The risk of smoking on multiple sclerosis: a meta-analysis based on 20,626 cases from case-control and cohort studies.
Background. Multiple sclerosis (MS) has become a disease that represents a tremendous burden on patients, families, and societies. The exact etiology of MS is still unclear, but it is believed that a combination of genetic and environmental factors contribute to this disease. Although some meta-analyses on the association between smoking and MS have been previously published, a number of new studies with larger population data have published since then. Consequently, these additional critical articles need to be taken into consideration. Method. We reviewed articles by searching in PubMed and EMBASE. Both conservative and non-conservative models were used to investigate the association between smoking and the susceptibility to MS. We also explored the effect of smoking on the susceptibility to MS in strata of different genders and smoking habits. The association between passive smoking and MS was also explored. Results.The results of this study suggest that smoking is a risk factor for MS (conservative model: odds ratio (OR) 1.55, 95% CI [1.48-1.62], p < 0.001; non-conservative model: 1.57, 95% CI [1.50-1.64], p < 0.001). Smoking appears to increase the risk of MS more in men than in women and in current smokers more than in past smokers. People who exposed to passive smoking have higher risk of MS than those unexposed. Conclusion.This study demonstrated that exposure to smoking is an important risk factor for MS. People will benefit from smoking cessation, and policymakers should pay attention to the association between smoking and MS.


Herpes simplex virus thymidine kinase transcripts are absent from both nucleus and cytoplasm during infection in the presence of cycloheximide.
Nick-translated DNA from a recombinant plasmid containing the herpes simplex virus type 1 thymidine kinase gene was used as a probe for the synthesis of thymidine kinase RNA. The recombinant plasmid was generated by inserting the 3.5-kilobase fragment derived by BamHI digestion of herpes simplex virus type 1 DNA into plasmid pBR322. At 8 h after infection, cytoplasmic and nuclear RNA hybridized to 14% and 19% of the recombinant DNA probe, respectively. However, no significant hybridization was found with either nuclear or cytoplasmic RNA extracted from cells infected and maintained in the presence of cycloheximide. This suggests that no thymidine kinase-related RNA was synthesized in the absence of alpha polypeptides, and supports the hypothesis that the alpha polypeptides effect new thymidine kinase RNA synthesis rather than being involved in processing or transport of thymidine kinase RNA. In cells infected and maintained in the presence of the arginine analog canavanine, about 2 to 3% of the plasmid DNA was found to hybridize with cytoplasmic and nuclear RNA. However, when a recombinant plasmid DNA containing only thymidine kinase coding sequences was used, no significant hybridization was found. The inhibition of thymidine kinase transcription by canavanine suggests that thymidine kinase belongs to the beta 2 kinetic class.


Di-2-pyridylketone 4,4-dimethyl-3-thiosemicarbazone (Dp44mT) overcomes multidrug resistance by a novel mechanism involving the hijacking of lysosomal P-glycoprotein (Pgp).
Multidrug resistance (MDR) is a major obstacle in cancer treatment. More than half of human cancers express multidrug-resistant P-glycoprotein (Pgp), which correlates with a poor prognosis. Intriguingly, through an unknown mechanism, some drugs have greater activity in drug-resistant tumor cells than their drug-sensitive counterparts. Herein, we investigate how the novel anti-tumor agent di-2-pyridylketone 4,4-dimethyl-3-thiosemicarbazone (Dp44mT) overcomes MDR. Four different cell types were utilized to evaluate the effect of Pgp-potentiated lysosomal targeting of drugs to overcome MDR. To assess the mechanism of how Dp44mT overcomes drug resistance, cellular studies utilized Pgp inhibitors, Pgp silencing, lysosomotropic agents, proliferation assays, immunoblotting, a Pgp-ATPase activity assay, radiolabeled drug uptake/efflux, a rhodamine 123 retention assay, lysosomal membrane permeability assessment, and DCF (2',7'-dichlorofluorescin) redox studies. Anti-tumor activity and selectivity of Dp44mT in Pgp-expressing, MDR cells versus drug-sensitive cells were studied using a BALB/c nu/nu xenograft mouse model. We demonstrate that Dp44mT is transported by the lysosomal Pgp drug pump, causing lysosomal targeting of Dp44mT and resulting in enhanced cytotoxicity in MDR cells. Lysosomal Pgp and pH were shown to be crucial for increasing Dp44mT-mediated lysosomal damage and subsequent cytotoxicity in drug-resistant cells, with Dp44mT being demonstrated to be a Pgp substrate. Indeed, Pgp-dependent lysosomal damage and cytotoxicity of Dp44mT were abrogated by Pgp inhibitors, Pgp silencing, or increasing lysosomal pH using lysosomotropic bases. In vivo, Dp44mT potently targeted chemotherapy-resistant human Pgp-expressing xenografted tumors relative to non-Pgp-expressing tumors in mice. This study highlights a novel Pgp hijacking strategy of the unique dipyridylthiosemicarbazone series of thiosemicarbazones that overcome MDR via utilization of lysosomal Pgp transport activity.


Prevention of Alzheimer's disease-associated Abeta aggregation by rationally designed nonpeptidic beta-sheet ligands.
A new concept is introduced for the rational design of beta-sheet ligands, which prevent protein aggregation. Oligomeric acylated aminopyrazoles with a donor-acceptor-donor (DAD) hydrogen bond pattern complementary to that of a beta-sheet efficiently block the solvent-exposed beta-sheet portions in Abeta-(1-40) and thereby prevent formation of insoluble protein aggregates. Density gradient centrifugation revealed that in the initial phase, the size of Abeta aggregates was efficiently kept between the trimeric and 15-meric state, whereas after 5 days an additional high molecular weight fraction appeared. With fluorescence correlation spectroscopy (FCS) exactly those two, i.e. a dimeric aminopyrazole with an oxalyl spacer and a trimeric head-to-tail connected aminopyrazole, of nine similar aminopyrazole ligands were identified as efficient aggregation retardants whose minimum energy conformations showed a perfect complementarity to a beta-sheet. The concentration dependence of the inhibitory effect of a trimeric aminopyrazole derivative allowed an estimation of the dissociation constant in the range of 10(-5) m. Finally, electrospray ionization mass spectrometry (ESI-MS) was used to determine the aggregation kinetics of Abeta-(1-40) in the absence and in the presence of the ligands. From the comparable decrease in Abeta monomer concentration, we conclude that these beta-sheet ligands do not prevent the initial oligomerization of monomeric Abeta but rather block further aggregation of spontaneously formed small oligomers. Together with the results from density gradient centrifugation and fluorescence correlation spectroscopy it is now possible to restrict the approximate size of soluble Abeta aggregates formed in the presence of both inhibitors from 3- to 15-mers.


Radical perineal prostatectomy in obese patients.
To evaluate the efficacy of radical perineal prostatectomy in obese patients. No study has ever been published providing evidence of success of any type of prostatectomy specifically in patients with significant truncal obesity. A retrospective review of 103 patients who underwent radical perineal prostatectomy between 1996 and 2002 was performed. Obesity is defined as having a body mass index greater than 30 kg/m(2). Seven obese patients were found. The operative time, blood loss, hospital length of stay, perioperative complications, urinary continence, and quality of specimen were assessed. The mean age was 61 years (range 56 to 67). The body mass index ranged between 30.21 and 47.9 (average 39.27). The average operative time and blood loss was 142 minutes and 542 mL, respectively. No complications occurred and no blood transfusions were needed perioperatively. Two specimens had a positive surgical margin. Six (85.7%) of the 7 patients went home on postoperative day 2; the remaining patient left on day 3. The 1-year continence rate was 66%. Radical perineal prostatectomy remains an excellent option for obese patients. It remains to be seen if this is the case with radical retropubic prostatectomy.


A genetic strategy to overcome the senescence of primary meningioma cell cultures.
Even though meningiomas are the second most common brain tumor in adults, little is known about the molecular basis of their growth and development. The lack of suitable cell culture model systems is an impediment to this understanding. Most studies on meningiomas rely on primary, early passage cell lines that eventually senesce or a few established cell lines that have been derived from aggressive variants of meningiomas. We have isolated three primary meningioma cell lines that are negative for telomerase activity. We can overcome the senescence of a Grade III derived meningioma cell line by expressing the telomerase catalytic subunit (hTERT), whereas Grade I meningioma cell lines require the expression of the human papillomavirus E6 and E7 oncogenes in conjunction with hTERT. Meningioma cell lines, immortalized in this manner, maintain their pre-transfection morphology and form colonies in vitro. We have confirmed the meningothelial origin of these cell lines by assessing expression of vimentin and desmoplakin, characteristic markers for meningiomas. Additionally, we have karyotyped these cell lines using array CGH and shown that they represent a spectrum of the genetic diversity seen in primary meningiomas. Thus, these cell lines represent novel cellular reagents for investigating the molecular oncogenesis of meningiomas.


Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis.
To evaluate the effectiveness of antipsychotic medications in preventing and treating delirium. Systematic review and meta-analysis. PubMed, EMBASE, CINAHL, and ClinicalTrials.gov databases were searched from January 1, 1988, to November 26, 2013. Adult surgical and medical inpatients. Antipsychotic administration for delirium prevention or treatment in randomized controlled trials or cohort studies. Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. Heterogeneity was considered as chi-square P < .1 or I(2) > 50%. Using a random-effects model (I(2) > 50%) or a fixed-effects model (I(2) < 50%), odds ratios (ORs) were calculated for dichotomous outcomes (delirium incidence and mortality), and mean or standardized mean difference for continuous outcomes (delirium duration, severity, hospital and intensive care unit (ICU) length of stay (LOS)). Sensitivity analyses included postoperative prevention studies only, exclusion of studies with high risk of bias, and typical versus atypical antipsychotics. Screening of 10,877 eligible records identified 19 studies. In seven studies comparing antipsychotics with placebo or no treatment for delirium prevention after surgery, there was no significant effect on delirium incidence (OR = 0.56, 95% confidence interval (CI) = 0.23-1.34, I(2) = 93%). Using data reported from all 19 studies, antipsychotic use was not associated with change in delirium duration, severity, or hospital or ICU LOS, with high heterogeneity among studies. No association with mortality was detected (OR = 0.90, 95% CI = 0.62-1.29, I(2) = 0%). Current evidence does not support the use of antipsychotics for prevention or treatment of delirium. Additional methodologically rigorous studies using standardized outcome measures are needed.


Linkage analysis of systemic lupus erythematosus induced in diabetes-prone nonobese diabetic mice by Mycobacterium bovis.
Systemic lupus erythematosus induced by Mycobacterium bovis in diabetes-prone nonobese diabetic mice was mapped in a backcross to the BALB/c strain. The subphenotypes-hemolytic anemia, antinuclear autoantibodies, and glomerular immune complex deposition-did not cosegregate, and linkage analysis for each trait was performed independently. Hemolytic anemia mapped to two loci: Bah1 at the MHC on chromosome 17 and Bah2 on distal chromosome 16. Antinuclear autoantibodies mapped to three loci: Bana1 at the MHC on chromosome 17, Bana2 on chromosome 10, and Bana3 on distal chromosome 1. Glomerular immune complex deposition did not show significant linkage to any genomic region. Mapping of autoantibodies (Coombs' or antinuclear autoantibodies) identified two loci: Babs1 at the MHC and Babs2 on distal chromosome 1. It has previously been reported that genes conferring susceptibility to different autoimmune diseases map nonrandomly to defined regions of the genome. One possible explanation for this clustering is that some alleles at loci within these regions confer susceptibility to multiple autoimmune diseases-the "common gene" hypothesis. With the exception of the H2, this study failed to provide direct support for the common gene hypothesis, because the loci identified as conferring susceptibility to systemic lupus erythematosus did not colocalize with those previously implicated in diabetes. However, three of the four regions identified had been previously implicated in other autoimmune diseases.


Is Tayside becoming a Scottish hotspot for Lyme borreliosis?
The epidemiology of Lyme borreliosis (LB) in Tayside was studied and compared with Highland (an area of high endemicity) and the rest of Scotland. From April 2001 to March 2008 the incidence of LB in Tayside rose from an estimated 2.57 to 5.84 per 100,000 population. In 2008/09 the incidence of LB in Tayside increased further to an estimated 13.85 per 100,000 population. This rise was significant and, although numerically less than that in Highland (37.24 to 49.69 per 100,000 population), it was proportionally much larger (137% vs 33%) and confirmed that LB in Tayside has diverged from that in non-endemic Scottish regions. The dramatic rise of LB in Tayside cannot be accounted for by changes in laboratory protocol or changes in the number or demographics of patients tested. However, changes in climatic conditions and alterations in clinical presentations may have contributed to this significant rise.


Salvage radiotherapy for locoregionally recurrent extrahepatic bile duct cancer after radical surgery.
This study evaluated the outcome of salvage radiotherapy for locoregionally recurrent extrahepatic bile duct cancer. We performed a retrospective review of 23 extrahepatic bile duct cancer patients who underwent radiotherapy with or without concomitant chemotherapy for isolated locoregional recurrence after radical surgery between August 2001 and September 2013. The median disease-free interval was 11.8 months. Salvage radiotherapy was delivered to the recurrent tumour with or without initial operation bed up to a median dose of 54 Gy (range, 45-60). 18 patients received concomitant chemotherapy. The median follow-up period was 14.2 months for all patients, and 48.8 months for survivors. The median overall survival and progression-free survival (PFS) were 18.4 (range, 4.4-114.6) and 15.5 months (range, 1.6-114.6), respectively. On multivariate analysis, the use of concomitant chemotherapy was a favourable prognostic factor for PFS (p = 0.027), and prolonged disease-free interval (≥1 year) was associated with a significantly poor overall survival (p = 0.047). Grade 3 or higher toxicities did not occur in follow-up period. Salvage radiotherapy showed promising survival outcomes in locoregional recurrence of extrahepatic bile duct cancer. Our results indicated that concomitant chemotherapy was associated with improved PFS. Concurrent chemoradiotherapy can be a viable salvage treatment option in selected patients. Advances in knowledge: Locoregional recurrence is the most common pattern of failure after radical resection in extrahepatic bile duct cancer. In this study, salvage radiotherapy showed favourable survival outcomes without severe complications in locoregionally recurrent extrahepatic bile duct cancer patients.


Mammalian peroxiredoxin isoforms can reduce hydrogen peroxide generated in response to growth factors and tumor necrosis factor-alpha.
Mammalian tissues express three immunologically distinct peroxiredoxin (Prx) proteins (Prx I, II, and III), which are the products of distinct genes. With the use of recombinant proteins Prx I, II, and III, all have now been shown to possess peroxidase activity and to rely on Trx as a source of reducing equivalents for the reduction of H2O2. Prx I and II are cytosolic proteins, whereas Prx III is localized in mitochondria. Transient overexpression of Prx I or II in cultured cells showed that they were able to eliminate the intracellular H2O2 generated in response to growth factors. Moreover, the activation of nuclear factor kappaB (NFkappaB) induced by extracellularly added H2O2 or tumor necrosis factor-alpha was blocked by overproduction of Prx II. These results suggest that, together with glutathione peroxidase and catalase, Prx enzymes likely play an important role in eliminating peroxides generated during metabolism. In addition, Prx I and II might participate in the signaling cascades of growth factors and tumor necrosis factor-alpha by regulating the intracellular concentration of H2O2.


Glucose and insulin response to a glucose load in Salisbury blacks. Part I. The effect of standards of living.
An oral glucose load was given in 238 Black adult males living in Salisbury, Rhodesia, and their metabolic responses were measured. Also determined were the body mass index and maximum volume of oxygen intake per kilogram body mass during the course of a measured work load. Subjects were stratified into groups by socio-economic status, income and level of formal education. The higher the socio-economic status of Blacks the higher the levels of serum insulin and the body mass index, and the lower the maximum volume of oxygen per kilogram body mass. This trend with serum insulin was statistically independent of duration of urban residence and area of tribal origin. On multiple regression analysis the increase in serum insulin with rise in socio-economic status was independent of age and body mass index and was dependent on the indirect effect of maximum volume of oxygen intake.


Early Caffeine and Weaning from Mechanical Ventilation in Preterm Infants: A Randomized, Placebo-Controlled Trial.
To evaluate in a randomized, double-blind, placebo-controlled trial the effect of early caffeine on the age of first successful extubation in preterm infants. Preterm infants born at 23-30 weeks of gestation requiring mechanical ventilation in the first 5 postnatal days were randomized to receive a 20 mg/kg loading dose followed by 5 mg/kg/day of caffeine or placebo until considered ready for extubation. The placebo group received a blinded loading dose of caffeine before extubation. Infants were randomized to receive caffeine (n = 41) or placebo (n = 42). Age at first successful extubation did not differ between early caffeine (median, 24 days; IQR, 10-41 days) and control groups (median, 20 days; IQR, 9-43 days; P = .7). An interim analysis at 75% enrollment showed a trend toward higher mortality in 1 of the groups and the data safety and monitoring board recommended stopping the trial. Unblinded analysis revealed mortality did not differ significantly between the early caffeine (9 [22%]) and control groups (5 [12%]; P = .22). Early initiation of caffeine in this group of premature infants did not reduce the age of first successful extubation. A nonsignificant trend toward higher mortality in the early caffeine group led to a cautious decision to stop the trial. These findings suggest caution with early use of caffeine in mechanically ventilated preterm infants until more efficacy and safety data become available. ClinicalTrials.gov: NCT01751724.


microRNA signature and expression of Dicer and Drosha can predict prognosis and delineate risk groups in neuroblastoma.
Neuroblastoma is a common childhood tumor and accounts for 15% of pediatric cancer deaths. To investigate the microRNA (miRNA) profile and role of Dicer and Drosha in neuroblastoma, we assessed the expression of 162 human miRNAs, Dicer and Drosha in 66 neuroblastoma tumors by using real-time PCR methods. We found global downregulation of miRNA expression in advanced neuroblastoma and identified 27 miRNAs that can clearly distinguish low- from high-risk patients. Furthermore, expression levels of Dicer or Drosha were low in high-risk neuroblastoma tumors, which accounted for global downregulation of miRNAs in advanced disease and correlated with poor outcome. Notably, for patients with non-MYCN-amplified tumors, low expression of Dicer can serve as a significant and independent predictor of poor outcome (hazard ratio, 9.6; P = 0.045; n = 52). Using plausible neural networks to select a combination of 15 biomarkers that consist of 12 miRNAs' signature, expression levels of Dicer and Drosha, and age at diagnosis, we were able to segregate all patients into four distinct patterns that were highly predictive of clinical outcome. In vitro studies also showed that knockdown of either Dicer or Drosha promoted the growth of neuroblastoma cell lines. Our results reveal that a combination of 15 biomarkers can delineate risk groups of neuroblastoma and serve as a powerful predictor of clinical outcome. Moreover, our findings of growth promotion by silencing Dicer/Drosha implied their potential use as therapeutic targets for neuroblastoma.


Pediatric office emergencies.
Pediatricians regularly see emergencies in the office, or children that require transfer to an emergency department, or hospitalization. An office self-assessment is the first step in determining how to prepare for an emergency. The use of mock codes and skill drills make office personnel feel less anxious about medical emergencies. Emergency information forms provide valuable, quick information about complex patients for emergency medical services and other physicians caring for patients. Furthermore, disaster planning should be part of an office preparedness plan.


Immunologic studies of heart tissue. IV. Serologic reactions with human heart tissue as revealed by immunofluorescent methods: isoimmune, Wassermann, and autoimmune reactions.
Reactions of normal and pathologic sera with heart tissue have been investigated by the immunofluorescent method, with particular reference to presumptive autoantibodies to heart and their differentiation from blood group isoantibodies and Wassermann antibody. In the heart, blood group substances A and B were found distributed in capillary walls, vascular endothelium, and interstitial connective tissue. In surveys of randomly selected sera, isoimmune reactions against tissue blood group substances A and B were noted infrequently. This finding was considered related to the limited sensitivity of fluorescent antibody methods. Heart tissue from blood group O individuals was used for screening of pathologic sera for presence of tissue-reactive factors. Wassermann antibody was found reactive with constituents of myocardial sarcoplasm, of which the major reactant was cardiolipin. Wassermann-positive sera absorbed with beef cardiolipin gave evidence of reaction with other constituents of myofiber sarcoplasm. Sera of patients with rheumatic fever, rheumatic heart disease, rheumatoid arthritis, disseminated lupus, and liver disease frequently showed a marked reactivity with constituents of myofiber sarcoplasm. These serum factors were differentiated from Wassermann antibody. At least three patterns of immunofluorescent staining could be differentiated by the distribution of reactants in the myofiber sarcoplasm. These reactants were extractable with ethanol and methanol but not by acetone. Sera found reactive by immunofluorescence frequently gave positive flocculation and complement-fixation tests with alcohol extracts of human heart. Immunofluorescent tests were best correlated with flocculation reactions. Sarcoplasmic-reactive factors were associated in some sera with 19S gamma globulin as demonstrated by the use of fluorescent anti-19S gamma globulin. Serologic reactions with homologous or autologous heart were observed particularly frequently with sera from rheumatic patients approximately 2 weeks following cardiac surgery, as well as in some non-rheumatic patients following cardiac or thoracic surgery or acute myocardial infarction. The pathogenetic significance of these presumptive autoantibodies to heart is unknown. As yet, no definite conclusions may be drawn regarding their relationship to bound gamma globulin in rheumatic hearts or to the postcardiotomy and post-infarction syndromes.


Determination of mycobacterial phylogeny on the basis of immunological relatedness of superoxide dismutases.
Sixteen strains of cultivable mycobacteria were grown in Sauton's medium, and Mycobacterium leprae was purified from armadillo liver. Cell extracts were prepared from log-phase growths of each of the cultivable mycobacterial strains. Superoxide dismutase (SOD) enzyme was purified from all cultivable mycobacterial strains included in the study, and antibodies against purified SOD enzyme were raised in rabbits. Immunological distances (ImDs) between these anti-SOD antibodies and SOD antigens were determined by a previously described immunoprecipitation method and by a recently developed enzyme-linked immunosorbent assay (ELISA) technique. The reciprocal ImDs among mycobacterial strains were constant, reproducible and consistent by these two methods. An evolutionary tree was constructed on the basis of estimated ImDs. Except for M. duvalii and M. terrae, slowly and rapidly growing mycobacterial species appeared to be separately grouped by this analysis. Rapid growers clustered into a group which is near that of some slow-growing mycobacteria. M. avium falls almost in the middle of the evolutionary tree and the position of M. leprae was found to be between those of M. avium and M. bovis BCG. Measurement of immunological relatedness of SODs provides an alternative system with which to study the taxonomical relatedness among mycobacteria.


[Quantitative patterns of tubocurarine action on the synaptic potentials of frog muscle].
The dependence of amplitude of synaptic potentials (EPP and mEPP) upon the d-tubocurarine concentration was studied in the frog cutaneous pectoral muscle. In the presence of d-tubocurarine up to 5 x 10(-7) M, the amplitude of EPP and mEPP decreased to the extent which strictly followed competitive action of d-tubocurarine. At a higher concentration, the inhibition of synaptic potentials was stronger than would be expected assuming that d-tubocurarine can only act as a competitive antagonist.


Communicating about opioids for chronic pain: a qualitative study of patient attributions and the influence of the patient-physician relationship.
Chronic pain poses numerous challenges for patients and providers, particularly when opioid treatment is discussed. Despite accounts of antagonistic patient-provider communication, little is known about how communication about opioids unfolds during clinic visits and, importantly, how the relationship history of a patient and physician shapes this communication. This study's objective was to advance understanding of communication about opioid treatment by recording primary care clinic visits and conducting in-depth interviews with patients to gain insight into the patient–provider relationship and its influence on clinical communication. Forty patients with chronic pain were audio recorded during their primary care clinic appointments and then interviewed about their pain care and relationships with their providers. Ten patients were excluded from analysis because pain was not discussed during the clinic visit. Qualitative analysis revealed that patients responded in markedly different ways to similar physician treatment decisions about opioids. Some patients attributed limiting or denying opioids to physicians' distrust or lack of caring. Others attributed these limitations to acting out of genuine concern for patients' health. These attributions appeared to be shaped by features of the patient–physician relationship as described by patients. Results are discussed within the framework of attribution theory. Understanding how patients and providers discuss opioid treatment is critical for optimal pain treatment. Physicians might be able to improve communication by re-framing treatment discussions about opioids around external factors, such as benefits and harms, and engaging in communication that fosters a strong therapeutic alliance and emphasizes concern for the patient.


Written versus verbal consent: a qualitative study of stakeholder views of consent procedures used at the time of recruitment into a peripartum trial conducted in an emergency setting.
Obtaining prospective written consent from women to participate in trials when they are experiencing an obstetric emergency is challenging. Alternative consent pathways, such as gaining verbal consent at enrolment followed, later, by obtaining written consent, have been advocated by some clinicians and bioethicists but have received little empirical attention. We explored women's and staff views about the consent procedures used during the internal pilot of a trial (GOT-IT), where the protocol permitted staff to gain verbal consent at recruitment. Interviews with staff (n = 27) and participating women (n = 22). Data were analysed thematically and interviews were cross-compared to identify differences and similarities in participants' views about the consent procedures used. Women and some staff highlighted benefits to obtaining verbal consent at trial enrolment, including expediting recruitment and reducing the burden on those left exhausted by their births. However, most staff with direct responsibility for taking consent expressed extreme reluctance to proceed with enrolment until they had obtained written consent, despite being comfortable using verbal procedures in their clinical practice. To account for this resistance, staff drew a strong distinction between research and clinical care and suggested that a higher level of consent was needed when recruiting into trials. In doing so, staff emphasised the need to engage women in reflexive decision-making and highlighted the role that completing the consent form could play in enabling and evidencing this process. While most staff cited their ethical responsibilities to women, they also voiced concerns that the absence of a signed consent form at recruitment could expose them to greater risk of litigation were an individual to experience a complication during the trial. Inexperience of recruiting into peripartum trials and limited availability of staff trained to take consent also reinforced preferences for obtaining written consent at recruitment. While alternative consent pathways have an important role to play in advancing emergency medicine research, and may be appreciated by potential recruits, they may give rise to unintended ethical and logistical challenges for staff. Staff would benefit from training and support to increase their confidence and willingness to recruit into trials using alternative consent pathways. This qualitative research was undertaken as part of the GOT-IT Trial (trial registration number: ISCRTN 88609453 ). Date of registration 26/03/2014.


Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I.
The summary presented herein represents Part I of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline. Part I outlines the appropriate evaluation of the male in an infertile couple. Recommendations proceed from obtaining an appropriate history and physical exam (Appendix I), as well as diagnostic testing, where indicated. The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed®, Embase®, and Medline from January, 2000 through May, 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1[Table: see text]). This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology. This Guideline provides updated, evidence-based recommendations regarding evaluation of male infertility as well as the association of male infertility with other important health conditions. The detection of male infertility increases the risk of subsequent development of health problems for men. In addition, specific medical conditions are associated with some causes for male infertility. Evaluation and treatment recommendations are summarized in the associated algorithm (figure[Figure: see text]). The presence of male infertility is crucial to the health of patients and its effects must be considered for the welfare of society. This document will undergo updating as the knowledge regarding current treatments and future treatment options continues to expand.


[A Case of Metastatic Colorectal Cancer with HER2 Overexpression/Amplification].
We report a case of panitumumab-resistant rectal cancer with HER2 gene amplification detected by CancerPlex®. A 51- year-old man was diagnosed with an obstructive rectal cancer having lung and adrenal metastases. He underwent the Hartmann 's operation, and KRAS mutations were not detected. After the surgery, 3 courses of CapeOx plus bevacizumab were administered as first-line chemotherapy; however, the lung and adrenal metastases progressed. Subsequently, 24 courses of IRIS/panitumumab was administered as second-line chemotherapy, and the metastases slowly progressed. Six courses of regorafenib were administered as third-line chemotherapy followed by a course of TAS-102 as fourth-line chemotherapy. Subsequently, a left femoral head metastasis and cerebellar metastases were detected. The patient received best supportive care including palliative femoral head replacement and stereotactic irradiation for the cerebellar metastases, and he died of cancer 3 years 5 months after the primary surgery. The comprehensive genomic analysis focusing on 413 cancer-related genes with CancerPlex®revealed that EGFR, BRAF, KRAS, NRAS, and HRAS had no mutations; however, ERBB2 amplification was detected. Furthermore, immunohistochemical staining revealed overexpression of HER2 protein in both the primary and bone metastatictumor. HER2 and EGFR independently promote the RAS-RAF-MAPK pathway. In the present case, the efficacy of anti-EGFR therapy may be attenuated because of ERBB2 amplification in the metastatic tumor.


Pre-clinical toxicity of a combination of berberine and 5-aminosalicylic acid in mice.
Our previous study demonstrated that a combination of alternative medicine berberine and conventional 5-aminosalicylic acid (5-ASA) showed promise to be a novel therapeutic strategy for ulcerative colitis (UC). This present study aims to sketch the pre-clinical toxicity profile of this combination (1:10 dose ratio) on mice. In acute toxicity test, the determined median lethal dose (LD50) was 278.7 mg/kg berberine plus 2787 mg/kg 5-ASA. The results from subacute toxicity test demonstrated that no toxic signs of clinical symptoms, no significant changes in hematological or biochemical parameters were detected in mice treated with 14 + 140, 28 + 280 or 56 + 560 mg/kg of berberine plus 5-ASA treatment. Histological examinations revealed that accompanied with an increase in spleen weight, frequently recorded enlargement and white pulp hyperplasia of spleen were detected in mice when exposed to three doses of combination treatments. Further in vitro assessment suggested that the spleen toxicity was originated from berberine by its inhibition in cell viability and cell proliferation of lymphocytes. The results of this study indicate that the combination of berberine and 5-ASA shows a slight toxic effect on spleen, suggesting that this combination should be used with caution for patients.


Ideas in pathology. Pivotal role of increased cell proliferation in human carcinogenesis.
Cancer develops secondary to multiple genetic events. Each time a cell divides there is a rare chance that a genetic error related to the carcinogenic process will occur. Thus, environmental agents or disease processes that produce sustained increased cell proliferation can enhance the likelihood of cancer development by providing additional cell divisions, each with an opportunity for spontaneous genetic error. Studies of hereditary cancers and of various DNA-damaging agents, such as radiation and certain viruses and chemicals, have provided insight into identification of the essential genes, but many examples of carcinogenesis in humans do not involve direct DNA damage. Also, most preneoplastic lesions in human carcinogenesis show increased proliferation compared with normal tissues, whether from increased mitotic rate, blocked differentiation, prolonged cell survival, or other mechanisms. Selected examples of proliferation-related carcinogenesis are described, including certain infectious agents, defective immune surveillance, hormonal imbalances, chronic inflammatory-regenerative processes, and exposure to various chemicals. A common biologic mechanism for these diverse stimuli is increased cell proliferation as a prelude to cancer. This mechanism seems essential to the genesis of many cancers in humans.


Reactivity of (ferrocenylmethyl)phosphine toward palladium and platinum chlorides. X-ray structure of [Pd(PH2CH2Fc)Cl(mu-PHCH2Fc)]4 (Fc = ferrocenyl), a unique complex containing a Pd4P4 cycle.
The reaction of 2 equiv of the air-stable primary phosphine (ferrocenylmethyl)phosphine (PH2CH2Fc, 1) with [Pd(cod)Cl2] (Fc = ferrocenyl; cod = 1,5-cyclooctadiene) at 298 K gave the phosphanido-bridged Pd(II) tetramer [Pd(PH2CH2Fc)Cl(mu-PHCH2Fc)]4 (2), which shows an unprecedented arrangement of four Pd atoms embedded in an eight-membered Pd4P4 ring. An X-ray diffraction study showed that 2 crystallizes in the triclinic space group P with a = 17.607(7) A, b = 17.944(7) A, c = 18.792(7) A, alpha = 107.120(12) degrees, beta = 96.344(13) degrees, gamma = 117.087(15) degrees . Each molecule contains four palladium atoms in a distorted square-planar coordination formed by one chlorine and three phosphorus atoms. Two of the latter belong to bridging primary phosphanides and the remaining one is contributed by a terminal PH2CH2Fc ligand. The coordination environments of neighboring metal centers adopt an almost perpendicular mutual orientation. The reaction of 2 equiv of 1 with [Pt(cod)Cl2] at 323 K yielded the analogous Pt(II) tetramer of formula [Pt(PH2CH2Fc)Cl(mu-PHCH2Fc)]4 (3), which was fully characterized by multinuclear and dynamic NMR, IR, and elemental analyses. Single-crystal X-ray diffraction on 3 confirmed the tetranuclear arrangement in the solid state, but orientational disorder of the molecule precludes a more detailed discussion of the structure. Low-temperature NMR experiments in CD2Cl2 showed the presence of two slowly interconnecting conformers. Reaction of 1 and [M(cod)Cl2] (M = Pd or Pt) at lower temperatures (273 K for Pd, 295 K for Pt) in dichloromethane allowed the detection in solution of the mononuclear species cis-[M(PH2CH2Fc)2Cl2] (M = Pd, 4; M = Pt, 5) which, upon heating, transformed into the tetramers 2 and 3, respectively. Solid samples of 4 and 5 could be isolated after workup at low temperature and were characterized by conventional spectroscopic methods.


Promoting healthy diet and exercise patterns amongst primary school children: a qualitative investigation of parental perspectives.
Parents represent a potentially powerful intermediary in behaviour change strategies aimed at improving the lifestyle behaviours of young children. However, to fulfil this role, parents need to have the necessary knowledge and motivation to assimilate dietary guidelines. This study aimed to assess these psychosocial constructs, and subsequent parental receptiveness to nutrition education, through investigation of the barriers and benefits perceived by parents to the provision of a healthy diet and adequate exercise for their children. A qualitative methodology was employed and 41 parents took part in seven focus groups separated by socio-economic status (SES). Across the groups, a combination of reported external barriers and unconscious internal barriers, stemming from high optimistic bias, low perceived control and unrealistic health expectations, were observed. SES differences were suggested in restrictive feeding practices, the responsibility attributed to the school and in the level and format of desired nutrition education. Overall a demand for interventions focusing on behavioural techniques rather than fact transmission was uncovered, in particular the promotion of parental self-awareness to reduce negative influences within the family food environment. Providing realistic definitions of appropriate behaviour and empowering parents to tackle children's weight issues were indicated as important targets for future education programmes.


Interactive web-based pulmonary rehabilitation programme: a randomised controlled feasibility trial.
The aim of this study was to determine if an interactive web-based pulmonary rehabilitation (PR) programme is a feasible alternative to conventional PR. Randomised controlled feasibility trial. Participants with a diagnosis of chronic obstructive pulmonary disease were recruited from PR assessments, primary care and community rehabilitation programmes. Patients randomised to conventional rehabilitation started the programme according to the standard care at their referred site on the next available date. 103 patients were recruited to the study and randomised: 52 to conventional rehabilitation (mean (±SD) age 66 (±8) years, Medical Research Council (MRC) 3 (IQR2-4)); 51 to the web arm (mean (±SD) age 66 (±10) years, MRC 3 (IQR2-4)). Participants had to be willing to participate in either arm of the trial, have internet access and be web literate. Patients randomised to the web-based programme worked through the website, exercising and recording their progress as well as reading educational material. Conventional PR consisted of twice weekly, 2 hourly sessions (an hour for exercise training and an hour for education). Recruitment rates, eligibility, patient preference and dropout and completion rates for both programmes were collected. Standard outcomes for a PR assessment including measures of exercise capacity and quality of life questionnaires were also evaluated. A statistically significant improvement (p≤0.01) was observed within each group in the endurance shuttle walk test (WEB: mean change 189±211.1; PR classes: mean change 184.5±247.4 s) and Chronic Respiratory disease Questionnaire-Dyspnoea (CRQ-D; WEB: mean change 0.7±1.2; PR classes: mean change 0.8±1.0). However, there were no significant differences between the groups in any outcome. Dropout rates were higher in the web-based programme (57% vs 23%). An interactive web-based PR programme is feasible and acceptable when compared with conventional PR. Future trials maybe around choice-based PR programmes for select patients enabling stratification of patient care. ISRCTN03142263; Results.


Contribution of Kv7 channels to basal coronary flow and active response to ischemia.
The goal of the present study was to determine the role of KCNQ-encoded Kv channels (Kv7 channels) in the passive and active regulation of coronary flow in normotensive and hypertensive rats. In left anterior descending coronary arteries from normotensive rats, structurally different Kv7.2 to 7.5 activators produced relaxations, which were considerably less in arteries from hypertensive rats and were not mimicked by the Kv7.1-specific activator R-L3. In isolated, perfused heart preparations, coronary flow rate increased in response to the Kv7.2 to 7.5 activator (S)-1 and was diminished in the presence of a Kv7 inhibitor. The expression levels of KCNQ1-5 and their known accessory KCNE1-5 subunits in coronary arteries were similar in normotensive and hypertensive rats as measured by quantitative polymerase chain reaction. However, Kv7.4 protein expression was reduced in hypertensive rats. Application of adenosine or A2A receptor agonist CGS-21680 produced concentration-dependent relaxations of coronary arteries from normotensive rats, which were attenuated by application of Kv7 inhibitors. Kv7 blockers also attenuated the ischemia-induced increase in coronary perfusion in Langendorff studies. Overall, these data establish Kv7 channels as crucial regulators of coronary flow at resting and after hypoxic insult.


Adjustments in fatty acid composition is a mechanism that can explain resilience to marine heatwaves and future ocean conditions in the habitat-forming seaweed Phyllospora comosa (Labillardière) C.Agardh.
Marine heatwaves are extreme events that can have profound and lasting impacts on marine species. Field observations have shown seaweeds to be highly susceptible to marine heatwaves, but the physiological drivers of this susceptibility are poorly understood. Furthermore, the effects of marine heatwaves in conjunction with ocean warming and acidification are yet to be investigated. To address this knowledge gap, we conducted a laboratory culture experiment in which we tested the growth and physiological responses of Phyllospora comosa juveniles from the southern extent of its range (43-31°S) to marine heatwaves, ocean warming and acidification. We used a 'collapsed factorial design' in which marine heatwaves were superimposed on current (today's pH and temperature) and future (pH and temperature projected by 2100) ocean conditions. Responses were tested both during the heatwaves, and after a 7-day recovery period. Heatwaves reduced net photosynthetic rates in both current and future conditions, while respiration rates were elevated under heatwaves in the current conditions only. Following the recovery period, there was little evidence of heatwaves having lasting negative effects on growth, photosynthesis or respiration. Exposure to heatwaves, future ocean conditions or both caused an increase in the degree of saturation of fatty acids. This adjustment may have counteracted negative effects of elevated temperatures by decreasing membrane fluidity, which increases at higher temperatures. Furthermore, P. comosa appeared to down-regulate the energetically expensive carbon dioxide concentrating mechanism in the future conditions with a reduction in δ13 C values detected in these treatments. Any saved energy arising from this down-regulation was not invested in growth and was likely invested in the adjustment of fatty acid composition. This adjustment is a mechanism by which P. comosa and other seaweeds may tolerate the negative effects of ocean warming and marine heatwaves through benefits arising from ocean acidification.


Respiration-dependent efflux of magnesium ions from heart mitochondria.
Energy-linked respiration causes a net movement of Mg2+ between rat heart mitochondria and the ambient medium. When the extramitochondrial concontration of Mg2+ is less that about 2.5 mM the net movement of Mg2+ constitutes an efflux, whereas a net influx of Mg2+ occurs when the external concentration of Mg2+ is greater than this. Both the efflux and the influx are induced to only a very small degree by externally added ATP. Evidence suggests that Pi may be required for the respiration-induced efflux of Mg2+.


Data model for the collaboration between land administration systems and agricultural land parcel identification systems.
The Common Agricultural Policy (CAP) of the European Union (EU) has dramatically changed after 1992, and from then on the CAP focused on the management of direct income subsidies instead of production-based subsidies. For this focus, Member States (MS) are expected to establish Integrated Administration and Control System (IACS), including a Land Parcel Identification System (LPIS) as the spatial part of IACS. Different MS have chosen different solutions for their LPIS. Currently, some MS based their IACS/LPIS on data from their Land Administration Systems (LAS), and many others use purpose built special systems for their IACS/LPIS. The issue with these different IACS/LPIS is that they do not have standardized structures; rather, each represents a unique design in each MS, both in the case of LAS based or special systems. In this study, we aim at designing a core data model for those IACS/LPIS based on LAS. For this purpose, we make use of the ongoing standardization initiatives for LAS (Land Administration Domain Model: LADM) and IACS/LPIS (LPIS Core Model: LCM). The data model we propose in this study implies the collaboration between LADM and LCM and includes some extensions. Some basic issues with the collaboration model are discussed within this study: registration of farmers, land use rights and farming limitations, geometry/topology, temporal data management etc. For further explanation of the model structure, sample instance level diagrams illustrating some typical situations are also included.


Endoneurial oxygen tension and radial topography in nerve edema.
Endoneurial edema occurs in numerous human and experimental neuropathies. We tested the hypothesis that the resultant increase in intercapillary distance (ICD) may result in endoneurial hypoxia. Experimental galactose neuropathy (EGN) was chosen since in this model, edema is due to the accumulation of galactitol, which does not directly damage nerve fibers, so that it was possible to study the role of endoneurial edema alone. We measured endoneurial oxygen tensions (PnO2) using oxygen-sensitive microelectrodes and related PnO2 radial topography to ICD. We also determined local oxygen consumption (VLO2) and critical PnO2(PcritO2). EGN and age-matched controls were studied at 4 months. (1) Caudal nerve conduction velocity was reduced in EGN. (2) The PnO2 values were reduced in EGN and the PnO2 histogram was shifted into the hypoxic range. These changes were paralleled by a significant increase in ICD in EGN. (3) The radial topography of PnO2 in EGN differed from the relatively uniform distribution in control nerves. In EGN the subperineurial PnO2 was significantly lower than the PnO2 at the center of the fascicle. These changes were paralleled by a significantly greater increase in ICD in the periphery. (4) That the PnO2 reduction in EGN was significant is suggested by the marked reduction in VLO2 and the large percentage (greater than 75%) of intrafascicular regions that fell below PcritO2 in EGN.


[Indexes of immunity and local protection in humans with intestine dysbacteriosis].
Study indexes of immunity and local protection in humans with intestine dysbacteriosis. Qualitative and quantitative intestine microbiocenosis, content of gamma-interferon (EIA method) in coprofiltrates in 204 individuals were studied, data from immunograms of 123 individuals with bacteriologically confirmed dysbacteriosis were analyzed. The presence of immune deficiency mainly by T-cell type was established in 92.7+/-2.4% of individuals with intestine dysbacteriosis. Significant variations in -interferon content in coprofiltrates of examined individuals was detected (from no less than 5 pcg/ml to 240 pcg/ml), a statistically significant dependence of gamma-interferon content in coprofiltrates on the number of opportunistic microbes and atypical escherichia (including hemolytic) in intestine microbiocenosis was determined. The presence of T-cell type immune deficiency in individuals with intestine dysbacteriosis combined with a reduced local protection, and the content of gamma-interferon in coprofiltrates gives evidence not only on the reduction of local protection but also to some extent mirrors the degree of this reduction.


Highly compliant biomimetic scaffolds for small diameter tissue-engineered vascular grafts (TEVGs) produced via melt electrowriting (MEW).
Biofabrication approaches toward the development of tissue-engineered vascular grafts (TEVGs) have been widely investigated. However, successful translation has been limited to large diameter applications, with small diameter grafts frequently failing due to poor mechanical performance, in particular mismatched radial compliance. Herein, melt electrowriting (MEW) of poly(ϵ-caprolactone) has enabled the manufacture of highly porous, biocompatible microfibre scaffolds with physiological anisotropic mechanical properties, as substrates for the biofabrication of small diameter TEVGs. Highly reproducible scaffolds with internal diameter of 4.0 mm were designed with 500 and 250µm pore sizes, demonstrating minimal deviation of less than 4% from the intended architecture, with consistent fibre diameter of 15 ± 2µm across groups. Scaffolds were designed with straight or sinusoidal circumferential microfibre architecture respectively, to investigate the influence of biomimetic fibre straightening on radial compliance. The results demonstrate that scaffolds with wave-like circumferential microfibre laydown patterns mimicking the architectural arrangement of collagen fibres in arteries, exhibit physiological compliance (12.9 ± 0.6% per 100 mmHg), while equivalent control geometries with straight fibres exhibit significantly reduced compliance (5.5 ± 0.1% per 100 mmHg). Further mechanical characterisation revealed the sinusoidal scaffolds designed with 250µm pores exhibited physiologically relevant burst pressures of 1078 ± 236 mmHg, compared to 631 ± 105 mmHg for corresponding 500µm controls. Similar trends were observed for strength and failure, indicating enhanced mechanical performance of scaffolds with reduced pore spacing. Preliminaryin vitroculture of human mesenchymal stem cells validated the MEW scaffolds as suitable substrates for cellular growth and proliferation, with high cell viability (>90%) and coverage (>85%), with subsequent seeding of vascular endothelial cells indicating successful attachment and preliminary endothelialisation of tissue-cultured constructs. These findings support further investigation into long-term tissue culture methodologies for enhanced production of vascular extracellular matrix components, toward the development of the next generation of small diameter TEVGs.


Impact of COVID-19 on clinical outcomes for patients with fractured hip: a multicentre observational cohort study.
There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic. We completed a multicentre cohort study across ten hospitals in England. Data were collected from 1 March 2020 to 6 April 2020, during which period the World Health Organization (WHO) declared COVID-19 to be a pandemic. Patients ≥ 60 years of age admitted with hip fracture and a minimum follow-up of 30 days were included for analysis. Primary outcome of interest was mortality at 30 days post-surgery or postadmission in nonoperative patients. Secondary outcomes included length of hospital stay and discharge destination. In total, 404 patients were included for final analysis with a COVID-19 diagnosis being made in 114 (28.2%) patients. Overall, 30-day mortality stood at 14.4% (n = 58). The COVID-19 cohort experienced a mortality rate of 32.5% (37/114) compared to 7.2% (21/290) in the non-COVID cohort (p < 0.001). In adjusted analysis, 30-day mortality was greatest in patients who were confirmed to have COVID-19 (odds ratio (OR) 5.64, 95% confidence interval (CI) 2.95 to 10.80; p < 0.001) with an adjusted excess risk of 20%, male sex (OR 2.69, 95% CI 1.37 to 5.29; p = 0.004) and in patients with ≥ two comorbidities (OR 4.68, CI 1.5 to 14.61; p = 0.008). Length of stay was also extended in the COVID-19 cohort, on average spending 17.6 days as an inpatient versus 12.04 days in the non-COVID-19 group (p < 0.001). This study demonstrates that patients who sustain a neck of femur fracture in combination with COVID-19 diagnosis have a significantly higher risk of mortality than would be normally expected.Cite this article: Bone Joint Open 2020;1-11:697-705.


Experience with a second language affects the use of fundamental frequency in speech segmentation.
This study investigates whether listeners' experience with a second language learned later in life affects their use of fundamental frequency (F0) as a cue to word boundaries in the segmentation of an artificial language (AL), particularly when the cues to word boundaries conflict between the first language (L1) and second language (L2). F0 signals phrase-final (and thus word-final) boundaries in French but word-initial boundaries in English. Participants were functionally monolingual French listeners, functionally monolingual English listeners, bilingual L1-English L2-French listeners, and bilingual L1-French L2-English listeners. They completed the AL-segmentation task with F0 signaling word-final boundaries or without prosodic cues to word boundaries (monolingual groups only). After listening to the AL, participants completed a forced-choice word-identification task in which the foils were either non-words or part-words. The results show that the monolingual French listeners, but not the monolingual English listeners, performed better in the presence of F0 cues than in the absence of such cues. Moreover, bilingual status modulated listeners' use of F0 cues to word-final boundaries, with bilingual French listeners performing less accurately than monolingual French listeners on both word types but with bilingual English listeners performing more accurately than monolingual English listeners on non-words. These findings not only confirm that speech segmentation is modulated by the L1, but also newly demonstrate that listeners' experience with the L2 (French or English) affects their use of F0 cues in speech segmentation. This suggests that listeners' use of prosodic cues to word boundaries is adaptive and non-selective, and can change as a function of language experience.


Organisation of the bph gene cluster of transposon Tn4371, encoding enzymes for the degradation of biphenyl and 4-chlorobiphenyl compounds.
Tn4371 is a 55 kb transposon which encodes enzymes for the degradation of biphenyl and 4-chlorobiphenyl compounds into benzoate and 4-chlorobenzoate derivatives. We constructed a cosmid library of Tn4371 DNA. The bph genes involved in biphenyl/4-chlorobiphenyl degradation were found to be clustered in the middle of the transposon. Sequencing revealed an organisation of the bph genes similar to that previously found in Pseudomonas sp. KKS102, i.e. the bphEGF genes are located upstream of bphA1A2A3 and bphA4 is separated from bphA1A2A3 by bphBCD. Consensus sequences for sigma54-associated RNA polymerase were found upstream of bphA1 and bphEGF. Plasmid RP4::Tn4371 was transferred into a mutant of Alcaligenes eutrophus H16 lacking sigma54. In contrast to wild-type H16 exconjugants, the sigma54 mutant exconjugants could not grow on biphenyl, indicating the dependence of Tn4371 bph gene expression on sigma54. The Tn4371-encoded bph pathway was activated when biphenyl and various biphenyl-like compounds were present in the growth medium. Preliminary observations indicate the presence of a region outside the catabolic genes downstream of bphA4 which is involved in mediating at least the basal expression of BphC.


Studies on a proteolytic enzyme in human plasma; the relationship between the proteolytic activity of plasma and blood coagulation.
A fraction of globulin was prepared from human plasma which was deficient in prothrombin, thrombin, fibrinogen, plasma thromboplastin, and accelerator globulin. The preparation of globulin contained considerable potential proteolytic activity which could be activated by streptococcal fibrinolysin. This fraction of globulin accelerated the clotting of normal platelet-deficient plasma. However, the clot-accelerating effect of the globulin fraction was the same whether or not its proteolytic property had been activated. The addition of streptococcal fibrinolysin to normal platelet-deficient plasma did not accelerate coagulation. Nor did the addition of streptococcal fibrinolysin to hemophilic platelet-deficient plasma promote its coagulation. The data presented suggest that proteolysis by activated plasma proteolytic enzyme is not an essential stage in the coagulation of the blood.


Analytical magnetapheresis of magnetically susceptible particles.
Analytical magnetapheresis is a newly developed technique for analyzing magnetic particles. The magnetically susceptible particles form deposition patterns after flowing through a separation channel in a magnetic field. The separation channel requirements for analytical magnetapheresis are an excellent seal for the carrier flow and ease of disassembly after magnetapheresis. Previously used separation channels often exhibit variable channel leakage and unstable flow velocities. We improved the separation channel assembly to ensure stable, high flow velocities and characterized the system with various magnetically susceptible and labeled particles. Our new separation channel featured silicone sealant with embedded nylon wires and met analytical magnetapheresis requirements. Characterization of this system was performed using several magnetically susceptible particles, and we studied a variety of diamagnetic sample labels with paramagnetic ions and magnetically susceptible particles at different flow-rates and solution pH values. The minimal labeling concentration for complete deposition was determined to be approximately 2.50 x 10(10) ions per particle for test samples at a flow velocity of 0.67 mm s(-1) and a magnetic field gradient of 2.8 T mm(-1). Silicas, yeasts and blood cells were used for these studies. We determined that the minimal difference in magnetic susceptibility (delta(chi)) for successful separation was approximately 2.00 x 10(-6) [SI]. The magnetic susceptibilities of Dynabeads M-450 at several separation distances and flow-rates were determined to be 0.25 [SI], within 2% of values published by other workers. The magnetic susceptibilities of various ion-labeled yeasts and cells were determined and most varied by less than 5% at different flow-rates. The results of this study provide very important references for analytical magnetapheresis applications.


Longer breastfeeding duration reduces the positive relationships among gestational weight gain, birth weight and childhood anthropometrics.
The relationship between gestational weight gain (GWG) and childhood growth remains controversial. An examination on whether infant feeding practices mediate this relationship may improve our understanding of it. We investigated whether the relationships among GWG, birth weight and childhood anthropometrics were mediated through infant feeding practices (breastfeeding duration and age at introduction of solid foods) in a cross-sectional multiethnic study of 1387 mothers and their children aged 0-5.9 years in the USA (2011-2012). Child anthropometrics included age-specific and sex-specific z-scores for weight-for-age (WAZ), height/length-for-age (HAZ), weight-for-height/length (WHZ) and body mass index-for-age (BMIZ); and ulnar length, a marker for limb growth. We used structural equation modelling to calculate standardised path coefficients and total, direct and indirect associations of GWG, birth weight and infant feeding practices with child anthropometrics. Maternal GWG had a positive indirect association with all anthropometrics mediated via birth weight, whereas longer breastfeeding duration reduced the positive associations of GWG and birth weight with WAZ, WHZ and BMIZ in non-Hispanics (β=-0.077, -0.064 and -0.106, respectively). Longer breastfeeding duration and introducing solid foods at a later age were positively associated with ulnar length (β=0.023 and 0.030, respectively) but not HAZ, suggesting a distinct association, for the first time, with limb growth. Findings suggest that promoting longer breastfeeding duration among women with excessive GWG who had high birthweight newborns may mitigate the potential for their offspring to develop obesity. In addition, findings reinforce the importance of promoting appropriate GWG and preventing high birth weight, which are positively associated with childhood anthropometrics.


Combination of DNA repair gene single nucleotide polymorphisms and increased levels of DNA adducts in a population-based study.
Inherited single nucleotide polymorphisms (SNPs) of DNA repair genes may contribute to variations in DNA repair capacity and susceptibility to cancer. We investigated the role of SNPs in three DNA repair genes (X-ray repair cross-complementing group 1-Arg399Gln, exon 10; X-ray repair cross-complementing group 3-Thr241Met, exon 7; and xeroderma pigmentosum-D-Lys751Gln, exon 23) and their combination, in modulating the levels of "bulky" DNA adducts in a population sample of 628 Italian healthy individuals belonging to the prospective European project "European Prospective Investigation into Cancer and Nutrition." DNA-adduct levels were measured as relative adduct level per 10(9) nucleotides by (32)P-post DNA labeling assay in WBCs from peripheral blood. Genotyping was performed by PCR-RFLP analysis or primer extension/denaturing high-performance liquid chromatography technique. We found a dose-response relationship between the number of at-risk alleles and levels of adducts (P = 0.0046). Individuals with at least three variant alleles had a statistically significant odds ratio (OR) for being in the highest tertile of adducts compared with those with undetectable adducts [three alleles, adjusted OR = 5.07, 95% confidence interval (CI) = 1.29-19.9; four alleles, adjusted OR = 5.03, 95% CI = 1.18-21.45; five alleles, adjusted OR = 7.65, 95% CI = 0.94-62.2]. Our study suggests that the combined effect of multiple variant alleles may be more important than the investigation of single SNP in modulating DNA repair capacity.


[The cares and anxiety of those involved in the Bijlmermeer aviation disaster did not diminish following the medical investigations].
On October 4, 1992 a cargo jet crashed in the Bijlmermeer district in Amsterdam, the Netherlands, killing 43 people and making hundreds homeless. Many years of confusion and prolonged media attention followed, including public debates and even a Parliamentary Inquiry as to the causes, exposure to various chemical, physical and biological risk factors, and related diseases. Two comprehensive large-scale medical investigations were carried out: a comparative epidemiological study analysing the long-term effects in involved and uninvolved care providers, and an individual medical examination of both residents and care providers with medical or psychological complaints. Later, an effects study was added analysing the effects of both medical investigations on the feelings of anxiety and the attribution of symptoms among the people involved. The epidemiological study revealed more physical and mental symptoms among the involved care providers. Blood, urine and saliva tests, however, revealed no differences. Although the studywas carried out with great care, the findings may have been biased to some extent by an evoked feeling of anxiety and by attention toward health problems brought about by the investigation itself. Another comment is the technical impossibility of stating, after so long a delay, that chemical exposure, e.g. to depleted uranium, could not have been a cause of adverse health effects. The effects study demonstrated that the medical investigations generally did not provide reassurance or decrease the anxiety about health problems. There was even a small increase in complaints. Residents with health problems that had been involved in the disaster still attribute their complaints to harmful chemical exposure.


[Myocardial protection during coronary artery bypass surgery while off-pump].
Myocardial protection during off-pump coronary artery bypass surgery (OPCAB) is a multifactorial problem and choice of graft sequence, maintenance of stable systemic hemodynamics are of central importance. New devices for atraumatic stabilization of the heart and visualization of coronary anastomoses allow grafting of all coronary arteries without cardiopulmonary bypass. Perfusion-assisted direct coronary artery bypass (PADCAB) techniques, in which coronary perfusion is independent of systemic arterial pressure, can eliminate unstable hemodynamic and improve myocardial protection during complex, multivessel OPCAB.


Methylumbelliferyl-beta-D-glucuronide-based medium for rapid isolation and identification of Escherichia coli.
Escherichia coli is the most common gram-negative microbe isolated and identified in clinical microbiology laboratories. It can be identified within 1 h by oxidase, indole, lactose, and beta-glucuronidase tests. The oxidase and indole tests are performed as spot tests, and lactose fermentation is read directly from MacConkey agar. It was found that 4-methylumbelliferyl-beta-D-glucuronide could be incorporated directly into a modified MacConkey agar to directly detect the presence of beta-glucuronidase. Other characteristics of MacConkey agar were not affected. The incorporation of 4-methylumbelliferyl-beta-D-glucuronide into modified agar obviated the need for manufacture, quality control, and incubation of reagent-containing test tubes. The time needed to identify E. coli strains was reduced from 1 h to 5 min, and the ability to detect this species in mixed specimens was also enhanced.


Human herpesvirus 8 interleukin-6 (vIL-6) signals through gp130 but has structural and receptor-binding properties distinct from those of human IL-6.
Human herpesvirus 8 (HHV-8) has been associated with classical, endemic (African), and AIDS-related Kaposi's sarcoma (KS), body cavity-based primary effusion lymphomas, and multicentric Castleman's disease (MCD). HHV-8 encodes a functional homologue of interleukin-6 (IL-6), a cytokine that promotes the growth of KS and myeloma cells and is found at elevated levels in MCD lesions and patient sera. We have previously reported that the viral IL-6 (vIL-6) gene product can support the growth of the IL-6-dependent murine hybridoma cell line, B9, and that the gp80 (IL-6 receptor [IL-6R]) component of the IL-6 receptor-signal transducer (gp180) complex plays a role in mediating this activity. However, it has been shown by others that vIL-6 can function in human cells independently of IL-6R. Here we have extended our functional studies of vIL-6 by identifying transcription factors and pathways used in human Hep3B cells, investigating the utilization of gp130 and IL-6R by vIL-6, and undertaking mutational analyses of vIL-6 and gp130. The data presented here establish that vIL-6, in common with its endogenous counterparts, can mediate signal transduction through gp130 and activate multiple transcription factors, map residues within the vIL-6 protein that are and are not important for vIL-6 signalling, and identify a gp130 mutant that is nonfunctional with respect to vIL-6 signalling in the absence of IL-6R but that retains the ability to mediate vIL-6 and human IL-6 (hIL-6) signal transduction when IL-6R is coexpressed. The data presented demonstrate functional and mechanistic similarities between vIL-6 and endogenous IL-6 proteins but also highlight differences in the structural and receptor-binding properties of vIL-6 relative to its human counterpart.


Role of the testis interstitial compartment in spermatogonial stem cell function.
Intricate cellular and molecular interactions ensure that spermatogonial stem cells (SSCs) proceed in a step-wise differentiation process through spermatogenesis and spermiogenesis to produce sperm. SSCs lie within the seminiferous tubule compartment, which provides a nurturing environment for the development of sperm. Cells outside of the tubules, such as interstitial and peritubular cells, also help direct SSC activity. This review focuses on interstitial (interstitial macrophages, Leydig cells and vasculature) and peritubular (peritubular macrophages and peritubular myoid cells) cells and their role in regulating the SSC self-renewal and differentiation in mammals. Leydig cells, the major steroidogenic cells in the testis, influence SSCs through secreted factors, such as insulin growth factor 1 (IGF1) and colony-stimulating factor 1 (CSF1). Macrophages interact with SSCs through various potential mechanisms, such as CSF1 and retinoic acid (RA), to induce the proliferation or differentiation of SSCs respectively. Vasculature influences SSC dynamics through CSF1 and vascular endothelial growth factor (VEGF) and by regulating oxygen levels. Lastly, peritubular myoid cells produce one of the most well-known factors that is required for SSC self-renewal, glial cell line-derived neurotrophic factor (GDNF), as well as CSF1. Overall, SSC interactions with interstitial and peritubular cells are critical for SSC function and are an important underlying factor promoting male fertility.


Examining the Reliability of the Landing Error Scoring System With Raters Using the Standardized Instructions and Scoring Sheet.
Dynamic movement-based screens, such as the Landing Error Scoring System (LESS), are becoming more widely used in research and practical settings. Currently, 3 studies have examined the reliability of the LESS. These studies have reported good interrater and intrarater reliability. However, all 3 studies involved raters, who were founders of the LESS. Therefore, it is unclear whether the reliability reported reflects that which would be observed with practitioners without such specialized and intimate knowledge of the screen and only using the standardized set of instructions. To investigate the interrater and intrarater reliability of the final score and the individual scoring criteria of the LESS. Reliability protocol. Controlled laboratory. Two raters scored 30 male participants (age = 21.8 [3.9] y; height = 1.75 [0.46] m; mass = 75.5 [6.6] kg) involved in a variety of college sports. Two raters using only the standardized scoring sheet assessed the interrater reliability of the total score and individual scoring criteria independently of each other. The principal author scored the videos again 6 weeks later for the intrarater reliability component of the study. Participants performed a drop box landing from a 30-cm box was recorded with a video camera from the front and side views. The intraclass coefficients interrater and intrarater reliability for the total scores were excellent (intraclass coefficients range = .95 and .96; SEM = 1.01 and 1.02). The individual scoring criteria of the LESS had between moderate and perfect agreement using kappa statistics (κ = .41-1.0). The final score and individual scoring criteria of the LESS have acceptable reliability with raters using the standardized scoring sheet. Practitioners using only the standardized scoring sheet should feel confident that the LESS is a reliable tool.


Salivary metabolite profiling distinguishes patients with oral cavity squamous cell carcinoma from normal controls.
Oral cavity squamous cell carcinoma (OCC) and oropharyngeal squamous cell carcinoma (OPC) are among the most common cancers worldwide and are associated with high mortality and morbidity. The purpose of this study is to identify potential biomarkers to distinguish OCC/OPC from normal controls and to distinguish OCC patients with and without nodal metastasis. We tested saliva samples from 101 OCC, 58 OPC, and 35 normal controls using four analytical platforms (NMR, targeted aqueous by LC-MS/MS, global aqueous and global lipidomics by LC-Q-TOF). Samples from OCC and normal controls were divided into discovery and validation sets. Using linear regression adjusting for age, sex, race and experimental batches, we found the levels of two metabolites (glycine and proline) to be significantly different between OCC and controls (FDR < 0.1 for both discovery and validation sets) but did not find any appreciable differences in metabolite levels between OPC and controls or between OCC with and without nodal metastasis. Four metabolites, including glycine, proline, citrulline, and ornithine were associated with early stage OCC in both discovery and validation sets. Further study is warranted to confirm these results in the development of salivary metabolites as diagnostic markers.


Coupling of bacterial endosymbiont and host mitochondrial genomes in the hydrothermal vent clam Calyptogena magnifica.
The hydrothermal vent clam Calyptogena magnifica (Bivalvia: Vesicomyidae) depends for its nutrition on sulfur-oxidizing symbiotic bacteria housed in its gill tissues. This symbiont is transmitted vertically between generations via the clam's eggs; however, it remains uncertain whether occasionally symbionts are horizontally transmitted or acquired from the environment. If symbionts are transmitted strictly vertically through the egg cytoplasm, inheritance of symbiont lineages should behave as if coupled to the host's maternally inherited mitochondrial DNA. This coupling would be obscured, however, with low rates of horizontal or environmental transfers, the equivalent of recombination between host lineages. Population genetic analyses of C. magnifica clams and associated symbionts from eastern Pacific hydrothermal vents clearly supported the hypothesis of strictly maternal cotransmission. Host mitochondrial and symbiont DNA sequences were coupled in a clam population that was polymorphic for both genetic markers. These markers were not similarly coupled with sequence variation at a nuclear gene locus, as expected for a randomly mating sexual population. Phylogenetic analysis of the two cytoplasmic genes also revealed no evidence for recombination. The tight association between vesicomyid clams and their vertically transmitted bacterial endosymbionts is phylogenetically very young (<50 million years) and may serve as a model for the origin and evolution of eukaryotic organelles.


Discharge characteristics of biceps brachii motor units at recruitment when older adults sustained an isometric contraction.
The purpose of this study was to compare the discharge characteristics of motor units recruited during an isometric contraction that was sustained with the elbow flexor muscles by older adults at target forces that were less than the recruitment threshold force of each isolated motor unit. The discharge times of 27 single motor units were recorded from the biceps brachii in 11 old adults (78.8 ± 5.9 yr). The target force was set at either a relatively small (6.6 ± 3.7% maximum) or large (11.4 ± 4.5% maximum) difference below the recruitment threshold force and the contraction was sustained until the motor unit was recruited and discharged action potentials for about 60 s. The time to recruitment was longer for the large target-force difference (P = 0.001). At recruitment, the motor units discharged repetitively for both target-force differences, which contrasts with data from young adults when motor units discharged intermittently at recruitment for the large difference between recruitment threshold force and target force. The coefficient of variation (CV) for the first five interspike intervals (ISIs) increased from the small (18.7 ± 7.9) to large difference (35.0 ± 10.2%, P = 0.008) for the young adults, but did not differ for the two target force differences for the old adults (26.3 ± 14.7 to 24.0 ± 13.1%, P = 0.610). When analyzed across the discharge duration, the average CV for the ISI decreased similarly for the two target-force differences (P = 0.618) in old adults. These findings contrast with those of young adults and indicate that the integration of synaptic input during sustained contractions differs between young and old adults.


Genome assembly and annotation of the California harvester ant Pogonomyrmex californicus.
The harvester ant genus Pogonomyrmex is endemic to arid and semiarid habitats and deserts of North and South America. The California harvester ant Pogonomyrmex californicus is the most widely distributed Pogonomyrmex species in North America. Pogonomyrmex californicus colonies are usually monogynous, i.e. a colony has one queen. However, in a few populations in California, primary polygyny evolved, i.e. several queens cooperate in colony founding after their mating flights and continue to coexist in mature colonies. Here, we present a genome assembly and annotation of P. californicus. The size of the assembly is 241 Mb, which is in agreement with the previously estimated genome size. We were able to annotate 17,889 genes in total, including 15,688 protein-coding ones with BUSCO (Benchmarking Universal Single-Copy Orthologs) completeness at a 95% level. The presented P. californicus genome assembly will pave the way for investigations of the genomic underpinnings of social polymorphism in the number of queens, regulation of aggression, and the evolution of adaptations to dry habitats.


Evaluation of three PCR assays for the identification of the sheep strain (genotype 1) of Echinococcus granulosus in canid feces and parasite tissues.
The performance of 3 PCR assays for the identification of the G1 sheep genotype of Echinococcus granulosus was evaluated using tissue and canid fecal samples. The "Dinkel" and "Stefanić" primers were the most sensitive in detecting E. granulosus DNA in feces of necropsied dogs (73.7% and 100%, respectively). The "Abbasi" primers detected 52.6% of E. granulosus infected dogs but were the most species-specific, cross-reacting only with Echinococcus shiquicus (tissue 90.9%; feces 75%). The Stefanić primers were the least specific (tissue, 27.3%; feces, 25%) for E. granulosus. The Dinkel primers also showed inter-species cross-reactivity (tissue, 63.6%; feces, 100%) but were found to be strain-specific for the E. granulosus G1 sheep genotype. Improvement of PCR tests for Echinococcus species and subspecific variants should rely on the use of less-conserved genes and development of protocols that improve the quality and quantity of DNA extracted from feces.


Reciprocal mutations of lung-tropic AAV capsids lead to improved transduction properties.
Considerable effort has been devoted to developing adeno-associated virus (AAV)-based vectors for gene therapy in cystic fibrosis (CF). As a result of directed evolution and capsid shuffling technology, AAV capsids are available with widespread tropism for airway epithelial cells. For example, AAV2.5T and AAV6.2 are two evolved capsids with improved airway epithelial cell transduction properties over their parental serotypes. However, limited research has been focused on identifying their specific cellular tropism. Restoring cystic fibrosis transmembrane conductance regulator (CFTR) expression in surface columnar epithelial cells is necessary for the correction of the CF airway phenotype. Basal cells are a progenitor population of the conducting airways responsible for replenishing surface epithelial cells (including secretory cells and ionocytes), making correction of this cell population vital for a long-lived gene therapy strategy. In this study, we investigate the tropism of AAV capsids for three cell types in primary cultures of well-differentiated human airway epithelial (HAE) cells and primary human airway basal cells. We observed that AAV2.5T transduced surface epithelial cells better than AAV6.2, while AAV6.2 transduced airway basal cells better than AAV2.5T. We also investigated a recently developed capsid, AAV6.2FF, which has two surface tyrosines converted to phenylalanines. Next, we incorporated reciprocal mutations to create AAV capsids with further improved surface and basal cell transduction characteristics. Lastly, we successfully employed a split-intein approach using AAV to deliver an adenine base editor (ABE) to repair the CFTR R553X mutation. Our results suggest that rational incorporation of AAV capsid mutations improves AAV transduction of the airway surface and progenitor cells and may ultimately lead to improved pulmonary function in people with CF.


European bio-naïve spondyloarthritis patients initiating TNF inhibitor: time trends in baseline characteristics, treatment retention and response.
To investigate time trends in baseline characteristics and retention, remission and response rates in bio-naïve axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients initiating TNF inhibitor (TNFi) treatment. Prospectively collected data on bio-naïve axSpA and PsA patients from routine care in 15 European countries were pooled. Three cohorts were defined according to year of TNFi initiation: A (1999-2008), B (2009-2014) and C (2015-2018). Retention, remission and response rates were assessed at 6, 12 and 24 months. In total, 27 149 axSpA and 17 446 PsA patients were included. Cohort A patients had longer disease duration compared with B and C. In axSpA, cohort A had the largest proportion of male and HLA-B27 positive patients. In PsA, baseline disease activity was highest in cohort A. Retention rates in axSpA/PsA were highest in cohort A and differed only slightly between B and C. For all cohorts, disease activity decreased markedly from 0 to 6 months. In axSpA, disease activity at 24 months was highest in cohort A, where also remission and response rates were lowest. In PsA, remission rates at 6 and 12 months tended to be lowest in cohort A. Response rates were at all time points comparable across cohorts, and less between-cohort disease activity differences were seen at 24 months. Our findings indicate that over the past decades, clinicians have implemented more aggressive treatment strategies in spondyloarthritis. This was illustrated by shorter disease duration at treatment initiation, decreased retention rates and higher remission rates during recent years.


Is there an immunologic basis for schizophrenia?
The cause of schizophrenia remains an enigma despite the development of effective antipsychotic drugs that act by modulating the dopaminergic and serotonergic systems in the limbic region of the brain. Although such drugs are undoubtedly clinically effective, many patients do not fully benefit from such treatments, and the side effects, such as weight gain and the exacerbation of insulin-dependent diabetes mellitus, are often problematic. In recent years, the possible cause of schizophrenia has switched from an emphasis on neurotransmitter dysfunction to possible genetic and neurodevelopmental abnormalities. The close link between the loci for insulin-dependent diabetes mellitus, human lymphocyte antigen system and schizophrenia may indicate an immune component for this disorder. This hypothesis gains further credibility from epidemiologic studies showing a link between viral infections in utero and the subsequent development of schizophrenia; the negative correlation between rheumatoid arthritis and schizophrenia gives further support to the hypothesis. Thus, the immune hypothesis of schizophrenia has developed from an understanding of the genetic, environmental and infectious sequelae that underlie the immune changes involving the cellular and humoral components of the adaptive immune system. The changes in the types of T-lymphocytes that are involved in the adaptive immune response are of particular importance. The T-helper 1 cells, that secrete interleukin-2 and interferon-gamma for example, are reduced in activity while the T-helper 2 cells, together with the macrophages, show an increased secretion of interleukins-6 and -10. As these immune changes are normalized following effective antipsychotic drug treatment, new types of antipsychotics could be developed that act directly on the imbalance in the components of the adaptive immune system. The finding that some anti-inflammatory drugs can exhibit modest antipsychotic activity is further evidence of the validity of the autoimmune nature of schizophrenia and an indication that drug development based on this concept may be a fruitful area for future research.


Left atrial appendage occlusion: rationale, evidence, devices, and patient selection.
Atrial fibrillation (AF) is a worldwide epidemic associated with significant morbidity and mortality, often due to disabling or fatal thromboembolic stroke. Oral anticoagulation is highly effective at preventing ischaemic stroke and improving all-cause survival in patients with non-valvular AF. Despite the efficacy of oral anticoagulation, many patients are not treated due to either absolute or perceived contraindications to therapy, including bleeding. Left atrial appendage (LAA) closure has emerged as a mechanical alternative to pharmacologic stroke prevention. Initial and mid-term clinical trial data suggest that LAA closure is safe, with less intracranial bleeding, and a net clinical benefit that appears to be non-inferior to oral anticoagulation. However, concern remains over the possible increased risk of ischaemic stroke in long-term follow-up. Careful patient selection for LAA closure is paramount. Patients with prior intracranial bleeding or recurrent serious bleeding who are not eligible for long-term oral anticoagulation are typical candidates for LAA closure; however, other populations may benefit as well, such as patients with end-stage renal disease. Clinical investigation and randomized trials are needed to clarify the best methods of LAA occlusion, optimal pharmacologic strategies in the short-term after LAA closure, and to identify patient populations who will derive the most benefit from LAA occlusion. In this article, we review the rationale for LAA closure, the currently available devices and their evidence base, patient selection, challenges in management, and future directions for LAA closure science.


Brain perivascular macrophages: current understanding and future prospects.
Brain perivascular macrophages are specialized populations of macrophages that reside in the space around cerebral vessels, such as penetrating arteries and venules. With the help of cutting-edge technologies such as cell fate mapping and single-cell multi-omics, their multifaceted, pivotal roles in phagocytosis, antigen presentation, vascular integrity maintenance, and metabolic regulation have more recently been further revealed under physiological conditions. Accumulating evidence also implies that perivascular macrophages are involved in the pathogenesis of neurodegenerative disease, cerebrovascular dysfunction, autoimmune disease, traumatic brain injury, and epilepsy. They can act in either protective or detrimental ways depending on the disease course and stage. However, the underlying mechanisms of perivascular macrophages remain largely unknown. Therefore, we highlight potential future directions in research on perivascular macrophages, including the utilization of genetic mice and novel therapeutic strategies that target these unique immune cells for neuroprotective purposes. In conclusion, this review provides a comprehensive update on the current knowledge of brain perivascular macrophages, shedding light on their pivotal roles in central nervous system health and disease.


The association between objective income and subjective financial need and depressive symptoms in South Koreans aged 60 and older.
This study aimed to investigate the effect of the gap between objective income and subjective financial need on depressive symptoms in individuals aged 60 and older. Data from the 2011 and 2013 Korean Retirement and Income Study were used. A total of 4891 individuals aged 60 and older were included at baseline. The Generalized Estimating Equation model was used to examine the association between the gap in objective income and subjective financial need and the presence of depressive symptoms, which were measured using the Center for Epidemiological Studies Depression Scale. Compared to individuals in the middle objective income-middle subjective financial need group, individuals in the low-low category (odds ratio (OR): 1.30, 95% confidence interval (CI): 1.04-1.61) and the low-middle category (OR: 1.26, 95%CI: 1.09-1.45) showed a statistically significant higher likelihood of having depressive symptoms. In contrast, participants in the middle-low (OR: 0.74, 95%CI: 0.54-0.99), high-low (OR: 0.50, 95%CI: 0.34-0.73), high-middle (OR: 0.74, 95%CI: 0.63-0.87), and high-high categories (OR: 0.74, 95%CI: 0.55-0.99) were less likely to exhibit depressive symptoms. Additionally, the lower likelihood of depressive symptoms found in middle- and high-income groups with lower levels of subjective financial need was strong among individuals with chronic disease. Differences in the prevalence of depressive symptoms generally exist between individuals of the same income category depending on perceived income adequacy. Therefore, it is important to consider discrepancies in objective income and subjective financial need when assessing risk factors for depressive symptoms in older populations.


The distinction between risk and hazard: understanding and use in stakeholder communication.
A major issue in all risk communication efforts is the distinction between the terms "risk" and "hazard." The potential to harm a target such as human health or the environment is normally defined as a hazard, whereas risk also encompasses the probability of exposure and the extent of damage. What can be observed again and again in risk communication processes are misunderstandings and communication gaps related to these crucial terms. We asked a sample of 53 experts from public authorities, business and industry, and environmental and consumer organizations in Germany to outline their understanding and use of these terms using both the methods of expert interviews and focus groups. The empirical study made clear that the terms risk and hazard are perceived and used very differently in risk communication depending on the perspective of the stakeholders. Several factors can be identified, such as responsibility for hazard avoidance, economic interest, or a watchdog role. Thus, communication gaps can be reduced to a four-fold problem matrix comprising a semantic, conceptual, strategic, and control problem. The empirical study made clear that risks and hazards are perceived very differently depending on the stakeholders' perspective. Their own worldviews played a major role in their specific use of the two terms hazards and risks in communication.


Resident training in community pediatricians' offices. Not a financial drain.
There are numerous disadvantages to teaching ambulatory pediatrics in hospital-based clinics. The present study evaluated the economic impact on community pediatricians' practices that served as continuity experience sites for pediatric residents by using an apprenticeship model. The number of patients seen and the dollars billed by the presence of a resident, even though these preceptors provided significantly more supervision to residents than that received by residents in hospital-based clinics. Furthermore, residents billed substantial revenues for preceptor practices. This approach to teaching general pediatrics is economically viable, providing resident stipends are not dependent on fees generated by patient visits.


Measuring trends in prevalence and incidence of HIV infection in countries with generalised epidemics.
Review of recent data and practice to derive guidance on questions relating to the measurement and analysis of trends in HIV prevalence and incidence. HIV prevalence among pregnant women attending antenatal clinics (ANCs) remains the principal data source to inform trends in the epidemic. Other data sources are: less available, representative of a small section of the population (sex workers, occupational groups), subject to additional bias (for example, voluntary counselling and testing service statistics), or are not yet available for multiple years (national surveys). Validity of HIV prevalence results may change over time due to improvements in HIV tests per se and implementation of laboratory quality assurance systems. The newer laboratory tests for recent infections require further validation and development of methodology to derive estimates of HIV incidence. Issues to consider during statistical analyses of trends among ANC attendees are: inclusion of consistent sites only, use of confidence intervals, stratification by site when performing a statistical test for trend, the need for at least three observations in a surveillance system with data collection every one to two years, and sound judgement. Trends in HIV prevalence among pregnant 15-24 year olds attending ANCs can be used to approximate trends in incidence. Indepth small area research studies are useful to inform the interpretation of surveillance data and provide directly measured trends in prevalence and incidence. Modelling can assess changes over time in prevalence, incidence, and mortality at the same time. Modelling tools need to be further developed to allow incorporation of estimates of HIV incidence and mortality, as these data are likely to become available in the future. To increase their explanatory power, models should also be extended to incorporate programmatic inputs.