Cardiovascular images: pacemaker-lead fracture and excessive coiling in a dog.

A seven-year-old male castrated Labrador Retriever presented emergently due to concern for pacemaker malfunction five years after successful transvenous pacemaker implantation to treat partial atrial standstill. On presentation, the dog's pulse rate was 30-50 beats per minute. An electrocardiogram showed no spontaneous atrial activity or paced ventricular activity. Pacemaker interrogation revealed an increased impedance of 7557 ohms, indicating a lead malfunction. Thoracic radiographs confirmed the lead was fractured and had excessive coiling. The transvenous pacing system was turned off, left in place, and an epicardial pacing system was implanted the following day. The dog was discharged with no perioperative complications. The dog eventually required escalated medical therapy for progressive cardiac disease and was euthanized two years after implantation of the replacement pacemaker. This manuscript illustrates a complete lead fracture and excessive lead coiling, which has not previously been detailed in veterinary medicine.

The human proton pump inhibitors inhibit Mycobacterium tuberculosis rifampicin efflux and macrophage-induced rifampicin tolerance.

Tuberculosis treatment requires months-long combination chemotherapy with multiple drugs, with shorter treatments leading to relapses. A major impediment to shortening treatment is that Mycobacterium tuberculosis becomes tolerant to the administered drugs, starting early after infection and within days of infecting macrophages. Multiple lines of evidence suggest that macrophage-induced drug tolerance is mediated by mycobacterial drug efflux pumps. Here, using assays to directly measure drug efflux, we find that M. tuberculosis transports the first-line antitubercular drug rifampicin through a proton gradient-dependent mechanism. We show that verapamil, a known efflux pump inhibitor, which inhibits macrophage-induced rifampicin tolerance, also inhibits M.tuberculosis rifampicin efflux. As with macrophage-induced tolerance, the calcium channel-inhibiting property of verapamil is not required for its inhibition of rifampicin efflux. By testing verapamil analogs, we show that verapamil directly inhibits M. tuberculosis drug efflux pumps through its human P-glycoprotein (PGP)-like inhibitory activity. Screening commonly used drugs with incidental PGP inhibitory activity, we find many inhibit rifampicin efflux, including the proton pump inhibitors (PPIs) such as omeprazole. Like verapamil, the PPIs inhibit macrophage-induced rifampicin tolerance as well as intramacrophage growth, which has also been linked to mycobacterial efflux pump activity. Our assays provide a facile screening platform for M. tuberculosis efflux pump inhibitors that inhibit in vivo drug tolerance and growth.

Neuromuscular fatigue and recovery after strenuous exercise depends on skeletal muscle size and stem cell characteristics.

Hamstring muscle injury is highly prevalent in sports involving repeated maximal sprinting. Although neuromuscular fatigue is thought to be a risk factor, the mechanisms underlying the fatigue response to repeated maximal sprints are unclear. Here, we show that repeated maximal sprints induce neuromuscular fatigue accompanied with a prolonged strength loss in hamstring muscles. The immediate hamstring strength loss was linked to both central and peripheral fatigue, while prolonged strength loss was associated with indicators of muscle damage. The kinematic changes immediately after sprinting likely protected fatigued hamstrings from excess elongation stress, while larger hamstring muscle physiological cross-sectional area and lower myoblast:fibroblast ratio appeared to protect against fatigue/damage and improve muscle recovery within the first 48 h after sprinting. We have therefore identified novel mechanisms that likely regulate the fatigue/damage response and initial recovery following repeated maximal sprinting in humans.

Variations of collagen-encoding genes are associated with exercise-induced muscle damage.

We investigated whether single nucleotide polymorphisms (SNPs) within genes encoding the alpha-1 chain of type I ( COL1A1, rs2249492 ; rs1800012 ), type II ( COL2A1, rs2070739 ), and type V (COL5A1, rs12722 ) collagen were associated with the variable response to exercise-induced muscle damage (EIMD). Knee extensor muscle strength and soreness were assessed pre-, post-, and 48 h post-EIMD (120 maximal eccentric knee extensor contractions) in 65 young healthy participants, who were genotyped for the aforementioned SNPs. We found that COL1A1 (minor) T-allele carriers ( rs1800012 ) and (major) T-allele homozygotes ( rs2249492 ) were generally weaker ( P ≤ 0.019); and (minor) A-allele carriers of COL2A1 ( P = 0.002) and (major) T-allele carriers of COL5A1 ( P = 0.004) SNPs reported greater muscle soreness, all compared with their respective major ( rs1800012 ; rs2070739 ) and minor ( rs2249492 ; rs12722 ) allele homozygote counterparts. To conclude, the risk alleles of these four SNPs appear to negatively influence muscle strength and post-EIMD recovery, possibly via a dysregulated collagen network affecting the muscle's mechanical properties.

TRIM63 (MuRF-1) gene polymorphism is associated with biomarkers of exercise-induced muscle damage.

Unaccustomed strenuous exercise can lead to muscle strength loss, inflammation and delayed-onset muscle soreness, which may be influenced by genetic variation. We investigated if a missense single nucleotide polymorphism (A>G, rs2275950 ) within the TRIM63 gene (encoding MuRF-1 and potentially affecting titin mechanical properties) was associated with the variable response to unaccustomed eccentric exercise. Sixty-five untrained, healthy participants (genotyped for rs2275950 : AA, AG, and GG) performed 120 maximal eccentric knee extensions (ECC) to induce muscle damage. Isometric and isokinetic maximal voluntary knee extension contractions (MVCs) and muscle soreness were assessed before, immediately after, and 48 h after ECC. AA homozygotes were consistently stronger [baseline isometric MVC: 3.23 ± 0.92 Nm/kg (AA) vs. 2.09 ± 0.67 Nm/kg (GG); P = 0.006] and demonstrated less muscle soreness over time ( P = 0.022) compared with GG homozygotes. This may be explained by greater titin stiffness in AA homozygotes, leading to intrinsically stronger muscle fibers that are more resistant to eccentric damaging contractions.

'"Why me, why now?" Using clinical immunology and epidemiology to explain who gets nontuberculous mycobacterial infection.

BACKGROUND: The prevalence of nontuberculous mycobacterial (NTM) disease is rising. An understanding of known risk factors for disease sheds light on the immunological and physical barriers to infection, and how and why they may be overcome. This review focuses on human NTM infection, supported by experimental and in vitro data of relevance to the practising clinician who seeks to understand why their patient has NTM infection and how to further investigate. DISCUSSION: First, the underlying immune response to NTM disease is examined. Important insights regarding NTM disease susceptibility come from nature's own knockouts, the primary immune deficiency disorders. We summarise the current knowledge surrounding interferon-gamma (IFNγ)-interleukin-12 (IL-12) axis abnormalities, followed by a review of phagocytic defects, T cell lymphopenia and rarer genetic conditions known to predispose to NTM disease. We discuss how these define key immune pathways involved in the host response to NTM. Iatrogenic immunosuppression is also important, and we evaluate the impact of novel biological therapies, as well as bone marrow transplant and chemotherapy for solid organ malignancy, on the epidemiology and presentation of NTM disease, and discuss the host defence dynamics thus revealed. NTM infection and disease in the context of other chronic illnesses including HIV and malnutrition is reviewed. The role of physical barriers to infection is explored. We describe how their compromise through different mechanisms including cystic fibrosis, bronchiectasis and smoking-related lung disease can result in pulmonary NTM colonisation or infection. We also summarise further associations with host factors including body habitus and age. We use the presented data to develop an over-arching model that describes human host defences against NTM infection, where they may fail, and how this framework can be applied to investigation in routine clinical practice.

Favorable Waitlist and Posttransplant Outcomes in Children and Adolescent Patients Supported With Durable Continuous-Flow Ventricular Assist Devices.

Pediatric centers are implanting durable adult continuous-flow ventricular assist devices (CFVADs) in children who are smaller than the industry-recommended size. Waitlist and posttransplant outcomes data in pediatric patients supported with CFVADs as a bridge to transplant are limited. We analyzed the United Network of Organ Sharing and Organ Procurement and Transplantation Network registry to identify patients aged ≤18 years with a CFVAD at the time of listing or transplantation. Patients were stratified by body surface area (BSA; >1.5 vs. ≤1.5 m(2) ) at time of listing. We identified 138 patients with a durable CFVAD during the listing period (100 with BSA >1.5 m(2) , 38 with BSA ≤1.5 m(2) ). Patients with BSA ≤1.5 m(2) were more likely to have a noncardiomyopathy diagnosis (18% vs. 4%, p = 0.007) and to be implanted with a centrifugal-flow rather than an axial-flow device (74% vs. 30%, p = 0.001). There was no difference in failure-free waitlist survival between BSA groups (p = 0.99) among patients with a CFVAD at listing. Posttransplantation survival was 100% and 88% at 1 and 5 years, respectively, for the entire cohort and did not differ by BSA group (p = 0.99). Consequently, waitlist and posttransplant outcomes are favorable for pediatric CFVAD recipients. Small patients (≤1.5 m(2) ) had pre- and posttransplant outcomes similar to those of larger patients that met the industry-recommended size for implantation.

The physical demands of Super League rugby: Experiences of a newly promoted franchise.

The physical match demands for a newly promoted European Super League (ESL) squad were analysed over a full season using global positioning systems. Players were classified into four positional groups: outside backs (OB), pivots (PIV), middle unit forwards (MUF) and wide running forwards (WRF). MUF covered less total distance (4318 ± 570 m) than WRF (6408 ± 629 m), PIV (6549 ± 853) and OB (7246 ± 333 m) (P < 0.05) and less sprint distance (185 ± 58 m) than WRF (296 ± 82 m), PIV (306 ± 108) and OB (421 ± 89 m; P < 0.05), likely attributable to less playing time by MUF (47.8 ± 6.6 min) compared with WRF (77.0 ± 9.0 min), PIV (72.8 ± 10.6 min) and OB (86.7 ± 3.4 min; P < 0.05). Metres per minute were greater for MUF (90.8 ± 2.2 m.min(-1)) compared with OB (83.6 ± 2.8 m.min(-1)) and WRF (83.4 ± 2.4 m.min(-1); P = 0.001) although not different from PIV (90.2 ± 3.3 m.min(-1); P > 0.05). WRF (36 ± 5) and MUF (35 ± 6) were involved in more collisions than OB (20 ± 3) and PIV (23 ± 3; P < 0.05). The high-speed running and collision demands observed here were greater than that previously reported in the ESL, which may reflect increased demands placed on the lower ranked teams. The present data may be used to inform coaches if training provides the physical stimulus to adequately prepare their players for competition which may be especially pertinent for newly promoted franchises.

Image-based midsole insert design and the material effects on heel plantar pressure distribution during simulated walking loads.

The primary objective of this paper is to study the use of medical image-based finite element (FE) modelling in subject-specific midsole design and optimisation for heel pressure reduction using a midsole plug under the calcaneus area (UCA). Plugs with different relative dimensions to the size of the calcaneus of the subject have been incorporated in the heel region of the midsole. The FE foot model was validated by comparing the numerically predicted plantar pressure with biomechanical tests conducted on the same subject. For each UCA midsole plug design, the effect of material properties and plug thicknesses on the plantar pressure distribution and peak pressure level during the heel strike phase of normal walking was systematically studied. The results showed that the UCA midsole insert could effectively modify the pressure distribution, and its effect is directly associated with the ratio of the plug dimension to the size of the calcaneus bone of the subject. A medium hardness plug with a size of 95% of the calcaneus has achieved the best performance for relieving the peak pressure in comparison with the pressure level for a solid midsole without a plug, whereas a smaller plug with a size of 65% of the calcaneus insert with a very soft material showed minimum beneficial effect for the pressure relief.

Computer simulation of stress distribution in the metatarsals at different inversion landing angles using the finite element method.

Metatarsal fracture is one of the most common foot injuries, particularly in athletes and soldiers, and is often associated with landing in inversion. An improved understanding of deformation of the metatarsals under inversion landing conditions is essential in the diagnosis and prevention of metatarsal injuries. In this work, a detailed three-dimensional (3D) finite element foot model was developed to investigate the effect of inversion positions on stress distribution and concentration within the metatarsals. The predicted plantar pressure distribution showed good agreement with data from controlled biomechanical tests. The deformation and stresses of the metatarsals during landing at different inversion angles (normal landing, 10 degree inversion and 20 degree inversion angles) were comparatively studied. The results showed that in the lateral metatarsals stress increased while in the medial metatarsals stress decreased with the angle of inversion. The peak stress point was found to be near the proximal part of the fifth metatarsal, which corresponds with reported clinical observations of metatarsal injuries.

Anti-HLA donor-specific antibodies detected in positive B-cell crossmatches by Luminex predict late graft loss.

The significance of B-cell crossmatching in kidney transplantation is controversial. Recipients (n = 471) transplanted in a single centre from 1987 to 2005 with complete T- and B-cell crossmatch records were studied. Sera from 83 patients transplanted across a positive B-cell crossmatch, with concomitant negative T-cell crossmatch (T-B+) on either current and/or peak sera were studied using Luminex to determine presence of donor-specific antibodies (DSA). Clinical outcomes of T-B+ patients were compared with 386 T-B- patients. T-B+ predicted vascular (p = 0.01), but not cellular (p = 0.82) or glomerular (p = 0.14) rejection. IgG HLA DSA were found in 33% (n = 27) of the T-B+ patients and were associated with higher risk of any (p = 0.047), vascular (p = 0.01) or glomerular (p < 0.001) rejection at 6 months. Of 27 patients with DSA, 18/21 (86%) were the complement-fixing IgG(1) and/or IgG(3) subclass antibodies. DSA imposed a statistically significant higher risk of graft loss 5 years posttransplant (1.8 [1.0-3.3], p = 0.045). This study showed that only one-third of positive B-cell crossmatch (BXM) was caused by DSA and was associated with late graft loss. Thus, using BXM to preclude kidney transplantation may potentially disadvantage >60% of patients in whom BXM is not indicative of the presence of DSA.

Variants in Apaf-1 segregating with major depression promote apoptosome function.

APAF1, encoding the protein apoptosis protease activating factor 1 (Apaf-1), has recently been established as a chromosome 12 gene conferring predisposition to major depression in humans. The molecular phenotypes of Apaf-1 variants were determined by in vitro reconstruction of the apoptosome complex in which Apaf-1 activates caspase 9 and thus initiates a cascade of proteolytic events leading to apoptotic destruction of the cell. Cellular phenotypes were measured using a yeast heterologous expression assay in which human Apaf-1 and other proteins necessary to constitute a functional apoptotic pathway were overexpressed. Apaf-1 variants encoded by APAF1 alleles that segregate with major depression in families linked to chromosome 12 shared a common gain-of-function phenotype in both assay systems. In contrast, other Apaf-1 variants showed neutral or loss-of-function phenotypes. The depression-associated alleles thus have a common phenotype that is distinct from that of non-associated variants. This result suggests an etiologic role for enhanced apoptosis in major depression.

High-speed non-invasive measurement of tibial rotation during the impact phase of running.

Several injuries to the lower extremity in runners have been linked to excessive rates of internal rotation of the tibia just after ground impact. This study presents an improved method of capturing internal/external tibial rotation, and investigates whether estimates of rates of internal tibial rotation during the first 50 ms of contact during running are influenced by the sampling rate and processing of tibial displacement data. A lightweight plate was moulded to the shape of each subject's right anterior-medial tibia. Nine male subjects ran barefoot (3.35 m.s(-1)) and the landing kinematics of the right leg were recorded at 1000 Hz. The group mean value for the total range of internal rotation of the tibia for the whole stance phase was consistent with the literature (15.4 degrees ), but peak angular velocities (8.3 rad.s(-1)) were substantially higher than previously reported. The cut-off frequency of the low-pass filter influenced the peak angular velocity values obtained with the largest changes occurring between 15 and 40 Hz. Typically, researchers using lower sample rates have to filter around 10 Hz and consequently are likely to underestimate peak angular velocities. These findings have implications for obtaining a sound quantitative foundation for transient tibial motion before furthering our understanding of injury mechanisms.

Mechanism of ubiquitin activation revealed by the structure of a bacterial MoeB-MoaD complex.

The activation of ubiquitin and related protein modifiers is catalysed by members of the E1 enzyme family that use ATP for the covalent self-attachment of the modifiers to a conserved cysteine. The Escherichia coli proteins MoeB and MoaD are involved in molybdenum cofactor (Moco) biosynthesis, an evolutionarily conserved pathway. The MoeB- and E1-catalysed reactions are mechanistically similar, and despite a lack of sequence similarity, MoaD and ubiquitin display the same fold including a conserved carboxy-terminal Gly-Gly motif. Similar to the E1 enzymes, MoeB activates the C terminus of MoaD to form an acyl-adenylate. Subsequently, a sulphurtransferase converts the MoaD acyl-adenylate to a thiocarboxylate that acts as the sulphur donor during Moco biosynthesis. These findings suggest that ubiquitin and E1 are derived from two ancestral genes closely related to moaD and moeB. Here we present the crystal structures of the MoeB-MoaD complex in its apo, ATP-bound, and MoaD-adenylate forms, and highlight the functional similarities between the MoeB- and E1-substrate complexes. These structures provide a molecular framework for understanding the activation of ubiquitin, Rub, SUMO and the sulphur incorporation step during Moco and thiamine biosynthesis.

Confirmation of positive antibody screens by solid-phase red cell adherence assay using a tube technique method with polyethylene glycol enhancement.

Our blood bank routinely screens donors for antibodies using a solid-phase red cell adherence (SPRCA) assay. Positive results are then confirmed using a tube technique with polyethylene glycol (PEG) enhancement due to reported higher specificity than with SPRCA. Over a 5-month period, 49,084 donor serum or plasma samples were tested using the SPRCA assay. Further identification of positive samples was performed using a PEG enhancement method. Testing was performed with strict adherence to the manufacturers' inserts. Of 49,084 samples, 313 (0.64%) were positive by the SPRCA assay. Of these, 99 (31.6%) samples remained positive when tested with PEG enhancement. The remaining 214 (68.4%) were negative, giving specificity for the SPRCA assay of 99.6 percent (48,985/ 49,199). We report a high specificity for antibody screening using the SPRCA assay. However, it is cost effective to perform a confirmatory tube test with PEG enhancement because 214 SPRCA assay samples were interpreted as having a negative antibody screen, thus allowing the release of valuable blood components for transfusion.

Determining the protective function of sports footwear.

To reduce the risk of injury associated with foot-ground interaction during sporting activities, there is a need for adequate assessment of the protective function of sports footwear. The present objectives are to review the typical biomechanical approaches used to identify protection offered by sports footwear during dynamic activities and to outline some of the recent methodological approaches aimed at improving this characterization. Attention is focused on biomechanical techniques that have been shown to best differentiate safety features of footwear. It was determined that subject tests would be used in combination with standard mechanical techniques to evaluate footwear protection. Impact attenuation characteristics of footwear during sporting activities were most distinguished by analysis of tibial shock signals in the frequency and joint time-frequency domains. It has been argued that lateral stability and traction properties of footwear are better assessed using game-like manoeuvres of subjects on the actual sporting surface. Furthermore, the ability of such tests to discriminate between shoes has been improved through methods aimed at reducing or accounting for variability in individual execution of dynamic manoeuvres. Advances in tools allowing measurement of dynamic foot function inside the shoe also aid our assessment of shoe protective performance. In combination, these newer approaches should provide more information for the design of safer sports footwear.

The crystal structure of the Escherichia coli MobA protein provides insight into molybdopterin guanine dinucleotide biosynthesis.

The molybdenum cofactor (Moco) is found in a variety of enzymes present in all phyla and comprises a family of related molecules containing molybdopterin (MPT), a tricyclic pyranopterin with a cis-dithiolene group, as the invariant essential moiety. MPT biosynthesis involves a conserved pathway, but some organisms perform additional reactions that modify MPT. In eubacteria, the cofactor is often present in a dinucleotide form combining MPT and a purine or pyrimidine nucleotide via a pyrophosphate linkage. In Escherichia coli, the MobA protein links a guanosine 5'-phosphate to MPT forming molybdopterin guanine dinucleotide. This reaction requires GTP, MgCl(2), and the MPT form of the cofactor and can efficiently reconstitute Rhodobacter sphaeroides apo-DMSOR, an enzyme that requires molybdopterin guanine dinucleotide for activity. In this paper, we present the crystal structure of MobA, a protein containing 194 amino acids. The MobA monomer has an alpha/beta architecture in which the N-terminal half of the molecule adopts a Rossman fold. The structure of MobA has striking similarity to Bacillus subtilis SpsA, a nucleotide-diphospho-sugar transferase involved in sporulation. The cocrystal structure of MobA and GTP reveals that the GTP-binding site is located in the N-terminal half of the molecule. Conserved residues located primarily in three signature sequence motifs form crucial interactions with the bound nucleotide. The binding site for MPT is located adjacent to the GTP-binding site in the C-terminal half of the molecule, which contains another set of conserved residues presumably involved in MPT binding.

Bleeding and selective serotonin reuptake inhibitors in childhood and adolescence.

The selective serotonin reuptake inhibitors (SSRIs) are becoming widely used in children and adolescents, with possible unexpected side effects being observed over time. SSRIs have been associated with bleeding in adults who have unremarkable routine hematologic laboratory results except abnormal bleeding time or platelet counts in few cases. Given the increase of pediatric SSRI prescriptions, in this article we describe five children, ages 8 through 15, who developed bruising or epistaxis 1 week to 3 months after starting SSRI treatment. It is possible that the effects SSRI on platelet functioning are causing the bleeding observed in some patients and/or that a separate coagulopathy is present and contributing to bleeding. The subject matter deserves future investigation.