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Δευτέρα 15 Μαΐου 2017

miR-146a-5p acts as a negative regulator of TGF-β signaling in skeletal muscle after acute contusion

Abstract
Growing evidence suggests the importance of microRNAs (miRNAs) in stress signaling pathways. Transforming growth factor-β (TGF-β) is a potent cytokine that promotes the development of skeletal muscle fibrosis after acute contusion. However, how miRNAs are involved in TGF-β signaling and confer the robustness of TGF-β-induced fibrotic response remains to be fully elucidated. Here, we demonstrated that miR-146a-5p (miR-146) levels were reduced in a fibrotic mouse model after acute muscle contusion. It was also found that TGF-β treatment decreased the expression of miR-146 in vitro in a dose- and time-dependent manner. In addition, overexpression of Smad3 and Samd4, two key players in TGF-β signaling, suppressed the expression of miR-146 in muscle cells. Overexpression of miR-146 inhibited the expressions of fibrosis markers both in vitro and in vivo. Moreover, increase in the expression of miR-146 in muscle cells was able to attenuate the effect of TGF-β on the expressions of fibrosis markers. Mechanistic analysis revealed that Smad4 is a direct target of miR-146 in muscle cells. Furthermore, the anti-fibrotic effect of miR-146 could be blocked by overexpression of Smad4 in vivo. These results suggest that Smad4 is down-regulated by miR-146 in skeletal muscle. Taken together, our results indicate that the anti-fibrotic miR-146 is a component of TGF-β signaling. It is down-regulated by Smad protein, and can inhibit the expression of Smad4. Our study suggests that miR-146 might have a therapeutic potential to reduce skeletal muscle fibrosis after injury.

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α-Asarone suppresses the proliferation and migration of ASMCs through targeting the lncRNA-PVT1/miR-203a/E2F3 signal pathway in RSV-infected rats

Abstract
Asthma is a chronic inflammatory pulmonary disease and respiratory syncytial virus (RSV) infection is a common cause of lower respiratory tract illness in infants and young children. α-Asarone presents many pharmacological effects and has been demonstrated to be useful in treating asthma. However, the functional mechanism of α-asarone in RSV-infected asthma has not been investigated. Long non-coding RNAs (lncRNAs) have been reported to play critical roles in many biological processes. Although many lncRNAs have been characterized, few were reported in asthma, especially in RSV-induced asthma. Currently, a novel post-transcriptional regulation has been proposed in which lncRNAs function as competing endogenous RNAs (ceRNAs) to competitively sponge miRNAs, thereby regulating the target genes. In the present study, we established an RSV-infected Sprague–Dawley rat model and demonstrated that lncRNA-PVT1 is involved in the mechanism of α-asarone in treating RSV-induced asthma, and lncRNA-PVT1 regulates the expression of E2F3 by functioning as a ceRNA which competitively sponges miR-203a.

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miR-290 contributes to the low abundance of cyclin D1 protein in mouse embryonic stem cells

Abstract
Mouse miR-290 cluster miRNAs are expressed specifically in early embryos and embryonic germ cells. These miRNAs play critical roles in the maintenance of pluripotency and self-renewal. Here, we showed that Cyclin D1 is a direct target gene of miR-290 cluster miRNAs. Negative relationships between the expression of Cyclin D1 protein and miR-290 cluster miRNAs in pluripotent and non-pluripotent cells, as well as in differentiating CGR8 cells were observed. Inhibition of miR-290 cluster miRNAs could arrest cells at the G1 phase and slow down the cell proliferation in CGR8 mouse stem cells. Since miR-290 cluster miRNAs are the most dominant stem-cell-specific miRNAs, our results revealed an important cause for the absence of Cyclin D1 in mouse embryonic stem cells.

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Detection of cytological changes in oral mucosa among users of smokeless tobacco (shamma) in the KSA

Background and aim

Smokeless tobacco (ST) use is a major cause of cytological changes in the oral mucosa. ST products, such as shamma, which is prevalent in southern Saudi Arabia, raise concerns about the adverse health effects among its users. We evaluated the cytological changes in the oral mucosa of users and nonusers of shamma in the city of Najran, using Papanicolaou staining.

Materials and methods

We designed questionnaires and consent forms for this study that were administered to a total of 397 participants, comprising 250 nonusers of shamma (controls) and 147 shamma users (cases). Buccal cell smears were collected from all participants, fixed, and Papanicolaou stained. Photomicrographs were taken of all stained smears, and samples were subsequently diagnosed.

Results

Various cytological changes were detected among both cases and controls: atypia (2.0%, 1.2%, respectively), keratinisation (0.7%, 0%, respectively), inflammation (13.6%, 10.8%, respectively), and infection (4.1%, 3.6%, respectively).

Conclusion

The results showed higher percentages of cytological changes among shamma users compared with nonusers; however, the differences were not statistically significant. Habitual use of other substances in the control group could be a confounding factor given this geographic region and the cytological changes we detected in both cases and controls.



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Fermentation induced changes in volatile components of African oil bean (Pentaclethra macrophylla Benth) seeds

Abstract

Fermented African oil bean (Pentaclethra macrophylla Benth) seed also referred to as "Ugba" is a known delicacy, mainly consumed by Africans. Human migration has also led to the introduction of this delicacy into most European and American countries. This study shows the changes in volatile components of African oil bean (P. macrophylla Benth) seed at different stages of fermentation. A quantity of 0.3 kg each of dehulled and sliced raw sample and cooked unfermented sample were separately ground, while 2 and 4 days fermented samples obtained by inoculating 0.6 kg of cooked, sliced and washed sample with 0.5 g of 4 days fermented seed was divided into two of 0.3 kg each and ground at the second and fourth day of fermentation. GC-MS analyses of the volatile components showed 9,12-Octadecadienoic acid (Z,Z)- and its esters as highest in raw seed, with total percentage concentration of 96.301, while 9-Octadecenoic acid, methyl ester, (E)- was highest in cooked unfermented seed, with percentage concentration 55.204. Phenol, 2-methoxy-3-(2-propenyl)- and its esters were the highest observed in cooked 2 days fermented seed, with total percentage concentration of 50.596, while 9-Octadecenoic acid (Z)-, methyl ester was highest in cooked 4 days fermented seed with percentage concentration of 67.788. Aside from softening the delicacy, a 4 days chance fermentation of cooked P. macrophylla Benth seed also reduces the eight component lipids present in the cooked unfermented seed to a more nutriceutical three component lipids (Hexadecanoic acid methyl ester, 9-Octadecenoic acid (Z)-methyl ester and Methyl stearate).

Thumbnail image of graphical abstract

This study shows the changes in volatile components of African oil bean (P. macrophylla Benth) seed at different stages of fermentation.



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A rounded opacity silhouetting the left heart border and hilum

A 73-year-old woman with hypertension and atrial fibrillation presented with head and neck injury after mechanical fall. During workup, chest X-ray anteroposterior view (figure 1) revealed a rounded opacity silhouetting the left heart border and hilum. Subsequent contrast-enhanced CT of the chest showed single, 6.4 cm, rounded, well-defined, thin-walled, non-enhanced, low attenuated (–20 and 20 Hounsfield Unit) and homogenous cyst-like structure at the left mediastinum connected to pericardial recesses and not attached to adjacent structures (figure 2A–C). Transthoracic echocardiogram ruled out left ventricular aneurysm, aortic aneurysm, solid tumour and outflow tracts obstruction. Although bronchogenic cyst, oesophageal duplication cyst, thymic tumour and mediastinal lymphoma were considered as possible differentials, radiological features such as CT appearance, homogenous attenuation, unrelated to the underlying structures favoured pericardial cyst. Since patient was asymptomatic, patient and family member were unwilling to undergo surgical removal and pathological confirmation. Follow-up with non-enhanced CT of...

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Transient hemiparaesthesias and dysarthria

A previously healthy 29-year-old Mexican woman presented to an emergency department with transient hemiparaesthesias and dysarthria. There was no evidence of stroke on cross-sectional imaging of the head, and she was discharged without a clear diagnosis. Two days later, she returned with acute abdominal pain. Abdominal imaging revealed complete occlusion of the right renal artery, prompting emergency embolectomy. Following the procedure, she developed acute haemoptysis, dyspnoea and hypoxaemia. Chest imaging demonstrated evidence of pulmonary venous hypertension. Cardiac auscultation revealed an opening snap followed by a diastolic murmur with presystolic accentuation. These sounds were better appreciated in combination with phonocardiography, a technique supplanted by echocardiography in the 1970s1 that visualised heart sounds (video 1). An echocardiogram confirmed the presence of mitral stenosis (MS), unifying the syndrome of embolic phenomena, haemoptysis and pulmonary hypertension. She underwent successful mitral valve replacement and has since returned to normal...


Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

MHC I presentation of Toxoplasma gondii immunodominant antigen does not require Sec 22b and is regulated by antigen orientation at the vacuole membrane

The intracellular Toxoplasma gondii parasite replicates within a parasitophorous vacuole (PV). T. gondii secretes proteins that remain soluble in the PV space, are inserted into PV membranes or are exported beyond the PV boundary. In addition to supporting T. gondii growth, these proteins can be processed and presented by MHC I for CD8+ T-cell recognition. Yet it is unclear whether membrane binding influences the processing pathways employed and if topology of membrane antigens impacts their MHC I presentation. Here we report that the MHC I pathways of soluble and membrane-bound antigens differ in their requirement for host ER recruitment. In contrast to the soluble SAG1-OVA model antigen, we find that presentation of the membrane-bound GRA6 is independent from the SNARE Sec 22b, a key molecule for transfer of host endoplasmic reticulum components onto the PV. Using parasites modified to secrete a transmembrane antigen with opposite orientations, we further show that MHC I presentation is highly favored when the C-terminal epitope is exposed to the host cell cytosol, which corresponds to GRA6 natural orientation. Our data suggest that the biochemical properties of antigens released by intracellular pathogens critically guide their processing pathway and are valuable parameters to consider for vaccination strategies.

This article is protected by copyright. All rights reserved



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Satellite glial cells in human trigeminal ganglia have a broad expression of functional Toll-like receptors

Toll-like receptors (TLRs) orchestrate immune responses to a wide variety of danger- and pathogen-associated molecular patterns. Compared to the central nervous system (CNS), expression profile and function of TLRs in the human peripheral nervous system (PNS) are ill-defined. We analyzed TLR expression of satellite glial cells (SGCs) and microglia, glial cells predominantly involved in local immune responses in ganglia of the human PNS and normal-appearing white matter (NAWM) of the CNS, respectively. Ex vivo flow cytometry analysis of cell suspensions obtained from human cadaveric trigeminal ganglia (TG) and NAWM showed that both SGCs and microglia expressed TLR1–5, TLR7 and TLR9, although expression levels varied between these cell types. Immunohistochemistry confirmed expression of TLR1–TLR4 and TLR9 by SGCs in situ. Stimulation of TG- and NAWM-derived cell suspensions with ligands of TLR1–TLR6, but not TLR7 and TLR9, induced interleukin 6 (IL-6) secretion. We identified CD45LOWCD14POS SGCs and microglia, but not CD45HIGH leukocytes and CD45NEG cells as the main source of IL-6 and tumor necrosis factor α upon stimulation with TLR3 and TLR5 ligands. In conclusion, human TG-resident SGCs express a broad panel of functional TLRs, suggesting their role in initiating and orchestrating inflammation to pathogens in human sensory ganglia.

This article is protected by copyright. All rights reserved



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Antiviral activity of nordihydroguaiaretic acid and its derivative tetra-O-methyl nordihydroguaiaretic acid against West Nile virus and Zika virus [PublishAheadOfPrint]

Flaviviruses are positive strand RNA viruses distributed all over the world that infect millions of people every year, and for which no specific antiviral agents have been approved. These viruses include the mosquito-borne West Nile virus (WNV) responsible for outbreaks of meningitis and encephalitis. Considering that nordihydroguaiaretic acid (NDGA) has been previously shown to inhibit the multiplication of the related dengue virus and hepatitis C virus, we have evaluated the effect of NDGA, and its methylated derivative tetra-O-methyl nordihydroguaiaretic (M4N), on the infection of WNV. Both compounds inhibited the infection of WNV likely by impairing viral replication. Since flavivirus multiplication is highly dependent on host cell lipid metabolism, the antiviral effect of NDGA has been previously related to its ability to disturb the lipid metabolism probably by interfering with the sterol regulatory element binding proteins (SREBP) pathway. Remarkably, we observed that other structurally unrelated inhibitors of the SREBP pathway, such as PF-429242 and Fatostatin, also reduced WNV multiplication, supporting that the SREBP pathway could constitute a druggable target suitable for antiviral intervention against flavivirus infection. Moreover, treatment with NDGA, M4N, PF-429242, and Fatostatin also inhibited the multiplication of the mosquito-borne flavivirus Zika virus (ZIKV), which has been recently associated with birth defects (microcephaly) and neurological disorders. Our results point to SREBP inhibitors such as NDGA and M4N as potential candidates for further antiviral development against medically relevant flaviviruses.



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Real-Life Assessment of the Safety and Effectiveness of the New Tablet and Intravenous Formulations of Posaconazole in the Prophylaxis of Invasive Fungal Infections: Analysis of 343 courses [PublishAheadOfPrint]

Background: Posaconazole is the preferred mold-active azole for prophylaxis against invasive fungal infection (IFI) in patients with hematologic malignancy (HM). Delayed release tablet and intravenous formulations of posaconazole have recently become available, but clinical data are limited. We sought to examine the real-world pharmacokinetics and prophylactic effectiveness of the new formulations of posaconazole given as prophylaxis in patients with HM.

Methods: A retrospective cohort of all consecutive adult inpatients with HM who received ≥3 days of posaconazole as tablet or intravenous from 12/1/2013-12/31/2015 for primary IFI prophylaxis at MD Anderson Cancer center. Clinical information were collected and correlated with low posaconazole serum levels (<700ng/mL). Rates of invasive fungal infections as well as safety events were assessed.

Results: 1,321 courses of posaconazole were administered at MD Anderson Cancer Center during the study time period, with 343 patient courses assessed for prophylactic safety and effectiveness. Seventy-nine patient (23%) courses had posaconazole serum levels available for interpretation. Acute myelogenous leukemia was the primary malignancy (62%) with 20% of all patients having previously received a stem cell transplant. Median posaconazole level was 1,380ng/ml (IQR 864-1860). A low posaconazole level (< 700ng/mL) was observed in 14 (18%) of patients. Proven or probable breakthrough IFI occurred in 8 patients (2%), 6 of whom had posaconazole TDM performed, all with levels above 700ng/mL. Overall, 19% of patients experienced grade 3/4 liver injury, primarily manifesting as hyperbilirubinemia and correlated with a serum level >1,830.

Conclusions: Although hepatotoxicity in a small percentage of patients is of concern, posaconazole tablets appeared to be generally safe and effective. As all breakthrough IFI in whom TDM was performed occurred in patients with levels >700ng/mL and a PCZ level >1,830ng/mL correlated with grade 3/4 liver toxicity, further studies are needed to assess the role of therapeutic drug monitoring.



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Efficacy and pharmacokinetics of the combination of OP0595 and cefepime in a mouse model of pneumonia caused by ESBL-producing Klebsiella pneumoniae [PublishAheadOfPrint]

Background: OP0595 (RG6080) is a novel diazobicyclooctane that inhibits class A and C serine beta-lactamases. Although the combination of OP0595 and cefepime (FEP) showed good in vitro activity against extended spectrum beta-lactamase (ESBL)-producing pathogens, the effect of the combination therapy against severe infections, such as pneumonia or bacteraemia, remains unknown in vivo.

Objectives: In this study, we investigated the efficacy and pharmacokinetics of the combination therapy of OP0595 and FEP in a mouse model of pneumonia caused by Klebsiella pneumoniae harbouring SHV and CTX-M-9-type ESBLs.

Methods: The infected BALB/c mice were intraperitoneally administered saline (control), 100 mg/kg of FEP, 20 mg/kg of OP0595, or both FEP and OP0595, twice a day.

Results: The minimum inhibitory concentration (MIC) of FEP against the bacteria was 8 mg/L and markedly improved to 0.06 mg/L with the addition of 0.5 mg/mL of OP0595. In the survival study, the combination of FEP and OP0595 significantly improved the survival rate compared to that reported with either OP0595 or FEP alone (P < 0.001). The number of bacteria in the lungs and blood significantly decreased in the combination therapy group compared to that reported for the monotherapy groups (P < 0.001). In addition, the in vivo effect depended on the dose of FEP. However, pharmacokinetic analysis revealed that the percentage of time above MIC remained constant when increasing the dose of FEP in combination with 20 mg/kg of OP0595.

Conclusions: The results of our study demonstrated the in vivo effectiveness of the combination of OP0595 and FEP.



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Toxic Electrophiles Induce Expression of the Multi-Drug Efflux Pump MexEF-OprN in Pseudomonas aeruginosa Through a Novel Transcriptional Regulator, CmrA [PublishAheadOfPrint]

The multidrug efflux system MexEF-OprN is produced at low levels in wild-type strains of Pseudomonas aeruginosa. However, mutational alteration of gene mexS results in constitutive overexpression of the pump along with an increased resistance of the bacterium to chloramphenicol, fluoroquinolones and trimethoprim. In this study, analysis of in vitro selected chloramphenicol-resistant clones of strain PA14 led to the identification of a new class of mutants (called nfxC2) exhibiting alterations in a so far uncharacterized gene, PA14_38040 (homolog of PA2047 in strain PAO1). This gene is predicted to encode an AraC-like transcriptional regulator, and was called CmrA (for Chloramphenicol resistance Activator). In nfxC2 mutants, the mutated CmrA increases its proper gene expression and upregulates operon mexEF-oprN through MexS and MexT, resulting in a multidrug resistance phenotype without significant loss in bacterial virulence. Transcriptomic experiments demonstrated that CmrA positively regulates a small set of 11 genes, including PA14_38020 (homolog of PA2048) which is required for the MexS/T-dependent activation of mexEF-oprN. PA2048 codes for a protein sharing conserved domains with quinol monooxygenase YgiN from Escherichia coli. Interestingly, exposure of strain PA14 to toxic electrophilic molecules (glyoxal, methylglyoxal, cinnamaldehyde) strongly activates the CmrA pathway, upregulates MexEF-OprN and thus increases the resistance of P. aeruginosa to the pump substrates. A picture emerges in which MexEF-OprN is central in the response of the pathogen to stresses affecting intracellular redox homeostasis.



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Safety, Pharmacokinetics and_Antiviral Activity of a Novel HIV Antiviral, ABX464, in Treatment- Naïve HIV Infected Subjects: a Phase II Randomized, Controlled Study [PublishAheadOfPrint]

We investigated the safety and anti-viral effects of an anti-HIV compound (ABX464) with a unique mechanism of viral replication inhibition. This was a randomized, double blind, placebo controlled, dose- ranging study in treatment naïve HIV infected patients. Participants were assigned to eight groups; each group included 8 subjects receiving either the study compound, ABX464 (n=6) or corresponding placebo (n=2), according to a randomization code. The first dose administered was 25 mg, given once or 3 times a day over a 2 to 3-week period. Ascending doses up to 150 mg were delivered after review of the safety data. The primary objective of the study was to assess safety and tolerability of ABX464 after repeated oral administrations in subjects infected by HIV. Sixty-six (66) subjects were enrolled and were randomized. Sixty-three (63) subjects completed the study according to the study protocol. Twenty-one (21) AEs were reported by 7 subjects out of 16 (44%) who received placebo and 158 AEs were reported by 39 subjects out of 50 (78%) who received the study drug. In the ABX464 treatment group, all of these adverse events were mild to moderate. No subjects discontinued treatment due to drug related AE's. Administration of ABX464 up to 150 mg, once a day was safe and well tolerated in HIV infected subjects. An efficacy signal with respect to reduction of viral load by ABX464 was detected, mainly in subjects treated at the highest dose. Further studies will be required to demonstrate anti-viral effects in HIV- infected subjects in combination with other anti-retroviral therapies.



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ERG11 gene mutations and MDR1 up-regulation confer pan-azole-resistance in Candida tropicalis causing disseminated candidiasis while on posaconazole prophylaxis in an acute lymphoblastic leukemia patient [PublishAheadOfPrint]

In this study, we presented a rare case of fatal breakthrough Candida tropicalis in a patient with acute lymphoblastic leukemia (ALL) while on posaconazole prophylaxis. And then we explored the mechanisms underlying azole resistance by focusing on enhanced efflux pumps and changes in the azole target enzyme Erg11p, which was encoded by the ERG11 gene. Our study demonstrates that Y132C substitution of Erg11p combined with MDR1 overexpression may be the pan-azole-resistance mechanisms in Candida tropicalis.



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Reduced vancomycin susceptibility of methicillin-susceptible Staphylococcus aureus: no significant impact on mortality but increase in complicated infection [PublishAheadOfPrint]

Methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections (BSIs) often lead to severe complications despite the availability of effective antibiotics. It remains unclear whether elevated vancomycin MICs are associated with worse outcomes.

We conducted a 2-year retrospective cohort study (n=252) of patients with MSSA BSIs at a tertiary care hospital. We defined reduced vancomycin susceptibility (RVS) as a Microscan MIC of 2 mg/L. All strains were genotyped (spa) and assessed for agr functionality. Multivariable logistic regression models were used to examine the impact of RVS phenotype and strain genotype on 30-day all-cause mortality and complicated bacteremia (metastatic spread, endovascular infection, or duration ≥3 days).

One third of patients (84/252) were infected with RVS isolates. RVS Infections were more frequently associated with metastatic or embolic sites of infection (36% vs. 17%, p<0.001), and endovascular infection (26% vs. 12%, p=0.004). They occurred more often in patients with fewer underlying comorbidities (CCI≥3: 73% vs. 88%, p=0.002). Genotyping identified 127 spa-types and 14 Spa-clonal complexes (Spa-CCs). Spa-CC002 and Spa-CC008 were more likely to exhibit the RVS phenotype versus other Spa-CCs (OR=2.2, p<0.01). The RVS phenotype was not significantly associated with 30-day mortality, however was associated with complicated bacteremia (aOR 2.35 [1.26, 4.37], p = 0.007) in adjusted analyses.

The association of RVS strains with complicated infection and fewer underlying comorbidities suggests the phenotype as a potential marker of strain virulence in MSSA BSIs. The RVS phenotype itself was not a significant predictor of mortality in this patient cohort. Further studies are necessary to explore this host-pathogen relationship.



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Genetic Characterization of Broad Host-range IncQ Plasmids Harboring blaVEB-18 in Vibrio spp. [PublishAheadOfPrint]

Dissemination of genetic elements encoding VEB type β-lactamases among Gram-negative bacteria has become a public health concern worldwide (1, 2)....



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Efficacy of a Binuclear Cyclopalladated Compound Therapy for cutaneous leishmaniasis in the murine model of infection with Leishmania amazonensis and its inhibitory effect on Topoisomerase 1B [PublishAheadOfPrint]

Leishmaniasis is a disease found throughout the (sub)tropical parts of the world caused by protozoan parasites of the Leishmania genus. Despite the numerous problems associated with existing treatments, pharmaceutical companies continue to neglect the development of better ones. The high toxicity of current drugs combined with emerging resistance makes the discovery of new therapeutic alternatives urgent. Here we report the evaluation of a binuclear cyclopalladated complex containing Pd(II) and N,N' -dimethylbenzylamine (Hdmba) against Leishmania amazonensis. The compound [Pd(dmba)(μ-N3)]2 (CP2) inhibits promastigote growth (IC50 = 13.2 ± 0.7 μM) and decreases the proliferation of intracellular amastigotes in in vitro incubated macrophages (IC50 = 10.2 ± 2.2 μM) without a cytotoxic effect when tested against peritoneal macrophages (CC50 = 506.0 ± 10.7 μM). Additionally, CP2 was also active against T. cruzi intracellular amastigotes (IC50 = 2.3 ± 0.5 μM, Selective Index = 225), an indication of its potential for use in Chagas disease therapy. In vivo assays using L. amazonensis-infected BALB/c showed an 80% reduction in parasite load when compared to infected and non-treated animals. Also, compared to amphotericin B treatment, CP2 did not show any side effects, which was corroborated by the analysis of plasma levels of different hepatic and renal biomarkers. Furthermore, CP2 was able to inhibit Leishmania donovani topoisomerase 1B (Ldtopo1B), a potentially important target in this parasite.



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Colistin resistance in carbapenem-resistant Klebsiella pneumoniae mediated by chromosomal integration of plasmid DNA [PublishAheadOfPrint]

Here we describe the spread of colistin resistance in clinical isolates of carbapenem-resistant-K. pneumoniae in Medellín, Colombia. Among 32 isolates collected between 2012 and 2014, 24 showed genetic alterations in mgrB. Nineteen isolates belonged to ST512 (or its SLV) and harbored a novel 8.1-Kb hsdMSR insertion, indicating a clonal expansion of the resistant strain. The insertion region showed 100% identity to several plasmids, suggesting the colistin resistance is mediated by chromosomal integration of plasmid DNA.



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Controlled release of plectasin NZ2114 from a hybrid silicone-hydrogel material for inhibition of Staphylococcus aureus biofilm [PublishAheadOfPrint]

Staphylococcus aureus is a major human pathogen in catheter-related infections. Modifying catheter material with interpenetrating polymer networks is a novel material technology that allows for impregnation with drugs and subsequent controlled release. Here we evaluated the potential for combining this system with plectasin derivate NZ2114, in an attempt to design an S. aureus biofilm-resistant catheter. The material demonstrated promising anti-biofilm properties, also against methicillin-resistant S. aureus, thus suggesting a novel application of this antimicrobial peptide.



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Pharmacokinetics of Levofloxacin in Multidrug- and Extensively Drug-Resistant Tuberculosis patients [PublishAheadOfPrint]

Pharmacodynamics are important in treatment of especially multidrug- and extensively resistant tuberculosis (M/XDR-TB). The free area under the concentration time curve in relation to minimal inhibitory concentration (fAUC/MIC) is the most relevant pharmacokinetic (PK)-pharmacodynamic (PD) parameter to predict the efficacy of levofloxacin (LFX). The objective of our study was to assess LFX PK variability in M/XDR-TB patients and its potential consequence for fAUC/MIC ratios. Patients with pulmonary M/XDR-TB received LFX as part of treatment regimen at a dose of 15 mg/kg once daily. Blood samples obtained at steady state before- and 1, 2, 3, 4, 7, and 12 hrs after drug administration were measured by validated a liquid chromatography-tandem mass spectrometry. MIC values of LFX were determined by the agar dilution method on Middlebrook 7H10 and the MGIT960 system. Twenty patients with a mean age of 31 (IQR; 27-35) years were enrolled in this study. The median AUC0-24h was 98.8 mg/h/L (IQR; 84.8-159.6). The MIC median value for LFX was 0,5 mg/L with a range of 0.25 to 2.0 mg/L and the median fAUC0-24/MIC ratio was 109.5 (IQR; 48.5-399.4). In four of the 20 patients the value was below the target value of ≥100. When a MIC of 0.25, 0.5, 1.0 and 2.0 mg/L were applicable, 19, 18, 3 and no patients, respectively, had a fAUC/MIC ratio that exceeded 100. We observed a large variability in AUC. A fAUC0-24/MIC of ≥ 100 was only observed in case MIC values for LFX were 0.25-0.5 mg/L. Dosages exceeding 15mg/kg should be considered for target attainment if exposures are assumed to be safe.



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In Vitro Cross-Resistance Profiles of Rilpivirine, Dapivirine and MIV-150: NNRTI Microbicides in Clinical Development for the Prevention of HIV-1 Infection [PublishAheadOfPrint]

Rilpivirine, dapivirine (DPV) and MIV-150 are in development as microbicides. It is not known whether they will block infection of circulating NNRTI-resistant HIV-1 variants. Here, we demonstrate that the activity of DPV and MIV-150 are compromised by many resistant viruses containing single or double substitutions. High DPV genital tract concentrations from DPV-ring use may block replication of resistant viruses. However, MIV-150 genital tract concentrations may be insufficient to inhibit many resistant viruses, including those harboring K103N or Y181C.



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Sensitivity of White and Opaque Candida albicans to Antifungal Drugs [PublishAheadOfPrint]

White and opaque cells of Candida albicans have the same genome but differ in gene expression patterns, metabolic profiles, and host niche preferences. We tested whether these differences (which include the differential expression of drug transporters) resulted in different sensitivities to 27 antifungal agents. The analysis was performed in two different strain backgrounds; although there was strain-to-strain variation, only terbinafine hydrochloride and caspofungin showed consistent, two-fold differences between white and opaque cells across both strains.



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MCR-1 and OXA-48 in vivo acquisition in KPC-producing Escherichia coli after colistin treatment. [PublishAheadOfPrint]

The spread of mcr-1-encoding plasmids into carbapenem-resistant Enterobacteriaceae raises concerns about the emergence of untreatable bacteria. We report the acquisition of mcr-1 in a carbapenem- resistant E. coli after a 3-week course of colistin in a patient repatriated to France from Portugal. Whole-genome sequencing revealed that the KPC-producing E. coli strain acquired two plasmids, an IncL OXA-48-encoding plasmid and an IncX4 mcr-1-encoding plasmid. This is the first report of mcr-1 in carbapenemase-encoding bacteria in France.



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Mitral valve vegetation diagnosed with oesophageal ultrasound with bronchoscope (EUS-B)

Oesophageal ultrasound with bronchoscope (EUS-B) is designed to evaluate mediastinal structures. We describe a case of a 78-year-old woman who presented with altered mental status for 2 weeks. CT head revealed a subacute infarct in the right middle cerebral artery distribution. She was also found to have a lung mass on chest imaging. EUS-B-guided fine needle aspiration demonstrated the presence of adenocarcinoma in station 7 lymph node and in the mass. Immunohistochemistry confirmed it to be a lung primary as the Thyroid Transcription Factor-1 (TTF-1) was strongly positive. During the procedure, the cardiac valves were evaluated, and a mitral valve vegetation was noted. Formal echocardiography confirmed the presence of the vegetation. During hospital stay, the patient developed fever. Her blood cultures grew oxacillin-resistant Staphylococcus aureus. She was subsequently treated for infective endocarditis. We suggest that the use of EUS-B to routinely scan adjacent structures during a procedure may help obtain additional clinical information that may be critical to patient management.



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Double hit lymphoma presenting as haemophagocytic lymphohistiocytosis

Description

A 67-year-old woman with history of severe rheumatoid arthritis and use of multiple biologics including infliximab, tocilizumab and abatacept presented with fever of 39.1°C and severe pancytopenia (white blood cell count (WBC)=1.0x109/L,  absolute neutrophil count (ANC)=0.55x109/L, haemoglobin=8.7 g/dL, platelets=46x109/L). As part of the pancytopenia evaluation, imaging (CT of the chest, abdomen and pelvis) showed diffuse lymphadenopathy. Further evaluation revealed an elevated ferritin (8564 ng/mL), hypofibrinogenaemia (fibrinogen=95 mg/dL), elevated triglycerides (399 mg/dL) and a soluble interleukin 2 receptor level of 41 167 units/mL, satisfying diagnostic criteria for haemophagocytic lymphohistiocytosis (HLH). A subsequent bone marrow biopsy also revealed morphological evidence of haemophagocytosis (figure 1A), in addition to a population of very large and atypical mononuclear cells with markedly irregular, folded nuclear contours, prominent nucleoli and moderate amounts of cytoplasm (figure 1B,C). A similar large cell infiltrate was identified in the left axillary lymph node, causing complete effacement of nodal architecture (figure...



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Mitral Stenosis

Description

A previously healthy 29-year-old Mexican woman presented to an emergency department with transient hemiparaesthesias and dysarthria. There was no evidence of stroke on cross-sectional imaging of the head, and she was discharged without a clear diagnosis. Two days later, she returned with acute abdominal pain. Abdominal imaging revealed complete occlusion of the right renal artery, prompting emergency embolectomy. Following the procedure, she developed acute haemoptysis, dyspnoea and hypoxaemia. Chest imaging demonstrated evidence of pulmonary venous hypertension. Cardiac auscultation revealed an opening snap followed by a diastolic murmur with presystolic accentuation. These sounds were better appreciated in combination with phonocardiography, a technique supplanted by echocardiography in the 1970s1 that visualised heart sounds (video 1). An echocardiogram confirmed the presence of mitral stenosis (MS), unifying the syndrome of embolic phenomena, haemoptysis and pulmonary hypertension. She underwent successful mitral valve replacement and has since returned to normal...



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Uncommon presentation of adult-form scimitar syndrome associated with single left pulmonary vein in a pregnant woman

Scimitar syndrome is the constellation of malformations including an abnormal venous drainage of the right lung into the inferior vena cava, associated with the right lung and systemic supply to the right lung. The anomalous vein looks like the curved, Turkish sword (scimitar), hence the name.

The adult form of scimitar syndrome is rare, and it is usually an incidental diagnosis based on the characteristic finding on radiological imaging since the patients are usually asymptomatic or with minimal symptoms.

Our patient presented with a rare presentation of scimitar syndrome, which is tachyarrhythmia (sinus tachycardia, with episodes of supraventricular tachycardia). The diagnosis of scimitar syndrome was made based on the typical radiological finding of the anomalous venous drainage on CT angiography. Our patient does not have the full spectrum of the scimitar syndrome; therefore, she did not suffer from the usual complication (pulmonary hypertension). She was treated with ablation without surgical intervention.



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Anaemia and respiratory failure in a child: can it be idiopathic pulmonary haemosiderosis?

We present an 8-year-old male child admitted with cough and high-grade fever for 7 days and respiratory difficulty for 2 days. There was a history of blood transfusion at 2 years of age during a respiratory illness. The child was anaemic, tachycardic, tachypnoeic and hypoxic at presentation. Chest examination revealed equal air entry with fine crackles bilaterally. Blood reports were suggestive of anaemia (haemoglobin 6.5 g/dL), leucocytosis and high C reactive protein levels. Chest radiograph revealed bilateral air space opacities involving diffuse lung fields, right more than left. Relevant microbiological workup was negative. Based on the clinical scenario and investigations, a provisional diagnosis of pulmonary haemosiderosis was kept. The patient was started on intravenous pulse methylprednisolone. Fibre-optic bronchoscopy was done following recovery from the acute event. Bronchoalveolar lavage demonstrated a significant number of haemosiderin-laden macrophages confirming pulmonary haemosiderosis.



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A rare case of thrombotic microangiopathy triggered by acute pancreatitis

Thrombotic microangiopathy (TMA) occurring after acute pancreatitis is rarely described. Without prompt intervention, TMA can be, and often is, lethal, so prompt recognition is important. Here, we present a case of a 61-year-old woman with a history of alcohol misuse who presented with epigastric pain, nausea and vomiting after binge drinking. Elevated serum lipase and imaging were suggestive of acute-on-chronic pancreatitis. Although the patient's symptoms of acute pancreatitis subsided, her anaemia, thrombocytopenia and acute kidney injury worsened. A peripheral blood smear revealed schistocytes, prompting suspicion for TMA. Therapeutic plasma exchange (TPE) was promptly initiated and she completed 10 TPE sessions that improved her anaemia and serum creatinine and resolved the thrombocytopenia. Since TPE was effective and the ADAMTS13 assay revealed 55% activity in the absence of anti-ADAMTS13 IgG prior to initiation of therapy, a confident diagnosis of TMA caused by acute pancreatitis was made. There was no evidence of relapse 2 years later.



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Novel use of combination of electromyography and ultrasound to guide quadratus lumborum block after open appendicectomy

The quadratus lumborum (QL) block facilitates the administration of anaesthesia to the anterior abdominal wall. The use of ultrasound (US) improves the accuracy of the QL block and reduces the risk of adverse events. Electromyography (EMG) in combination with US for muscle plane blocks has not been described previously. We postulated that the addition of EMG-guided needle positioning might assist the execution of this block. This case report describes the first use of combined needle EMG and US to carry out a QL block performed for postoperative analgesia following an open appendicectomy.



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Pericardial incidentaloma: benign pericardial cyst

Description

A 73-year-old woman with hypertension and atrial fibrillation presented with head and neck injury after mechanical fall. During workup, chest X-ray anteroposterior view (figure 1) revealed a rounded opacity silhouetting the left heart border and hilum. Subsequent contrast-enhanced CT of the chest showed single, 6.4 cm, rounded, well-defined, thin-walled, non-enhanced, low attenuated (–20 and 20 Hounsfield Unit) and homogenous cyst-like structure at the left mediastinum connected to pericardial recesses and not attached to adjacent structures (figure 2A–C). Transthoracic echocardiogram ruled out left ventricular aneurysm, aortic aneurysm, solid tumour and outflow tracts obstruction. Although bronchogenic cyst, oesophageal duplication cyst, thymic tumour and mediastinal lymphoma were considered as possible differentials, radiological features such as CT appearance, homogenous attenuation, unrelated to the underlying structures favoured pericardial cyst. Since patient was asymptomatic, patient and family member were unwilling to undergo surgical removal and pathological confirmation. Follow-up with non-enhanced CT of...



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Herbal Medicine Treatment for Children with Autism Spectrum Disorder: A Systematic Review

Objective. To summarize and evaluate the efficacy and safety of herbal medicines used for the treatment of autism spectrum disorder (ASD) in children. Methods. Thirteen electronic databases were searched from their inception to November 2016. Randomized controlled trials (RCTs) that assessed the efficacy of herbal medicines alone or in combination with other Traditional Chinese Medicine treatments for ASD in children were included. The Cochrane Risk of Bias Tool was used and other data analyses were performed using RevMan (Version 5.3). Results. Ten RCTs involving 567 patients with ASD were included for qualitative synthesis. In conjunction with conventional therapy, herbal medicines significantly improved the Childhood Autism Rating Scale (CARS) score, but the results of effects on total effective rate (TER) were different between the included studies. The use of herbal medicines with integrative therapy improved the CARS score and TER. In the studies that documented adverse events, no serious events were associated with herbal medicines. Conclusions. The efficacy of herbal medicines for the treatment of ASD appears to be encouraging but was inconclusive owing to low methodological quality, herbal medicine diversity, and small sample size of the examined studies.

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Yokenella regensburgei Septicemia in a Chinese Farmer Immunosuppressed by HIV: A Case Report and Literature Review

Yokenella regensburgei is a member in the family Enterobacteriaceae and a few cases have been reported in immunocompromised hosts. Herein, we described a case of septicemia in a human immunodeficiency virus (HIV) infected patient in South West China, which is the first reported case of Y. regensburgei infection in HIV-infected populations. We then reviewed the literature on all the reported cases of Y. regensburgei infection worldwide and presented some common features of them. Our case report and literature review will help increase the knowledge of the bacterium Y. regensburgei and its clinical implications.

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Improving the temperature characteristics and catalytic efficiency of a mesophilic xylanase from Aspergillus oryzae, AoXyn11A, by iterative mutagenesis based on in silico design

To improve the temperature characteristics and catalytic efficiency of a glycoside hydrolase family (GHF) 11 xylanase from Aspergillus oryzae (AoXyn11A), its variants were predicted based on in silico design. Fir...

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Application of response surface methodology for optimization of medium components for the production of secondary metabolites by Streptomyces diastatochromogenes KX852460

A bioactive strain Streptomyces diastatochromogenes KX852460 was selected for the production of secondary metabolites to control the target spot disease on tobacco leaves, caused by the Rhizoctonia solani AG-3. P...

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Why are females more susceptible to cholestasis-induced liver injury — Could it be LncRNA H19?



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The novel intracellular protein CREG inhibits hepatic steatosis, obesity and insulin resistance

Abstract

Cellular repressor of E1A-stimulated genes (CREG), a novel cellular glycoprotein, has been identified as a suppressor of various cardiovascular diseases (CVDs) because of its capacity to reduce hyperplasia, maintain vascular homeostasis, and promote endothelial restoration. However, the effects and mechanism of CREG in metabolic disorder and hepatic steatosis remain unknown. Here, we report that hepatocyte-specific CREG deletion dramatically exacerbates high fat diet (HFD) and leptin deficiency-induced (ob/ob) adverse effects such as obesity, hepatic steatosis and metabolic disorders, whereas a beneficial effect is conferred by CREG overexpression. Additional experiments demonstrated that JNK1 but not JNK2 is largely responsible for the protective effect of CREG on the above mentioned pathologies. Notably, JNK1 inhibition strongly prevents the adverse effects of CREG deletion on steatosis and related metabolic disorders. Mechanistically, CREG directly interacts with apoptosis signal-regulating kinase1 (ASK1) and inhibits its phosphorylation, thereby blocking the downstream MKK4/7-JNK1 signaling pathway and leading to significantly alleviated obesity, insulin resistance and hepatic steatosis. Importantly, dramatically reduced CREG expression and hyper-activated JNK1 signaling was observed in the livers of NAFLD patients, thus suggesting that CREG might be a promising therapeutic target for NAFLD and related metabolic diseases. Conclusion: The results of our study provide the first evidence that CREG is a robust suppressor of hepatic steatosis and metabolic disorders through its direct interaction with ASK1 and the resultant inactivation of ASK1-JNK1 signaling. This study offers new insights into NAFLD pathogenesis and its complicated pathologies, such as obesity and insulin resistance, and paves the way for disease treatment through targeting CREG. This article is protected by copyright. All rights reserved.



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Nicotinic acid phosphoribosyltransferase regulates cancer cell metabolism, susceptibility to NAMPT inhibitors and DNA repair

In the last decade, substantial efforts have been made to identify NAD+ biosynthesis inhibitors, specifically against nicotinamide phosphoribosyltransferase (NAMPT), as preclinical studies indicate their potential efficacy as cancer drugs. However, the clinical activity of NAMPT inhibitors has proven limited, suggesting that alternative NAD+ production routes exploited by tumors confer resistance. Here we show the gene encoding nicotinic acid phosphoribosyltransferase (NAPRT), a second NAD+ producing enzyme, is amplified and overexpressed in a subset of common types of cancer, including ovarian cancer, where NAPRT expression correlates with a BRCAness gene expression signature. Both NAPRT and NAMPT increased intracellular NAD+ levels. NAPRT silencing reduced energy status, protein synthesis, and cell size in ovarian and pancreatic cancer cells. NAPRT silencing sensitized cells to NAMPT inhibitors both in vitro and in vivo; similar results were obtained with the NAPRT inhibitor 2-hydroxynicotinic acid. Reducing NAPRT levels in a BRCA2-deficient cancer cell line exacerbated DNA damage in response to chemotherapeutics. In conclusion, NAPRT-dependent NAD+ biosynthesis contributes to cell metabolism and to the DNA repair process in a subset of tumors. This knowledge could be used to increase the efficacy of NAMPT inhibitors and chemotherapy.

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Metformin improves the glucose and lipid metabolism via influencing the level of serum total bile acids in rats with streptozotocin-induced type 2 diabetes mellitus

OBJECTIVE: To study the effects of metformin on streptozotocin-induced type 2 diabetes mellitus (T2DM) in rats.

MATERIALS AND METHODS: Wistar male rats were divided into two groups: standard diet (SD, n = 20) group and high-fat diet (HFD, n = 80) group. Twenty rats in HFD group were randomly treated with metformin (EI group). After 6 weeks, among rats in HFD group, 20 rats were intraperitoneally injected with citrate buffered saline (IR group), 20 rats treated with metformin per day for 4 weeks (LI group), and 20 rats were given nothing (DM group). Rats in SD group were injected with citrate buffered saline as normal control (NC) group. Moreover, streptozotocin (STZ) was used for inducing diabetes. The metabolic parameters, such as body weight, fasting blood glucose (FBG), fasting insulin concentration (FINS), total cholesterol (TC), total triglycerides (TG), low-density lipoprotein cholesterol (LDLC) and total bile acid (TBA) were measured.

RESULTS: Compared with SD group, the levels of body weight, FBG, TC, LDLC, TBA and FINS and AUC (glucose) were significantly higher in HFD group. After administration of metformin, the levels of FBG, TG, TC, LDLC and TBA in DM and LI group were higher than NC group. Besides, the FBG, TG, TC, TBA and LDLC levels in EI group were higher than DM group.

CONCLUSIONS: Metformin may help to improve the glucose and lipid metabolism by influencing the level of serum total bile acids. A combination of HFD and metformin could be effective in the treatment of rats with T2DM.

L'articolo Metformin improves the glucose and lipid metabolism via influencing the level of serum total bile acids in rats with streptozotocin-induced type 2 diabetes mellitus sembra essere il primo su European Review.



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MAIT cells and MR1-antigen recognition

Andrew N Keller | Alexandra J Corbett | Jacinta M Wubben | James McCluskey | Jamie Rossjohn

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Unusual antigen presentation offers new insight into HIV vaccine design

Andrew J McMichael | Louis J Picker

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miR-138 suppressed the progression of osteoarthritis mainly through targeting p65

OBJECTIVE: MicroRNAs are reported to play key roles in regulating the main risk factors for osteoarthritis (OA) chondrogenesis. In the current study, we focused on miR-138, which has never been explored in OA.

PATIENTS AND METHODS: The expression of miR-138 and p65 was explored in the cartilage tissues of OA patients and compared with those of normal controls. We then explored the effects of miR-138 on NF-κB signaling activation in both human OA chondrocytes and chondrogenic SW1353 cells in the presence of 10 nM TNFα. The protein levels of p65, COX-2 and IL6 were determined using Western blot analysis. To validate the target gene of miR-138, a dual luciferase reporter assay was performed.

RESULTS: The level of miR-138 was markedly reduced in the OA cartilage tissues compared with those of normal controls. Real-time PCR analysis demonstrated that the level of miR-138 decreased after TNFα treatment for 3, 6, and 12 h in the normal chondrocytes and OA chondrocytes. Furthermore, overexpression of miR-138 suppressed the protein levels of p65, COX-2 and IL6 in human OA chondrocytes and chondrogenic SW1353 cells. A dual luciferase reporter assay demonstrated that miR-138 significantly suppressed the relative luciferase activity of pmirGLO-p65-3'UTR. More importantly, treatment with TNFα significantly enhanced the protein levels of p65, COX-2 and IL6. However, overexpression of miR-138 could partially abolish such effects.

CONCLUSIONS: We demonstrated that reduced miR-138 expression enhanced the destruction of the cartilage tissues among OA patients, mainly through targeting p65.

L'articolo miR-138 suppressed the progression of osteoarthritis mainly through targeting p65 sembra essere il primo su European Review.



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Exam 1: Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study



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Exam 2: Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound-Guided Fine-Needle Aspiration



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Computational fluid dynamics study of intra-arterial chemotherapy for oral cancer

Intra-arterial chemotherapy (IAC) for oral cancer can deliver a higher concentration of anticancer agent into a tumor-feeding artery than intravenous systemic chemotherapy. However, distribution of anticancer ...

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Inertial measurement systems for segments and joints kinematics assessment: towards an understanding of the variations in sensors accuracy

Joints kinematics assessment based on inertial measurement systems, which include attitude and heading reference system (AHRS), are quickly gaining in popularity for research and clinical applications. The var...

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Reply

We thank Dr Bachynski for her thoughtful letter. She states that our data "suggest the importance of examining how broader social contexts may influence this apparent disconnect between what a physician would do for his or her own child and what he or she recommends for patients." Bachynski suggests that "one probable key factor is race." We did not ask physicians for the racial/ethnic makeup of their practice, so we cannot speculate about whether patient race/ethnicity influences physician counseling practices, as has been found in other studies.

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The Effect of Immunosuppression on Airway Integrity.

Background: Insults to the airway epithelium play a key role in constrictive bronchiolitis following lung transplantation (LTx), the typical hallmark of chronic rejection. Our hypothesis is that immunosuppressives might affect airway integrity. Methods: A biculture of lung bronchial epithelial cells (16HBE) and lung microvascular endothelial cells (HLMVEC) was exposed to immunosuppressives (serum through levels) for 24h or 4 days. Cytotoxicity, trans-epithelial electrical resistance (TEER) and permeability was measured after exposure to monotherapies and combination therapies. Apoptosis, oxidative stress, inflammation (IL-8), real time PCR for epithelial-to-mesenchymal-transition (EMT) and tight junction proteins were assessed in exposed cells. Results: MMF and combination therapies including MMF, at serum trough levels and higher, are toxic for the 16HBE cells after 4 days exposure. Moreover, already after 24h, TEER of cells exposed to MMF decreases and permeability increases. MMF did not induce apoptosis, oxidative stress, loss of tight junctions or production of IL-8 after 24h, but possibly induces EMT in epithelial cells. MMF was detectable at both sides of the biculture and was also present in broncho-alveolar-lavage (BAL) of LTx patients. Other immunosuppressives were not toxic, neither changed TEER or permability. Conclusions: Our findings suggest that MMF is present in the airways of lung transplant patients and might affect the structural integrity of the airway, which needs further investigation and validation in the clinical setting. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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A RODENT MODEL OF CARDIAC DONATION AFTER CIRCULATORY DEATH AND NOVEL BIOMARKERS OF CARDIAC VIABILITY DURING EX VIVO HEART PERFUSION.

Background: Organ donation after circulatory death (DCD) is increasingly being used as a means of addressing the organ supply/demand mismatch in solid organ transplantation. There is reluctance to use DCD hearts, due to an inability to precisely identify hearts that have suffered irreversible injury. We investigated novel biomarkers and clinically relevant endpoints across a spectrum of warm ischemic times (WITs), prior to and during ex vivo heart perfusion (EVHP), to identify features associated with a non-viable cardiac phenotype. Methods: Donor rats sustained a hypoxic cardiac arrest, followed by variable acirculatory standoff periods (DCD groups). Left ventricular function, histochemical injury, and differences in left ventricular gene expression were studied prior to, and during, EVHP. Results: As WIT exposure increased in DCD groups, fewer hearts were functional during EVHP, and ventricular function was increasingly impaired. Histochemical assessment identified severely injured hearts during EVHP. A novel gene expression signature identified severely injured hearts during EVHP (upregulation of c-Jun: 3.19 (2.84-3.60), p=0.0014; HMOX-1: 3.87 (2.72-5.50), p=0.0037; and Hsp90: 7.66 (6.32-9.27), p

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Combined heart lung transplantation: an updated review of the current literature.

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Heart lung transplantation is a viable treatment option for patients with many end stage heart and lung pathologies. However, given the complex nature of the procedure, it is imperative that patients are selected appropriately and the clinician is aware of the many unique aspects in management of this population. This review seeks to describe updated organ selection policies, peri and postoperative management strategies, monitoring of graft function, and clinical outcomes for patients following combined heart-lung transplantation in the current era. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Autonomic Nervous System Pretransplant Malfunction is a Powerful Predictor of Survival after Allogeneic Hematopoietic Cell Transplantation.

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Background: Autonomic nervous system function indexed by heart rate variability (HRV) has shown prognostic value for mortality in various cardiovascular and noncardiovascular diseases including cancer. The purpose of this study was to evaluate an association between HRV and outcomes of allogeneic hematopoietic cell transplantation (allo-HCT) Methods: We prospectively measured HRV as a surrogate pretransplant marker of autonomic nervous system activity in consecutive allo-HCTs with hematological diseases. Results: We analyzed 112 allo-HCTs performed between July 2011 and July 2013 in our center. Univariate analysis showed that increased values of HRV components (low-frequency and high-frequency spectral component (LF and HF), standard deviation of NN interval (SDNN), and squares of the differences between adjacent normal-to-normal RR intervals (r-MSSD) were significantly associated with decreased probability of overall mortality (OM) (hazard ratio: 0.3 for LF, p

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(P076) Sequential Boost Compared With Simultaneous Integrated Boosts for HPV Positive Oropharyngeal Cancer Patients

We hypothesized that sequential boost plans (SEQ) may reduce acute toxicity while maintaining excellent control and survival rates for patients with Human Papilloma Virus (HPV) associated squamous cell carcinomas of the oropharynx.

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Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients.

BACKGROUND: Antiplatelet medications are usually discontinued before elective neurosurgery, but this is not an option for emergent neurosurgery. We performed a retrospective cohort study to examine whether preoperative aspirin use was associated with worse outcomes after emergency neurosurgery in elderly patients. METHODS: We analyzed all cases of emergency neurosurgical procedures for traumatic intracranial hemorrhage from 2008 to 2012 at a level 1 trauma center. Demographics, comorbidities, and outcomes were compared for patients >=65 years by preoperative aspirin exposure. Exclusion criteria were: (1) polytrauma, (2) concomitant use of other preoperative anticoagulants or antiplatelet agents, (3) surgical indication other than subdural, extradural, or intraparenchymal hemorrhage, and (4) repeat neurosurgical procedures within a single admission. Estimated intraoperative blood loss, postprocedural intracranial bleeding requiring reoperation, death in hospital, intensive care unit, and hospital lengths of stay and perioperative blood product transfusion from 48 hours before 48 hours after surgery were the study outcomes. We also examined whether platelet transfusion had an impact on outcomes for patients on aspirin. RESULTS: The cohort included 171 patients. Patients receiving preoperative aspirin (n = 87, 95% taking 81 mg/day) were the same age as patients not receiving aspirin (n = 84; 78.3 +/- 7.8 vs 75.9 +/- 7.9 years, P > .05), had slightly higher admission Glasgow Coma Scale scores (12.8 +/- 3.4 vs 11.4 +/- 4, P = .02) and tended to have more coronary artery disease (P =65 years undergoing emergency neurosurgery for traumatic intracranial hemorrhage, preoperative low-dose aspirin treatment was not associated with increased perioperative bleeding, hospital lengths of stay, or in-hospital mortality. (C) 2017 International Anesthesia Research Society

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Tablet e-Logbooks: Four Thousand Clinical Cases and Complications e-Logged by 14 Nondoctor Anesthesia Providers in Nepal.

BACKGROUND: To meet the need for essential surgery across rural Nepal, anesthesia at district level is delivered by nondoctor anesthetists. They require support to maintain confidence and competence, and upgraded professional registration to secure their status. To meet these needs, a distance-blended learning course was pioneered and delivered. A core course requirement was to log all clinical cases; these were logged on a new e-logbook. METHODS: Fourteen nondoctor anesthesia providers working in 12 different districts across Nepal were enrolled in the 1-year course. The course is based on self-completion on a tablet loaded with new learning modules, a resource library, and a case logbook. Continuous educational mentoring was provided by anesthesiologists by phone and email. The logbook included preanesthesia assessment and interventions, American Society of Anesthesiologists (ASA) grading, types of cases and anesthesia given, monitors used, complications, outcomes and free text remarks. Cases were uploaded monthly to a database, and mentors reviewed all logbook entries. RESULTS: The 14 nondoctor anesthesia providers were widely distributed across the country in district, zonal, community, and mission hospitals, and had different levels of clinical experience and caseloads. Logbooks and uploads were regularly completed without difficulty; 1% cases were entered incompletely with no case details provided. A total of 4143 cases were recorded. Annual caseload per nondoctor anesthesia provider ranged from 50 to 788, the majority of which were under spinal anesthesia; 34% of the total cases were cesarean deliveries, of which 99% received spinal anesthesia. Fifty gastrointestinal laparotomies (1% total) were recorded. Ninety-one percent of cases were ASA I, 0.8% ASA III/IV. Pulse oximetry was used in 98% of cases. Complications were recorded in 6% of cases; the most common were circulation problems (69%) including hypotension and occasional bradycardia after spinal anesthesia. Airway complications were usually under ketamine anesthesia requiring basic airway maneuvers; 4 difficult intubations were recorded under general anesthesia. Anesthesia outcomes were good with overall mortality of 0.1% (total 4 cases). Causes of death included severe preeclampsia, sepsis postlaparotomy, and patients with multiorgan failure for minor procedure. CONCLUSIONS: The tablet-based electronic anesthesia logbook was successfully used to record cases, complications, and outcomes across rural Nepal. The nondoctor anesthesia providers had trust and confidence in recording outcomes. It remains to be tested whether an e-logbook would be routinely completed outside of a specific training course. Such a logbook could be incorporated into all continuous professional development programs for rural nondoctor anesthetists. (C) 2017 International Anesthesia Research Society

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Structural Behavior of the Endothelial Glycocalyx Is Associated With Pathophysiologic Status in Septic Mice: An Integrated Approach to Analyzing the Behavior and Function of the Glycocalyx Using Both Electron and Fluorescence Intravital Microscopy.

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BACKGROUND: The endothelial surface layer (ESL) regulates vascular permeability to maintain fluid homeostasis. The glycocalyx (GCX), which has a complex and fragile ultrastructure, is an important component of the ESL. Abnormalities of the GCX have been hypothesized to trigger pathological hyperpermeability. Here, we report an integrated in vivo analysis of the morphological and functional properties of the GCX in a vital organ. METHODS: We examined the behavior of the ESL and GCX, using both electron microscopy (EM) and intravital microscopy (IVM). We also compared morphological changes in the ESL of mouse skin in a glycosidase-treated and control group. Combined approaches were also used to examine both morphology and function in a lipopolysaccharide-induced septic model and the pathophysiological features of leukocyte-endothelial interactions and in vivo vascular permeability. RESULTS: Using IVM, we identified an illuminated part of the ESL as the GCX and confirmed our observation using morphological and biochemical means. In septic mice, we found that the GCX was thinner than in nonseptic controls in both an EM image analysis (0.98 +/- 2.08 nm vs 70.68 +/- 36.36 nm, P

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Red Blood Cell Transfusion and Surgical Site Infection After Colon Resection Surgery: A Cohort Study.

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BACKGROUND: Surgical site infections (SSIs) after colon surgery remain a critical safety issue. Patients with an SSI have an increased risk of death, prolonged hospitalization, and increased costs of care. Red blood cell (RBC) transfusion is given during the perioperative period to increase blood oxygen delivery, but it is associated with complications, including infection. We hypothesized that RBC transfusion would be associated with increased SSI risk in patients undergoing colon resection surgery. METHODS: A retrospective cohort study was performed using the 2014 National Surgical Quality Improvement Program participant use file. Patients who had colon resection surgery were identified using current procedural terminology codes. The association between perioperative RBC transfusion and superficial and deep incisional SSIs, organ space SSIs, and postoperative septic shock was modeled using logistic regression with propensity score analysis. RESULTS: Of 23,388 patients who had colon resection surgery, 1845 (7.9%) received perioperative RBC transfusion. After controlling for confounders with propensity score analysis and inverse probability of treatment weighting, RBC transfusion had no apparent association with superficial incisional SSI (odds ratio [OR], 1.18; 99% confidence interval [CI], 0.48-2.88) or deep incisional SSI (OR, 1.47; 99% CI, 0.23-9.43). However, RBC transfusion appeared to be associated with increased risk of organ space SSI (OR, 2.93; 99% CI, 1.43-6.01) and septic shock (OR, 9.23; 99% CI, 3.53-24.09). CONCLUSIONS: RBC transfusion has no apparent association with increased risk for incisional SSIs, but may be associated with increased risk for organ space SSI and septic shock after colon resection surgery. (C) 2017 International Anesthesia Research Society

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Stroke Volume Variation and Pulse Pressure Variation Are Not Useful for Predicting Fluid Responsiveness in Thoracic Surgery.

BACKGROUND: Stroke volume variation (SVV) and pulse pressure variation (PPV) are used as indicators of fluid responsiveness, but little is known about the usefulness of these dynamic preload indicators in thoracic surgery, which involves an open thoracic cavity and one-lung ventilation (OLV). Therefore, we investigated whether SVV and PPV could predict fluid responsiveness, and whether the thresholds of these parameters should be adjusted for thoracic surgery. METHODS: This was a prospective, controlled study conducted in a tertiary care center. Eighty patients scheduled for an elective lobectomy requiring OLV were included (n = 40, video-assisted thoracoscopic surgery (VATS); n = 40, open thoracotomy). Twenty minutes after opening the thoracic cavity, 7 mL/kg hydroxyethyl starch was administered for 30 minutes. Various hemodynamic parameters were measured before and after fluid challenge. RESULTS: Among the 80 patients enrolled in this study, 37% were fluid responders (increase in stroke volume index >=10%). SVV before fluid challenge was not different between nonresponders and responders (mean +/- SD: 7.1 +/- 2.7% vs 7.4 +/- 2.6%, P = .68). This finding was true regardless of whether the surgery involved open thoracotomy or VATS. PPV before fluid challenge showed the difference between nonresponders and responders (mean +/- SD: 6.9 +/- 3.0% vs 8.4 +/- 3.2%; P = .045); however, the sensitivity and specificity of the threshold value (PPV = 7%) were low (58% and 62%, respectively) and the area under the receiver operating characteristics curve was only 0.63 (95% confidence interval, 0.52-0.74; P = .041). CONCLUSIONS: Dynamic preload indicators are not useful for predicting fluid responsiveness in VATS or open thoracic surgery. (C) 2017 International Anesthesia Research Society

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A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients.

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INTRODUCTION: Serious complications are common during the intensive care of postoperative cardiac surgery patients. Some of these complications may be influenced by communication during the process of handover of care from the operating room to the intensive care unit (ICU) team. A structured transfer of care process may reduce the rate of communication errors and perioperative complications. METHODS: We hypothesized that a collaborative, comprehensive, structured handover of care from the intraoperative team to the ICU team would reduce a specific set of postoperative complications. We tested this hypothesis by developing and introducing a comprehensive multidisciplinary transfer of care process. We measured patient outcomes before and after the intervention using a linkage between 2 care databases: an Anesthesia Information Management System and a critical care complication registry database. RESULTS: There were 1127 total postoperative cardiac surgery admissions during the study period, 550 before and 577 after the intervention. There was no statistical difference between overall complications before and after the intervention (P = .154). However, there was a statistically significant reduction in preventable complications after the intervention (P = .023). DISCUSSION: The main finding of this investigation is that the introduction of a collaborative, comprehensive transfer of care process from the operating room to the ICU was associated with patients suffering fewer preventable complications. (C) 2017 International Anesthesia Research Society

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Trends in Perioperative Practice and Resource Utilization in Patients With Obstructive Sleep Apnea Undergoing Joint Arthroplasty.

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BACKGROUND: Emerging evidence associating obstructive sleep apnea (OSA) with adverse perioperative outcomes has recently heightened the level of awareness among perioperative physicians. In particular, estimates projecting the high prevalence of this condition in the surgical population highlight the necessity of the development and adherence to "best clinical practices." In this context, a number of expert panels have generated recommendations in an effort to provide guidance for perioperative decision-making. However, given the paucity of insights into the status of the implementation of recommended practices on a national level, we sought to investigate current utilization, trends, and the penetration of OSA care-related interventions in the perioperative management of patients undergoing lower joint arthroplasties. METHODS: In this population-based analysis, we identified 1,107,438 (Premier Perspective database; 2006-2013) cases of total hip and knee arthroplasties and investigated utilization and temporal trends in the perioperative use of regional anesthetic techniques, blood oxygen saturation monitoring (oximetry), supplemental oxygen administration, positive airway pressure therapy, advanced monitoring environments, and opioid prescription among patients with and without OSA. RESULTS: The utilization of regional anesthetic techniques did not differ by OSA status and overall 50% and a concurrent decrease in opioid prescription. Interestingly, while the absolute number of patients with OSA receiving perioperative oximetry, supplemental oxygen, and positive airway pressure therapy significantly increased over time, the proportional use significantly decreased by approximately 28%, 36%, and 14%, respectively. A shift from utilization of intensive care to telemetry and stepdown units was seen. CONCLUSIONS: On a population-based level, the implementation of OSA-targeted interventions seems to be limited with some of the current trends virtually in contrast to practice guidelines. Reasons for these findings need to be further elucidated, but observations of a dramatic increase in absolute utilization with a proportional decrease may suggest possible resource constraints as a contributor. (C) 2017 International Anesthesia Research Society

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Remote Ischemic Preconditioning Decreases Oxidative Lung Damage After Pulmonary Lobectomy: A Single-Center Randomized, Double-Blind, Controlled Trial.

BACKGROUND: During lobectomy in patients with lung cancer, the operated lung is often -collapsed and hypoperfused. Ischemia/reperfusion injury may then occur when the lung is -re-expanded. We hypothesized that remote ischemic preconditioning (RIPC) would decrease oxidative lung damage and improve gas exchange in the postoperative period. METHODS: We conducted a single-center, randomized, double-blind trial in patients with nonsmall cell lung cancer undergoing elective lung lobectomy. Fifty-three patients were randomized to receive limb RIPC immediately after anesthesia induction (3 cycles: 5 minutes ischemia/5 minutes reperfusion induced by an ischemia cuff applied on the thigh) and/or control therapy without RIPC. Oxidative stress markers were measured in exhaled breath condensate (EBC) and arterial blood immediately after anesthesia induction and before RIPC and surgery (T0, baseline); during operated lung collapse, immediately before resuming two-lung ventilation (TLV) (T1); immediately after resuming TLV (T2); and 120 minutes after resuming TLV (T3). The primary outcome was 8-isoprostane levels in EBC at T1, T2, and T3. Secondary outcomes included the following: NO2-+NO3-, H2O2 levels, and pH in EBC and in blood (8-isoprostane, NO2-+NO3-) and pulmonary gas exchange variables (PaO2/FiO2, A-aDO2, a/A ratio, and respiratory index). RESULTS: Patients subjected to RIPC had lower EBC 8-isoprostane levels when compared with controls at T1, T2, and T3 (differences between means and 95% confidence intervals): -15.3 (5.8-24.8), P = .002; -20.0 (5.5-34.5), P = .008; and -10.4 (2.5-18.3), P = .011, respectively. In the RIPC group, EBC NO2-+NO3- and H2O2 levels were also lower than in controls at T2 and T1-T3, respectively (all P

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The Labor Analgesia Requirements in Nulliparous Women Randomized to Epidural Catheter Placement in a High or Low Intervertebral Space.

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BACKGROUND: We hypothesized that an epidural catheter placed in a lower vertebral interspace will require less medication for labor analgesia. METHODS: Nulliparous women requesting neuraxial labor analgesia were randomized to epidural catheter placement at the ultrasound-confirmed L1-2 or L4-5 interspace. Patient-controlled epidural analgesia and breakthrough manual epidural boluses of 10 mL of 0.125% bupivacaine with 50 [micro]g of fentanyl or 8 mL of 2% lidocaine were utilized. Abdominal and perineal pain scores were assessed at 30 and 60 minutes after standardized initiation of epidural analgesia. Pain scores during pushing were assessed after delivery. The primary outcome was the proportion of patients requiring manual boluses and was compared using a [chi]2 test. Secondarily, we analyzed the number of boluses given in early (up to 4 hours before delivery) versus late labor using [chi]2 tests and the pain scores using Mann-Whitney U tests, with adjustment of P values for multiple testing. RESULTS: We analyzed 148 patients. Overall, the percentage of patients in the low versus high groups who required manual boluses was 46% vs 51% (P = 1.0). For the 56 patients in each group who delivered vaginally, 22 (52%) vs 20 (48%) manual boluses were given to the low epidural group in early versus late labor, compared to 9 (20%) vs 36 (80%) in the high epidural group (P = .014). There was no statistical difference in patient-controlled epidural analgesia requirements or patient satisfaction. Comparing the low versus high groups, the median (interquartile range) pain scores were: 3 (1, 6) vs 0 (0, 2) (P = .013) at 30 minutes and 1 (1, 3) vs 0 (0, 1) (P = .013) at 60 minutes for abdominal pain; 0 (0, 2) vs 1 (1, 3) (P = .36) and 0 (0, 1) vs 1 (1, 3) (P = .014) at these same time points for perineal pain; and 1 (0, 5) vs 0 (0, 3) (P = .9) for abdominal and 2 (0, 5) vs 4 (1, 8) (P = .025) for perineal pain during pushing. The percentage of patients who underwent instrumental delivery was 15% vs 5% (P = .06) for the low versus high group. CONCLUSIONS: An L4-5 epidural catheter initially provides less relief of abdominal pain but more relief of perineal labor pain. Patients with an L4-5 catheter require more manual boluses during early labor but less during late labor. The possible association of low epidural catheters with instrumental delivery merits further investigation. (C) 2017 International Anesthesia Research Society

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Somatic mosaicism with reversion to normality of a mutated transthyretin allele related to a familial amyloidotic polyneuropathy

Abstract

Familial amyloidotic polyneuropathy (FAP) is a progressive neuropathy, with onset in adulthood and high mortality. It is related to an altered transthyretin (TTR) plasma protein, mainly produced by the liver and responsible for amyloid deposit in the peripheral nervous system. SNPs in the TTR gene were associated with FAP, and the G>C substitution (NM_000371.3:c.325G>C) in the 109th codon (GAG vs CAG; NP_362.1:p.E109Q) was previously described in Sicily (Italy). Here, we report on a Sicilian family with several patients affected by FAP related to the E109Q mutation, which displayed a somatic mosaicism with the reversion to normality of the c.325G>C mutation. After exclusion of isodisomy and allele deletion, this event seems to be due to a rare, post-zygotic interallelic gene conversion with the wild-type allele serving as a donor. Further investigations will be necessary to better understand the molecular basis of this phenomenon, and could help determine if this can be induced in a targeted manner in the context of natural gene therapy to treat TTR-related FAP patients, as previously proposed for other diseases. Moreover, our results confirm the need to perform DNA-based diagnostic tests with at least a second tissue when a suspected germline mutation in a candidate gene is not identified in the first tissue.



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CRISPR/Cas9-mediated somatic and germline gene correction to restore hemostasis in hemophilia B mice

Abstract

Hemophilia B (HB) is an X-linked disorder caused by defects of F9 encoded coagulation factor IX, which is an ideal model for gene therapy. Most existing HB gene therapies are based on viral mediated gene supplementation, which could increase immunoreaction. In this study, CRISPR/Cas9 system was used for gene correction in an F9 mutant HB mouse model in both adult mice (in vivo) and in germline cells (ex vivo). In vivo, naked Cas9-sgRNA plasmid and donor DNA were delivered to HB mice livers to recover the mutation via hydrodynamic tail vein (HTV) injection. 62.5% of the HTV-treated mice showed a detectable gene correction (>1%) in the F9 alleles of hepatocytes, which was sufficient to remit the coagulation deficiency. Ex vivo, three different forms of Cas9 were microinjected into germline cells of HB mice to investigate their efficiency and safety in gene correction. Cas9 protein showed higher gene recovery rates, less embryo toxicity, and lower mosaic repair percentage, making it more suitable for germline gene therapy. Our study strongly supports that CRISPR/Cas9-mediated genome editing is feasible in gene therapy of genetic disorders.



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In older men with low testosterone levels and age-associated memory impairment, testosterone did not improve memory



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Handgun Acquisitions in California After Two Mass Shootings

Background:
Mass shootings are common in the United States. They are the most visible form of firearm violence. Their effect on personal decisions to purchase firearms is not well-understood.
Objective:
To determine changes in handgun acquisition patterns after the mass shootings in Newtown, Connecticut, in 2012 and San Bernardino, California, in 2015.
Design:
Time-series analysis using seasonal autoregressive integrated moving-average (SARIMA) models.
Setting:
California.
Population:
Adults who acquired handguns between 2007 and 2016.
Measurements:
Excess handgun acquisitions (defined as the difference between actual and expected acquisitions) in the 6-week and 12-week periods after each shooting, overall and within subgroups of acquirers.
Results:
In the 6 weeks after the Newtown and San Bernardino shootings, there were 25 705 (95% prediction interval, 17 411 to 32 788) and 27 413 (prediction interval, 15 188 to 37 734) excess acquisitions, respectively, representing increases of 53% (95% CI, 30% to 80%) and 41% (CI, 19% to 68%) over expected volume. Large increases in acquisitions occurred among white and Hispanic persons, but not among black persons, and among persons with no record of having previously acquired a handgun. After the San Bernardino shootings, acquisition rates increased by 85% among residents of that city and adjacent neighborhoods, compared with 35% elsewhere in California.
Limitations:
The data relate to handguns in 1 state. The statistical analysis cannot establish causality.
Conclusion:
Large increases in handgun acquisitions occurred after these 2 mass shootings. The spikes were short-lived and accounted for less than 10% of annual handgun acquisitions statewide. Further research should examine whether repeated shocks of this kind lead to substantial increases in the prevalence of firearm ownership.
Primary Funding Source:
None.

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The Clearing



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Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk

Background:
Interpersonal firearm violence among youth is a substantial public health problem, and emergency department (ED) physicians require a clinical screening tool to identify high-risk youth.
Objective:
To derive a clinically feasible risk index for firearm violence.
Design:
24-month prospective cohort study.
Setting:
Urban, level 1 ED.
Participants:
Substance-using youths, aged 14 to 24 years, seeking ED care for an assault-related injury and a proportionately sampled group of non–assault-injured youth enrolled from September 2009 through December 2011.
Measurements:
Firearm violence (victimization/perpetration) and validated questionnaire items.
Results:
A total of 599 youths were enrolled, and presence/absence of future firearm violence during follow-up could be ascertained in 483 (52.2% were positive). The sample was randomly split into training (75%) and post–score-construction validation (25%) sets. Using elastic-net penalized logistic regression, 118 baseline predictors were jointly analyzed; the most predictive variables fell predominantly into 4 domains: violence victimization, community exposure, peer influences, and fighting. By selection of 1 item from each domain, the 10-point SaFETy (Serious fighting, Friend weapon carrying, community Environment, and firearm Threats) score was derived. SaFETy was associated with firearm violence in the validation set (odds ratio [OR], 1.47 [95% CI, 1.23 to 1.79]); this association remained (OR, 1.44 [CI, 1.20 to 1.76]) after adjustment for reason for ED visit. In 5 risk strata observed in the training data, firearm violence rates in the validation set were 18.2% (2 of 11), 40.0% (18 of 45), 55.8% (24 of 43), 81.3% (13 of 16), and 100.0% (6 of 6), respectively.
Limitations:
The study was conducted in a single ED and involved substance-using youths. SaFETy was not externally validated.
Conclusion:
The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence. Although broader validation is required, SaFETy shows potential to guide resource allocation for prevention of firearm violence.
Primary Funding Source:
National Institute on Drug Abuse R01024646.

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Botulinum Toxin for Burning Mouth Syndrome



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Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection A Collaborative Meta-analysis

Background:
High-sensitivity assays for cardiac troponin T (hs-cTnT) are sometimes used to rapidly rule out acute myocardial infarction (AMI).
Purpose:
To estimate the ability of a single hs-cTnT concentration below the limit of detection (Data Sources:

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Review: In COPD, injectable polyvalent pneumococcal vaccines reduce risk for community-acquired pneumonia



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Clinical Trials of Therapeutics for the Prevention of Congenital Zika Virus Disease: Challenges and Potential Solutions

Zika virus (ZIKV) infection in pregnancy is associated with adverse fetal outcomes, such as microcephaly and other congenital malformations. No therapeutic options are available to pregnant women with ZIKV infection to prevent these effects. Drug trials in pregnancy raise several scientific, ethical, and logistic challenges, which are compounded further in ZIKV because of limited knowledge of the disease pathophysiology and a product development pipeline in its infancy. We evaluate the major challenges in choosing therapeutics to prevent congenital ZIKV disease and conducting clinical trials of these treatments, with a focus on preventing congenital central nervous system malformations. These challenges must be characterized and planned for now so that clinical trials can progress expediently and effectively in the future.

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Annals Consult Guys - The Adult Survivor of Hodgkin Disease: Falling Through the Cracks



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Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper

Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.

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Patient-Centered Medical Homes and Adherence to Chronic Disease Medications



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Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness and Reduce Burnout

This commentary summarizes recommendations for methodologically rigorous research in 6 dimensions to help address physician burnout.

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Guideline: Insufficient evidence exists on screening for obstructive sleep apnea in asymptomatic adults



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Physicians, Patients, and Firearms: The Courts Say “Yes”

This commentary discusses a recently overturned Florida law that sought to limit physicians discussing firearm safety with patients.

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Review: After coronary DES, ≤ 6 mo and 1 y of dual-antiplatelet therapy do not differ for CV events at 1 y



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What We Do (and Don't) Know About the Health Effects of Cannabis and Whether Marijuana Is Medicine

This commentary highlights the major findings of the recent National Academies of Sciences, Engineering, and Medicine report on the health effects of cannabis and cannabinoids.

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Review: Strategies to improve provider adoption and implementation of clinical practice guidelines were assessed



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The Development and Performance of After-Hours Primary Care in the Netherlands A Narrative Review

In many Western countries, hospital emergency departments are overcrowded, leading to the desire to strengthen primary care, particularly after hours. To achieve this goal, an increasing number of Western nations are reorganizing their after-hours primary care systems into large-scale primary care physician (PCP) cooperatives. This article provides an overview of the organization, performance, and development of PCP cooperatives in the Netherlands. The Dutch after-hours primary care system might offer opportunities for other countries facing problems with after-hours care and inappropriate emergency department visits.During the past several years, the number of contacts with Dutch PCP cooperatives has increased to 245 contacts per 1000 citizens per year. Many contacts (45%) are nonurgent, and about half occur as part of a series of primary care contacts. Low accessibility and availability of daytime primary care are related to greater use of after-hours primary care. To prevent unnecessary attendance at the cooperatives, physicians advocate copayment, a stricter triage system, and a larger role for telephone doctors.More than half of the PCP cooperatives in the Netherlands have integrated with hospital emergency departments, forming "emergency care access points." This collaboration has decreased emergency department use by 13% to 22%, and treatment of self-referrals by PCP cooperatives in emergency care access points is safe and cost-effective. Direct access to diagnostic facilities may optimize efficiency even more. Other recent developments include access to electronic health records of daytime primary care practices, task substitution from physicians to nurses, and the launch of a 2-year training program for PCPs to become experts in emergency care.

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Annals for Hospitalists - 16 May 2017



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The True Effect of Mass Shootings on Americans

The editorialist discusses Studdert and colleagues' findings and ways to counter social and political forces that lead to policies and behaviors that translate into more gun ownership and more gun-related violence, injury, and death.

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Membrane Fusion Stalks and Lipid Rafts: A Love-Hate Relationship

Coarse-grained molecular dynamics simulations are applied to explore the experimentally observed ability of the liquid-ordered (lo)/liquid-disordered (ld) phase boundary to facilitate viral membrane fusion. Surprisingly, a formed fusion stalk can be both attracted (i.e., stalkophilic) and repelled (i.e., stalkophobic) by the lo/ld phase boundary. The phase boundary becomes stalkophilic if the lo phase constituents have the larger negative spontaneous curvature. In such a case, location of the highly curved stalk near the less-ordered and thus (relatively) softer boundary region becomes energetically favorable.

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Acute Pancreatitis: How Soon Should We Feed Patients?

Early enteral nutrition, defined as the provision of nutrients within 48 hours of hospitalization, has been associated with reduced mortality and complications compared with delayed enteral nutrition in patients with acute pancreatitis. Vaughn and colleagues report a systematic review of early versus delayed enteral nutrition. The editorialists discuss the results, why they should be interpreted with caution, and the evidence gaps in defining when and how to best feed patients with acute pancreatitis.

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Prevalence of Elevated Cardiovascular Risks in Young Adults



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Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations

Background:
Measles outbreaks continue to occur in the United States and are mostly due to infections in returning travelers.
Objective:
To describe how providers assessed the measles immunity status of departing U.S. adult travelers seeking pretravel consultation and to assess reasons given for nonvaccination among those considered eligible to receive the measles, mumps, rubella (MMR) vaccine.
Design:
Observational study in U.S. pretravel clinics.
Setting:
24 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention–funded consortium.
Patients:
Adults (born in or after 1957) attending pretravel consultations at GTEN sites (2009 to 2014).
Measurements:
Structured questionnaire completed by traveler and provider during pretravel consultation.
Results:
40 810 adult travelers were included; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]).
Limitation:
These estimates could underrepresent the opportunities for MMR vaccination because providers accepted verbal histories of disease and vaccination as evidence of immunity.
Conclusion:
Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider's assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus.
Primary Funding Source:
Centers for Disease Control and Prevention, National Institutes of Health, and the Steve and Deborah Gorlin MGH Research Scholars Award.

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Prevalence of Elevated Cardiovascular Risks in Young Adults A Cross-sectional Analysis of National Health and Nutrition Examination Surveys

Background:
The 2013 cholesterol management guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) recommend lipid screening in all adults older than 20 years to identify those at increased risk for atherosclerotic cardiovascular disease (ASCVD). Statins may be considered for patients with elevated 10-year risk (>5%) or a low-density lipoprotein cholesterol (LDL-C) level of 4.92 mmol/L (190 mg/dL) or greater.
Objective:
To describe the prevalence of elevated ASCVD risk among nondiabetic adults younger than 50 years.
Design:
Cross-sectional.
Setting:
NHANES (National Health and Nutrition Examination Survey), 1999 to 2000 through 2011 to 2012.
Participants:
Adults aged 30 to 49 years without known ASCVD or diabetes.
Measurements:
10-year ASCVD risk was estimated by using the 2013 ACC/AHA ASCVD risk calculator. Participants were subdivided by age, sex, and history of smoking and hypertension. The percentages of adults in each subgroup with a 10-year ASCVD risk greater than 5% and of those with an LDL-C level of 4.92 mmol/L (190 mg/dL) or greater were estimated. Low-prevalence subgroups were defined as those in which a greater than 1% prevalence of elevated cardiovascular risk could be ruled out (that is, the upper 95% confidence bound for prevalence was ≤1%).
Results:
Overall, 9608 NHANES participants representing 67.9 million adults were included, with approximately half (47.12%, representing 32 million adults) in low-prevalence subgroups. In the absence of smoking or hypertension, 0.09% (95% CI, 0.02% to 0.35%) of adult men younger than 40 years and 0.04% (CI, 0.0% to 0.26%) of adult women younger than 50 years had an elevated risk. Among other subgroups, 0% to 75.9% of participants had an increased risk. Overall, 2.9% (CI, 2.3% to 3.5%) had an LDL-C level of 4.92 mmol/L (190 mg/dL) or greater.
Limitation:
No information was available regarding cardiovascular outcomes.
Conclusion:
In the absence of risk factors, the prevalence of increased ASCVD risk is low among women younger than 50 and men younger than 40 years.
Primary Funding Source:
None.

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Early Versus Delayed Feeding in Patients With Acute Pancreatitis A Systematic Review

Background:
Acute pancreatitis is among the most common and costly reasons for hospitalization in the United States. Bowel rest, pain control, and intravenous fluids are the cornerstones of treatment, but early feeding might also be beneficial.
Purpose:
To compare length of hospital stay, mortality, and readmission in adults hospitalized with pancreatitis who received early versus delayed feeding.
Data Sources:
MEDLINE via Ovid, EMBASE, the Cochrane Library, CINAHL, and Web of Science through January 2017.
Study Selection:
Two authors independently reviewed and selected studies if they were randomized clinical trials, included adults hospitalized with acute pancreatitis, and compared early versus delayed feeding (≤48 vs. >48 hours after hospitalization).
Data Extraction:
Two investigators independently extracted study data and rated risk of bias using the Cochrane Collaboration tool.
Data Synthesis:
Eleven randomized trials (8 peer-reviewed publications, 3 abstract-only presentations) that included 948 patients were eligible. Seven trials (3 with low risk of bias) enrolled patients with mild to moderate pancreatitis. Four trials (1 with low risk of bias) included patients with predicted severe pancreatitis. Routes used for early feeding included oral (4 studies), nasogastric (2 studies), nasojejunal (4 studies), and oral or nasoenteric (1 study). Among patients with mild to moderate pancreatitis, early feeding was associated with reduced length of stay in 4 of 7 studies (including 2 of 3 with low risk of bias). Other outcomes were heterogeneous and variably reported, but no study showed an increase in adverse events with early feeding. Among patients with severe pancreatitis, limited evidence revealed no statistically significant difference in outcomes between early and delayed feeding.
Limitation:
Heterogeneity of feeding protocols and outcomes, scant data, and unclear or high risk of bias in several studies.
Conclusion:
Limited data suggest that early feeding in patients with acute pancreatitis does not seem to increase adverse events and, for patients with mild to moderate pancreatitis, may reduce length of hospital stay.
Primary Funding Source:
None. (PROSPERO: CRD42015016193)

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Postmalaria Neurologic Syndrome—Autoimmune Encephalitis With Anti–Voltage-Gated Potassium-Channel Antibodies: A Case Report



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Cholesterol Evaluation in Young Adults: Absence of Clinical Trial Evidence Is Not a Reason to Delay Screening

In this issue, Patel and colleagues estimate the prevalence of elevated atherosclerotic risk among nondiabetic adults younger than 50 years, with the stated aim of identifying subgroups for whom cholesterol screening would not provide actionable information. The authors thus suggest that their findings support delayed screening until age 40 years for men and 50 years for women. The editorialists discuss the limitations of the study and why they think the primary prevention of cardiovascular disease should include early-life evaluation of low-density lipoprotein cholesterol, not a delayed approach.

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MACRA: Big Fix or Big Problem?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) aims to improve health care by rewarding clinicians providing higher-quality and lower-cost care who would receive increases in their Medicare reimbursement rates. Poorer performers would receive reductions in their rates. The author discusses how the design of MACRA will, however, result in unintended consequences and incentives that will increase health care disparities without reducing costs.

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Why Aren't International Travelers Vaccinated for Measles?

In this issue, Hyle and colleagues report that only 47% of adults eligible for measles vaccine at a pretravel clinic visit were vaccinated. The editorialists note that efforts to increase measles immunization rates are focused mainly on young children and that the need to immunize unvaccinated travelers at risk for transmitting measles within the United States after international travel often is overlooked. They argue that vigilance is needed to ensure that travelers do not bring the virus back from overseas.

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Sites of colonization in hospitalized patients with infections caused by extended-spectrum beta-lactamase organisms: a prospective cohort study

The objective of this study was to determine whether patients infected with extended-spectrum beta-lactamase (ESBL)-producing organisms are colonized at multiple body sites.

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The threat of antimicrobial resistance in developing countries: causes and control strategies

The causes of antimicrobial resistance (AMR) in developing countries are complex and may be rooted in practices of health care professionals and patients' behavior towards the use of antimicrobials as well as ...

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Determinants of felt demand for dengue vaccines in the North Caribbean region of Colombia

The increasing burden associated with dengue in Latin America makes it essential to understand the community's interest in acquiring vaccines, as an input to plan its introduction in endemic regions. The objec...

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Mindfulness-based stress reduction in Parkinson’s disease: a systematic review

Mindfulness based stress reduction (MBSR) is increasingly being used to improve outcomes such as stress and depression in a range of long-term conditions (LTCs). While systematic reviews on MBSR have taken pla...

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