Real-world super-response to biologics in severe asthma: A French monocentric retrospective cohort study.
Biologics have dramatically improved outcomes in severe T2-high asthma. Although the identification of patients with the best response is key to understand the efficacy of these agents and select the best target populations, the definition and predictors of super-response are not fully established yet. This study aimed to describe super-response and to identify predictors of super-response to biologics in a French severe eosinophilic asthma cohort followed in a severe asthma tertiary care center between January 2005 and December 2020. Super-response was defined a priori as no oral corticosteroids intake and no exacerbations over 12 months. Collected data at baseline and after 12 months included asthma history, comorbidities, clinical characteristics, lung function, T2-biomarkers, baseline asthma-related treatments, and asthma control. Among 157 patients assessed for eligibility, 108 were included, corresponding to 166 treatments with biologics. Overall response rate was 63.2 % (105/166) and super-response rate was 39.7 % (66/166). In omalizumab group (n = 67), lower dose of oral corticosteroids in maintenance was the only factor associated with super-response (p = 0.008). In the anti-IL-5/anti-IL-5R group (n = 99), absence or lower dose of oral corticosteroids in maintenance and absence of eosinophilic granulomatosis with polyangiitis were statistically associated with super-response (p = 0.009, p = 0.001 and p = 0.02 respectively). In this real-life study in severe T2-high asthma patients, a lower dose or absence of daily oral corticosteroids and absence of eosinophilic granulomatosis with polyangiitis were the only identifiable predictors of super-response to biologics. Physicians should not wait for maintenance oral corticosteroids to be required before considering the initiation of a biologic in severe asthma.


Inducible Genome Editing with Conditional CRISPR/Cas9 Mice.
Genetically engineered mouse models (GEMMs) are powerful tools by which to probe gene function in vivo, obtain insight into disease etiology, and identify modifiers of drug response. Increased sophistication of GEMMs has led to the design of tissue-specific and inducible models in which genes of interest are expressed or ablated in defined tissues or cellular subtypes. Here we describe the generation of a transgenic mouse harboring a doxycycline-regulated Cas9 allele for inducible genome engineering. This model provides a flexible platform for genome engineering since editing is achieved by exogenous delivery of sgRNAs and should allow for the modeling of a range of biological and pathological processes.


The effect of casein phosphopeptide-amorphous calcium phosphate on remineralization of artificial caries-like lesions: an in vitro study.
The aims of this study were to investigate the efficacy of CPP-ACP containing Tooth Mousse on the remineralization of enamel lesions and to compare its efficacy to that of a fluoride-containing toothpaste. Permanent teeth were placed in demineralizing solution for 96 hours to produce artificial caries-like lesions 120-200 microm in depth. They were sectioned into 100-150 microm thick samples and randomly assigned to five groups: for Group A, a fluoridated toothpaste (1100 ppm) was used as a positive control and in Group B, a non-fluoridated toothpaste was used as a negative control. Tooth Mousse containing CPP-ACP was tested by three different means: as a toothpaste (Group C); as a topical coating (Group D); and (Group E) as a topical coating after treating the sections with the same fluoridated toothpaste as in Group A. The lesion depth decreased significantly by 7 per cent in Group A, 10.1 per cent in Groups C and D, and 13.1 per cent in Group E (Paired t- test, p < 0.05), while in Group B the lesion depth increased significantly by 23 per cent. Based on the data obtained, CPP-ACP containing Tooth Mousse remineralized initial enamel lesions and it showed a higher remineralizing potential when applied as a topical coating after the use of a fluoridated toothpaste.


Pharmacologic agents for the prevention and treatment of delirium in patients undergoing cardiac surgery: systematic review and metaanalysis.
Postcardiac surgery delirium is associated with increased risks of morbidity, cognitive decline, poor health-related quality of life and mortality, and higher healthcare costs. We performed a systematic review of randomized controlled trials to examine the effect of pharmacologic agents for the prevention and the treatment of delirium after cardiac surgery. Electronic search on PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, ISI Web of Science, and CINAHL up to December 2013. Randomized controlled trials of pharmacologic agents used for the prevention and the treatment of delirium after emergency or elective cardiac surgery in adults. We extracted data on patient population, pharmacologic agents, delirium characteristics, rescue treatment, length of stays in the ICU and hospital, and mortality. For each trial, we assessed the risk of bias domains and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. Of the 13 studies (10 prevention and three treatment) involving 5,848 patients, one multicentered randomized controlled trial on prophylactic dexamethasone made up 77% of the total sample size. The use of pharmacologic agents (dexamethasone, rivastigmine, risperidone, ketamine, dexmedetomidine, propofol, and clonidine) reduced the risk of delirium (relative risk, 0.57; 95% CI, 0.40-0.80) with quality of evidence rated as moderate. There was high quality of evidence for no increased risk of mortality (relative risk, 0.89; 95% CI, 0.57-1.38) associated with the use of prophylactic pharmacologic agents. Metaanalysis of treatment trials was not undertaken because of high heterogeneity. In two small trials (total number of patients = 133), haloperidol did not appear to be effective in treating delirium. Moderate to high-quality evidence supports the use of pharmacologic agents for the prevention of delirium, but results are based largely on one randomized controlled trial. The evidence for treating postcardiac surgery delirium with pharmacologic agents is inconclusive.


Cushing's syndrome caused by an ACTH-producing large cell neuroendocrine carcinoma of the gallbladder.
Malignancies of the gallbladder, including neuroendocrine tumors, are uncommon, mostly found incidentally after cholecystectomy and are frequently asymptomatic in the early stages, but highly fatal. Limited data is available on adrenocorticotropic hormone (ACTH)-producing neuroendocrine tumors specifically originating from the gallbladder. We report the clinical and radiographic findings, which included positron emission tomography and computed tomography, of a patient with a gallbladder mass who presented with Cushing's syndrome. Subsequently, a diagnosis of ACTH-producing large cell neuroendocrine carcinoma of the gallbladder was made. Despite being rare and having a poor prognosis, hormone-producing neuroendocrine tumors should be part of the differential diagnosis in the approach of patients with Cushing's syndrome.


Classical phenylketonuria presenting as maternal PKU syndrome in the offspring of an intellectually normal woman.
Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism resulting from a deficiency of phenylalanine hydroxylase (PAH). If untreated by dietary restriction of phenylalanine intake, impaired postnatal cognitive development results from the neurotoxic effects of excessive phenylalanine (Phe). Signs and symptoms include severe intellectual disability and behavior problems with a high frequency of seizures and variable microcephaly. Maternal PKU syndrome refers to fetal damage resulting in congenital abnormalities when the mother has untreated PKU during pregnancy. Here, we report an intellectually normal 32-year-old female who presented with recurrent pregnancy loss and two neonatal deaths with congenital heart disease, microcephaly, intrauterine growth restriction, and respiratory distress. She was diagnosed with PKU through exome sequencing performed for carrier testing with a homozygous pathogenic variant in the PAH gene, c.169_171del, p.(Glu57del) that is associated with classical PKU. Consistent with the genetic finding, she had a markedly increased plasma phenylalanine concentration of 1642 μmol/L (normal <100). This case demonstrates that recurrent pregnancy loss due to untreated maternal PKU may present as an initial finding in otherwise unsuspected classical PKU and illustrates that extreme degrees of variable expressivity may occur in classical PKU. Moreover, this case illustrates the value of genomic sequencing of women who experience recurrent pregnancy loss or neonatal anomalies.


Control of the oestrous cycle in mares with altrenogest.
The clinical effectiveness of the synthetic progestagen, altrenogest, was evaluated in field trials with 449 mares during the 1980 breeding season. An oral dose of 27 mg altrenogest was administered daily for 15 days. In the first trial treated mares were compared with controls, and in the second trial the effectiveness of treatment for prolonged or erratic spring oestrus was evaluated. Oestrus was suppressed in 94% of the treated mares in the first trial. The post-treatment response was related to the stage during the transition from winter anoestrus to the spring breeding season and degree of ovarian activity when mares were treated. In mares treated during the early transition period (before 15 March), the mean diameter of the largest follicle was about 1.4 cm. There were no differences (P greater than 0.05) in the duration of oestrus or interval to conception between treated (13.0, 41 days) and control (16.6, 39 days) mares. In mares treated after 15 March (late transition period), the mean diameter of the largest follicle was about 2.1 cm and the duration of oestrus and interval to conception was less (P less than 0.05) in treated (7.7, 28 days) than in control (12.1, 40 days) mares. The duration of oestrus and interval to conception was also less (P less than 0.05) for mares treated during the late transition period than in those treated early. More (P less than 0.05) mares treated during the late transition period (75%) exhibited regular post-treatment oestrous cycles than did controls (57%) or mares treated during the early transition period (55%). The mean interval to oestrus after treatment was 4.4 days. There were no differences in pregnancy rates among any of the groups. In the second trial, 78% of the mares had exhibited oestrus for 9-30 days before treatment. All mares returned to oestrus within 10 days after altrenogest treatment: 56% conceived within 18 days and 80% within 45 days.


Unraveling intermittent features in single-particle trajectories by a local convex hull method.
We propose a model-free method to detect change points between distinct phases in a single random trajectory of an intermittent stochastic process. The local convex hull (LCH) is constructed for each trajectory point, while its geometric properties (e.g., the diameter or the volume) are used as discriminators between phases. The efficiency of the LCH method is validated for six models of intermittent motion, including Brownian motion with different diffusivities or drifts, fractional Brownian motion with different Hurst exponents, and surface-mediated diffusion. We discuss potential applications of the method for detection of active and passive phases in the intracellular transport, temporal trapping or binding of diffusing molecules, alternating bulk and surface diffusion, run and tumble (or search) phases in the motion of bacteria and foraging animals, and instantaneous firing rates in neurons.


CD40, but not CD154, expression on B cells is necessary for optimal primary B cell responses.
CD40 is an important costimulatory molecule for B cells as well as dendritic cells, monocytes, and other APCs. The ligand for CD40, CD154, is expressed on activated T cells, NK cells, mast cells, basophils, and even activated B cells. Although both CD40(-/-) and CD154(-/-) mice have impaired ability to isotype switch, form germinal centers, make memory B cells, and produce Ab, it is not entirely clear whether these defects are intrinsic to B cells, to other APCs, or to T cells. Using bone marrow chimeric mice, we investigated whether CD40 or CD154 must be expressed on B cells for optimal B cell responses in vivo. We demonstrate that CD40 expression on B cells is required for the generation of germinal centers, isotype switching, and sustained Ab production, even when other APCs express CD40. In contrast, the expression of CD154 on B cells is not required for the generation of germinal centers, isotype switching, or sustained Ab production. In fact, B cell responses are completely normal when CD154 expression is limited exclusively to Ag-specific T cells. These results suggest that the interaction of CD154 expressed by activated CD4 T cells with CD40 expressed by B cells is the primary pathway necessary to achieve B cell activation and differentiation and that CD154 expression on B cells does not noticeably facilitate B cell activation and differentiation.


Behavioral changes following PCB 153 exposure in the spontaneously hypertensive rat - an animal model of Attention-Deficit/Hyperactivity Disorder.
Attention-Deficit/Hyperactivity Disorder (ADHD) is a behavioral disorder affecting 3-5% of children. Although ADHD is highly heritable, environmental factors like exposure during early development to various toxic substances like polychlorinated biphenyls (PCBs) may contribute to the prevalence. PCBs are a group of chemical industrial compounds with adverse effects on neurobiological and cognitive functioning, and may produce behavioral impairments that share significant similarities with ADHD. The present study examined the relation between exposure to PCB 153 and changes in ADHD-like behavior in an animal model of ADHD, the spontaneously hypertensive rats (SHR/NCrl), and in Wistar Kyoto (WKY/NHsd) controls. SHR/NCrl and WKY/NHsd, males and females, were orally given PCB 153 dissolved in corn oil at around postnatal day (PND) 8, 14, and 20 at a dosage of 1, 3 or 6 mg/kg bodyweight at each exposure. The control groups were orally administered corn oil only. The animals were behaviorally tested for exposure effects from PND 37 to 64 using an operant procedure. Exposure to PCB 153 was associated with pronounced and long-lasting behavioral changes in SHR/NCrl. Exposure effects in the SHR/NCrl depended on dose, where 1 mg/kg tended to reduce ADHD-like behaviors and produce opposite behavioral effects compared to 3 mg/kg and 6 mg/kg, especially in the females. In the WKY/NHsd controls and for the three doses tested, PCB 153 exposure produced a few specific behavioral changes only in males. The data suggest that PCB 153 exposure interacts with strain and sex, and also indicate a non-linear dose-response relation for the behaviors observed. Exposure to PCB 153 seems to interact with several variables including strain, sex, dose, and time of testing. To the extent that the present findings can be generalized to humans, exposure effects of PCB 153 on ADHD behavior depends on amount of exposure, where high doses may aggravate ADHD symptoms in genetically vulnerable individuals. In normal controls, exposure may not constitute an environmental risk factor for developing the full range of ADHD symptoms, but can produce specific behavioral changes.


Sexual Orientation-Based Differential Item Functioning in Measures of Body Image Concerns and Ideals among Men.
Body image concerns and body ideals are linked with eating disorders and psychological health. Body image and ideals among men differ by sexual orientation, which may influence the utility of common measures of such constructs. The present study used differential item functioning (DIF) analyses to examine whether item endorsement differs as a function of sexual orientation in three commonly used measures of body image concerns and ideals. Participants were sexual minority (n=209) and heterosexual (n=494) men in the United States. Scores on the Drive for Muscularity Scale (DMS), Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4), and Objectified Body Consciousness Scale (OBCS) were examined. DIF was tested in a three-step regression wherein item scores were predicted by: (1) subscale score, (2) subscale and sexual orientation, and (3) subscale, sexual orientation and their product term. Model fit and variance explain comparisons identified DIF. Δ pseudo R2 value ≥ .035 from step 1 to 3 signified clinical significant DIF. There was no evidence of clinically significant DIF for the DMS, SATAQ-4, or OBSC. Findings suggest that DMS, SATAQ-4, and OBSC perform similarly for sexual minority and heterosexual men.


Masticatory muscle thickness, bite force, and occlusal contacts in young children with unilateral posterior crossbite.
Few investigations have evaluated the characteristics of functional and structural malocclusion in young children. Thus, the aim of this study was to assess the ultrasonographic thickness of the masseter and anterior portion of the temporalis muscles, the maximum bite force, and the number of occlusal contacts in children with normal occlusion and unilateral crossbite, in the primary and early mixed dentition. Forty-nine children (26 males and 23 females) was divided into four groups: primary-normal occlusion (PNO), mean (PNO) age 58.67 months; primary-crossbite (PCB), mean age 60.50 months; mixed-normal occlusion (MNO), mean age 72.85 months; and mixed-crossbite (MCB), mean age 71.91 months. Thickness was evaluated with the muscles at rest and during maximal clenching, and comparison was made between the right and left side (normal occlusion), and between the normal and crossbite side (crossbite). The results were analysed using Pearson's correlation, paired and unpaired t-test, and Mann-Whitney ranked sum test. The anterior temporalis thickness at rest was statistically thicker for the crossbite side than the normal side in the MCB group (P = 0.0106). A statistical difference in bite force and the number of occlusal contacts was observed between the MNO and MCB groups, with greater values for the MNO subjects (P < 0.05). Masseter muscle thickness showed a positive correlation with bite force, but the anterior temporalis thickness in the PCB and MCB groups was not related to bite force. Masticatory muscle thickness and bite force did not present a significant correlation with occlusal contacts, weight, or height. It was concluded that functional and anatomical variables differ in the early mixed dentition in the presence of a malocclusion and early diagnosis and treatment planning should be considered.


Enhanced spatial discrimination learning in rats following 5,7-DHT-induced serotonergic deafferentation of the hippocampus.
Learning in rats trained in the Stone 14-unit T-maze, a complex, positively reinforced spatial discrimination task was assessed following cytotoxic (5,7-dihydroxytryptamine; 5,7-DHT) deafferentation of the serotonergic inputs to the hippocampus. Serotonergic deafferentation was accomplished by infusing the cytotoxin in to the fornix-fimbria/cingulum bundle. Lesioned rats reached criterion (i.e. learned) in significantly fewer trials and made significantly fewer errors throughout training than either vehicle-injected or sham-operated controls. This represents the first time that the effects of selective chronic destruction of serotonergic inputs to the hippocampus have been investigated. The present results provide, therefore, evidence in support of a neuromodulatory role for serotonin (5-HT) within the rat hippocampus in the mediation of the processes underlying learning and memory for this task. Other studies are, therefore, warranted in order to determine whether hippocampal 5-HT also plays a role in the mediation of the processes underlying learning and memory in other types of tasks.


Reference point insensitive molecular data analysis.
In biomedicine, every molecular measurement is relative to a reference point, like a fixed aliquot of RNA extracted from a tissue, a defined number of blood cells, or a defined volume of biofluid. Reference points are often chosen for practical reasons. For example, we might want to assess the metabolome of a diseased organ but can only measure metabolites in blood or urine. In this case, the observable data only indirectly reflects the disease state. The statistical implications of these discrepancies in reference points have not yet been discussed. Here, we show that reference point discrepancies compromise the performance of regression models like the LASSO. As an alternative, we suggest zero-sum regression for a reference point insensitive analysis. We show that zero-sum regression is superior to the LASSO in case of a poor choice of reference point both in simulations and in an application that integrates intestinal microbiome analysis with metabolomics. Moreover, we describe a novel coordinate descent based algorithm to fit zero-sum elastic nets. The R-package "zeroSum" can be downloaded at https://github.com/rehbergT/zeroSum Moreover, we provide all R-scripts and data used to produce the results of this manuscript as Supplementary Material CONTACT: firstname.lastname@example.com, email@example.com and firstname.lastname@example.com information: Supplementary material is available at Bioinformatics online.


Disordered eating in a population-based sample of young adults during the COVID-19 outbreak.
The present study aimed to describe the experience of, and factors associated with, disordered eating in a population-based sample of emerging adults during the COVID-19 outbreak. Participants in the EAT 2010-2018 (Eating and Activity over Time) study were invited to complete the C-EAT (COVID-19 EAT) survey in April-May 2020. There were 720 respondents to the survey (age: 24.7 ± 2.0 years). Psychological distress, stress, stress management, financial difficulties, and food insecurity during the COVID-19 pandemic were examined as cross-sectional correlates of disordered eating in 2020. Open-ended questions assessed the perceived impact of the pandemic on eating behaviors. Low stress management was significantly associated with a higher count of extreme unhealthy weight control behaviors (UWCBs). Food insecurity, higher depressive symptoms, and financial difficulties were significantly associated with a higher count of less extreme UWCBs. Higher stress and depressive symptoms were significantly associated with greater odds of binge eating. Six themes pertaining to disordered eating during the pandemic emerged: (a) mindless eating and snacking; (b) increased food consumption; (c) generalized decrease in appetite or dietary intake; (d) eating to cope; (e) pandemic-related reductions in dietary intake; and (f) re-emergence or marked increase in eating disorder symptoms. Psychological distress, stress management, financial difficulties, and abrupt schedule changes may have contributed to disordered eating during the COVID-19 pandemic. Interventions that target stress management, depressive symptoms, and financial strain and provide tools to develop a routine may be particularly effective for emerging adults at risk of developing disordered eating during public health crises.


Novel pathological abnormalities of deep brain structures including dysplastic neurons in anterior striatum associated with focal cortical dysplasia in epilepsy.
Some patients are not seizure free even after epileptogenic cortical resection. The authors recently described a case of frontal lobe epilepsy cured after the resection of periventricular white matter and striatum, in which dysplastic neurons were revealed. The authors attempted to confirm similar cases. They reviewed the records of 8 children with frontal lobe epilepsy who had daily (7) or monthly (1) seizures and underwent resections including deep brain structures. Five patients underwent multiple resections. Neuroimaging of the deep structures showed the transmantle sign in 3 patients, ictal hyperperfusion in 6, reduced iomazenil uptake in 2, and spike dipole clustering in 6. All patients became seizure free postoperatively. Focal cortical dysplasia of various types was diagnosed in all patients. Dysmorphic neurons were found in the cortex and subcortical white matter of 5 patients. The striatum was verified in 3 patients in whom dysmorphic neurons were scattered. In the periventricular white matter, prominent astrocytosis was evident in all cases. Pathological abnormalities such as dysmorphic neurons and astrocytosis in deep brain structures would play a key role in epileptogenesis.


Adherence to oral hypoglycemic medication among patients with diabetes in Saudi Arabia.
Diabetes mellitus is a chronic progressive disease characterized by numerous health complications. Medication adherence is an important determinant of therapeutic outcome. The objective of this study was to assess hypoglycemic medication adherence. This is a descriptive cross-sectional web-based study. The eight-item Morisky medication adherence scale was used to assess adherence. A convenience sample of 290 patients with diabetes was studied; of them, 10.7% had a high adherence, 34.5% had a medium adherence, and 54.8% had a low adherence level. Adherence score was a positively and significantly correlated with age (P < 0.05). Similar significant correlation was found between adherence level and gender (P < 0.05). However, adherence was not significantly associated with diabetes duration of disease (P > 0.05) and number of hypoglycemic medications (P >0.05). The majority of patients with diabetes in this study had low adherence rate. The three main factors may contribute to non-adherence to medication are non-adherence to regular follow-up in diabetes clinic, non-adherence to healthy diet, and non-adherence to instruction to take medication.


Progressive coding and transmission of digital diagnostic pictures.
In radiology, as a result of the increased utilization of digital imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), over a third of the images produced in a typical radiology department are currently in digital form, and this percentage is steadily increasing. Image compression provides a means for the economical storage and efficient transmission of these diagnostic pictures. The level of coding distortion that can be accepted for clinical diagnosis purposes is not yet well-defined. In this paper we introduce some constraints on the design of existing transform codes in order to achieve progressive image transmission efficiently. The design constraints allow the image quality to be asymptotically improved such that the proper clinical diagnoses are always possible. The modified transform code outperforms simple spatial-domain codes by providing higher quality of the intermediately reconstructed images. The improvement is 10 dB for a compression factor of 256:1, and it is as high as 17.5 dB for a factor of 8:1. A novel progressive quantization scheme is developed for optimal progressive transmission of transformed diagnostic images. Combined with a discrete cosine transform, the new approach delivers intermediately reconstructed images of comparable quality twice as fast as the more usual zig-zag sampled approach. The quantization procedure is suitable for hardware implementation.


Mucin deposits within inguinal hernia sacs: a presenting finding of low-grade mucinous cystic tumors of the appendix. A report of two cases and a review of the literature.
Two male patients, both 41 years of age, presented clinically with a typical inguinal hernia. The herniorrhaphy specimens were found on routine pathologic examination to contain abundant mucin that was focally organizing and was devoid of associated epithelial cells. Both cases were seen in consultation because of uncertainty as to the nature of the process. The possibility that the mucin might represent spread from an appendiceal mucinous cystic tumor led to the investigation of the appendix and in both cases such a tumor was discovered. The widespread involvement of the peritoneum that is characteristic of pseudomyxoma peritonei was absent in each case. These cases represent one of the many "surprise" findings that may be encountered in hernia sac specimens and one of the many problematic pathologic manifestations that may be associated with low-grade mucinous neoplasms of the appendix. Although this phenomenon is described in the literature, experience with our two cases indicates that it may still pose a significant diagnostic challenge.


Clinical Factors Associated With Adherence to the Premedication Protocol for Withdrawal of Mechanical Ventilation in Terminally Ill Patients: A 4-Year Experience at a Single Medical Center in Asia.
Data on end-of-life care practices in Asia are scarce. This study aimed to analyze the clinical factors associated with the recommended premedication protocol for mechanical ventilation withdrawal, in Taiwan. A total of 135 terminally ill patients who had mechanical ventilation withdrawn between 2013 and 2016 from a single medical center in Taiwan were enrolled. A premedication protocol of morphine and midazolam intravenous bolus was routinely recommended for the patients before mechanical ventilation withdrawal. Receipt of opioids and/or benzodiazepines during the withdrawal process was defined as full (both), partial (1 drug), and no (none) adherence. The clinical factors relevant to the adherence of recommended premedication protocol for mechanical ventilation withdrawal were analyzed. Overall, 126 (93.3%) patients died, 8 (5.9%) patients were transferred to other institutions for further care, and 1 (0.7%) patient was discharged to home after mechanical ventilation withdrawal. The median survival time was 45 minutes, and 102 (75.6%) patients died within 1 day after the withdrawal process. The full, partial, and no adherence rates for premedication guideline were 17.8%, 40.0%, and 42.2%, respectively. The main diagnosis of cancer, receipt of hospice care, and preservation of spontaneous respiration were independent variables associated with the partial or full adherence to the premedication protocol. Our data show that adherence to the premedication protocol for mechanical ventilation withdrawal in terminally ill patients was inadequate in Taiwan. Promoting hospice care and educating medical personnel in the compassionate withdrawal of mechanical ventilation, especially in patients with noncancer disease, are warranted.


See, seek, support: a policy framework to uplift first-generation low-income medical professionals.
The First-Generation and/or Low-Income (FGLI) identity is not readily visible, encapsulating those who are the first in their families to complete a 4-year college degree and/or those living near or below the poverty line. In the backdrop of unprecedented levels of socioeconomic inequality in a country where household income predicts educational attainment, we explore the current state of U.S. society regarding socioeconomic status and health care. We describe challenges in diversifying the health care workforce and present a multi-pronged policy approach for visibilizing, recruiting, supporting, and retaining FGLI trainees in medicine, with the promise of improving the quality of health care delivery altogether. Through this work, we aim to render the field of medicine more equitable for trainees, physicians, and patients alike.


A genetic screen for temperature-sensitive morphogenesis-defective Caenorhabditis elegans mutants.
Morphogenesis involves coordinated cell migrations and cell shape changes that generate tissues and organs, and organize the body plan. Cell adhesion and the cytoskeleton are important for executing morphogenesis, but their regulation remains poorly understood. As genes required for embryonic morphogenesis may have earlier roles in development, temperature-sensitive embryonic-lethal mutations are useful tools for investigating this process. From a collection of ∼200 such Caenorhabditis elegans mutants, we have identified 17 that have highly penetrant embryonic morphogenesis defects after upshifts from the permissive to the restrictive temperature, just prior to the cell shape changes that mediate elongation of the ovoid embryo into a vermiform larva. Using whole genome sequencing, we identified the causal mutations in seven affected genes. These include three genes that have roles in producing the extracellular matrix, which is known to affect the morphogenesis of epithelial tissues in multicellular organisms: the rib-1 and rib-2 genes encode glycosyltransferases, and the emb-9 gene encodes a collagen subunit. We also used live imaging to characterize epidermal cell shape dynamics in one mutant, or1219ts, and observed cell elongation defects during dorsal intercalation and ventral enclosure that may be responsible for the body elongation defects. These results indicate that our screen has identified factors that influence morphogenesis and provides a platform for advancing our understanding of this fundamental biological process.


Clinical, Functional, and Nutritional Efficacy of a Glutamine-Enriched Oligomeric Diet in Patients with Rectal Cancer.
This work aims to evaluate the efficacy of nutritional supplementation with a glutamine-enriched oligomeric diet (GEOD) compared to a standard polymeric diet (SPD) in terms of oncology treatment-related diarrhea (OTRD) (frequency and consistency of stools), gastrointestinal toxicity, and functional and nutritional progress. This prospective cohort study compared two groups of patients with rectal cancer in treatment with neoadjuvant chemotherapy and radiotherapy who were at risk of malnutrition. Patients were randomized to receive either 400 ml of GEOD or of SPD from the start of radiotherapy to 30 days after its completion. Eighty patients were recruited, 40 per arm. The GEOD arm had improved stool consistency and a greater reduction in the number of stools compared to the SPD arm (p < 0.001). The relative risk (RR) of developing diarrhea in the GEOD arm was 0.059 (95% CI 0.015-0.229). There was a reduced risk of developing intestinal mucositis in the GEOD arm compared to the SPD arm [RR 0.202 (95% CI 0.102 - 0.399)]. The GEOD arm had greater improvements in functional and nutritional status (p < 0.001). GEOD had a protective effect in terms of the development of gastrointestinal toxicity associated with chemotherapy and radiotherapy treatment in patients with rectal cancer.


Microgaps and Demineralization Progress around Composite Restorations.
This study investigated the influence of adhesives and marginal sealing on demineralization progress using optical coherence tomography (OCT). Cavities (4 × 2 mm) were prepared in bovine incisors and restored using Clearfil SE Protect (SP), Bond Force (BF), Scotchbond Universal (SB), or G-Bond Plus (GB), followed by Estelite Flow Quick flowable composite. The control group received no adhesive (n = 10). After 3-d incubation in artificial saliva and 10,000 thermal cycles, gaps at enamel and dentin margins were measured at 8 locations on cross-sectional images obtained from each restoration using swept-source OCT at 1310-nm wavelength. Specimens were demineralized using acidified gel (pH = 4.5) for 5 wk and scanned every week to monitor the lesion progress at the same marginal locations. Repeated-measures analysis of variance showed that demineralization period and adhesive type and their interaction had a significant effect on the lesion size in both substrates (P < 0.001). SP, BF, and SB had significantly lower enamel and dentin initial gaps than the control and GB (P < 0.05). Enamel lesion progress was slower in the fluoride-releasing adhesives SP and BF and significantly different from SB, GB, and the control (P < 0.001). SP and BF dentin lesions were significantly different from GB and the control (P < 0.001), but not from SB (P > 0.05). A significant positive correlation (P < 0.05) was found between initial gap length and formed lesion size in both substrates, which was stronger in enamel (r = 0.63) than dentin (r = 0.35). Microgaps forming at the margins of restorations depend on adhesives and significantly contribute to the progress of demineralization around the margins, while fluoride release may decrease the rate of progression.


Extraordinary antigenicity of the human Ro52 autoantigen.
Autoantibody levels to the SSA complex, composed of Ro52 and Ro60 proteins, are commonly measured in the diagnoses of Sjögren's Syndrome (SjS), as well as other rheumatological diseases. One of these proteins, Ro52, is an interferon-inducible member of the tripartite motif family bearing a RING motif functioning as an E3 ligase that ubiquitinates interferon regulatory factor 8 and other proteins. Using Luciferase Immunoprecipitation Systems (LIPS) we explored the antigenicity of Ro52 in detail. Analysis of antibody responses against Ro52 and 20 other established antigens revealed that Ro52 had the highest antibody titers and most likely represents one of the most immunogenic human proteins. While the antibody titers in many of the SjS patients were significantly and substantially higher than the controls, all healthy individuals had anti-Ro52 autoantibodies. N- and C-terminal fragments of Ro52 showed immunoreactivity in these serum samples, but the sums of these antibody titers were significantly lower than the antibody titers directed against the full-length Ro52. Antibody profiling of controls and SjS patients with three different N-terminal fragments of Ro52 revealed that the coiled-coil region was the most useful diagnostic (66% sensitivity), followed by the B-box (31% sensitivity), and then the RING-finger (24% sensitivity). The C-terminal region of Ro52, containing the B30.2 domain, showed higher antibody titers in SjS patients compared to controls and this region was responsible for the high level of Ro52 immunoreactivity in healthy individuals. Analysis of immunoreactivity to TRIM5, a Ro52-related protein, and the B30.2 domain from BTN1 and pyrin, failed to show significant antibody titers with the control or SjS patient serum. These results highlight the unusually high level of Ro52 antigenicity and demonstrate that autoantibodies are directed at both linear and conformational epitopes spanning the entire molecule.


Protein phosphatase 2A plays a critical role in interleukin-2-induced beta 2-integrin dependent homotypic adhesion in human CD4+ T cell lines.
Besides its function as a growth factor for T lymphocytes, interleukin 2 (IL-2) induces beta 2-integrin mediated adhesion, migration, and extravasation of T lymphocytes. It is, however, largely unknown how IL-2 receptors (IL-2R) are coupled to the beta 2-integrin adhesion pathway. Because IL-2 modulates enzymatic activity and/or subcellular distribution of serine/threonine phosphatases 1 and 2A (PP1/PP2A) in T cells, we examined the role of these phosphatases in IL-2 induced homotypic adhesion in antigen specific human CD4+ T cell lines. We show that calyculin A, a potent inhibitor of PP1 and PP2A, blocks PP1/PP2A activity and IL-2 induced adhesion, whereas cyclosporin A, an inhibitor of protein serine/threonine phosphatase 2B (PP2B), does not, suggesting that PP1 and/or PP2A are involved in IL-2 induced adhesion. Endothall, which preferentially inhibits PP2A, strongly inhibited cytokine induced adhesion, whereas the structurally related compound 1,4-dimethylendothall had no effect on either phosphatase activity or the adhesion response. Okadaic acid, which preferentially inhibits PP2A, almost completely blocked IL-2-induced adhesion, whereas tautomycin, a potent inhibitor of PP1, had no inhibitory effect on cytokine induced adhesion at concentrations which strongly inhibited phosphatase activity. In conclusion, these data provide evidence that PP2A plays a critical role in IL-2-induced beta 2-integrin-dependent adhesion of human T cell lines.


MDM2 SNP309 polymorphism as risk factor for susceptibility and poor prognosis in renal cell carcinoma.
MDM2 is a major negative regulator of p53, and a single nucleotide polymorphism in the MDM2 promoter region SNP309 (rs2279744) has been shown to increase the affinity of the transcriptional activator Sp1, resulting in elevated MDM2 transcription and expression in some cancers. There is currently no information about the role of MDM2 polymorphism in renal cell carcinoma (RCC). We investigated polymorphisms in p53-related genes, including MDM2, and their interactions in renal cancer. We genotyped three single nucleotide polymorphisms of three genes (p53 Arg(72)Pro, p21 Ser(31)Arg, and MDM2 SNP309) in 200 patients with renal cancer and 200 age- and gender-matched healthy subjects. Genotyping was confirmed by direct DNA sequencing. Samples that showed significant polymorphic variants were analyzed for MDM2 expression by immunohistochemistry. Association of polymorphic variants on survival of RCC patients was analyzed by Kaplan-Meier curves. A significant increase in the GG genotype of the MDM2 SNP309 was observed in RCC patients compared with healthy controls (odds ratio, 1.80; 95% confidence interval, 1.14-2.84). To investigate the effect of the MDM2 SNP309 polymorphism on MDM2 expression, immunohistochemistry was done in genotyped RCC tissues. Positive staining for MDM2 was detected in 2 of 15 (13%) TT genotype, 4 of 15 (26%) TG genotype, and 5 of 10 (50%) GG genotype carriers. The frequency of MDM2 expression in GG genotype carriers was significantly higher than that in TT genotype carriers. Polymorphisms of p53 Arg(72)Pro and p21 Ser(31)Arg did not show significant association with RCC. In univariate and multivariate analysis, MDM2 SNP309 GG genotype was independently associated with poor prognosis. Kaplan-Meier curve analysis showed that survival of patients with GG carriers was significantly worse than that of carriers with TG + TT genotypes. This is the first report to show a significant association between functional polymorphisms in MDM2 and increased risk of developing renal cancer. In addition, the MDM2 polymorphism was shown to be an independent adverse prognostic factor for RCC. Patients with MDM2 309GG genotype showed worse prognosis and low survival.


An effective therapy for both undifferentiated (including Burkitt's) lymphomas and lymphoblastic lymphomas in children and young adults.
We have used a single intensive chemotherapy regimen in the treatment of young patients with diffuse, aggressive, malignant lymphomas. There were two major histologic types of lymphoma in our series: lymphoblastic lymphomas, which presented most often with mediastinal tumor (64%), and undifferentiated lymphomas (mostly Burkitt's lymphomas), which occurred predominantly in the abdomen (86%). Our objective was to examine the determinants of prognosis in a uniformly treated patient group that included 31 children (2-16 yr) and 34 young adults 17-35 yr). Patients with extensive bone marrow involvement (greater than 50% replacement by tumor cells) were included in the study. Treatment consisted essentially of a 4-drug combination (cytoxan, adriamycin, vincristine, and prednisone) alternating with a 42-hr methotrexate infusion, followed by leukovorin rescue, and included intrathecal prophylactic therapy against central nervous system (CNS) disease. Patients with localized or resected undifferentiated lymphoma received 6 therapy cycles; all other patients received 15 cycles. Radiation therapy was used only in exceptional circumstances. Fifty-eight of 65 patients (89%) achieved complete remission: 97% of children and 82% of adults. The estimated 3-yr survival was 60% (SE 6.4%) with a median follow-up of 3 yr. Analysis of factors associated with remission duration and survival indicated that bone marrow involvement at referral and extensive disease were poor prognostic variables. Patients with lymphoblastic lymphomas and patients with completely resected undifferentiated lymphomas had the best prognosis (81% +/- 12% and 94% +/- 6% estimated 3-yr survival, respectively). Patients with extensive intraabdominal undifferentiated lymphoma (stage D) had the worst prognosis (33% +/- 11% estimated 3 yr survival), but even in this subgroup, bone marrow involvement was an adverse factor (estimated survival in stage D patients with and without bone marrow involvement was 14% +/- 13% and 43% +/- 15%, respectively). Elevated uric acid and/or lactic dehydrogenase (LDH) were also of prognostic significance, but predominantly reflected state, i.e., extent of disease. Age did not significantly influence prognosis. In the undifferentiated lymphoma subgroup, histology (i.e., Burkitt's lymphoma versus non-Burkitt's lymphoma) was not of prognostic significance. Total white count was below 1,000/cu mm in 39% of cycles, and fever associated with granulocytopenia occurred in 17% of cycles. Stomatitis of moderate to severe extent occurred in 50% of cycles.(ABSTRACT TRUNCATED AT 400 WORDS)


Mathematical analysis of the API enteric 20 profile register using a computer diagnostic model.
Results for 21 biochemical tests using the API-20 Enteric kit were obtained from the manufacturer's files for 27,820 bacterial isolates. These isolates were identified by the API Profile Register and also by a computer diagnostic model which estimates the relative likelihoods of various identifications. The computer confirmed the identification in the API Profile Register for 99.36% of the isolates. The manufacturer has reviewed areas of the API Profile Register questioned by the computer analysis; a number of resulting modifications to the API Profile Register have been incorporated in an update letter. This computer model provides a convenient and powerful way to interpret a large number of test results for bacterial identification. This study also demonstrates the use of a large collection of isolates to refine the data matrix used by the diagnostic model.


Mouse beta-galactoside alpha 2,3-sialyltransferases: comparison of in vitro substrate specificities and tissue specific expression.
Four types of beta-galactoside alpha 2,3-sialyltransferase (ST3Gal I-IV) have been cloned from several animals, but some contradictory observations regarding their substrate specificities and expression have been reported. Therefore, it is necessary to concurrently analyze the substrate specificities of the four enzymes, of which the source should be one animal. Accordingly, the acceptor substrate specificities and gene expression of mST3Gal I-IV were analyzed. Since we had already cloned ST3Gal I and II, as previously reported (Lee, Y.-C. et al., Eur. J. Biochem., 216, 377-385 (1993); J. Biol. Chem., 269, 10028-10033 (1994)), the cDNAs of ST3Gal III and IV were cloned from mouse cDNA libraries. Each of the four enzymes was expressed in COS-7 cells as a recombinant enzyme fused with protein A, and applied on an IgG-Sepharose gel to eliminate endogenous sialyltransferase activity. ST3Gal I and II showed the highest activity toward Gal beta 1, 3 GalNAc (type III), very low activity toward Gal beta 1,3GlcNAc (type I), but none toward Gal beta 1,4GlcNAc (type II). ST3Gal III and IV exhibited high activity toward the type I and II disaccharides, but very low activity toward the type III one. On the other hand, asialo-GM1 (Gg4Cer) was as good a substrate for ST3Gal I and II as the type III disaccharide, though ST3Gal III and IV hardly utilized glycolipids as substrates, as indicated by in vitro experiments. Northern blot analysis revealed that enzymes of the ST3Gal-family are expressed mainly in a tissue-specific manner. The ST3Gal I gene was strongly expressed in spleen and salivary gland, and weakly in brain, liver, heart, kidney, and thymus. The ST3Gal II gene was strongly expressed in brain, and weakly in colon, thymus, salivary gland, and testis, and developmentally expressed in liver, heart, kidney, and spleen. The ST3Gal III and IV genes were expressed in a wide variety of tissues. These differences in tissue specific expression suggest the expression of each ST3Gal influences the distribution of sialyl-glycoconjugates in vivo.


Highly purified eicosapentaenoic acid and docosahexaenoic acid in humans have similar triacylglycerol-lowering effects but divergent effects on serum fatty acids.
To compare the effects of highly purified ethyl ester concentrates of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) on serum lipids, apolipoproteins, and serum phospholipid fatty acids in humans, we conducted a double-blind, placebo-controlled, parallel design intervention study. Healthy nonsmoking men (n = 234) aged 36-56 y were randomly assigned to dietary supplementation with 3.8 g EPA/d, 3.6 g DHA/d, or 4.0 g corn oil/d (placebo) for 7 wk. Serum triacylglycerols decreased 26% (P < 0.0001) in the DHA group and 21% (P = 0.0001) in the EPA group compared with the corn oil group. Although not significant, net decreases in serum triacylglycerols were consistently greater in the DHA group across all quartiles of baseline triacylglycerol concentrations. Serum high-density-lipoprotein cholesterol increased 0.06 mmol/L (P = 0.0002) in the DHA group. In the EPA group, serum total cholesterol decreased 0.15 mmol/L (P = 0.02) and apolipoprotein A-I decreased 0.04 g/L (P = 0.0003). In the DHA group, serum phospholipid DHA increased by 69% and EPA increased by 29%, indicating retroconversion of DHA to EPA. In the EPA group, serum phospholipid EPA increased by 297% whereas DHA decreased by 15%, suggesting that EPA is not elongated to DHA in humans. The serum phospholipid ratio of n-3 to n-6 fatty acids increased in both groups, whereas the relative changes in n-6 fatty acids suggested possible alterations in liver desaturation activity in the DHA group. We conclude that both DHA and EPA decrease serum triacylglycerols, but have differential effects on lipoprotein and fatty acid metabolism in humans.


The Influence of Breast Density on Preoperative MRI Findings and Outcome in Patients with a Known Diagnosis of Breast Cancer.
The role of breast density as an indication for preoperative breast magnetic resonance imaging (MRI) for surgical planning in women with breast cancer is unknown. We retrospectively reviewed breast cancer patients diagnosed from 2007 to 2011 who underwent preoperative MRI. We obtained clinical and pathological data and grouped patients by mammographic breast density, with Breast Imaging Reporting and Data System (BI-RADS) density A and B considered low density, and C and D considered high density. We analyzed local recurrence rates by breast density. Among 683 patients, 66.6% had high breast density. We noted MRI abnormalities in the ipsilateral breast in 41.8% high-density and 30.7% low-density breasts, while contralateral abnormalities were noted in 24.9% high-density and 13.8% low-density breasts. Biopsy was recommended for MRI findings in a similar number of patients regardless of density cohort. While more abnormalities were found in high-density breasts, the rate of additional cancer found was not significantly different (ipsilateral: 32 vs. 23%; contralateral: 6.2 vs. 3.2%) for high-and low-density patients, respectively (both p > 0.15). With a median follow-up of 89 months, and similar rates of adjuvant systemic and radiation therapy, no difference in local recurrence rates existed when stratified according to density classification (p > 0.53). While more abnormalities were identified on MRI in dense breasts, there was no statistically significant difference in the number of cancers identified or in recurrence rates. These findings question the routine use of preoperative breast MRI in women with newly diagnosed breast cancer based solely on breast density.


Insights into nervous system repair from the fruit fly.
Millions of people experience injury to the central nervous system (CNS) each year, many of whom are left permanently disabled, providing a challenging hurdle for the field of regenerative medicine. Repair of damage in the CNS occurs through a concerted effort of phagocytosis of debris, cell proliferation and differentiation to produce new neurons and glia, distal axon/dendrite degeneration, proximal axon/dendrite regeneration and axon re-enwrapment. In humans, regeneration is observed within the peripheral nervous system, while in the CNS injured axons exhibit limited ability to regenerate. This has also been described for the fruit fly Drosophila. Powerful genetic tools available in Drosophila have allowed the response to CNS insults to be probed and novel regulators with mammalian orthologs identified. The conservation of many regenerative pathways, despite considerable evolutionary separation, stresses that these signals are principal regulators and may serve as potential therapeutic targets. Here, we highlight the role of Drosophila CNS injury models in providing key insight into regenerative processes by exploring the underlying pathways that control glial and neuronal activation in response to insult, and their contribution to damage repair in the CNS.


Cognitive-emotional sensitization and somatic health complaints.
Sensitization is conceptually related to cognitive bias in experimental psychopathology, and they share the basic mechanism of neuronal sensitization. Every strongly relevant individual concern, like fears, can yield cognitive bias or "cognitive-emotional sensitization". It might also be present for bodily and environmental information related to illness, and could be an etiological factor in medically unexplained complaints. Physiological and cognitive sensitization are theoretically compared. There is evidence for cognitive-emotional sensitization in some medically unexplained somatic complaints, and negative affect is suggested as a catalyst. Prolonged cognitive-emotional sensitization ("perseverative negative cognition" or worry, rumination) might even have demonstrable somatic pathological effects. It is concluded that sensitization may be organized at different levels, both in the organism and in the larger living system within which the organism is subsumed. This view might not only help to clarify medically unexplained pain syndromes, but virtually every subjective complaint, both with and without recognized physiopathology.


The Prescription Opioid Epidemic: Social Media Responses to the Residents' Perspective Article.
In June 2014, Annals of Emergency Medicine collaborated with the Academic Life in Emergency Medicine (ALiEM) blog-based Web site to host an online discussion session featuring the Annals Residents' Perspective article "The Opioid Prescription Epidemic and the Role of Emergency Medicine" by Poon and Greenwood-Ericksen. This dialogue included a live videocast with the authors and other experts, a detailed discussion on the ALiEM Web site's comment section, and real-time conversations on Twitter. Engagement was tracked through various Web analytic tools, and themes were identified by content curation. The dialogue resulted in 1,262 unique page views from 433 cities in 41 countries on the ALiEM Web site, 408,498 Twitter impressions, and 168 views of the video interview with the authors. Four major themes about prescription opioids identified included the following: physician knowledge, inconsistent medical education, balance between overprescribing and effective pain management, and approaches to solutions. Free social media technologies provide a unique opportunity to engage with a diverse community of emergency medicine and non-emergency medicine clinicians, nurses, learners, and even patients. Such technologies may allow more rapid hypothesis generation for future research and more accelerated knowledge translation.


Bi-allelic Alterations in AEBP1 Lead to Defective Collagen Assembly and Connective Tissue Structure Resulting in a Variant of Ehlers-Danlos Syndrome.
AEBP1 encodes the aortic carboxypeptidase-like protein (ACLP) that associates with collagens in the extracellular matrix (ECM) and has several roles in development, tissue repair, and fibrosis. ACLP is expressed in bone, the vasculature, and dermal tissues and is involved in fibroblast proliferation and mesenchymal stem cell differentiation into collagen-producing cells. Aebp1-/- mice have abnormal, delayed wound repair correlating with defects in fibroblast proliferation. In this study, we describe four individuals from three unrelated families that presented with a unique constellation of clinical findings including joint laxity, redundant and hyperextensible skin, poor wound healing with abnormal scarring, osteoporosis, and other features reminiscent of Ehlers-Danlos syndrome (EDS). Analysis of skin biopsies revealed decreased dermal collagen with abnormal collagen fibrils that were ragged in appearance. Exome sequencing revealed compound heterozygous variants in AEBP1 (c.1470delC [p.Asn490_Met495delins(40)] and c.1743C>A [p.Cys581∗]) in the first individual, a homozygous variant (c.1320_1326del [p.Arg440Serfs∗3]) in the second individual, and a homozygous splice site variant (c.1630+1G>A) in two siblings from the third family. We show that ACLP enhances collagen polymerization and binds to several fibrillar collagens via its discoidin domain. These studies support the conclusion that bi-allelic pathogenic variants in AEBP1 are the cause of this autosomal-recessive EDS subtype.


Receptor tyrosine kinases in the nucleus.
To date, 18 distinct receptor tyrosine kinases (RTKs) are reported to be trafficked from the cell surface to the nucleus in response to ligand binding or heterologous agonist exposure. In most cases, an intracellular domain (ICD) fragment of the receptor is generated at the cell surface and translocated to the nucleus, whereas for a few others the intact receptor is translocated to the nucleus. ICD fragments are generated by several mechanisms, including proteolysis, internal translation initiation, and messenger RNA (mRNA) splicing. The most prevalent mechanism is intramembrane cleavage by γ-secretase. In some cases, more than one mechanism has been reported for the nuclear localization of a specific RTK. The generation and use of RTK ICD fragments to directly communicate with the nucleus and influence gene expression parallels the production of ICD fragments by a number of non-RTK cell-surface molecules that also influence cell proliferation. This review will be focused on the individual RTKs and to a lesser extent on other growth-related cell-surface transmembrane proteins.


Enhancing H2O2 Tolerance and Separation Performance through the Modification of the Polyamide Layer of a Thin-Film Composite Nanofiltration Membrane by Using Graphene Oxide.
Through interfacial polymerization (IP), a polyamide (PA) layer was synthesized on the top of a commercialized polysulfone substrate to form a thin-film composite (TFC) nanofiltration membrane. Graphene oxide (GO) was dosed during the IP process to modify the NF membrane, termed TFC-GO, to enhance oxidant resistance and membrane performance. TFC-GO exhibited increased surface hydrophilicity, water permeability, salt rejection, removal efficiency of pharmaceutical and personal care products (PPCPs), and H2O2 resistance compared with TFC. When H2O2 exposure was 0-96,000 ppm-h, the surfaces of the TFC and TFC-GO membranes were damaged, and swelling was observed using scanning electron microscopy. However, the permeate flux of TFC-GO remained stable, with significantly higher NaCl, MgSO4, and PPCP rejection with increasing H2O2 exposure intensity than TFC, which exhibited a 3.5-fold flux increase with an approximate 50% decrease in salt and PPCP rejection. GO incorporated into a PA layer could react with oxidants to mitigate membrane surface damage and increase the negative charge on the membrane surface, resulting in the enhancement of the electrostatic repulsion of negatively charged PPCPs. This hypothesis was confirmed by the significant decrease in PPCP adsorption onto the surface of TFC-GO compared with TFC. Therefore, TFC-GO membranes exhibited superior water permeability, salt rejection, and PPCP rejection and satisfactory resistance to H2O2, indicating its great potential for practical applications.


Mitochondrial genome sequencing and development of genetic markers for the detection of DNA of invasive bighead and silver carp (Hypophthalmichthys nobilis and H. molitrix) in environmental water samples from the United States.
Invasive Asian bighead and silver carp (Hypophthalmichthys nobilis and H. molitrix) pose a substantial threat to North American aquatic ecosystems. Recently, environmental DNA (eDNA), genetic material shed by organisms into their environment that can be detected by non-invasive sampling strategies and genetic assays, has gained recognition as a tool for tracking the invasion front of these species toward the Great Lakes. The goal of this study was to develop new species-specific conventional PCR (cPCR) and quantitative (qPCR) markers for detection of these species in North American surface waters. We first generated complete mitochondrial genome sequences from 33 bighead and 29 silver carp individuals collected throughout their introduced range. These sequences were aligned with those from other common and closely related fish species from the Illinois River watershed to identify and design new species-specific markers for the detection of bighead and silver carp DNA in environmental water samples. We then tested these genetic markers in the laboratory for species-specificity and sensitivity. Newly developed markers performed well in field trials, did not have any false positive detections, and many markers had much higher detection rates and sensitivity compared to the markers currently used in eDNA surveillance programs. We also explored the use of multiple genetic markers to determine whether it would improve detection rates, results of which showed that using multiple highly sensitive markers should maximize detection rates in environmental samples. The new markers developed in this study greatly expand the number of species-specific genetic markers available to track the invasion front of bighead and silver carp and will improve the resolution of these assays. Additionally, the use of the qPCR markers developed in this study may reduce sample processing time and cost of eDNA monitoring for these species.


The impact of multiple sclerosis onset symptom on cardiac repolarization.
Multiple sclerosis is associated with prolonged cardiac repolarization but the underlying physiology has remained unknown. In this study, we compared cardiac repolarization during the relapsing-remitting multiple sclerosis (RRMS) disease course in patients with motor and sensory onset symptom. Twenty-five RRMS patients with motor and 33 RRMS patients with sensory onset symptom having 12-lead electrocardiogram (ECG) recorded at the time of the first demyelinating event (ECG1) as well as at the later disease course (ECG2) were identified from the patient records. The average time interval between ECG1 and ECG2 was 8.6 ± 5.9 y. Heart rate-corrected QT intervals reflecting cardiac repolarization were calculated by Bazett (QTcBaz), Fridericia (QTcFri), and Karjalainen (QTcKar) formulas. Heart rate-corrected QT intervals as well as heart rate were similar in patients with motor and sensory onset symptom in ECG1. However, QTcBaz (p = .002), QTcFri (p = .019), and QTcKar (p = .026) were longer and heart rate was higher (p = .035) in patients with motor than sensory onset symptom in ECG2. Correspondingly, QTcBaz (p = .002), QTcFri (p = .033), and QTcKar (p = .043) prolonged and heart rate tended to increase (p = .060) during the disease course only in the patients with motor onset symptom. Cardiac repolarization prolonged and heart rate increased during the disease course in RRMS patients with motor but not with sensory onset symptom. This suggests different traits in RRMS according to its initial manifestation and also association of motor onset symptom with more unfavorable cardiovascular prognostic determinants.


Aversiveness of sounds in phocid seals: psycho-physiological factors, learning processes and motivation.
Aversiveness of sounds and its underlying physiological mechanisms in mammals are poorly understood. In this study we tested the influence of psychophysical parameters, motivation and learning processes on the aversiveness of anthropogenic underwater noise in phocid seals (Halichoerus grypus and Phoca vitulina). We compared behavioural responses of seals to playbacks of sounds based on a model of sensory unpleasantness for humans, sounds from acoustic deterrent devices and sounds with assumed neutral properties in different contexts of food motivation. In a captive experiment with food presentation, seals habituated quickly to all sound types presented at normalised received levels of 146 dB re. 1 microPa (r.m.s., root mean square). However, the fast habituation of avoidance behaviour was also accompanied by a weak sensitisation process affecting dive times and place preference in the pool. Experiments in the wild testing animals without food presentation revealed differential responses of seals to different sound types. We observed avoidance behaviour at received levels of 135-144 dB re. 1 microPa (sensation levels of 59-79 dB). In this experiment, sounds maximised for 'roughness' perceived as unpleasant by humans also caused the strongest avoidance responses in seals, suggesting that sensory pleasantness may be the result of auditory processing that is not restricted to humans. Our results highlight the importance of considering the effects of acoustic parameters other than the received level as well as animal motivation and previous experience when assessing the impacts of anthropogenic noise on animals.


Occurrence, virulence genes and antibiotic resistance of enteropathogenic Escherichia coli (EPEC) from twelve bovine farms in the north-east of Ireland.
Cattle faecal samples (n = 480) were collected from a cluster of 12 farms, and PCR screened for the presence of the intimin gene (eae). Positive samples were cultured, and colonies were examined for the presence of eae and verocytotoxin (vtx) genes. Colonies which were positive for the intimin gene and negative for the verocytotoxin genes were further screened using PCR for a range of virulence factors including bfpA, espA, espB, tir ehxA, toxB, etpD, katP, saa, iha, lpfAO157/OI-141 and lpfAO157/OI-154. Of the 480 faecal samples, 5.8% (28/480) were PCR positive, and one isolate was obtained from each. All 28 isolates obtained were bfpA negative and therefore atypical EPEC (aEPEC). The serotypes detected included O2:H27, O8:H36, O15:H2, O49:H+, O84:H28, O105:H7 and O132:H34 but half of the isolates could not be serogrouped using currently available antisera. Twenty-two (79%) of the isolates carried the tir gene but only 25% were espB positive, and all other virulence genes tested for were scarce or absent. Several isolates showed intermediate resistance to ciprofloxacin, kanamycin, nalidixic acid, minocycline and tetracycline; full resistance to nalidixic acid or tetracycline with one isolate (O-:H8) displaying resistance to aminoglycosides (kanamycin and streptomycin), quinolones (nalidixic acid) and sulphonamides. This study provides further evidence that cattle are a potential source of aEPEC and add to the very limited data currently available on virulence genes and antibiotic resistance in this pathogenic E. coli group in animals.


Synthesis, structure and non-linear optical properties of new isostructural β-D-fructopyranose alkaline halide metal-organic frameworks: a theoretical and an experimental study.
In this work four metal-organic framework isomorphs, based on fructose and alkali-earth halogenides, were investigated to better understand the effect of the size of the cation and the different polarizability of the anion on the calculated hyperpolarizability and optical susceptibility, which are correlated to non-linear optical properties. The compounds were characterized by X-ray diffraction and the first hyperpolarizability and the second-order susceptibility were obtained from theoretical calculations. Furthermore, a new method to measure the second-harmonic (SH) efficiency on a small quantity of powder at different wavelengths of excitation was optimized and an attempt was made to assess the reduction of the SH intensity for small quantities of nano-crystals, in order to ascertain the possibility of applications in biological systems. The results of this work show that both the intrinsic nature of the anion and the induced dissociation of cations and anions by fructose play a role in the second-harmonic generating properties of such compounds.


Patterns of vegetative growth and gene flow in Rhizopogon vinicolor and R. vesiculosus (Boletales, Basidiomycota).
We have collected sporocarps and tuberculate ectomycorrhizae of both Rhizopogon vinicolor and Rhizopogon vesiculosus from three 50 x 100 m plots located at Mary's Peak in the Oregon Coast Range (USA); linear map distances between plots ranged from c. 1 km to c. 5.5 km. Six and seven previously developed microsatellite markers were used to map the approximate size and distribution of R. vinicolor and R. vesiculosus genets, respectively. Genetic structure within plots was analysed using spatial autocorrelation analyses. No significant clustering of similar genotypes was detected in either species when redundant samples from the same genets were culled from the data sets. In contrast, strong clustering was detected in R. vesiculosus when all samples were analysed, but not in R. vinicolor. These results demonstrate that isolation by distance does not occur in either species at the intraplot sampling scale and that clonal propagation (vegetative growth) is significantly more prevalent in R. vesiculosus than in R. vinicolor. Significant genetic differentiation was detected between some of the plots and appeared greater in the more clonal species R. vesiculosus with Phi(ST) values ranging from 0.010 to 0.078*** than in R. vinicolor with Phi(ST) values ranging from -0.002 to 0.022** (*P < 0.05, **P < 0.01, ***P < 0.001). When tested against the null hypothesis of no relationship between individuals, parentage analysis detected seven likely parent/offspring pairs in R. vinicolor and four in R. vesiculosus (alpha = 0.001). Of these 11 possible parent/offspring pairs, only two R. vinicolor pairs were still supported as parent/offspring when tested against the alternative hypothesis of being full siblings (alpha = 0.05). In the latter two cases, parent and offspring were located at approximately 45 m and 28 m from each other. Challenges to parentage analysis in ectomycorrhizal fungi are discussed.


Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors.
The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. It was found that IDUs who had formerly been exchange users were more likely than never-exchangers to report a substantial (> or= 75%) reduction in injection (ARR = 2.85, 95% confidence limit [CL] 1.47-5.51), to stop injecting altogether (ARR = 3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.


Aspergillus ibericus: a new species of section Nigri isolated from grapes.
As part of a study on the ochratoxin producing mycoflora of grapes, several Aspergillus strains were isolated and tested for their ochratoxin A (OTA) producing abilities. Aspergillus strains of the section Nigri, which did not produce detectable amounts of OTA but which had a similar morphology to A. carbonarius, were isolated from wine grapes and/or dried vine fruit in Portugal and Spain. These strains, however, have characters that allow morphological distinction from the other species in the section, particularly the conidia size (5-7 microm), which allows separation of the species from the two most common biseriate species in section Nigri: A. carbonarius (7-9 microm) and A. niger and its aggregate species (3-5 microm). The strains are described here as belonging to a new species, named A. ibericus. The validation of this new taxon is supported further by analysis of the ITS-5.8S rDNA and calmodulin gene sequences and by analysis of the amplified fragment length polymorphism (AFLP) patterns, which were consistent in separating these strains from other species in the section. A. ibericus strains do not produce OTA therefore they are interesting for biotechnological exploration because many metabolites with commercial value are produced by other species in the section.


MS2Analyzer: A software for small molecule substructure annotations from accurate tandem mass spectra.
Systematic analysis and interpretation of the large number of tandem mass spectra (MS/MS) obtained in metabolomics experiments is a bottleneck in discovery-driven research. MS/MS mass spectral libraries are small compared to all known small molecule structures and are often not freely available. MS2Analyzer was therefore developed to enable user-defined searches of thousands of spectra for mass spectral features such as neutral losses, m/z differences, and product and precursor ions from MS/MS spectra in MSP/MGF files. The software is freely available at http://fiehnlab.ucdavis.edu/projects/MS2Analyzer/ . As the reference query set, 147 literature-reported neutral losses and their corresponding substructures were collected. This set was tested for accuracy of linking neutral loss analysis to substructure annotations using 19 329 accurate mass tandem mass spectra of structurally known compounds from the NIST11 MS/MS library. Validation studies showed that 92.1 ± 6.4% of 13 typical neutral losses such as acetylations, cysteine conjugates, or glycosylations are correct annotating the associated substructures, while the absence of mass spectra features does not necessarily imply the absence of such substructures. Use of this tool has been successfully demonstrated for complex lipids in microalgae.


Re-implantation of suboptimal prostate seed implantation: technique with intraoperative treatment planning.
Post-implant dosimetry following prostate seed implantation (PSI) occasionally reveals suboptimal dosimetric coverage of the gland. Published reports of re-implantation techniques have focused on earlier-generation techniques, including preplanned approaches and stranded seeds. The purpose of this case report is to describe a customizable approach to perform corrective re-implantation using loose seeds and intraoperative planning technique. This case report describes a 63-year-old male with favorable risk prostate adenocarcinoma receiving PSI. Thirty day post-implant dosimetric evaluation revealed suboptimal coverage of the base of the gland. Using guidance from post-implant CT-images and real-time planning, the patient received a corrective re-implantation with intraoperative planning. Post-implant dosimetry after re-implantation procedure with intraoperative planning yielded improved target volume coverage that achieved standard dosimetric criteria. Re-implantation as a salvage treatment technique after sub-optimal PSI is a valid treatment option performed with intraoperative real-time planning.


From assistive to enhancing technology: should the treatment-enhancement distinction apply to future assistive and augmenting technologies?
The treatment-enhancement distinction is often used to delineate acceptable and unacceptable medical interventions. It is likely that future assistive and augmenting technologies will also soon develop to a level that they might be considered to provide users, in particular those with disabilities, with abilities that go beyond natural human limits, and become in effect an enhancing technology. In this paper, we describe how this process might take place, and discuss the moral implications of such developments. We argue that such developments are morally acceptable and indeed desirable.


Cell geometry and the cytoskeleton impact the nucleo-cytoplasmic localisation of the SMYD3 methyltransferase.
Mechanical cues from the cellular microenvironment are converted into biochemical signals controlling diverse cell behaviours, including growth and differentiation. But it is still unclear how mechanotransduction ultimately affects nuclear readouts, genome function and transcriptional programs. Key signaling pathways and transcription factors can be activated, and can relocalize to the nucleus, upon mechanosensing. Here, we tested the hypothesis that epigenetic regulators, such as methyltransferase enzymes, might also contribute to mechanotransduction. We found that the SMYD3 lysine methyltransferase is spatially redistributed dependent on cell geometry (cell shape and aspect ratio) in murine myoblasts. Specifically, elongated rectangles were less permissive than square shapes to SMYD3 nuclear accumulation, via reduced nuclear import. Notably, SMYD3 has both nuclear and cytoplasmic substrates. The distribution of SMYD3 in response to cell geometry correlated with cytoplasmic and nuclear lysine tri-methylation (Kme3) levels, but not Kme2. Moreover, drugs targeting cytoskeletal acto-myosin induced nuclear accumulation of Smyd3. We also observed that square vs rectangular geometry impacted the nuclear-cytoplasmic relocalisation of several mechano-sensitive proteins, notably YAP/TAZ proteins and the SETDB1 methyltransferase. Thus, mechanical cues from cellular geometric shapes are transduced by a combination of transcription factors and epigenetic regulators shuttling between the cell nucleus and cytoplasm. A mechanosensitive epigenetic machinery could potentially affect differentiation programs and cellular memory.


Survival and functional outcomes after hip fracture among nursing home residents.
Little is known regarding outcomes after hip fracture among long-term nursing home residents. To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture. Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009. Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture. Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P < .001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P < .001]), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P < .001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P < .001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P < .001]), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 [P < .001]). Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.


Proximal tibia medial open-wedge osteotomy using plates with wedges: early results in 58 cases.
We evaluated in this study indications, surgical technique, and results of wedge plates for fixation in proximal tibia medial opening wedge osteotomy. Fifty-eight knees in 56 consecutive patients (9 men, 47 women; mean age 52 years; ranging between 36 and 66 years) with medial compartment osteoarthrosis were treated with proximal tibia medial open-wedge osteotomy. For fixation, plates which were designed by the first author and which support the osteotomy surface with wedge-shaped projections were used. The plates were either rectangular in shape with two or four holes or had an inverse "L" shape with four holes, and had bearing metal wedges of varying heights from 5 to 15 mm. Tricortical (n=8) and bicortical (n=43) iliac bone autografts and allografts (n=7) were used. The average follow-up time was 21 months (ranging between 6 and 44 months). The mean preoperative tibiofemoral angle was 4.6 degrees varus (0 degrees -11 degrees ) while it was 5.6 degrees valgus (2 degrees -11 degrees ) postoperatively. The mean preoperative HSS score was 58 (range 51-75) and it was found 89 (range 79-96) postoperatively. As complications, lateral tibial plateau fracture in 5 knees (8.6%) and lateral cortex fracture in 15 knees (25.8%) were encountered during surgery. Deep vein thrombosis in two cases (3.4%) and nonfatal pulmonary embolism in one case (1.7%), delayed wound healing in two knees (3.4%), and delayed union as well as breakdown of a distal screw in one knee (1.7%) were encountered postoperatively. In conclusion, using wedge plates for fixation of proximal tibia medial opening wedge osteotomy in the treatment of medial osteoarthritis with unicompartmental involvement of the knee, provides adequate stabilization to allow early movement for functional rehabilitation and keeps the obtained correction level.


The nucleotide sequences of 5S rRNAs from a multicellular green alga, Ulva pertusa, and two brown algae, Eisenia bicyclis and Sargassum fulvellum.
The nucleotide sequences of 5S rRNA from a multicellular green alga Ulva pertusa, and multicellular brown algae Eisenia bicyclis and Sargassum fulvellum, have been determined. The 5S rRNA from Ulva is composed of 120 nucleotides, and those from Eisenia and Sargassum have 118 nucleotides. The nucleotide sequence of Ulva 5S rRNA is rather similar to 5S rRNAs from unicellular green algae and higher plants, while those of Eisenia and Sargassum 5S rRNAs are unique.


Expression of leukotriene C4 synthase mRNA by the choroid plexus in mouse brain suggests novel neurohormone functions of cysteinyl leukotrienes.
Leukotriene C(4) is a potent mediator of allergic and inflammatory reactions, and is formed from arachidonic acid and glutathione through the sequential action of 5-lipoxygenase and leukotriene C(4) synthase (LTCS). These enzymes are predominantly expressed in cells of myeloid lineage. In this report, we have investigated LTCS mRNA expression in mouse brain. Expression was demonstrated using RT-PCR and RNase protection assays. In situ hybridization experiments showed exclusive staining of the choroid plexus of all brain ventricles. This expression pattern may provide a mechanism for the generation of LTC(4) on the cerebral side of the blood-brain barrier and suggests a possible novel regulator function of LTC(4) in the formation of cerebrospinal fluid.


Peptide and carbohydrate complexes of nickel in human kidney.
The predominant renal and urinary forms of nickel consist of low-Mr complexes. Similarities in the nature of these complexes have been found in kidneys of rats exposed parenterally to NiCl2 and in rat kidneys treated with NiCl2 in vitro. Similar complexes have also been identified after treatment of bovine and human renal soluble fractions with NiCl2. The bulk of nickel in all cases is associated with sulphated oligosaccharide fractions containing uronic acids and neutral sugars. This binding is non-specific, and nickel is readily displaced from these fractions by copper. Smaller amounts of nickel are bound to an acidic peptide, which was purified from human kidneys and partially characterized. Nickel was not displaced from this material by copper at physiological pH. These nickel complexes have not been found in plasma, suggesting that ligand exchange occurs during or after glomerular filtration of the metal.


[Approach to aortic aortic valve diseases in the elderly].
Aortic valve diseases are the most common among the valvular heart diseases. Significant increases in the frequency of degenerative aortic sclerosis and aortic stenosis (AS) are observed, particularly with aging of the population and diminished rheumatic heart disease. Aortic regurgitation (AR) is less common in the elderly and is accompanied by AS rather than pure AR. Considering the comorbid diseases, fragility and cognitive functions in elderly patients, special approach is needed during diagnosis, evaluation, treatment and follow-up. We will also touch on the issues that should be considered in aortic valve diseases in the elderly, including more aortic stenosis in this article.


Endoscopic-Assisted Removal of a Rare Mucocele Complicating From Alloplastic Medial Orbital Fracture Reconstruction.
Orbital wall fracture reconstruction is usually recommended to prevent subsequent functional and esthetic complications. Mucocele development following such injuries or its management is recognized but rare sequelae. When they occur, they represent a diagnostic and management dilemma. The authors described a patient with orbital and ethmoidal mucocele. A 62-year-old female patient presented with progressive left exophthalmos 1 year following titanium mesh reconstruction of a medial orbital wall fracture. Computed tomography and magnetic resonance imaging demonstrated an encysted lesion encasing the mesh plate in the left orbit and extending into the ethmoidal sinus. The patient is treated surgically through endoscopic-assisted approach with complete removal of the lesion and lacrimal duct stenting. The patient improved immediately after surgery.


Antimicrobial Resistance in Pneumococcal Carriage Isolates from Children under 2 Years of Age in Rural Pakistan.
Antimicrobial resistance is an emerging public health concern. Ten-valent pneumococcal vaccine (PCV10) was introduced in Pakistan's Expanded Program on Immunization (EPI) in 2012 as a 3 + 0 schedule without catchup. From 2014 to 2018, children <2 years were randomly selected in two rural union councils of Matiari, Pakistan. Nasopharyngeal swabs were collected using standard WHO guidelines by trained staff and processed at Infectious Disease Research Laboratory at The Aga Khan University, Karachi using culture on sheep blood agar and Multiplex PCR methods described by CDC, USA. Pneumococcal isolates were identified by optochin sensitivity and bile solubility tests. Isolates were then tested for antimicrobial susceptibility by standard Kirby-Bauer disk-diffusion method on Mueller-Hinton Agar (MHA) with 5% sheep blood agar as per Clinical & Laboratory Standards Institute (CLSI) recommendations. Of 3140 children enrolled, pneumococcal isolates were detected in 2370 (75%). Vaccine coverage improved from 41% to 68.4%. Out of the 2370 isolates, 88.4%, 37.6% and 25% were resistant to cotrimoxazole, tetracycline and erythromycin, respectively. There was no resistance to penicillin, ceftriaxone, and vancomycin. For erythromycin, resistance increased from 20% in 2014/15 to 30.8% in 2017/18 and for tetracycline it increased from 34.9% to 41.8% both of which were explained by an increase in prevalence of serotype 19A. Pneumococcal isolates were susceptible to penicillin, ceftriaxone, and vancomycin. They were largely resistant to cotrimoxazole and tetracycline. There was an increase in erythromycin and tetracycline resistance attributed to increasing prevalence of serotype 19A. Pneumococcal isolates from carriage and invasive disease should be closely monitored for antimicrobial susceptibility. IMPORTANCE Antimicrobial resistance is an emerging public health concern particularly in low- and middle-income countries where there is poor regulation and easy availability of antibiotics. This is the first study from Pakistan to report antimicrobial resistance patterns of pneumococcus after vaccine introduction in the community. Pakistan was the first South-Asian country to introduce PCV10 in its Expanded Program on Immunization (EPI) in 2012 as a 3 + 0 schedule without catchup. In this study, we describe the PCV10 impact on antimicrobial resistance patterns of pneumococcal nasopharyngeal carriage in children younger than 2 years of age in a rural district in Pakistan after the introduction of the vaccine.


Total Single-Stage Autologous Breast Reconstruction with Free Nipple Grafts.
Outstanding results are difficult to achieve in postmastectomy reconstructions in obese ptotic patients. We describe an autologous single-stage reconstruction with free nipple grafts that is best suited for these difficult patients. This technique allows for delayed volume supplementation with implants or fat grafting but does not commit the patient to additional surgery. It avoids the common complications of immediate implant-based reconstructions. This technique is also an excellent option in patients with a known requirement for radiotherapy as it does not sacrifice a valuable autologous flap nor does it subject the patient to capsular contracture, infection, and extrusion. It also obviates the psychological trauma that many women suffer awaiting a reconstruction after radiotherapy. We believe it should be considered as a first-line reconstructive option.


The ner gene of Photorhabdus: effects on primary-form-specific phenotypes and outer membrane protein composition.
The nematode-bacterium complex of Heterorhabditis-Photorhabdus is pathogenic to insect larvae. The bacteria undergo a form of phenotypic switching whereby the primary form, at the stationary phase of the growth cycle, makes a range of products and has the capacity to support nematode growth, whereas the secondary form does not express these phenotypes. The work described here investigated the mechanism regulating phenotypic variation by transforming the primary cells with secondary-form DNA on a low-copy-number vector and screening for colonies which did not produce the yellow pigment characteristic of primaries. Four transformants all carrying the same gene were found to loose primary-form-specific characteristics, and the gene was sequenced and identified as ner, a regulatory gene in gram-negative bacteria and their phages. Unexpectedly, inactivation of the endogenous gene in the secondaries did not cause them to revert to the primary phenotype, and the gene was expressed in the primary form as well as the secondary form during exponential but not stationary phase and deregulated in the plasmid-bearing primary form. These and other pieces of evidence indicate that the endogenous ner gene is not responsible for the secondary phenotype, but that ner, when overexpressed, can repress expression of primary phenotypes at stationary phase. Inactivation of the endogenous ner gene in the primary form affected the outer membrane protein profile. A number of outer membrane proteins displayed differential accumulation in the primary and secondary forms at stationary phase, and two of the primary-form-specific proteins were absent from the ner primary strain.


The role of a combined regimen with intravesical chemotherapy and hyperthermia in the management of non-muscle-invasive bladder cancer: a systematic review.
Due to the suboptimal clinical outcomes of current therapies for non-muscle-invasive bladder cancer (NMIBC), the search for better therapeutic options continues. One option is chemohyperthermia (C-HT): microwave-induced hyperthermia (HT) with intravesical chemotherapy, typically mitomycin C (MMC). During the last 15 yr, the combined regimen has been tested in different clinical settings. To perform a systematic review to evaluate the efficacy of C-HT as a treatment for NMIBC. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An electronic search of the Medline, Embase, Cochrane Library, CancerLit, and ClinicalTrials.gov databases was undertaken. Relevant conference abstracts and urology journals were also searched manually. Two reviewers independently reviewed candidate studies for eligibility and abstracted data from studies that met inclusion criteria. The primary end point was time to recurrence. Secondary end points included time to progression, bladder preservation rate, and adverse event (AE) rate. A total of 22 studies met inclusion criteria and underwent data extraction. When possible, data were combined using random effects meta-analytic techniques. Recurrence was seen 59% less after C-HT than after MMC alone. Due to short follow-up, no conclusions can be drawn about time to recurrence and progression. The overall bladder preservation rate after C-HT was 87.6%. This rate appeared higher than after MMC alone, but valid comparison studies were lacking. AEs were higher with C-HT than with MMC alone, but this difference was not statistically significant. Published data suggest a 59% relative reduction in NMIBC recurrence when C-HT is compared with MMC alone. C-HT also appears to improve bladder preservation rate. However, due to a limited number of randomized trials and to heterogeneity in study design, definitive conclusions cannot be drawn. In the future, C-HT may become standard therapy for high-risk patients with recurrent tumors, for patients who are unsuitable for radical cystectomy, and in cases for which bacillus Calmette-Guérin treatment is contraindicated.


Marjolin's Ulcer in Laron Syndrome - an Unexpected Combination: A Case Report.
Marjolin's ulcer is an atypical malignancy that develops from deep scars of chronically traumatised skin. Laron syndrome (LS) is a rare autosomal recessive growth retardation from a mutation in the growth hormone receptor (GHR) gene leading to defective GHR, growth hormone insensitivity and eventual low levels of insulin-like growth factor type 1 (IGF-1). Affected individuals present with proportionate dwarfism and other characteristic physical defects, but at the same time are conferred protection against cancer due to low serum levels of IGF-1. We report an exceptional case of Marjolin's ulcer in the foot of a female LS patient 30 years after she sustained flame burns as a 6-month-old baby. Three months before coming to us, she had a 2x3cm ulcer that turned into a rapidly enlarging fungating mass involving the leg, ankle, and foot. Histopathologic analysis of an incision biopsy showed well-differentiated squamous cell carcinoma. The extent of her lesion precluded wide excision. Below knee amputation was done. A second biopsy confirmed the histopathologic diagnosis. This is the first reported case in the literature of Marjolin's ulcer in LS which raises the possibility that IGF-1 deficiency does not completely protect against squamous cell cancer.


Growth hormone binding protein, insulin-like growth factor-I and short stature in two pygmy populations from the Philippines.
The molecular basis and biochemical mediators of genetic growth propensity and adult height achievement in the general population are largely unknown. Pygmies represent one extreme of the height spectrum that may provide important clues regarding this issue. Previous studies in pygmies from Africa and Papua-New Guinea have shown decreased serum levels of growth hormone binding protein (GHBP), the circulating ectodomain of the growth hormone receptor (GHR). By inference, a similar limitation in tissue GHR expression has been assumed to be responsible for the partial growth hormone (GH) resistance observed in African pygmies. It is not clear how generalizable this concept is to other populations. To address this question, we studied two pygmy populations from the Philippines (Aeta and Mamanwa people) that are unrelated to the African pygmies. Serum GHBP and IGF-I levels were significantly decreased in both pygmy populations, compared to normal-statured Philippino controls. The results, together with previous observations in African and New Guinean pygmies, indicate that short stature is associated with low serum GHBP levels in pygmy populations of diverse origins and in different parts of the world. This strengthens the tentative postulate that the GHBP/GHR system plays an important role in the genetic and perhaps nutritional determination of adult stature in humans. Molecular genetic studies of the GHR gene in various pygmy populations may shed further light on the mystery of pygmy short stature.


Effect of pH on the denitrification proteome of the soil bacterium Paracoccus denitrificans PD1222.
Denitrification is a respiratory process by which nitrate is reduced to dinitrogen. Incomplete denitrification results in the emission of the greenhouse gas nitrous oxide and this is potentiated in acidic soils, which display reduced denitrification rates and high N2O/N2 ratios compared to alkaline soils. In this work, impact of pH on the proteome of the soil denitrifying bacterium Paracoccus denitrificans PD1222 was analysed with nitrate as sole energy and nitrogen source under anaerobic conditions at pH ranging from 6.5 to 7.5. Quantitative proteomic analysis revealed that the highest difference in protein representation was observed when the proteome at pH 6.5 was compared to the reference proteome at pH 7.2. However, this difference in the extracellular pH was not enough to produce modification of intracellular pH, which was maintained at 6.5 ± 0.1. The biosynthetic pathways of several cofactors relevant for denitrification and nitrogen assimilation like cobalamin, riboflavin, molybdopterin and nicotinamide were negatively affected at pH 6.5. In addition, peptide representation of reductases involved in nitrate assimilation and denitrification were reduced at pH 6.5. Data highlight the strong negative impact of pH on NosZ synthesis and intracellular copper content, thus impairing active NosZ assembly and, in turn, leading to elevated nitrous oxide emissions.