An Exercise Immune Fitness Test to Unravel Disease Mechanisms-A Proof-of-Concept Heart Failure Study.

Background: Cardiorespiratory fitness positively correlates with longevity and immune health. Regular exercise may provide health benefits by reducing systemic inflammation. In chronic disease conditions, such as chronic heart failure and chronic fatigue syndrome, mechanistic links have been postulated between inflammation, muscle weakness, frailty, catabolic/anabolic imbalance, and aberrant chronic activation of immunity with monocyte upregulation. We hypothesize that (1) temporal changes in transcriptome profiles of peripheral blood mononuclear cells during strenuous acute bouts of exercise using cardiopulmonary exercise testing are present in adult subjects, (2) these temporal dynamic changes are different between healthy persons and heart failure patients and correlate with clinical exercise-parameters and (3) they portend prognostic information. Methods: In total, 16 Heart Failure (HF) patients and 4 healthy volunteers (HV) were included in our proof-of-concept study. All participants underwent upright bicycle cardiopulmonary exercise testing. Blood samples were collected at three time points (TP) (TP1: 30 min before, TP2: peak exercise, TP3: 1 h after peak exercise). We divided 20 participants into 3 clinically relevant groups of cardiorespiratory fitness, defined by peak VO2: HV (n = 4, VO2 ≥ 22 mL/kg/min), mild HF (HF1) (n = 7, 14 < VO2 < 22 mL/kg/min), and severe HF (HF2) (n = 9, VO2 ≤ 14 mL/kg/min). Results: Based on the statistical analysis with 20-100% restriction, FDR correction (p-value 0.05) and 2.0-fold change across the three time points (TP1, TP2, TP3) criteria, we obtained 11 differentially expressed genes (DEG). Out of these 11 genes, the median Gene Expression Profile value decreased from TP1 to TP2 in 10 genes. The only gene that did not follow this pattern was CCDC181. By performing 1-way ANOVA, we identified 8/11 genes in each of the two groups (HV versus HF) while 5 of the genes (TTC34, TMEM119, C19orf33, ID1, TKTL2) overlapped between the two groups. We found 265 genes which are differentially expressed between those who survived and those who died. Conclusions: From our proof-of-concept heart failure study, we conclude that gene expression correlates with VO2 peak in both healthy individuals and HF patients, potentially by regulating various physiological processes involved in oxygen uptake and utilization during exercise. Multi-omics profiling may help identify novel biomarkers for assessing exercise capacity and prognosis in HF patients, as well as potential targets for therapeutic intervention to improve VO2 peak and quality of life. We anticipate that our results will provide a novel metric for classifying immune health.

How to do an ultrasound or computed tomography guided hook-wire localization excisional biopsy of non-palpable lymph nodes.

This article describes the use of USS or CT guided hook-wire localization to aid the excisional biopsy of non-palpable lymph nodes in the cervical, axillary and inguinal regions. This technique allows a more focussed surgical approach intra-operatively to reduce surgical time and morbidity for the patients.

Relationship between cortical and medullary thickness and glomerular filtration rate among living kidney donors.

The relationship between the kidney cortex and medulla is not well understood in healthy populations. This study characterised the relationship between cortical/medullary thickness and measured glomerular filtration rate (GFR) in 390 living kidney donors. A positive relationship was observed between medullary, but not cortical, thickness and GFR. We propose that this reflects a correlation between juxtamedullary nephron number and GFR.

Left testicular venous infarction secondary to large spontaneous retroperitoneal haematoma compressing left testicular vein: a case report.

A man in his early 50s presented with a spontaneous large left-sided retroperitoneal haematoma (RPH), on a background of therapeutic anticoagulation with warfarin for homozygous factor V Leiden. His international normalised ratio was found to be supra-therapeutic at 9.0 on presentation. He was treated non-operatively with prompt reversal of the coagulopathy and close monitoring. On day 4 of the admission, the patient reported scrotal pain and swelling. An urgent scrotal ultrasound revealed infarction of the left testis and the patient was taken to an emergency scrotal exploration. Intraoperatively, the left testis was found to be no longer viable with the left spermatic vein and venules completely thrombosed with extensive clots, while the left testicular artery remained intact. Consequently, a left orchidectomy was performed. Therapeutic anticoagulation was recommenced on day 3 postoperatively. It is thought that the large RPH caused extrinsic compression of the left testicular vein, in addition to the patient's pre-existing factor V Leiden, which resulted in thrombosis of the blood vessel.

No laughing matter - Myeloneuropathy due to heavy chronic nitrous oxide abuse.

Chronic nitrous oxide abuse is a known cause of myeloneuropathy. Nitrous oxide irreversibly inactivates vitamin B12 causing demyelination of the dorsal spinal columns, clinically indistinguishable from that which is caused by vitamin B12 deficiency. We report a 37-year-old female who presented with ataxia, loss of lower extremity proprioception, demyelination of her cervical dorsal spinal columns, and other laboratory and physical exam findings consistent with nitrous oxide abuse. The patient reported daily use in excess of 500 nitrous oxide cartridges, also known as "whippits". Nitrous oxide myeloneuropathy should be included in the differential diagnoses for emergency medicine physicians when evaluating a patient with bilateral neurologic deficits and ataxia.

Post-traumatic Stress Disorder in Family-witnessed Resuscitation of Emergency Department Patients.

INTRODUCTION: Family presence during emergency resuscitations is increasingly common, but the question remains whether the practice results in psychological harm to the witness. We examine whether family members who witness resuscitations have increased post-traumatic stress disorder (PTSD) symptoms at one month following the event. METHODS: We identified family members of critically ill patients via our emergency department (ED) electronic health record. Patients were selected based on their geographic triage to an ED critical care room. Family members were called a median of one month post-event and administered the Impact of Event Scale-Revised (IES-R), a 22-item validated scale that measures post-traumatic distress symptoms and correlates closely with Diagnostic and Statistical Manual of Mental Disorders-IV criteria for post-traumatic stress disorder (PTSD). Family members were placed into two groups based on whether they stated they had witnessed the resuscitation (FWR group) or not witnessed the resuscitation (FNWR group). Data analyses included chi-square test, independent sample t-test, and linear regression controlling for gender and age. RESULTS: A convenience sample of 423 family members responded to the phone interview: 250 FWR and 173 FNWR. The FWR group had significantly higher mean total IES-R scores: 30.4 vs 25.6 (95% confidence interval [CI], -8.73 to -0.75; P<.05). Additionally, the FWR group had significantly higher mean score for the subscales of avoidance (10.6 vs 8.1; 95% CI, -4.25 to -0.94; P<.005) and a trend toward higher score for the subscale of intrusion (13.0 vs 11.4; 95% CI, -3.38 to .028; P = .054). No statistical significant difference was noted between the groups in the subscale of hyperarousal (6.95 vs 6.02; 95% CI, -2.08 to 0.22; P=.121). All findings were consistent after controlling for age, gender, and immediate family member (spouse, parent, children, and grandchildren). CONCLUSION: Our results suggest that family members who witness ED resuscitations may be at increased risk of PTSD symptoms at one month. This is the first study that examines the effects of family visitation for an unsorted population of very sick patients who would typically be seen in the critical care section of a busy ED.

Cutaneous Branch of the Obturator Nerve Extending to the Medial Ankle and Foot: A Report of Two Cadaveric Cases.

The area of skin supplied by the cutaneous branch of the obturator nerve (CBO) is highly variable. Although most introductory anatomy texts describe the CBO as innervating only a portion of the medial thigh, there are numerous reports in the literature of CBOs passing the knee to innervate the proximal, middle, or even distal leg. There are no previous reports of CBOs extending to the ankle and foot. Herein we describe 2 cases of CBOs extending at least to the medial foot. Both cases were discovered incidentally, during routine cadaver dissections by osteopathic and podiatric medical students in the anatomy laboratory of Western University of Health Sciences in California. In both instances, the anomalously long CBOs shared several characteristics: (1) they arose as direct branches of the anterior division of the obturator nerve, not from the subsartorial plexus; (2) they coursed immediately posterior to the great saphenous vein from the distal thigh to the distal leg, only deviating away from the saphenous vein just above the medial malleolus; and (3) they terminated in radiating fibers to the posterior half of the medial ankle and foot. In both cases, the saphenous branch of the femoral nerve was present but restricted to the area anterior to the great saphenous vein. It is likely that the variant CBOs carried fibers of the L4 spinal nerve and thus provided cutaneous innervation to the medial foot and ankle, a function most commonly reserved for the saphenous branch of the femoral nerve distal to the knee. Saphenous neuropathy is a common postoperative complication of saphenous cutdowns for coronary artery bypass grafts, so the potential involvement of a long CBO can add additional complexity to regional anesthetic blocks for foot and ankle surgery and procedures such as vein harvesting for coronary artery bypass grafts.

Rhesus TRIM5α disrupts the HIV-1 capsid at the inter-hexamer interfaces.

TRIM proteins play important roles in the innate immune defense against retroviral infection, including human immunodeficiency virus type-1 (HIV-1). Rhesus macaque TRIM5α (TRIM5α(rh)) targets the HIV-1 capsid and blocks infection at an early post-entry stage, prior to reverse transcription. Studies have shown that binding of TRIM5α to the assembled capsid is essential for restriction and requires the coiled-coil and B30.2/SPRY domains, but the molecular mechanism of restriction is not fully understood. In this study, we investigated, by cryoEM combined with mutagenesis and chemical cross-linking, the direct interactions between HIV-1 capsid protein (CA) assemblies and purified TRIM5α(rh) containing coiled-coil and SPRY domains (CC-SPRY(rh)). Concentration-dependent binding of CC-SPRY(rh) to CA assemblies was observed, while under equivalent conditions the human protein did not bind. Importantly, CC-SPRY(rh), but not its human counterpart, disrupted CA tubes in a non-random fashion, releasing fragments of protofilaments consisting of CA hexamers without dissociation into monomers. Furthermore, such structural destruction was prevented by inter-hexamer crosslinking using P207C/T216C mutant CA with disulfide bonds at the CTD-CTD trimer interface of capsid assemblies, but not by intra-hexamer crosslinking via A14C/E45C at the NTD-NTD interface. The same disruption effect by TRIM5α(rh) on the inter-hexamer interfaces also occurred with purified intact HIV-1 cores. These results provide insights concerning how TRIM5α disrupts the virion core and demonstrate that structural damage of the viral capsid by TRIM5α is likely one of the important components of the mechanism of TRIM5α-mediated HIV-1 restriction.

HIV-1 Vpr loads uracil DNA glycosylase-2 onto DCAF1, a substrate recognition subunit of a cullin 4A-ring E3 ubiquitin ligase for proteasome-dependent degradation.

The human immunodeficiency virus type 1 (HIV-1) accessory protein, Vpr, interacts with several host cellular proteins including uracil DNA glycosylase-2 (UNG2) and a cullin-RING E3 ubiquitin ligase assembly (CRL4(DCAF1)). The ligase is composed of cullin 4A (CUL4A), RING H2 finger protein (RBX1), DNA damage-binding protein 1 (DDB1), and a substrate recognition subunit, DDB1- and CUL4-associated factor 1 (DCAF1). Here we show that recombinant UNG2 specifically interacts with Vpr, but not with Vpx of simian immunodeficiency virus, forming a heterotrimeric complex with DCAF1 and Vpr in vitro as well as in vivo. Using reconstituted CRL4(DCAF1) and CRL4(DCAF1-Vpr) E3 ubiquitin ligases in vitro reveals that UNG2 ubiquitination (ubiquitylation) is facilitated by Vpr. Co-expression of DCAF1 and Vpr causes down-regulation of UNG2 in a proteasome-dependent manner, with Vpr mutants that are defective in UNG2 or DCAF1 binding abrogating this effect. Taken together, our results show that the CRL4(DCAF1) E3 ubiquitin ligase can be subverted by Vpr to target UNG2 for degradation.