitalizations and to assess how this spending varied over time and by patient characteristics, region, and type of insurance. A retrospective analysis of medical claims for 7.3 million hospitalizations using 2009-2013 data from Aetna, UnitedHealthcare, and Humana insurance companies representing approximately 50 million members was performed. Out-of-pocket spending was evaluated by age, sex, type of insurance, region, and principal diagnosis or procedure for hospitalized adults aged 18 to 64 years who were enrolled in employer-sponsored and individual-market health insurance plans from January 1, 2009, to December 31, 2013. The study was conducted between July 1, 2015, and March 1, 2016. Primary outcomes were total out-of-pocket spending and spending attributed to deductibles, copayments, and coinsurance for all hospitalizations. Other outcomes included out-of-pocket spending associated with 7 commonly occurring inpatient diagnoses and procedures: acute myocardial infarction, live birth, pneumonia, appendicitis, coronary artery bypass graft, total knee arthroplasty, and spinal fusion. From 2009 to 2013, total cost sharing per inpatient hospitalization increased by 37%, from $738 in 2009 (95% CI, $736-$740) to $1013 in 2013 (95% CI, $1011-$1016), after adjusting for inflation and case-mix differences. This rise was driven primarily by increases in the amount applied to deductibles, which grew by 86% from $145 in 2009 (95% CI, $144-$146) to $270 in 2013 (95% CI, $269-$271), and by increases in coinsurance, which grew by 33% over the study period from $518 in 2009 (95% CI, $516-$520) to $688 in 2013 (95% CI, $686-$690). In 2013, total cost sharing was highest for enrollees in individual market plans ($1875 per hospitalization; 95% CI, $1867-$1883) and consumer-directed health plans ($1219; 95% CI, $1216-$1223). Cost sharing varied substantially across regions, diagnoses, and procedures. Mean out-of-pocket spending among commercially insured adults exceeded $1000 per inpatient hospitalization in 2013. Wide variability in out-of-pocket spending merits greater attention from policymakers.


Using patient and public involvement to improve the research design and funding application for a project aimed at fostering a more collaborative approach to the NHS health check: the CaVIAR project (better Care Via Improved Access to Records).
Following an initial NHS Health Check appointment, the National Institute for Health and Care Excellence (NICE) suggest patients with QRISK2 scores of ≥10% should be offered advice on lifestyle and the risks and benefits of starting a statin. NICE recommend GPs should ascertain patients' pre-existing knowledge of cardiovascular disease risk, explore health beliefs, assess readiness to change, offer support, and engage family members. Condensing this complex discussion into a short consultation may result in inadequate patient understanding of the benefits of preventive measures. An alternative approach is needed. We propose a digital adjunct giving patients the opportunity to interact with their health check results from home before returning to see their GP. Before embarking on funding applications we sought the views of patients and members of the public. We consulted the Primary Care Research in Manchester Engagement Resource (PRIMER), an established departmental Patient and Public Involvement (PPI) group (N = 9) and then ran a workshop with 19 members of the public, co-facilitated by 4 members of PRIMER. Following a brief presentation on the background to the project, attendees were split into four groups and introduced to Ketso, a toolkit for creative engagement. Ketso was used to encourage group discussions regarding the project idea. This PPI work improved the study design and proposed intervention. Discussions focussed on three themes: 1) positive feedback, 2) challenges and solutions, and 3) improvements/alternatives. Positive feedback included benefits to the NHS and patients. Challenges identified related to: 1) access, 2) data security, 3) engagement, and 4) negative consequences. Workshop members generated various solutions to these challenges and made additional suggestions for improvement relating to: 1) population (e.g. also including those with QRISK2 scores ≤10%), 2) duration (e.g. ongoing access to provide continued feedback), and 3) platform content (e.g. signposting to relevant services). This PPI work helped identify potential challenges and solutions not previously considered by the research team. Findings have informed the subsequent intervention design and strengthened the bid for funding. We aim to ensure ongoing patient and public involvement in all future stages.


Synthesis by High-Efficiency Liquid-Phase (HELP) Method of Oligonucleotides Conjugated with High-Molecular Weight Polyethylene Glycols (PEGs).
The chemical modification of synthetic oligonucleotides has recently been investigated to improve their pharmacological utilization. In addition to chemical alterations of the backbone and of the heterocyclic bases, their conjugation with amphiphylic moieties, such as the polyethylene glycol has been proposed. The large scale production of these molecules as demanded for commercial purposes is hampered by the heterogeneity of the solid-phase processes and by the low reactivity of high-molecular weight PEGs in solution. A new synthetic procedure based on the recently developed liquid-phase method (HELP), has been set up to overcome these limitations.