Feasibility of ω-3 fatty acid supplementation as an adjunct therapy for people with chronic obstructive pulmonary disease: study protocol for a randomized controlled trial.
There is evidence to support the use of supplementation with long-chain omega-3 polyunsaturated fatty acids (LCn-3PUFA) from oily fish or fish oil for the treatment of various inflammatory diseases such as rheumatoid arthritis. Chronic obstructive pulmonary disease (COPD) is a progressive, terminal disease characterized by persistent airflow limitation, lung and systemic inflammation. To date, one randomized controlled trial has been published that assessed the efficacy of LCn-3PUFA in people with this condition. The aim of this article is to discuss the feasibility of conducting a trial to evaluate fish oil supplementation as adjunct therapy in people with COPD. A 16-week parallel, double-blind, randomized, placebo-controlled dietary supplementation trial will be evaluated. Forty participants meeting spirometric and clinical criteria for COPD will be recruited from metropolitan Adelaide, South Australia. Participants will be randomized by minimization, based on a score derived from the modified Medical Research Council Scale for breathlessness, to receive 6 g/day of fish oil (approximately 3.6 g/day of LCn-3PUFA), or placebo (6 g/day of corn oil) capsules. Feasibility outcomes (recruitment, retention, supplement adherence, and time lost to exacerbation) and scientific outcomes (effect size and estimates of variance for inflammatory biomarkers, incorporation of LCn-3PUFA into erythrocytes, small airways function, dyspnea and functional exercise capacity) will be assessed pre- and post-intervention. Key feasibility criteria include recruitment of 40 participants in 52 weeks, 75% participant retention rate, 2% increase in the proportion of long-chain omega-3 fatty acids in erythrocytes, and a positive moderate effect size in at least three efficacy measures. There are a number of challenges in designing supplementation intervention studies with this population. These include the lack of prior data from which to select appropriate primary outcomes or to estimate effect sizes, and the feasibility of continuous supplementation in a population characterized by multiple comorbidities and a high likelihood of exacerbations, potentially requiring hospitalization or change in medication. Upon completion of this protocol, feasibility outcomes will guide the direction of future multicentre dietary interventions in this population. Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000158864.


Hospital and emergency department use by young low-income children.
Limited data are available concerning determinants of health care service usage by low-income young children. To explore predictors of hospitalization and emergency department (ED) use by young children of low-income families by using the Aday and Andersen Access Framework. Low-income women (n = 474) with a child younger than 6 years completed a structured face-to-face interview at human service offices or Women, Infants, and Children (WIC) clinics in four central Ohio counties. Women were considered low-income if they or their child were Medicaid eligible or uninsured. Data were collected for both the mother and the index child on sociodemographic status, health services use, health status, and access to care. Fifteen percent of the children had been hospitalized the previous year, and half had an ED visit. Hospitalization was significantly related to maternal hospitalization the previous year (OR = 2.5), child age younger than 1 year old (OR = 2.1) and more than two chronic conditions (OR = 2.2). Maternal ED usage in the last year (OR = 2.2), Medicaid fee for service plan (OR = 1.7), and rural residence (OR = 2.0) were predictive of ED use. Predisposing characteristics (maternal hospital/ED use) were predictive of both hospitalization and ED use by the index child. Enabling characteristics (fee-for-service Medicaid plan, rurality) were only predictive of ED use, and need characteristics (child's health) were only predictive of hospitalization. Further research to explore linkages between maternal and child use of health care services as well as the effect of changes in health care access, managed care, and other innovations on hospitalization and ED use in young, low-income children is recommended.


COVID-19 and democratic resilience.
The COVID-19 experience has sharpened debates about democracy's future worldwide. In reflecting on these debates, this paper does three things. First, it assesses how resilient democracy has been in the COVID-19 emergency. Second, it examines the effect the pandemic has had on the pre-existing trends in democratic politics. And third, it suggests ways in which the COVID-19 crisis both requires and possibly opens the door to democratic rejuvenation.


Phenethyl isothiocyanate-induced apoptosis in p53-deficient PC-3 human prostate cancer cell line is mediated by extracellular signal-regulated kinases.
Previous studies have suggested that p53 is required for apoptosis induction by phenethyl isothiocyanate (PEITC), which is a highly promising cancer chemopreventive agent. Here, we report that p53 is not required for PEITC-induced apoptosis in the PC-3 human prostate cancer cell line and that the PEITC-induced apoptosis is mediated by extracellular signal-regulated kinases (ERK1/2). Exposure of PC-3 cells to an apoptosis-inducing concentration of PEITC (10 microM) resulted in a rapid and sustained activation of ERK1/2 that was evident as early as 1 h after PEITC treatment and persisted for the duration of the experiment (24-h after PEITC exposure). The PEITC-mediated activation of ERK1/2 was associated with an increase in phosphorylation of its substrate Elk-1 at Ser383. The PEITC-induced activation of ERK1/2 as well as apoptosis was abolished in the presence of mitogen-activated protein/ERK kinase 1 (a kinase upstream of ERK1/2) inhibitor PD98059. Exposure of PC-3 cells to 10 microM PEITC also resulted in a time-dependent activation of p38 protein kinase that was associated with increased phosphorylation of activating transcription factor 2 at Thr71. Even though the PEITC-induced activation of p38 protein kinase was abrogated in the presence of its specific inhibitor SB202190, inhibition of p38 protein kinase activation did not prevent PEITC-induced apoptosis. In contrast to previous reports in other cellular systems, c-Jun NH(2)-terminal kinases were not activated by PEITC treatment in PC-3 human prostate carcinoma cell line. In conclusion, the results of the present study indicate that p53 is not essential for PEITC-induced apoptosis and that the PEITC-induced apoptosis in PC-3 human prostate carcinoma cell line is mediated by ERKs. Thus, it seems reasonable to postulate that PEITC may be effective against tumors with normal as well as mutant p53.


The association between body weight indices, behavioral factors, and type 2 diabetes mellitus in Africa: A systematic review and meta-analysis of population-based epidemiological studies.
Type 2 diabetes mellitus (T2DM) is a significant public health concern in Africa. While the associations between modifiable risk factors and T2DM are likely to be Africa-specific, their overall estimations have not been published. This study aimed to use systematic and meta-analytic methods to examine the strength of associations between modifiable risk factors and T2DM in Africa. A systematic search of literature published between January 2000 to March 2022 was conducted. The review included only population-based studies and data extracted from 57 studies. Of these, unadjusted data from 50 studies were included in meta-analysis. With considerable heterogeneity between studies, random-effect models were calculated to ascertain the odds ratios (OR) and 95% confidence intervals (CI) for the associations between obesity (OB) and overweight (OV), defined by BMI; central obesity (waist circumference (OB-WC), waist-to-hip-ratio (OB-WHR)), alcohol, fruit and vegetable consumption, smoking, physical activity (PA) and T2DM. Moderator effects of age, African regions, and urban/rural location were assessed. Risk factors associated with T2DM include BMI-OB [OR = 3.05, 95% CI: (2.58, 3.61)], BMI-OV [OR = 2.38, 95% CI: (1.51, 3.75)], and BMI-OV/OB [OR = 2.07, 95% CI: (1.82, 2.34)]; OB-WC [OR = 2.58, 95% CI: (2.09, 3.18)] and OB-WHR [OR = 2.22, 95% CI: (1.69, 2.92)]; PA [OR = 1.85, 95% CI: (1.50, 2.30)]. Significant moderator effects were not observed. Obesity defined by BMI and central obesity, but not behavioral risk factors were most strongly associated with T2DM in African populations, emphasizing the need for obesity prevention to limit the rise of T2DM. The PROSPERO registration number is CRD42016043027.


Rapid and Efficient One-Step Metabolic Pathway Integration in E. coli.
Methods for importing heterologous genes into genetically tractable hosts are among the most desired tools of synthetic biology. Easy plug-and-play construction methods to rapidly test genes and pathways stably in the host genome would expedite synthetic biology and metabolic engineering applications. Here, we describe a CRISPR-based strategy that allows highly efficient, single step integration of large pathways in Escherichia coli. This strategy allows high efficiency integration in a broad range of homology arm sizes and genomic positions, with efficiencies ranging from 70 to 100% in 7 distinct loci. To demonstrate the large size capability, we integrated a 10 kb construct to implement isobutanol production in a single day. The ability to efficiently integrate entire metabolic pathways in a rapid and markerless manner will facilitate testing and engineering of novel pathways using the E. coli genome as a stable testing platform.


Case Report: Use of Prosthetic Replacement of the Ocular Surface Ecosystem Treatment of Traumatic Lid Ptosis in a Pediatric Patient.
This report shares the long-term outcomes of an uncommon use of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment and scleral lenses in the treatment for patients with ptosis who are not surgical candidates. This study aimed to describe a case of pediatric traumatic lid ptosis and follow-up during an 8-year period with PROSE treatment. A 7-year-old Honduran girl presented with a history of severe cranial, facial, and ocular trauma as a result of a motor vehicle accident. Significant ptosis with left-sided facial paralysis and irregular astigmatism significantly reduced the patient's visual function in the left eye. She was evaluated and treated with a scleral prosthetic device in the left eye to improve vision, the ocular surface, and overall function for activities of daily living. After 8 years of PROSE treatment, acuity in the left eye remained stable at 20/25. The corneal health remained stable throughout this period, without complications of corneal neovascularization or corneal edema. Prosthetic replacement of the ocular surface ecosystem treatment provided support of the ocular surface and mechanical left upper eyelid lift in a traumatic eyelid ptosis, ultimately providing improved visual function during an extensive 8-year period in a pediatric patient. Further studies are needed to evaluate the applicability of this approach in broader ptosis cases.


A Bilayer Vaginal Tablet for the Localized Delivery of Disulfiram and 5-Fluorouracil to the Cervix.
This study was performed to develop an adjuvant therapy in the form of a self-administered vaginal tablet regimen for the localized delivery of chemotherapeutic drugs. This therapy will help to reduce relapse by eradicating cancerous cells in the margin of cervical tumors. The vaginal tablet is a very common formulation that is easy to manufacture, easy to place in the vagina, and has a low cost of manufacture, making them ideal for use in developing countries. A combination of disulfiram and 5-fluorouracil, which are both off-patent drugs and provide different modes of action, were evaluated. The tablets developed were evaluated for weight variation, thickness, hardness, friability, swelling index, differential scanning calorimetry (DSC), particle morphology, in vitro drug release, and cytotoxicity on Ca-Ski cells. Both layers were designed to release both drugs concurrently for a synergistic effect. The polymer-polymer interaction between the layers was able to reduce the loss of formulation due to chitosan. While the bilayer tablet had satisfactory performance in the physicochemical tests, in vitro cell culture with Ca-Ski also showed a synergistic effect using a combination of drugs at a low dose. However, the formulation only had 24-h dose release before degradation. Further drug combinations should be evaluated in subsequent studies.


High-Performance Vertical Light-Emitting Transistors Based on ZnO Transistor/Quantum-Dot Light-Emitting Diode Integration and Electron Injection Layer Modification.
Vertical light-emitting transistors (VLETs) consisting of vertically stacked unipolar transistors and organic light-emitting diodes (OLEDs) have been proposed as a prospective building block for display technologies. In addition to OLEDs, quantum-dot (QD) LEDs (QLEDs) with high brightness and high color purity have also become attractive light-emitting devices for display applications. However, few studies have attempted to integrate QLEDs into VLETs, as this not only involves technical issues such as compatible solution process of QDs and fine patterning of electrodes in multilayer stacked geometries but also requires a high driving current that is demanding on transistor design. Here we show that these integration issues of QLEDs can be addressed by using inorganic transistors with robust processability and high mobility, such as the studied ZnO transistor, which facilitates simple fabrication of QD VLETs (QVLETs) with efficient emission in the patterned channel area, suitable for high-resolution display applications. We perform a detailed optimization of QVLET by modifying ZnO:polyethylenimine nanocomposite as the electron injection layer (EIL) between the integrated ZnO transistor/QLED, and achieve the highest external quantum efficiency of ~3% and uniform emission in the patterned transistor channel. Furthermore, combined with a systematic study of corresponding QLEDs, electron-only diodes, and electroluminescence images, we provide a deeper understanding of the effect of EIL modification on current balance and distribution, and thus on QVLET performance.


Increased incidence of gastrointestinal surgical complications in renal transplant recipients with polycystic kidney disease.
We had the impression that, although our renal transplant recipients with polycystic kidney disease (PKD) had excellent long-term renal graft function, they had an increased incidence of postoperative gastrointestinal (GI) complications. Over a 10-year period (1987 through 1996), 1467 renal transplants were performed in 1417 patients; 145 of these transplants involved PKD recipients. In the PKD group, 18 patients (12.4%) developed a posttransplant complication necessitating GI surgery (PKD-GI), an incidence twice that in the non-PKD recipients (73 patients or 6.2%, non-PKD-GI). PKD and non-PKD recipients displayed no significant difference in mortality. The PKD patients had better long-term renal graft survival than the non-PKD patients (P=0.08). There was no difference in mortality (P>0.6) or renal graft survival (P>0.6) between the PKD-GI and PKD-non-GI groups. The PKD-GI group had no increased mortality over the non-PKD-GI patients (P>0.6), despite a higher incidence of GI surgical complications in the PKD group versus the non-PKD group (overall: 12.4 vs. 6.2%, P<0.01; within 90 days of transplant: 7.6 vs. 3.3%, P<0.02) and a greater propensity for small and large bowel complications (overall: 9.0 vs. 2.6%; P< 0.001; less than 90 days: 6.9 vs. 2.0%, P<0.002). The PKD-GI recipients tended toward less long-term graft loss than their non-PKD-GI counterparts (11.1 vs. 27.4%; P=.22). The PKD-GI recipients suffered no acute rejection episodes within 90 days after their GI operation versus 11 of 73 non-PKD-GI recipients (O vs. 15.1%; P=0.075). PKD recipients of renal grafts should be watched closely early after transplant because of their increased risk of GI complications. These complications resulted in no increase in mortality or graft loss compared to non-PKD recipients with GI complications despite the PKD group's higher incidence of bowel perforation and increased age at time of transplant.


Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA. This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors. Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity. Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement.


Does binding of ouabain to human alpha1-subunit of Na+, K+-ATPase affect the ATPase activity of adjacent rat alpha1-subunit?
To ascertain whether ouabain binding to human alpha1-subunit influences coexpression of rat alpha1-subunit, the ouabain-sensitive profiles of Na+,K+-ATPase activity and 86Rb+ uptake activity and ouabain binding capacity were measured in HeLa cells stably expressing rat alpha1-subunit. The ouabain-sensitive profile of ATPase and 86Rb+ uptake activity seemed to be the sum of two components, one with high and one with low apparent affinity to ouabain, which were similar to that observed in HeLa and NRK-52E cells derived from human and rat, respectively. The ATPase activity with low sensitivity to ouabain increased in simple proportion to the amount of the rat alpha1 mRNA derived from transfected cDNA, which was determined by the reverse transcription-polymerase chain reaction method. The turnover number of the human Na+,K+-ATPase activity obtained from the ratio of the Na+,K+-ATPase activity to the ouabain binding capacity is about 150/sec. The expression of the rat alpha1-subunit had no effect on the turnover numbers of the Na+,K+-ATPase activity with high affinity to ouabain estimated from the ouabain binding capacity as the active site concentration. These results suggested that the ouabain bound to human alpha1-subunit did not inhibit the ATPase activity of the coexpressing rat alpha1 in these cells.


The fruitfulness of a nomothetic approach to investigating AAC: comparing two speech encoding schemes across cerebral palsied and nondisabled children.
The observation that typical users of augmentative and alternative communication (AAC) systems vary widely in their characteristics raises issues about the utility of a nomothetic approach for investigating and evaluating important variables, as well as about the value of studying children without disabilities to contribute to the understanding of AAC systems. To provide an initial basis for examining the fruitfulness of the nomothetic approach, the effects of 2 fundamental variables, number of display levels (single vs. dual) and vocabulary abstractness (concrete vs. abstract words), on vocabulary acquisition were examined for children without disabilities and for speech impaired children with cerebral palsy (CP). Children demonstrated the same pattern of acquisition, regardless of disability status. Both groups of children made more errors on the dual-level display than on the single-level display and made more abstract errors than concrete errors. Importantly, the performance of individuals consistently conformed to group performance. These findings suggest that a nomothetic research approach that includes results of children without disabilities can usefully illuminate consequences of important variables in AAC systems. Clinical implications based on these findings were also discussed.


mRNA decapping in yeast requires dissociation of the cap binding protein, eukaryotic translation initiation factor 4E.
A major pathway of eukaryotic mRNA turnover occurs by deadenylation-dependent decapping that exposes the transcript to 5'-->3' exonucleolytic degradation. A critical step in this pathway is decapping, since removal of the cap structure permits 5'-->3' exonucleolytic digestion. Based on alterations in mRNA decay rate from strains deficient in translation initiation, it has been proposed that the decapping rate is modulated by a competition between the cytoplasmic cap binding complex, which promotes translation initiation, and the decapping enzyme, Dcp1p. In order to test this model directly, we examined the functional interaction of Dcp1p and the cap binding protein, eukaryotic translation initiation factor 4E (eIF4E), in vitro. These experiments indicated that eIF4E is an inhibitor of Dcp1p in vitro due to its ability to bind the 5' cap structure. In addition, we demonstrate that in vivo a temperature-sensitive allele of eIF4E (cdc33-42) suppressed the decapping defect of a partial loss-of-function allele of DCP1. These results argue that dissociation of eIF4E from the cap structure is required before decapping. Interestingly, the temperature-sensitive allele of eIF4E does not suppress the decapping defect seen in strains lacking the decapping activators, Lsm1p and Pat1p. This indicates that these activators of decapping affect a step in mRNA turnover distinct from the competition between Dcp1 and eIF4E.


Patient considerations in the treatment of COPD: focus on the new combination inhaler umeclidinium/vilanterol.
Medication adherence among patients with chronic diseases, such as COPD, may be suboptimal, and many factors contribute to this poor adherence. One major factor is the frequency of medication dosing. Once-daily dosing has been shown to be an important variable in medication adherence in chronic diseases, such as COPD. New inhalers that only require once-daily dosing are becoming more widely available. Combination once-daily inhalers that combine any two of the following three agents are now available: 1) a long-acting muscarinic antagonist; 2) a long acting beta2 agonist; and 3) an inhaled corticosteroid. A new once-daily inhaler with both a long-acting muscarinic antagonist, umeclidinium bromide, and a long acting beta2 agonist, vilanterol trifenatate, is now available worldwide for COPD treatment. It provides COPD patients convenience, efficacy, and a very favorable adverse-effects profile. Additional once-daily combination inhalers are available or will soon be available for COPD patients worldwide. The use of once-daily combination inhalers will likely become the standard maintenance management approach in the treatment of COPD because they improve medication adherence.


Importance of olfactory and vomeronasal systems for male sexual function.
Chemosensory cues stimulate male sexual arousal and behavior. The main olfactory system has an important role in attracting males to estrous females, and the vomeronasal receptors are important for activating accessory olfactory pathways that engage mating behavior in a sexually dimorphic manner. The gonadotropin releasing hormone (GnRH) neurons like the vomeronasal organ (VNO) neurons take their origin in the olfactory placode and migrate to the basal forebrain along pathfinder axons that take their origin in the developing VNO. The maturation of both systems is synchronized in time such that the early postnatal testosterone surge masculinizes the VNO neural relay en route to the medio preoptic area (MPOA). Although VNO slices and VNO receptor neurons in culture respond to volatile odors, in vivo electrophysiological recordings at the first relay in the accessory olfactory bulb (AOB) are silent until the male makes active nuzzling investigations of the female. The VNO neurons may therefore respond to volatiles that are transported into the organ on carrier peptides that themselves may play a part in receptor activation. In the context of modern molecular phylogenetic studies, it is becoming less likely that pheromones acting via the VNO have any part to play in human sexual behavior, but the possibility exists for conserved VNO genes influencing human reproduction via fertilization.


Cell lineage analysis of pattern formation in the Tubifex embryo. I. Segmentation in the mesoderm.
Annelids are strongly segmented animals that display a high degree of metamerism in their body plan. The embryonic origin of metameric segmentation was examined in an oligochaete annelid Tubifex using lineage tracers. Segmental organization arises sequentially in the anterior-to-posterior direction along the longitudinal axis of the mesodermal germ band, a coherent column of primary blast cells that are produced from the mesodermal teloblast. Shortly after its birth, each primary blast cell undergoes a spatiotemporally stereotyped sequence of cell divisions to generate three classes of cells (in terms of cell size), which together give rise to a distinct cell cluster. Each cluster is composed of descendants of a single primary blast cell; there is no intermingling of cells between adjacent clusters. Relatively small-sized cells in each cluster become localized at its periphery, and they form coelomic walls including an intersegmental septum to establish individuality of segments. A set of cell ablation experiments showed that these features of mesodermal segmentation are not affected by the absence of the overlying ectodermal germ band. These results suggest that each primary blast cell serves as a founder cell of each mesodermal segment and that the boundary between segments is determined autonomously. It is concluded that the metameric body plan of Tubifex arises from an initially simple organization (i.e., a linear series) of segmental founder cells.


Exploratory secondary analyses of a cognitive-behavioral intervention for knee osteoarthritis demonstrate reduction in biomarkers of adipocyte inflammation.
To investigate the effects of pain coping skills training (PCST) and a lifestyle behavioral weight management (BWM) program on inflammatory markers and biomarker associations with pain and function in the OA LIFE study. Serum samples were available from a subset (N = 169) of the overweight or obese knee OA participants in the OA LIFE study that evaluated: PCST, BWM, combined PCST + BWM, or standard care (SC). Inflammatory markers (hsCRP, IL-1ra, IL-1β, IL-6, IL-8, TNF-α, TNFRI, TNFRII, and hyaluronic acid (HA)), and adipokines (leptin and adiponectin) were measured before and after the 24-week treatment period. Biomarkers were assessed for effects of treatment and for associations with change in weight, pain and disability (unadjusted and adjusted for age, race, sex, baseline body mass index (BMI), and baseline biomarker concentration). PCST + BWM was associated with significant reductions in hsCRP (P = 0.0014), IL-6 (P = 0.0075), and leptin (P = 0.0001). After adjustment, there was a significant effect of PCST + BWM on changes in leptin (b = -0.19, P = 0.01) and IL-6 (b = -0.25, P = 0.02) relative to SC. Reductions in leptin and IL-6 were significantly correlated with reductions in weight, BMI and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain; reductions in IL-6 were correlated with improvements in WOMAC and Arthritis Impact Measurement Scales (AIMS) physical function. By mediation analyses, weight loss was responsible for 54% of the change in IL-6 and all of the change in leptin. OA-related inflammatory markers were reduced by a 24-week combined PCST + BWM intervention. This suggests that the inflammatory state can be successfully modified in the context of a readily instituted clinical intervention with a positive clinical outcome.


Return-to-work self-efficacy after occupational rehabilitation for musculoskeletal and common mental health disorders: Secondary outcomes of a randomized clinical trial.
To assess the effects of adding a workplace intervention to inpatient occupational rehabilitation on return-to-work self-efficacy, and whether changes in return-to-work self-efficacy were associated with future work outcomes. Randomized clinical trial. Individuals aged 1860 years, sick-listed 212 months were randomized to multimodal inpatient rehabilitation with (n?=?88) or without (n?=?87) a workplace intervention. Between-group differences for 4 months follow-up were assessed using linear mixed models. Associations between self-efficacy scores and future sickness absence days during 12 months of follow-up were assessed by linear regression. There were no statistically significant between-group differences in self-efficacy during follow-up. Participants with high or medium self-efficacy scores at the end of rehabilitation had fewer sickness absence days during follow-up compared with participants with low scores. Participants with consistently high scores or an increasing score throughout the programme showed fewer sickness absence days than those with reduced or consistently low scores. Receiving an added workplace intervention did not increase return-to-work self-efficacy more than standard inpatient occupational rehabilitation alone. High scores and a positive development in return-to-work self-efficacy were associated with higher work participation. This suggests that return-to-work self-efficacy could be an important factor to consider in the return-to-work process.


The pathologist's role in management of patients with Hodgkin's disease.
The pathologist's role in the management of patients with Hodgkin's disease may be summarized as follows: (a) to establish a firm diagnosis of Hodgkin's disease: (b) to recognize the value of the Lukes-Butler classification in histologic diagnosis as well as its limitations as a prognostic indicator in patients undergoing modern therapy; (c) to carefully examine and identify all sites of involvement in staging laparotomy material; and (d) to prepare tissues for appropriate histopathologic studies and for new techniques in the investigation of Hodgkin's disease. The pathologist should demand of his or her technician optimal histopathologic sections since technical artifacts frequently compound diagnostic problems. Poor-quality sections clearly constitute one of the major obstacles to the diagnosis and subclassification of Hodgkin's disease and allied disorders.


Differentiating primary progressive aphasias in a brief sample of connected speech.
A brief speech expression protocol that can be administered and scored without special training would aid in the differential diagnosis of the 3 principal forms of primary progressive aphasia (PPA): nonfluent/agrammatic PPA, logopenic variant PPA, and semantic variant PPA. We used a picture-description task to elicit a short speech sample, and we evaluated impairments in speech-sound production, speech rate, lexical retrieval, and grammaticality. We compared the results with those obtained by a longer, previously validated protocol and further validated performance with multimodal imaging to assess the neuroanatomical basis of the deficits. We found different patterns of impaired grammar in each PPA variant, and additional language production features were impaired in each: nonfluent/agrammatic PPA was characterized by speech-sound errors; logopenic variant PPA by dysfluencies (false starts and hesitations); and semantic variant PPA by poor retrieval of nouns. Strong correlations were found between this brief speech sample and a lengthier narrative speech sample. A composite measure of grammaticality and other measures of speech production were correlated with distinct regions of gray matter atrophy and reduced white matter fractional anisotropy in each PPA variant. These findings provide evidence that large-scale networks are required for fluent, grammatical expression; that these networks can be selectively disrupted in PPA syndromes; and that quantitative analysis of a brief speech sample can reveal the corresponding distinct speech characteristics.


The clinical reasoning characteristics of diagnostic experts.
The aim of this study was to identify and describe the clinical reasoning characteristics of diagnostic experts. A group of 21 experienced general practitioners were asked to complete the Diagnostic Thinking Inventory (DTI)and a set of 10 clinical reasoning problems (CRP) to evaluate their clinical reasoning. Both the DTI and the CRPs were scored, and the CRP response patterns of each GP examined in terms of the number and type of errors contained in them. Analysis of these data showed that six GPs were able to reach the correct diagnosis using significantly less clinical information than their colleagues. These GPs also made significantly fewer interpretation errors but scored lower on both the DTI and the CRPs. Additionally, this analysis showed that more than 20% of misdiagnoses occurred despite no errors being made in the identification and interpretation of relevant clinical information. These rests indicate that these six GPs diagnose efficiently,effectively and accurately using relatively few clinical data and can therefore be classified as diagnostic experts. They also indicate that a major cause of misdiagnoses is failure to properly integrate clinical data. We suggest that increased emphasis on this step in the reasoning process should prove beneficial to the development of clinical reasoning skill in undergraduate medical students.


The effect of intra-articular injection of autologous bone marrow stem cells on pain and knee function in patients with osteoarthritis.
Management of osteoarthritis (OA) is basically symptomatic. Recently, stem cells (SC) have been used in the search for an optimum treatment. We decided to conduct a controlled clinical trial to determine if a single intra-articular injection of in vivo stimulated bone marrow SC could lead to an improvement in pain management and quality of life in patients with knee OA. This was a prospective, open-label, phase I/II clinical trial to assess the safety and efficacy of a single intra-articular injection of autologous stimulated bone marrow stem cells (BM-SC) in patients with knee OA. Individuals of both genders older than 30 years with confirmed diagnosis of OA who signed informed consent were included in two groups: SC group received in vivo BM stimulation with subcutaneous administration of granulocyte colony stimulating factor (G-CSF). SC were obtained by BM aspiration and administered in a single intra-articular injection. The control group received exclusively oral acetaminophen. Visual analogue scale and Western Ontario and McMaster Universities Osteoarthritis Index scores were performed at 1 week, 1 month and 6 months in both groups. This trial was registered in ClinialTrials.gov NCT01485198. A total of 61 patients were included. Socio-demographic characteristics, OA grades and initial scores were similar in both groups. The BM-SC group showed significant improvement in knee pain and quality of life during the 6-month follow-up. The study demonstrates feasibility and supports efficacy of a completely ambulatory procedure in treatment of knee OA.


Multimodal transcranial magnetic stimulation: using concurrent neuroimaging to reveal the neural network dynamics of noninvasive brain stimulation.
Since its introduction in the 1980s, Transcranial Magnetic Stimulation (TMS) has proven to be a versatile method to non-invasively study human brain function by reversibly altering ongoing neural processing. In addition, TMS has been explored as a therapeutic intervention in a number of neurological and neuropsychiatric conditions. However, our understanding of TMS-induced changes in neural activity patterns is still rather limited, particularly when it comes to changes in neural network dynamics beyond the cortical site directly targeted by TMS. In order to monitor both its local and remote neurophysiological effects, TMS has been combined with complementary neuroimaging methods that allow additional insights into how observed TMS effects at the behavioral level can be interpreted by taking into account the full scale of its impact throughout the brain. The current review provides a comprehensive overview of the existing multimodal TMS literature, covering studies in which TMS was combined with one of the three main neuroimaging modalities, namely Electroencephalography, Positron Emission Tomography, and functional Magnetic Resonance Imaging. Besides constituting a reflection of the status quo in this exciting multidisciplinary research field, this review additionally reveals both convergent and divergent observations across modalities that await corroboration or resolution, thereby further guiding ongoing basic research and providing useful constraints to optimize future clinical applications.


Interorganizational network structures and diffusion of information through a health system.
I used computational models to test the relationship between interorganizational network structures and diffusion of moderate- to high-priority health information throughout a system. I examined diffusion effects of mean and variance in organizational partnering tendencies, arrangement of ties among subgroups of the system, and the diffusing organization's effective network size. I used agent-based models to simulate local information-sharing processes and observe the outcomes of system-level diffusion. Graphs of diffusion curves demonstrated differences among intergroup structures, and regression models were used to test effects of parameterized and emergent network variables on diffusion. The average tendency of participating organizations to engage in partnerships with other network members influenced diffusion of information, but variance in partnering tendencies had little effect. Fully connected subgroup structures outperformed hierarchical connections among subgroups, and all outperformed group-to-group chains. Introduction of a small proportion of randomness in connections among members of the chain structure improved diffusion without increasing network density. Finally, greater effective size in the diffusing organization's network increased diffusion of information. Small interventions that build connecting structures among subgroups within a health system can be particularly effective at facilitating natural dissemination of information.


Entry pathway of vesicular stomatitis virus into different host cells.
A biochemical and morphological investigation of the mechanism of entry of vesicular stomatitis virus (VSV) into host cells of mammalian (HeLa), avian (CER), piscine (EPC) and arthropod (Aedes albopictus) origin, is described. VSV was capable of infecting all cell lines tested by a endosome- and/or a lysosome-dependent step since ammonium chloride and amantadine blocked the early stages of infection. Complement-dependent immune lysis of infected host cells provided evidence that in none of the four different cell types examined did insertion of VSV antigens occur from the outside to any great extent on the cell surface. When the entry process was studied by electron microscopy, virus particles were seen to be bound to the cell surface at 0 degrees C. After warming at 37 degrees C for homeothermic cells or at 26 degrees C for poikilothermic cells, virus was detected within coated pits and coated vesicles and, later, in lysosomes. VSV entry was seen to take place by endocytosis in all four cell lines, which were derived from phylogenetically unrelated species.


Diverging effects of anthropogenic acidification and natural acidity on community structure in Swedish streams.
Anthropogenic acidification caused by aerial deposition of acidifying substances is known to have detrimental effects on freshwater biota, including reductions in species diversity and ecosystem functioning. However, such impairment is not found in systems acidified to a similar extent by natural processes. A proposed explanation for this difference is that freshwater organisms have had far more time to evolve and adapt to natural than anthropogenic acidification. Thus, where acidity is natural, adaptation may account for diverse and functional communities. Here, we investigated whether adaptations--that were previously implied to occur on small spatial scales--may explain the species richness patterns on a much larger geographical scale, apply to ecological functioning, and are relevant in Sweden, where natural acidity is geologically relatively recent. Therefore, we compared differences in species diversity and ecosystem process rates between 24 acidic and circumneutral streams in northern Sweden, where acidity is natural, and southern Sweden, where acidity is largely anthropogenic. In agreement with our predictions, the difference in macroinvertebrate species richness between acidic and circumneutral streams was threefold larger in the region where acidity was anthropogenic than where it was natural, albeit marginally non-significantly. In contrast, no such trend was found for the rates of decomposition by microbes and leaf-feeding macroinvertebrates, possibly due to functional redundancy. The structure of species assemblages differed between acidic and circumneutral sites and between the regions. Our results agree with the notion that freshwater biota are adapted to natural acidity, but competing explanations including other differences in water chemistry and differences in the biogeographical colonization histories may also account for part of the observed patterns. Since naturally acidic environments similar to those in northern Sweden are widespread, we predict that diverse and functionally efficient freshwater communities that are well adapted to such conditions are more common than currently recognized.


CXCL10 and Nrf2-upregulated mesenchymal stem cells reinvigorate T lymphocytes for combating glioblastoma.
Lack of tumor-infiltrating T lymphocytes and concurrent T-cell dysfunction have been identified as major contributors to glioblastoma (GBM) immunotherapy resistance. Upregulating CXCL10 in the tumor microenvironment (TME) is a promising immunotherapeutic approach that potentially increases tumor-infiltrating T cells and boosts T-cell activity but is lacking effective delivery methods. In this study, mesenchymal stem cells (MSCs) were transduced with a recombinant lentivirus encoding Cxcl10, Nrf2 (an anti-apoptosis gene), and a ferritin heavy chain (Fth) reporter gene in order to increase their CXCL10 secretion, TME survival, and MRI visibility. Using FTH-MRI guidance, these cells were injected into the tumor periphery of orthotopic GL261 and CT2A GBMs in mice. Combination therapy consisting of CXCL10-Nrf2-FTH-MSC transplantation together with immune checkpoint blockade (ICB) was also performed for CT2A GBMs. Thereafter, in vivo and serial MRI, survival analysis, and histology examinations were conducted to assess the treatments' efficacy and mechanism. CXCL10-Nrf2-FTH-MSCs exhibit enhanced T lymphocyte recruitment, oxidative stress tolerance, and iron accumulation. Under in vivo FTH-MRI guidance and monitoring, peritumoral transplantation of CXCL10-Nrf2-FTH-MSCs remarkably inhibited orthotopic GL261 and CT2A tumor growth in C57BL6 mice and prolonged animal survival. While ICB alone demonstrated no therapeutic impact, CXCL10-Nrf2-FTH-MSC transplantation combined with ICB demonstrated an enhanced anticancer effect for CT2A GBMs compared with transplanting it alone. Histology revealed that peritumorally injected CXCL10-Nrf2-FTH-MSCs survived longer in the TME, increased CXCL10 production, and ultimately remodeled the TME by increasing CD8+ T cells, interferon-γ+ cytotoxic T lymphocytes (CTLs), GzmB+ CTLs, and Th1 cells while reducing regulatory T cells (Tregs), exhausted CD8+ and exhausted CD4+ T cells. MRI-guided peritumoral administration of CXCL10 and Nrf2-overexpressed MSCs can significantly limit GBM growth by revitalizing T lymphocytes within TME. The combination application of CXCL10-Nrf2-FTH-MSC transplantation and ICB therapy presents a potentially effective approach to treating GBM.


Myostatin and CXCL11 promote nervous tissue macrophages to maintain osteoarthritis pain.
Pain is the most debilitating symptom of knee osteoarthritis (OA) that can even persist after total knee replacement. The severity and duration of pain do not correlate well with joint tissue alterations, suggesting other mechanisms may drive pain persistence in OA. Previous work identified that macrophages accumulate in the dorsal root ganglia (DRG) containing the somas of sensory neurons innervating the injured knee joint in a mouse OA model and acquire a M1-like phenotype to maintain pain. Here we aimed to unravel the mechanisms that govern DRG macrophage accumulation and programming. The accumulation of F4/80+iNOS+ (M1-like) DRG macrophages was detectable at day 3 after mono-iodoacetate (MIA)-induced OA in the mouse. Depletion of macrophages prior to induction of OA resolved pain-like behaviors by day 7 without affecting the initial development of pain-like behaviors. Analysis of DRG transcript identified CXCL11 and myostatin. CXCL11 and myostatin were increased at 3 weeks post OA induction, with CXCL11 expression partially localized in satellite glial cells and myostatin in sensory neurons. Blocking CXCL11 or myostatin prevented the persistence of OA pain, without affecting the initiation of pain. CXCL11 neutralization reduced the number of total and F4/80+iNOS+ DRG macrophages, whilst myostatin inhibition diminished the programming of F4/80+iNOS+ DRG macrophages. Intrathecal injection of recombinant CXCL11 did not induce pain-associated behaviors. In contrast, intrathecal myostatin increased the number of F4/80+iNOS+ DRG macrophages concurrent with the development of mechanical hypersensitivity that was prevented by macrophages depletion or CXCL11 blockade. Finally, myostatin inhibition during established OA, resolved pain and F4/80+iNOS+ macrophage accumulation in the DRG. In conclusion, DRG macrophages maintain OA pain, but are not required for the induction of OA pain. Myostatin is a key ligand in neuro-immune communication that drives the persistence of pain in OA through nervous tissue macrophages and represent a novel therapeutic target for the treatment of OA pain.


[Correlation between interactions of younger elderly women with close non-family friends and neighbors and health-related QOL].
This study was conducted to examine the correlation between interactions of younger elderly women with close non-family friends and neighbors and their health-related QOL, in order to expand understanding of social relationships of the elderly and their health perceptions. Questionnaires were mailed to 1,000 randomly selected women aged 65 to 74 living in City A (population: 180,000; elderly: 14.9%), a bed town community outside a metropolitan area. From 602 valid replies, analysis was limited to self-reports from 525 women who were independent in daily life and interacted with close non-family friends and neighbors. For this purpose the Daily Mutual Caring Interactions (DMCI) scale was applied--its items indicate aims and reciprocal acts in interactions of younger elderly women with close non-family friends and neighbors (Cronbach's alpha = 0.85)--and the Japanese Version SF-36v2, a widely used measure of health-related QOL (Cronbach's alpha = 0.93). Structural equation modeling analysis examined the four constructs of DMCI and their correlations with the physical and psychological health-related components of SF-36v2. The conceived meaning of a correlation among DMCI constructs in the final model (GFI = 0.930, RMSEA = 0.045) is that there is "an appropriate distance between individuals" by holding "mutual concern for each other's daily lives" and "sympathetic mutual understanding", and through these mutual actions one is able to "confirm one's own identity." An extremely weak positive correlation was found between "sympathetic mutual understanding" and the physical and psychological components of SF-36v2. However, no significant correlations were found for "confirmation of one's own identity," the objective of interaction, with either physical or psychological components. An additional finding was an extremely strong correlation between SF-36v2 physical and psychological components. From our study of the interactions of younger elderly women with close non-family friends and neighbors and their health-related QOL, there are no clear direct links that would support the idea that social relations enhance physical or psychological health perceptions. Even so, because the model fits the data for younger elderly women aware of irreversible changes brought on by aging and irrespective of their degree of perceived health, it is possible that interactions with non-family friends and neighbors help these women to share an understanding of existing conditions and live their lives actively and positively. From the perspective of the QOL of the elderly, this suggests the necessity for further discussion about effects of supporting elderly people's own health enhancement efforts that focus on the social aspects of daily life.


[Education in operating room nursing: transformation of the discipline at University of São Paulo School of Nursing (Brazil)].
The objectives of this paper are to present a summary of the evolution of the content of perioperative nursing at the University of São Paulo School of Nursing (EEUSP) and reflect on the National Curriculum Directives (NCD) for the nursing course. The study was developed from a brief history of the practice of perioperative nursing and the inclusion of this topic in the nursing curriculum at EEUSP. The National Curriculum Directives are important because they permit undergraduate schools to determine the amount of teaching time for each course that will comprise their curriculum, but the competencies and skills proposed are nonspecific. We believe that the general nurse should have theoretical and practical learning opportunities to work in every area and level of healthcare.


Late Carboniferous paleoichnology reveals the oldest full-body impression of a flying insect.
Insects were the first animals to evolve powered flight and did so perhaps 90 million years before the first flight among vertebrates. However, the earliest fossil record of flying insect lineages (Pterygota) is poor, with scant indirect evidence from the Devonian and a nearly complete dearth of material from the Early Carboniferous. By the Late Carboniferous a diversity of flying lineages is known, mostly from isolated wings but without true insights into the paleoethology of these taxa. Here, we report evidence of a full-body impression of a flying insect from the Late Carboniferous Wamsutta Formation of Massachusetts, representing the oldest trace fossil of Pterygota. Through ethological and morphological analysis, the trace fossil provides evidence that its maker was a flying insect and probably was representative of a stem-group lineage of mayflies. The nature of this current full-body impression somewhat blurs distinctions between the systematics of traces and trace makers, thus adding to the debate surrounding ichnotaxonomy for traces with well-associated trace makers.


[Study of the bactericidal effect of cefpodoxime using an in vitro pharmacokinetic model].
Cefpodoxime is a new oral prodrug antibiotic. Following absorption from the proximal intestine, non-specific esterases hydrolyze this cleavable ester, releasing cefpodoxime, a new broad-spectrum third-generation cephalosporin with sustained plasma levels in humans. Cefpodoxime killing kinetics were studied using an in vitro model which simulates the pharmacokinetic profile obtained in healthy volunteers given a single oral dose of cefpodoxime proxetil providing 100, 200 or 400 mg active cefpodoxime. Cefpodoxime exhibited strong antibacterial activity against tested strains of Escherichia coli, Streptococcus pneumoniae and Staphylococcus aureus. These results suggest that use of two daily doses of 100 or 200 mg each are appropriate for the treatment of E. coli and S. pneumoniae infections in view of the pharmacokinetic properties of cefpodoxime. Less intensive therapy is probably adequate in uncomplicated community-acquired urinary tract infections. The bactericidal effect of cefpodoxime against S. aureus is prolonged due to a postantibiotic effect.


Deoxyribonucleic acid base composition and biochemical properties of certain coagulase-negative enterotoxigenic cocci.
Eight coagulase-negative, enterotoxigenic strains of cocci and one weakly coagulase-positive strain isolated from a number of different sources, including cases of food poisoning incidents, were evaluated for their relationship to Staphylococcus aureus on the basis of deoxyribonucleic acid (DNA) buoyant density and physiological studies. One strain of cocci produced enterotoxins A and C, two strains produced types B and C, four strains produced only type C, and one strain only type D. The enterotoxin produced by one strain of cocci was serologically untypable. None of the test organisms produced detectable amounts of enterotoxin in broth cultures. The test strains of cocci exhibited the following profile: all produced catalase; all grew anaerobically and fermented glucse; five were sensitive to lysostaphin; the percentage of guanine plus cytosine content of their DNA varied from 32.7 to 37.6; five produced acid from mannitol both aerobically and anaerobically; two formed delta-hemolysin; five produced phosphatase and acetoin; and all produced heat-stable nuclease. None of the organisms exhibited typical characteristics of S. aureus, S. epidermidis, or S. saprophyticus. On the basis of the present data and data reported elsewhere, these organisms should be considered as variants or mutants of S. aureus.


High tumor interstitial fluid pressure identifies cervical cancer patients with improved survival from radiotherapy plus cisplatin versus radiotherapy alone.
Radiotherapy (RT) with concurrent cisplatin (CRT) is standard treatment for locally advanced cervical cancer. However, not all patients benefit from the addition of cisplatin to RT alone. This study explored the value of pretreatment tumor interstitial fluid pressure (IFP) and hypoxia measurements as predictors of cisplatin response in 291 patients who were treated with RT (1994-1998) or RT plus concurrent cisplatin (1999-2009). Clinical characteristics were similar between the two groups, apart from a greater proportion of patients with pelvic lymph node metastases and hypoxic tumors in the CRT cohort. Patients were followed for a median duration of 5.6 years. Information about recurrence and survival was recorded prospectively. The addition of cisplatin to RT improved survival compared to treatment with RT alone (HR 0.61, p = 0.0097). This improvement was confined to patients with high-IFP tumors at diagnosis (HR 0.40, p = 0.00091). There was no benefit of adding cisplatin in those with low-IFP tumors (HR 1.05, p = 0.87). There was no difference in the effectiveness of cisplatin in patients with more or less hypoxic tumors. In conclusion, patients with locally advanced cervical cancer and high tumor IFP at diagnosis have greater benefit from the addition of cisplatin to RT than those with low IFP. This may reflect high tumor cell proliferation, which is known to influence IFP, local tumor control and patient survival.


The Penn State Protein Ladder system for inexpensive protein molecular weight markers.
We have created the Penn State Protein Ladder system to produce protein molecular weight markers easily and inexpensively (less than a penny a lane). The system includes plasmids which express 10, 15, 20, 30, 40, 50, 60, 80 and 100 kD proteins in E. coli. Each protein migrates appropriately on SDS-PAGE gels, is expressed at very high levels (10-50 mg per liter of culture), is easy to purify via histidine tags and can be detected directly on Western blots via engineered immunoglobulin binding domains. We have also constructed plasmids to express 150 and 250 kD proteins. For more efficient production, we have created two polycistronic expression vectors which coexpress the 10, 30, 50, 100 kD proteins or the 20, 40, 60, 80 kD proteins. 50 ml of culture is sufficient to produce 20,000 lanes of individual ladder protein or 3750 lanes of each set of coexpressed ladder proteins. These Penn State Protein Ladder expression plasmids also constitute useful reagents for teaching laboratories to demonstrate recombinant expression in E. coli and affinity protein purification, and to research laboratories desiring positive controls for recombinant protein expression and purification.


The pharmacological management of acute behavioural disturbance: Data from a clinical audit conducted in UK mental health services.
A quality improvement programme addressing prescribing practice for acutely disturbed behaviour was initiated by the Prescribing Observatory for Mental Health. This study analysed data from a baseline clinical audit conducted in inpatient mental health services in member trusts. Fifty-eight mental health services submitted data on 2172 episodes of acutely disturbed behaviour. A benzodiazepine alone was administered in 60% of the 1091 episodes where oral medication only was used and in 39% of the 1081 episodes where parenteral medication (rapid tranquillisation) was used. Haloperidol was combined with lorazepam in 22% of rapid tranquillisation episodes and with promethazine in 3%. Physical violence towards others was strongly associated with receiving rapid tranquillisation in men (odds ratio 1.74, 1.25-2.44; p<0.001) as was actual or attempted self-harm in women (odds ratio 1.87, 1.19-2.94; p=0.007). Where physical violence towards others was exhibited, a benzodiazepine and antipsychotic was more likely to be prescribed than a benzodiazepine alone (odds ratio 1.39, 1.00-1.92; p=0.05). The data suggested that 25% of patients were at least 'extremely or continuously active' in the hour after rapid tranquillisation was administered. The current management of acutely disturbed behaviour with parenteral medication may fail to achieve a calming effect in up to a quarter of episodes. The most common rapid tranquillisation combination used was lorazepam and haloperidol, for which the randomised controlled trial evidence is very limited. Rapid tranquillisation prescribing practice was not wholly consistent with the relevant National Institute for Health and Care Excellence guideline, which recommends intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine. Clinical factors prompting the use of rapid tranquillisation rather than oral medication may differ between the genders.


[Relationship between dominance and richness of local species: an analysis of the underlying reasons with arboreal and avian communities of the West Caucasus as an example].
Dominance level is traditionally expressed as a ratio between the number of individuals belonging to the most abundant species and the total number of individuals in a biological community. It is known that local species richness is usually higher in biological communities with high dominance level than in communities with low one. Taking into account a complex nature of the dominance phenomenon, the underlying reasons (or mechanisms) may be diverse: 1. Dominance level may be determined by bioecological traits of the most abundant species as well as stochastic impacts. The more abundant is dominant species, the fewer amount of resources goes to concomitant species and, therefore, the lower is community species richness. 2. The part of community resources used by the dominant species may be not a special case but can be a reflection of general pattern of resources distribution among species under specific environmental conditions. Correspondingly, in communities with higher dominance level there might be more "strict" distribution of resources among concomitant species, which, in turn, might influence community species richness. 3. The relationship between dominance level and community species richness may be caused by their dependence on the third variable, namely regional species pool. In the present paper we tackle the problem using arboreal and insectivorous bird communities of the West Caucasus as a case study. The data were collected in different altitudinal belts on both macroslopes of the western part of the Main Caucasian Ridge. The number of tree species and individual trees was counted within homogenous patches of arboreal phytocenoses 300 m2 in area. Species richness and numbers of insectivorous birds were estimated in course of route surveys with a route length being about 5 km. An analysis of empirical data was carried out using univariate and multiple correlation-regression techniques. The results indicate that the relationship between dominance and local species richness is determined to a large extent (by 50-60%) by a dominant taking over greater or lesser amount of the resources (mechanism 1). The role of two other mechanisms (2 and 3) is not so prominent--together, they are responsible for 25-40% of the relationship power. Relative contribution of different mechanisms to the relationship under consideration depends on conformity of species abundance rank structure with the geometric series model. At those sites where this conformity is manifested, the relationship between dominance level and species richness is due mainly to mechanisms 1 and 2, i.e., is determined by local processes. At other sites, where the conformity of species abundance rank structure with the geometric series model is not so good, a certain role belongs to the size of regional species pool (mechanism 3).


[Environmental variability and physiological responses from Polylepis cuadrijuga (Rosaceae) in a fragmented environment in the Páramo de la Rusia (Colombia].
Polylepis cuadrijuga is an endemic woody species from the Colombian Eastern range, being the only tree species with capacity to live on mountainous environments beyond 4 000m of altitude. Grazing and agriculture have transformed at least 30% of the Guantiva-La Rusia region, turning continuous extensions of high Andean forest in a fragmented landscape, and P cuadrijuga remnants have become smaller and more isolated. The aim of this study was to establish the environmental differences between a matrix of grazing pastures and the interior of fragments, to evaluate the physiological responses of P cuadrijuga and determining the edge effect. Air temperature and humidity, soil water holding capacity and photosynthetic active radiation, were measured along two 50X2m transects from the matrix toward the center of fragment. Six trees inside the transects were chosen in each one of three sites (matrix, edge and interior) to measure the index chlorophyll content and to sample leaves to assess the leaf area, leaf biomass, specific leaf area, anatomy, health condition and pubescence. Results showed significantly differences between the matrix and the interior and intermediate conditions in the edge. Radiation, temperature and air desiccation were higher in the matrix than in the interior, submitting P cuadrijuga trees to a stressing environment, where they presented stratification of epidermis and palisade parenchyma, and a higher leaf area, leaf thickness, chlorophyll content and pubescence than in the interior of fragments. All these physiological traits allow avoiding the photoxidation and damages by freezing or desiccation to which trees are exposed in a grazing pasture matrix. Nevertheless, there was a higher frequency of healthy leaves in the interior of fragments, showing that high irradiations and extreme air temperature and humidity reach adversely affect to P cuadrijuga. Individuals in the edge had ecophysiological traits similar to the matrix ones, which confirm an edge effect that could penetrate 17m inside the fragments. We conclude that P cuadrijuga is a plastic species, able to overcome the stress conditions from anthropogenic transformations, species able to be used in high Andean forest restoration programs


Metabolism of malonic semialdehyde in man.
Malonic semialdehyde is formed in the alternative pathway of propionate metabolism and in the catabolism of beta-alanine. Studies of these pathways in cultured cells from a patient with mitochondrial malonyl-CoA decarboxylase deficiency indicate that malonic semialdehyde is directly converted into acetyl-CoA in man.


Blood cultures at central line insertion in the intensive care unit: comparison with peripheral venipuncture.
Blood cultures are a key diagnostic test for intensive care unit (ICU) patients; however, contaminants complicate interpretations and lead to unnecessary antibiotic administration and costs. Indications for blood cultures and central venous catheter (CVC) insertions often overlap for ICU patients. Obtaining blood cultures under the strict sterile precautions utilized for CVC insertion might be expected to decrease culture contamination. This retrospective study compared the results of blood cultures taken at CVC insertion, at arterial line insertion, and from peripheral venipuncture in order to validate the advantage of CVC insertion cultures. Cultures from indwelling lines were excluded. Results of 14,589 blood cultures, including 2,736 (19%) CVC, 1,513 (10%) arterial line, and 10,340 (71%) peripheral cultures taken over 5.5 years in two ICUs (general and medical) were analyzed. CVC cultures were contaminated more frequently than arterial line or peripheral cultures (225/2,736 [8%] CVC, 48/1,513 [3%] arterial line, and 378/10,340 (4%) peripheral cultures [P < 0.001 for CVC versus peripheral and CVC versus arterial line cultures]). True pathogens were found more frequently in CVC insertion cultures (334/2,736 [12%] CVC, 155/1,513 [10%] arterial line, and 795/10,340 [8%] peripheral cultures [P < 0.001 for CVC versus peripheral cultures; P = 0.055 for CVC versus arterial line cultures; P < 0.001 for peripheral versus arterial line cultures]). Contamination and true-positive rates were similar for culture sets from the two ICUs for each given culture source. Despite superior sterile precautions, cultures taken at the time of central line insertion had a higher contamination rate than did either peripheral or arterial line blood cultures. This may be related to the increased manipulations required for CVC insertion.


The relationship between urologic cancer outcomes and national Human Development Index: trend in recent years.
To describe the influence of the socioeconomic development on worldwide age-standardized incidence and mortality rates, as well as mortality-to-incidence ratio (MIR) and 5-year net survival of urologic cancer patients in recent years. The Human Development Index (HDI) values were obtained from the United Nations Development Programme, data on age-standardized incidence/mortality rates of prostate, bladder and kidney cancer were retrieved from the GLOBOCAN database, 5-year net survival was provided by the CONCORD-3 program. We then evaluated the association between incidence/MIR/survival and HDI, with a focus on geographic variability as well as temporal patterns during the last 6 years. Urologic cancer incidence rates were positively correlated with HDIs, and MIRs were negatively correlated with HDIs. Prostate cancer survival also correlated positively with HDIs, solidly confirming the interrelation among cancer indicators and socioeconomic factors. Most countries experienced incidence decline over the most recent 6 years, and a substantial reduction in MIR was observed. Survival rates of prostate cancer have simultaneously improved. Development has a prominent influence on urologic cancer outcomes. HDI values are significantly correlated with cancer incidence, MIR and survival rates. HDI values have risen along with increased incidence and improved outcomes of urologic caner in recent years.


[Effect of electroacupuncture pretreatment on transient receptor potential vanilloid 1(TRPV1)/calcitonin gene-related peptide(CGRP) signal and NF-κB p65 protein expression in rats with acute myocardial ischemia].
To observe the effect of electroacupuncture(EA)pretreatment on transient receptor potential vanilloid 1(TRPV1)/calcitonin gene-related peptide(CGRP)signal and nuclear factor-κB p65 (NF-κB p65) protein expression in myocardial tissue of acute myocardial ischemic injury (AMI) rats, and to investigate the possible mechanism of electroacupuncture pretreatment against AMI. A total of 60 adult male SD rats were randomly divided into blank control, sham operation, model and EA pretreatment groups, 15 rats in each group. The acute myocardial ischemia model was established by ligating the left anterior descending (LAD)branch of the coronary artery in the model group and EA pretreatment group, while threading but no ligating at left anterior descending branch of the coronary artery was applied in the sham operation group. In the EA pretreatment group, bilateral "Neiguan"(PC6) acupoints were selected, with intensity of 2 mA and frequency of 2 Hz/100 Hz, for 20 min, once daily for 7 days before modeling. Electrocardiogram (ECG) was recorded by physiological signal acquisition system, and the ST segment potential offset values of standard Ⅱ lead were analyzed before surgery,30 min and 24 h after operation. The TTC staining was used to observe the percentage of myocardial infarction area. The HE staining was used to observe the pathological changes of myocardial tissue and the degree of inflammatory cell infiltration. And Western blot was used to detect TRPV1/CGRP signal and NF-κB p65 protein expression levels in myocardial tissue. Compared with the sham operation group, the ECG-J point potential in the model group was significantly increased at 30 min and decreased at 24 h after operation (P<0.05), myocardial infarction area increased significantly (P<0.05), the myocardial fibers were obviously disordered, inflammatory cell infiltration was obvious, and the expressions of TRPV1,CGRP and NF-κB p65 proteins were all increased (P<0.05). Compared with the model group, the EA pretreatment group was decreased in the ECG-J point potential at 30 min after operation(P<0.05), significantly reduced in myocardial infarction area (P<0.05), improved in the morphology of myocardial fibers, reduced ininflammatory cell infiltration, and increased in the protein expressions of TRPV1 and CGRP in myocardium (P<0.05), significantly decreased in the protein expression of NF-κB p65 (P<0.05). EA pretreatment may enhance TRPV1/CGRP signaling, down-regulate NF-κB p65 protein expression, reduce myocardial inflammatory response status, improve AMI injury, and reduce myocardial infarction area.


[Realities and hopes of gene therapy].
The work represents an introduction article of editors of special issue of the magazine devoted to gene therapy and therapeutics. The main results of clinical gene therapy in the past decade are critically considered in connection with a changes of paradigms of the field. They are: 1) change of the main target of genetic therapy--correction of defects in chromosomes--onto expression and/or output of target genes for gene therapy; 2) transfer from gene transplantation to cell transplantation; 3) tendency for the use of safe/non-viral vectors instead of viral ones.; and 4) conflict of interests in gene therapy. Outlooks in the field are discussed.


Achieving the Sustainable Development Goals for water and sanitation in Indonesia - Results from a five-year (2013-2017) large-scale effectiveness evaluation.
Access to safe sanitation and the elimination of open defecation are pre-conditions for improved child health and nutrition and wider achievement of the Sustainable Development Goals (SDGs). While Indonesia has a solid policy framework, the country ranks third globally in terms of numbers of people practicing open defecation. Our aim was to assess the effectiveness of a five-year strategy to reduce open defecation through accelerating implementation of the national sanitation program across districts receiving variable levels of external support. Among three provinces with poor sanitation program performance, districts were selected to receive one of three levels of external support. High intensity districts (n = 6) benefitted from enabling environment strengthening support including political and social mobilization, direct capacity development, and efforts to strengthen planning, budgeting, monitoring and supervision; learning districts (n = 16) benefitted from cross-district learning opportunities and political mobilization through provincial government advocacy efforts; and comparison districts (n = 58) were monitored under routine program conditions. Outcomes included open defecation free (ODF) status and new toilet facility construction and were assessed through village level monitoring systems across all districts. Negative binomial regression and multivariate analysis were used to assess associations between levels of intervention intensity and outcomes. Among districts receiving high-intensity external support improvements in political commitment, planning, coordination, financing, monitoring and supervision were observed. Relative to comparison districts, high intensity districts were more likely to be ODF (aRR 4.65, CI 2.12-10.20) with greater increase in household toilet coverage (aRR 11.15 CI 1.04-119.82). Weaker non-significant associations with ODF were observed among learning districts relative to comparison districts. Efforts to strengthen provincial and district government capacity to implement sanitation programming in Indonesia can yield substantial improvements in outcomes in a relatively short period of time.


Development of amitriptyline buccoadhesive tablets for management of pain in dental procedures.
Administration of lidocaine and nonsteroidal anti-inflammatory drugs (NSAIDs) as a routine procedure for relief of dental pains by and large is restricted due to some side effects. Amitriptyline (AM) has long been known to exert analgesic activity as a result of blocking the Na⁺ channels. The objective of the present investigation was to prepare suitable buccoadhesive tablets using cellulose derivatives in order to obtain new formulations containing AM to provide local analgesic action. The tablets were evaluated in terms of physical characteristics, mucoadhesion performance, drug release, and in vivo assessment of analgesic efficiency. Tablets containing higher amounts of high-viscosity hydroxypropylmethyl cellulose (HPMC-K4M) significantly demonstrated enhanced adhesive performances. On the other hand, presence of sodium carboxymethyl cellulose (NaCMC) in formulations including HPMC of lower-viscosity grade (HPMC-E5LV) provided further adhesiveness by increase in viscosity. Rate of drug release from HPMC-E5LV tablets was significantly higher than the HPMC-K4M tablets. Kinetically, patterns of AM release from the tablets fitted best to Higuchi model. Moreover, in a randomized double-blind trial, analgesic efficiency of the prepared bioadhesive tablets was revealed to be satisfactory. It is suggested that applying the topical AM mucoadhesive tablet containing the low amount of drug is a safe and promising alternative to relief the pain in the buccal region.


Toward the Required Detection Limits for Volatile Organic Constituents in Marine Environments with Infrared Evanescent Field Chemical Sensors.
A portable sensor system for the simultaneous detection of multiple environmentally relevant volatile organic compounds (VOCs) in real seawater based on Fourier transform infrared fiber-optic evanescent wave spectroscopy (FT-IR-FEWS) was developed. A cylindrical silver halide (AgX) fiber with an ethylene/propylene copolymer (E/P-co) coated flattened segment was used as an active optical transducer. The polymer membrane enriches the hydrophobic analytes, while water is effectively excluded from the penetration depth of the evanescent field. Determination of multicomponent mixtures (i.e., 10 VOCs in real-world seawater samples) collected in Arcachon Bay, France revealed a high accuracy and reproducibility with detection limits down to 560 ppb. The measurement showed no significant influence from changing water conditions (e.g., salinity, turbidity, and temperature or other interfering substances). The time constants for 90% saturation of the polymer ranged from 20 to 60 min. The sensor system is capable of being transported for on-site monitoring of environmental pollutants in aqueous matrices with efficient long-term stability, thus showing great potential to be utilized as an early warning system.


Status of research in vascular access for dialysis.
Vascular access issues impose a major financial burden to health care and can be associated with increased morbidity and mortality. In this context, strategies, guidelines and available published information become important tools for health-care facilities and workers. While published data form a sound basis of formulating clinical practice guidelines for vascular access (VA), quality of the medical information is critically important. This study investigates the current status of VA publications. A PubMed search was performed to capture all articles related to dialysis vascular access published from January 1997 to December 2009. The articles were categorized by publication type, study subject, year of publication and specialty of the authors. A total of 2260 articles from 60 medical journals were identified. Insignificant publications (letters/communications, n = 125) were excluded from the analysis. Therefore, 2135 articles formed the basis for analysis. Sixteen of the 60 journals routinely published on vascular access and generated 1747 articles [nephrology = 7 (publications = 782); radiology = 4 (publications = 333); surgery = 5 (publications = 486)], while 44/60 journals published scarcely and produced 388 articles over the 13-year period. Overall, 1213 (57%) of the articles were published by the direct involvement of nephrologists [nephrologists alone (n = 564); nephrologists in collaboration with others (n = 649)]. There were 1194 observational studies, 444 case reports/series, 375 review/editorials, 51 basic research, 12 meta-analyses and 59 randomized controlled trials published over the 13-year period. The average impact factor for nephrology, radiology and surgery journals that routinely published on vascular access was 4.425, 3.099 and 2.679, respectively. Despite an increased rate of scholarly activity in the area of vascular access, there remains a significant challenge ahead due to the lack of randomized controlled trials and research focusing on the biology of vascular access stenosis.


SETD2 loss-of-function promotes renal cancer branched evolution through replication stress and impaired DNA repair.
Defining mechanisms that generate intratumour heterogeneity and branched evolution may inspire novel therapeutic approaches to limit tumour diversity and adaptation. SETD2 (Su(var), Enhancer of zeste, Trithorax-domain containing 2) trimethylates histone-3 lysine-36 (H3K36me3) at sites of active transcription and is mutated in diverse tumour types, including clear cell renal carcinomas (ccRCCs). Distinct SETD2 mutations have been identified in spatially separated regions in ccRCC, indicative of intratumour heterogeneity. In this study, we have addressed the consequences of SETD2 loss-of-function through an integrated bioinformatics and functional genomics approach. We find that bi-allelic SETD2 aberrations are not associated with microsatellite instability in ccRCC. SETD2 depletion in ccRCC cells revealed aberrant and reduced nucleosome compaction and chromatin association of the key replication proteins minichromosome maintenance complex component (MCM7) and DNA polymerase δ hindering replication fork progression, and failure to load lens epithelium-derived growth factor and the Rad51 homologous recombination repair factor at DNA breaks. Consistent with these data, we observe chromosomal breakpoint locations are biased away from H3K36me3 sites in SETD2 wild-type ccRCCs relative to tumours with bi-allelic SETD2 aberrations and that H3K36me3-negative ccRCCs display elevated DNA damage in vivo. These data suggest a role for SETD2 in maintaining genome integrity through nucleosome stabilization, suppression of replication stress and the coordination of DNA repair.


Microtubule assembly and pole coalescence: early steps in Caenorhabditiselegans oocyte meiosis I spindle assembly.
How oocytes assemble bipolar meiotic spindles in the absence of centrosomes as microtubule organizing centers remains poorly understood. We have used live cell imaging in Caenorhabditis elegans to investigate requirements for the nuclear lamina and for conserved regulators of microtubule dynamics during oocyte meiosis I spindle assembly, assessing these requirements with respect to recently identified spindle assembly steps. We show that the nuclear lamina is required for microtubule bundles to form a peripheral cage-like structure that appears shortly after oocyte nuclear envelope breakdown and surrounds the oocyte chromosomes, although bipolar spindles still assembled in its absence. Although two conserved regulators of microtubule nucleation, RAN-1 and γ-tubulin, are not required for bipolar spindle assembly, both contribute to normal levels of spindle-associated microtubules and spindle assembly dynamics. Finally, the XMAP215 ortholog ZYG-9 and the nearly identical minus-end directed kinesins KLP-15/16 are required for proper assembly of the early cage-like structure of microtubule bundles, and for early spindle pole foci to coalesce into a bipolar structure. Our results provide a framework for assigning molecular mechanisms to recently described steps in C. elegans oocyte meiosis I spindle assembly.


Dominant Plant Functional Group Determine the Response of the Temporal Stability of Plant Community Biomass to 9-Year Warming on the Qinghai-Tibetan Plateau.
Ecosystem stability characterizes ecosystem responses to natural and anthropogenic disturbance and affects the feedback between ecosystem and climate. A 9-year warming experiment (2010-2018) was conducted to examine how climatic warming and its interaction with the soil moisture condition impact the temporal stability of plant community aboveground biomass (AGB) of an alpine meadow in the central Qinghai-Tibetan Plateau (QTP). Under a warming environment, the AGB percentage of grasses and forbs significantly increased but that of sedges decreased regardless of the soil water availability in the experimental plots. The warming effects on plant AGB varied with annual precipitation. In the dry condition, the AGB showed no significant change under warming in the normal and relatively wet years, but it significantly decreased in relatively drought years (16% in 2013 and 12% in 2015). In the wet condition, the AGB showed no significant change under warming in the normal and relatively drought years, while it significantly increased in relatively wet years (12% in 2018). Warming significantly decreased the temporal stability of AGB of plant community and sedges. Species richness remained stable even under the warming treatment in both the dry and wet conditions. The temporal stability of AGB of sedges (dominant plant functional group) explained 66.69% variance of the temporal stability of plant community AGB. Our findings highlight that the temporal stability of plant community AGB is largely regulated by the dominant plant functional group of alpine meadow that has a relatively low species diversity.


Prevalence of self-reported thyroid disease among adults with depression.
Thyroid disorders are a common comorbidity in patients with depression, yet there is limited information available about the clinical epidemiology of thyroid diseases in this specific population. This study aims to describe the prevalence of thyroid disease among US adults with depression from 2007 to 2018. This cross-sectional study used nationally representative data collected through the National Health and Nutrition Examination Survey (NHANES) between January 1, 2007, to December 31, 2018. Age-standardized prevalence of thyroid disease among depressed patients was calculated within 4-year survey periods (2007-2010, 2011-2014, and 2015-2018), and adjusted to the 2000 U.S. standard population. In our weighed sample, 6.1% of depressed individuals and 4.3% of non-depressed individuals reported thyroid disease between 2007 and 2018 (P < 0.0001). The age-standardized prevalence of thyroid disease in patients with depression increased over time, from 5.4% (95%CI, 4.6%-6.2%) in 2007-2010 to 6.8% (95%CI, 5.8%-8.0%) in 2015-2018 (P for trend = 0.0270). Furthermore, thyroid disease prevalence was highest in non-Hispanic white individuals, increased with age, and tended to be higher in women. Mean depression scores in patients with thyroid disease (9.1; 95%CI, 8.7-9.5) did not significantly different from those without thyroid disease (9.1; 95%CI, 9.0-9.3) (P = 0.96). The age-standardized prevalence of thyroid disease among US adults with depression exhibited a consistent increase from 2007 to 2018, with the highest rate occurring in older, non-Hispanic white individuals, and women.


Expanding the anti-flaviviral arsenal: Discovery of a baicalein-derived Compound with potent activity against DENV and ZIKV.
With approximately 3.8 billion people at risk of infection in tropical and sub-tropical regions, Dengue ranks among the top ten threats worldwide. Despite the potential for severe disease manifestation and the economic burden it places on endemic countries, there is a lack of approved antiviral agents to effectively treat the infection. Flavonoids, including baicalein, have garnered attention for their antimicrobial properties. In this study, we took a rational and iterative approach to develop a series of baicalein derivatives with improved antiviral activity against Dengue virus (DENV). Compound 11064 emerged as a promising lead candidate, exhibiting antiviral activity against the four DENV serotypes and representative strains of Zika virus (ZIKV) in vitro, with attractive selectivity indices. Mechanistic studies revealed that Compound 11064 did not prevent DENV attachment at the cell surface, nor viral RNA synthesis and viral protein translation. Instead, the drug was found to impair the post-receptor binding entry steps (endocytosis and/or uncoating), as well as the late stage of DENV infection cycle, including virus assembly/maturation and/or exocytosis. The inability to raise DENV resistant mutants, combined with significant antiviral activity against an unrelated RNA virus (Enterovirus-A71) suggested that Compound 11064 targets the host rather than a viral protein, further supporting its broad-spectrum antiviral potential. Overall, Compound 11064 represents a promising antiviral candidate for the treatment of Dengue and Zika.


Social sources of racial disparities in health.
Racial disparities in mortality over time reflect divergent pathways to the current large racial disparities in health. The residential concentration of African Americans is high and distinctive, and the related inequities in neighborhood environments, socioeconomic circumstances, and medical care are important factors in initiating and maintaining racial disparities in health. Efforts are needed to identify and maximize health-enhancing resources that may reduce some of the negative effects of psychosocial factors on health. Health and health disparities are embedded in larger historical, geographic, sociocultural, economic, and political contexts. Changes in a broad range of public policies are likely to be central to effectively addressing racial disparities.


[News from the cochrane library: mu opioid antagonists for opioid-induced bowel dysfunction].
Constipation and other gastrointestinal symptoms are frequent adverse effects of either short-term postoperative or chronic opioid therapy. The review authors have identified 23 studies to evaluate the efficacy of micro-opioid antagonists for the prevention and treatment of these complications. The data on safety and efficacy of the traditional antagonists naloxone and nalbuphine are insufficient. The results of studies with the newer, peripherally-acting antagonists alvimopan and methylnaltrexone are promising. Methylnaltrexone resulted in four studies with healthy probands in a significant shortening of the gastrointestinal transit time (-52 min). In the postoperative setting, five studies showed a significant improvement of the hazard ratios for different outcomes (e. g., bowel movement, tolerance of solid food) in the alvimopan group. Future studies will be needed to show whether these results can be reproduced in different patient groups on a larger scale. Also, with regard to other pharmacological (e. g., lactulose) and non-pharmacological interventions, the role of the above-mentioned not yet approved medications needs to be defined.