The heparin-von Willebrand factor interaction and conventional tests of haemostasis - the challenges in predicting bleeding in cardiopulmonary bypass.

Bleeding is a significant complication of cardiopulmonary bypass (CPB), despite routine anticoagulation monitoring. This is likely to be multifactorial. In this prospective, single-centre cohort study of 30 patients undergoing CPB surgery, our aim was to characterise the changes in von Willebrand factor (VWF) function, platelet interaction and the global coagulation changes during and after CPB surgery and to determine whether bleeding can be predicted. Samples were taken at six time points before, during and after CPB surgery. We observed a significant rise in VWF antigen (VWF:Ag) throughout surgery, which continued postoperatively. The absolute VWF collagen-binding assays (VWF:CB) and VWF ristocetin cofactor (VWF:RCo) rose significantly but the VWF:CB/VWF:Ag and VWF:Ag/VWF:RCo fell significantly (P = 0·0015 and P = 0·0143), suggesting loss of large multimers. We detected a non-significant trend to loss of VWF:RCo after heparinisation and a significant recovery after protamine reversal which could reflect a direct heparin effect. There was a significant increase in the R and K times with a fall in alpha angle and maximum amplitude after heparin administration, using heparinase-thromboelastography (TEG). The parameters both significantly improved following protamine (P = 0·007 and P = 0·0054). The activated clotting time (ACT) and heparin anti-Xa level correlated poorly; neither predicted clinically significant bleeding. None of these parameters had a relationship with intraoperative blood loss or requirement for blood product replacement.

Preclinical to Human Translational Pharmacology of the Novel M1 Positive Allosteric Modulator MK-7622.

The current standard of care for treating Alzheimer's disease is acetylcholinesterase inhibitors, which nonselectively increase cholinergic signaling by indirectly enhancing activity of nicotinic and muscarinic receptors. These drugs improve cognitive function in patients, but also produce unwanted side effects that limit their efficacy. In an effort to selectively improve cognition and avoid the cholinergic side effects associated with the standard of care, various efforts have been aimed at developing selective M1 muscarinic receptor activators. In this work, we describe the preclinical and clinical pharmacodynamic effects of the M1 muscarinic receptor-positive allosteric modulator, MK-7622. MK-7622 attenuated the cognitive-impairing effects of the muscarinic receptor antagonist scopolamine and altered quantitative electroencephalography (qEEG) in both rhesus macaque and human. For both scopolamine reversal and qEEG, the effective exposures were similar between species. However, across species the minimum effective exposures to attenuate the scopolamine impairment were lower than for qEEG. Additionally, there were differences in the spectral power changes produced by MK-7622 in rhesus versus human. In sum, these results are the first to demonstrate translation of preclinical cognition and target modulation to clinical effects in humans for a selective M1 muscarinic receptor-positive allosteric modulator.

Intra- to extracellular crystallization of calcite in the freshwater green algae Phacotus lenticularis.

Phacotus lenticularis is a freshwater unicellular green alga that forms lens-shaped calcitic shells around the cell. We documented P. lenticularis biomineralization pathways in live daughter cells while still within the reproductive complex, using scanning confocal microscopy and after vitrification using cryo-scanning electron microscopy (cryo-SEM). We show that some or all of the calcium ions required for mineral formation enter the cell through endocytosis, as inferred from the uptake of calcein fluorescent dye. Ions first concentrate inside intracellular vesicles to form small crystals that were detected by birefringence, reflectance, and cryo-SEM of cells in near-native, hydrated state. The crystals later exit the cell and build up the lens-shaped shell. The small crystals first cover the outer lorica surface and later fuse to form a thin continuous shell. This is most likely followed by a second shell maturation phase in which the shell undergoes thickening and crystal reorganization. Crystal assembly within the confined protected volume of the reproduction complex allows controlled shell formation outside the daughter cell. Only two other unicellular marine calcifiers, coccolithophores and miliolid foraminifera, are known to perform intracellular crystal formation. STATEMENT OF SIGNIFICANCE: Calcium carbonate (CaCO3) deposition in aquatic environments is a major component of the global carbon cycle, which determines the CO2 content of the atmosphere. In freshwater ecosystems, the green alga Phacotus lenticularis is considered the main contributor of autochthonous calcite precipitation and the only algal species known to form its shell through a controlled process. The chemical and ecological effects of P. lenticularis are intensively investigated, but our understanding of its shell formation is limited. We used advanced confocal laser scanning microscopy and cryo-scanning electron microscopy (cryo-SEM) to provide new insights into mineral formation and trafficking in the calcifying P. lenticularis cells.

Impact of Point-of-Care Ultrasound in Medical Decision Making: Informing the Development of an Internal Medicine Global Health POCUS Curriculum.

BACKGROUND: Point-of-care Ultrasound (POCUS) is particularly useful in low-middle income countries (LMICs) where advanced imaging modalities and diagnostics are often unavailable. However, its use among Internal Medicine (IM) practitioners is limited and without standard curricula. This study describes POCUS scans performed by U.S. IM residents rotating in LMICs to provide recommendations for curriculum development. METHODS: IM residents within a global health track performed clinically-indicated POCUS scans at two sites. They logged their interpretations and whether or not the scan changed diagnosis or management. Scans were quality-assured by POCUS experts in the US to validate results. Using the criteria of prevalence, ease of learning, and impact, a framework was developed for a POCUS curriculum for IM practitioners within LMICs. RESULTS: A total of 256 studies were included in analysis. 237 (92.5%) answered the clinical question, 107 (41.8%) changed the diagnosis, and 106 (41.4%) changed management. The most frequently used applications were the Focused Assessment for Sonography for HIV associated TB (FASH) exam, finding fluid (pericardial effusion, pleural effusion, ascites), qualitative assessment of left ventricular function, and assessment for A-lines/B-lines/consolidation. The following scans met ease of learning criteria: FASH-basic, assessment of LV function, A-lines vs. B-lines, and finding fluid. Finding fluid and assessment of LV function changed diagnosis and management most frequently, greater than 50% of the time for each category. DISCUSSION/CONCLUSION: We recommend the following applications as highest yield for inclusion in a POCUS curriculum for IM practitioners within LMICs: finding fluid (pericardial effusion, pleural effusion, ascites) and assessment of gross LV function.

Inhibition of lipopolysaccharide-stimulated chronic obstructive pulmonary disease macrophage inflammatory gene expression by dexamethasone and the p38 mitogen-activated protein kinase inhibitor N-cyano-N'-(2-{[8-(2,6-difluorophenyl)-4-(4-fluoro-2-methylphenyl)-7-oxo-7,8-dihydropyrido[2,3-d] pyrimidin-2-yl]amino}ethyl)guanidine (SB706504).

p38 mitogen-activated protein kinase (MAPK) signaling is known to be increased in chronic obstructive pulmonary disease (COPD) macrophages. We have studied the effects of the p38 MAPK inhibitor N-cyano-N'-(2-{[8-(2,6-difluorophenyl)-4-(4-fluoro-2-methylphenyl)-7-oxo-7,8-dihydropyrido[2,3-d]-pyrimidin-2-yl]amino}ethyl)guanidine (SB706504) and dexamethasone on COPD macrophage inflammatory gene expression and protein secretion. We also studied the effects of combined SB706504 and dexamethasone treatment. Lipopolysaccharide (LPS)-stimulated monocyte derived macrophages (MDMs) and alveolar macrophages (AMs) were cultured with dexamethasone and/or SB706504. MDMs were used for gene array and protein studies, whereas tumor necrosis factor (TNF) alpha protein production was measured from AMs. SB706504 caused transcriptional inhibition of a range of cytokines and chemokines in COPD MDMs. The use of SB706504 combined with dexamethasone caused greater suppression of gene expression (-8.90) compared with SB706504 alone (-2.04) or dexamethasone (-3.39). Twenty-three genes were insensitive to the effects of both drugs, including interleukin (IL)-1beta, IL-18, and chemokine (CC motif) ligand (CCL) 5. In addition, the chromosome 4 chemokine cluster members, CXCL1, CXCL2, CXCL3, and CXCL8, were all glucocorticoid-resistant. SB706504 significantly inhibited LPS-stimulated TNFalpha production from COPD and smoker AMs, with near-maximal suppression caused by combination treatment with dexamethasone. We conclude that SB706504 targets a subset of inflammatory macrophage genes and when used with dexamethasone causes effective suppression of these genes. SB706504 and dexamethasone had no effect on the transcription of a subset of LPS-regulated genes, including IL-1beta, IL-18, and CCL5, which are all known to be involved in the pathogenesis of COPD.

Recruiting and retaining child welfare workers: is preparing social work students enough for sustained commitment to the field?

Graduates of specialized BSW child welfare education programs are more likely to be retained after two years of service in the agency, but many leave at the four year mark. Two studies explored possible reasons for departure at this time. The first study found that graduates of specialized child welfare programs were significantly more likely to engage in best practices in nine areas than workers from other fields. Thus, frustration with practice skill was ruled out as a cause. The second qualitative study found that poor supervision, lack of coworker support, and organizational stress among other variables prompted these high-functioning workers to leave the agency. Suggestions for innovative interventions to enhance retention at this critical juncture are included.

Cigarette smoke extract induced cytokine and chemokine gene expression changes in COPD macrophages.

Macrophages are key inflammatory cells in chronic obstructive pulmonary disease (COPD). The transcriptional regulation of inflammatory signalling pathways by cigarette smoke (CS) in COPD macrophages is not well understood. We have studied the effects of acute CS exposure on COPD macrophage cytokine, chemokine and signal transduction gene expression profiles. Monocyte derived macrophages (MDMs) from whole blood from patients with COPD (n=6) were stimulated with 1%, 10% and 25% CS extract (CSE) for 6h for microarray and quantitative polymerase chain reaction (Q-PCR) analysis. We observed a CSE dose dependant increase in the numbers of significantly regulated genes; 24, 340 and 627 genes at 1%, 10% and 25% CSE, respectively. IL-8 mRNA levels were up-regulated by 10% CSE (2.25-fold increase, 95% CI 1.28-4.00). In contrast a range of other cytokines and chemokines were down-regulated at both 10% and 25% CSE, including IL-1beta, -6, -10 and -18, chemokine ligands CCL-2, -3, -4, -5, -8, -15, -20 and CXCL-1, -2 and -10. Q-PCR and microarray data were highly correlated (r=0.95, p=0.0001). NF-kappaB component p50 and IkappaBalpha expression were suppressed by CSE, while there was up-regulation of the AP-1 components c-Jun, FOSL1 and FOSL2. Acute CSE exposure decreased macrophage inflammatory gene expression, with the exception of increased IL-8. There was diverse regulation of key inflammatory signal pathway genes. The effects of acute CS exposure appear to encompass both up-regulation of chemotaxis mechanisms through IL-8, but also down-regulation of innate immunity.

Long-term assessment of whale shark population demography and connectivity using photo-identification in the Western Atlantic Ocean.

The predictable occurrence of whale sharks, Rhincodon typus, has been well documented in several areas. However, information relating to their migratory patterns, residency times and connectivity across broad spatial scales is limited. In the present study photo-identification data is used to describe whale shark population structure and connectivity among known aggregation sites within the Western Central Atlantic Ocean (WCA). From 1999 to 2015, 1,361 individuals were identified from four distinct areas: the Yucatan Peninsula, Mexico (n = 1,115); Honduras (n = 146); northern Gulf of Mexico, United States (n = 112), and Belize (n = 49). Seasonal patterns in whale shark occurrence were evident with encounters occurring in the western Caribbean Sea earlier in the year than in the GOM. There was also a significant sex bias with 2.6 times more males present than females. Seventy sharks were observed in more than one area and the highest degree of connectivity occurred among three aggregation sites along the Mesoamerican Reef. Despite this, the majority of resightings occurred in the area where the respective sharks were first identified. This was true for the WCA as a whole, with the exception of Belize. Site fidelity was highest in Mexico. Maximum likelihood modelling resulted in a population estimate of 2,167 (95% c.i. 1585.21-2909.86) sharks throughout the entire region. This study is the first attempt to provide a broad, regional population estimate using photo-identification data from multiple whale shark aggregations. Our aim is to provide population metrics, along with the description of region-scale connectivity, that will help guide conservation action in the WCA. At a global level, rapidly growing photographic databases are allowing for researchers to look beyond the description of single aggregation sites and into the ocean-scale ecology of this pelagic species.

The effects of dexamethasone on cigarette smoke induced gene expression changes in COPD macrophages.

Chronic obstructive pulmonary disease (COPD) is a smoking related inflammatory airway disease in which macrophages play a key role. Previously we have shown that cigarette smoke extract (CSE) causes suppression of macrophage inflammatory mediators, with the exception of IL-8. We now investigate the effects of dexamethasone on these gene expression changes. Monocyte derived macrophages (MDMs) were cultured with CSE and dexamethasone. Microarray analysis was used to assess inflammatory mediator regulation, with qPCR and ELISA also performed for selected cytokines. The major effect of CSE was down-regulation of inflammatory genes (11 probe sets). For CSE regulated genes (n=13), the median fold change with CSE alone was -2.84 and with dexamethasone alone was -2.97. Both treatments combined caused the greatest suppression of gene expression; -4.47. qPCR also showed that IL-1beta, GM-CSF and IL-6 mRNA levels were significantly reduced by CSE and further suppressed by dexamethasone. qPCR and ELISA showed that IL-8 levels were increased by CSE, with suppression by dexamethasone. We show that CSE suppressed the expression of some inflammatory genes whilst up-regulating IL-8. Dexamethasone further suppressed gene expression when combined with CSE. The combined effect of GC and CSE causes suppression of the macrophage innate immune response.

Wet-milling transgenic maize seed for fraction enrichment of recombinant subunit vaccine.

The production of recombinant proteins in plants continues to be of great interest for prospective large-scale manufacturing of industrial enzymes, nutrition products, and vaccines. This work describes fractionation by wet-milling of transgenic maize expressing the B subunit of the heat-labile enterotoxin of Escherichia coli (LT-B), a potent immunogen and candidate for oral vaccine and vaccine components. The LT-B gene was directed to express in seed by an endosperm specific promoter. Two steeping treatments, traditional steeping (TS, 0.2% SO(2) + 0.5% lactic acid) and water steeping (WS, water only), were evaluated to determine effects on recovery of functional LT-B in wet-milled fractions. The overall recovery of the LT-B protein from WS treatment was 1.5-fold greater than that from TS treatment. In both steeping types, LT-B was distributed similarly among the fractions, resulting in enrichment of functional LT-B in fine fiber, coarse fiber and pericarp fractions by concentration factors of 1.5 to 8 relative to the whole kernels on a per-mass basis. Combined with endosperm-specific expression and secretory pathway targeting, wet-milling enables enrichment of high-value recombinant proteins in low-value fractions, such as the fine fiber, and co-utilization of remaining fractions in alternative industrial applications.

Short-acting T-type calcium channel antagonists significantly modify sleep architecture in rodents.

A novel phenyl acetamide series of short-acting T-type calcium channel antagonists has been identified and evaluated using in vitro and in vivo assays. Heterocycle substitutions of the 4-position of the phenyl acetamides afforded potent and selective antagonists that exhibited desired short plasma half-lives across preclinical species. Lead compound TTA-A8 emerged as a compound with excellent in vivo efficacy as indicated by its significant modulation of rat sleep architecture in an EEG telemetry model, favorable pharmacokinetic properties, and excellent preclinical safety. TTA-A8 recently progressed into human clinical trials, and in line with our predictions, preliminary studies (n = 12) with a 20 mg oral dose afforded a high C max of 1.82 ± 0.274 µM with an apparent terminal half-life of 3.0 ± 1.1 h.

Discovery of 1,4-substituted piperidines as potent and selective inhibitors of T-type calcium channels.

The discovery of a novel series of potent and selective T-type calcium channel antagonists is reported. Initial optimization of high-throughput screening leads afforded a 1,4-substituted piperidine amide 6 with good potency and limited selectivity over hERG and L-type channels and other off-target activities. Further SAR on reducing the basicity of the piperidine and introducing polarity led to the discovery of 3-axial fluoropiperidine 30 with a significantly improved selectivity profile. Compound 30 showed good oral bioavailability and brain penetration across species. In a rat genetic model of absence epilepsy, compound 30 demonstrated a robust reduction in the number and duration of seizures at 33 nM plasma concentration, with no cardiovascular effects at up to 5.6 microM. Compound 30 also showed good efficacy in rodent models of essential tremor and Parkinson's disease. Compound 30 thus demonstrates a wide margin between CNS and peripheral effects and is a useful tool for probing the effects of T-type calcium channel inhibition.

Gene expression profiling in breast cancer: understanding the molecular basis of histologic grade to improve prognosis.

BACKGROUND: Histologic grade in breast cancer provides clinically important prognostic information. However, 30%-60% of tumors are classified as histologic grade 2. This grade is associated with an intermediate risk of recurrence and is thus not informative for clinical decision making. We examined whether histologic grade was associated with gene expression profiles of breast cancers and whether such profiles could be used to improve histologic grading. METHODS: We analyzed microarray data from 189 invasive breast carcinomas and from three published gene expression datasets from breast carcinomas. We identified differentially expressed genes in a training set of 64 estrogen receptor (ER)-positive tumor samples by comparing expression profiles between histologic grade 3 tumors and histologic grade 1 tumors and used the expression of these genes to define the gene expression grade index. Data from 597 independent tumors were used to evaluate the association between relapse-free survival and the gene expression grade index in a Kaplan-Meier analysis. All statistical tests were two-sided. RESULTS: We identified 97 genes in our training set that were associated with histologic grade; most of these genes were involved in cell cycle regulation and proliferation. In validation datasets, the gene expression grade index was strongly associated with histologic grade 1 and 3 status; however, among histologic grade 2 tumors, the index spanned the values for histologic grade 1-3 tumors. Among patients with histologic grade 2 tumors, a high gene expression grade index was associated with a higher risk of recurrence than a low gene expression grade index (hazard ratio = 3.61, 95% confidence interval = 2.25 to 5.78; P < .001, log-rank test). CONCLUSIONS: Gene expression grade index appeared to reclassify patients with histologic grade 2 tumors into two groups with high versus low risks of recurrence. This approach may improve the accuracy of tumor grading and thus its prognostic value.

Breast cancer classification and prognosis based on gene expression profiles from a population-based study.

Comprehensive gene expression patterns generated from cDNA microarrays were correlated with detailed clinico-pathological characteristics and clinical outcome in an unselected group of 99 node-negative and node-positive breast cancer patients. Gene expression patterns were found to be strongly associated with estrogen receptor (ER) status and moderately associated with grade, but not associated with menopausal status, nodal status, or tumor size. Hierarchical cluster analysis segregated the tumors into two main groups based on their ER status, which correlated well with basal and luminal characteristics. Cox proportional hazards regression analysis identified 16 genes that were significantly associated with relapse-free survival at a stringent significance level of 0.001 to account for multiple comparisons. Of 231 genes previously reported by others [van't Veer, L. J., et al. (2002) Nature 415, 530-536] as being associated with survival, 93 probe elements overlapped with the set of 7,650 probe elements represented on the arrays used in this study. Hierarchical cluster analysis based on the set of 93 probe elements segregated our population into two distinct subgroups with different relapse-free survival (P < 0.03). The number of these 93 probe elements showing significant univariate association with relapse-free survival (P < 0.05) in the present study was 14, representing 11 unique genes. Genes involved in cell cycle, DNA replication, and chromosomal stability were consistently elevated in the various poor prognostic groups. In addition, glutathione S-transferase M3 emerged as an important survival marker in both studies. When taken together with other array studies, our results highlight the consistent biological and clinical associations with gene expression profiles.