The Northern Territory Medical Program - growing our own in the NT.

CONTEXT: The Northern Territory (NT) is characterised by major health inequalities. A high proportion of the population is Indigenous, with poor socioeconomic conditions and a high burden of disease. The small NT population - 1% of the total Australian population - is dispersed over one-sixth of Australia's land mass. Given this very low population density and the geographical isolation of many small communities, access to services is often difficult. Medical workforce recruitment and retention have been persistent problems. Prior to 2011, NT residents who aspired to study medicine had to leave the NT. This was the only Australian state or territory that did not have the capacity for students to complete an entire medical degree within the jurisdiction. This article describes the development, implementation and outcomes of the Northern Territory Medical Program (NTMP), which commenced in Darwin in 2011. This was a major development of the Flinders University distributed program, which aimed to develop the medical workforce for the challenging NT environment. ISSUES: Based on evidence regarding the importance of selection in achieving rural workforce outcomes, and a national priority to graduate more Indigenous Australian doctors, NT residents and Indigenous applicants to the NTMP were prioritised in the selection process. Aspiring doctors would not now have to move interstate to study. The curriculum of Flinders University, based in Adelaide, South Australia, would be contextualised to the NT. The NTMP was developed and implemented in collaboration with Charles Darwin University, the major university in the NT. LESSONS LEARNED: Some of the lessons learned may be useful to others contemplating the delivery of a distributed program that includes a full medical program in a remote area. These include: Leadership at the highest levels of the university is crucial. Expect faculty turnover and avoid single person vulnerabilities. Actively engage local clinicians. Ensure a strong focus on new or alternative selection processes that are able to predict progression. Provide preparatory skills and support for students, especially Indigenous students, with non-science backgrounds. Appreciate and accommodate the community and family pressures experienced by some Indigenous students. Anticipate that the first pioneering cohort of students will not be typical of future cohorts, and work with them to adapt the curriculum, teaching and selection methods. Whilst exemplary telecommunications are needed, some elements of the curriculum will be able to be delivered far better locally than at the larger campus. Do not underestimate the level of student and staff support required both locally and centrally. Develop a 'network' rather than a 'hub and spoke' model. The network may include multiple dispersed placement sites, requiring infrastructure, staffing and ongoing support. The 'new kid' will mean the 'older sibling' will change for the better and use the small size and agility to explore innovations. Focus on the goals. We wanted to contribute to improved economic, social and health outcomes for NT residents by developing an appropriately prepared medical workforce, thereby eliminating the need to recruit doctors from interstate and overseas, and by graduating more Indigenous doctors - potential medical leaders for Australia. Build your expectation for success based on past successes in innovation. Flinders University was able to build on its experience in developing the first 4-year medical program in Australia.

The Wnt5a Receptor, Receptor Tyrosine Kinase-Like Orphan Receptor 2, Is a Predictive Cell Surface Marker of Human Mesenchymal Stem Cells with an Enhanced Capacity for Chondrogenic Differentiation.

Multipotent mesenchymal stem cells (MSCs) have enormous potential in tissue engineering and regenerative medicine. However, until now, their development for clinical use has been severely limited as they are a mixed population of cells with varying capacities for lineage differentiation and tissue formation. Here, we identify receptor tyrosine kinase-like orphan receptor 2 (ROR2) as a cell surface marker expressed by those MSCs with an enhanced capacity for cartilage formation. We generated clonal human MSC populations with varying capacities for chondrogenesis. ROR2 was identified through screening for upregulated genes in the most chondrogenic clones. When isolated from uncloned populations, ROR2+ve MSCs were significantly more chondrogenic than either ROR2-ve or unfractionated MSCs. In a sheep cartilage-repair model, they produced significantly more defect filling with no loss of cartilage quality compared with controls. ROR2+ve MSCs/perivascular cells were present in developing human cartilage, adult bone marrow, and adipose tissue. Their frequency in bone marrow was significantly lower in patients with osteoarthritis (OA) than in controls. However, after isolation of these cells and their initial expansion in vitro, there was greater ROR2 expression in the population derived from OA patients compared with controls. Furthermore, osteoarthritis-derived MSCs were better able to form cartilage than MSCs from control patients in a tissue engineering assay. We conclude that MSCs expressing high levels of ROR2 provide a defined population capable of predictably enhanced cartilage production. Stem Cells 2017;35:2280-2291.

Associations between metabolic syndrome components and markers of inflammation in Welsh school children.

We investigated the multivariate dimensionality and strength of the relationship between metabolic syndrome (MetS) and inflammation in children. Caucasian school children (N = 229; 12-14 years) from Wales were tested on several health indicators including measures of body composition, inflammation, fasting glucose regulation, blood pressure, and lipids. The multivariate association between MetS and inflammation was investigated via canonical correlation analysis. Data were corrected for non-normality by log transformation, and sex-specific z-scores computed for variables where there was a significant sex difference. Structure r's were interpreted to determine the dimensions of MetS and inflammation responsible for significant canonical variates. The overall multivariate association between MetS and inflammation was significant (Wilks' Lambda = 0.54, p < 0.001). The relationship was explained primarily by the waist circumference dimension of MetS (CC = 0.87) and inflammatory markers of fibrinogen (CC = 0.52) and C-reactive protein (CC = 0.50). The pattern of results was similar regardless of whether variables were adjusted for sex differences. CONCLUSION: Central adiposity is the strongest predictor of the inflammatory aspect of cardiovascular disease risk in Caucasian adolescents. Future research into MetS and cardiometabolic risk should consider multivariate statistical approaches, in order to identify the separate contributions of each dimension in interrelationships and to identify which dimensions are influenced by preventive interventions. What is Known: • Metabolic syndrome (MetS) is associated with increased risk of cardiovascular disease (CVD) and type 2 diabetes. Markers of inflammation are also potential predictors of later development of CVD and type 2 diabetes. • The contribution of individual markers in interrelationships between MetS and inflammation is unknown. What is New: • We uniquely demonstrate that within a multivariate model, waist circumference is the primary link between MetS variables and markers of inflammation in children. • Waist circumference may therefore be a useful population-level screening tool to identify future risk of CVD.

Recruitment of doctors to work in 'our hinterland': first results from the Swansea Graduate Entry Programme in Medicine.

INTRODUCTION: Recruitment and retention of doctors to rural and remote areas is a well-known problem to which very few countries are immune. Planning effective interventions to enable appropriate recruitment to rural areas requires an understanding of the specificities of each country and region, understanding 'what works' and 'why' in each specific context and then consideration of what that might mean in the context of neighbouring countries. In order to inform local policy makers and stakeholders, this study aimed to investigate 'how and why students elect to study in Wales, UK' and, more importantly, 'what influences students' choices about either staying, or leaving Wales, after graduation'. 'Our hinterland', in the title of this article, refers to the more rural parts of the country. METHODS: Two cohorts of medical graduates at different stages of their training (one cohort approaching the first year and the other approaching the third year of postgraduate training) were recruited as participants. A mixed-method, sequential study was conducted by means of an online questionnaire (phase 1) followed up by semi-structured telephone interviews (phase 2). Phase 1 results informed the interview schedule for phase 2. A thematic analysis of the interview transcripts was conducted using QSR NVivo v10. RESULTS: The results show that students elect to study in Wales (Swansea in this case) for a variety of reasons that include liking key features of the course, the attractive location and being able to pursue and maintain ties with family and others. Despite some identified challenges for long-term career prospects, early exposure to clinical placements in rural areas seems to be regarded as a rich, enjoyable learning opportunity that can constitute valuable preparation for future practice as a doctor. Participants also revealed how their choices were made as a result of balancing career aspirations, perceived opportunities and personal factors or circumstances. All seem to be determinants for medical career decision-making and reveal the complexities underlying these life choices. CONCLUSIONS: Despite the many positive aspects of studying in Wales and of having placements in rural areas emphasised by study participants, the prospect of entering postgraduate training in those regions is, for some, inhibited by feelings of social isolation and lack of opportunities. Some students still perceive rural locations as a backward step in the natural progression of their work and career. Graduates are concerned about discontinuity with family ties (for example stemming from the unpredictability of job allocation) and tend to gravitate to where family members, including life partners, reside. In line with international concerns and local efforts about these issues, the Swansea Graduate Entry Programme in Medicine will continue to monitor students' opinions and attitudes towards career pathways and training locations to maximise the likelihood of high-quality healthcare provision to rural communities.

Faith-based HIV prevention and counseling programs: findings from the Cincinnati census of religious congregations.

Congregations are well positioned to address HIV in their communities, but their response to HIV has been mixed. An emerging literature describes HIV programming in urban, predominantly black congregations, but population-based data remain limited. This study examined the levels of HIV prevention and counseling programs and associated factors (e.g., religious, organizational) by using data from a phone census of congregations in the Greater Cincinnati area (N = 447). Over 10 % of congregations (36 % of Black Protestant and 5-18 % of other types of congregations) offered HIV education/prevention alone or in combination with counseling or with counseling and testing. Path analysis results showed notable significant (p < 0.05) total effects of theology-polity on HIV prevention/counseling programs, but these effects were fully mediated by other factors, including other community work and racial composition. The levels of HIV programming in this study were high by national standards, but further outreach is needed in high-risk African American communities.

Immunological and Structural Characterization of Titin Main Immunogenic Region; I110 Domain Is the Target of Titin Antibodies in Myasthenia Gravis.

Myasthenia gravis (MG) is an autoimmune disease caused by antibodies targeting the neuromuscular junction (NJ) of skeletal muscles. The major MG autoantigen is nicotinic acetylcholine receptor. Other autoantigens at the NJ include MuSK, LRP4 and agrin. Autoantibodies to the intra-sarcomeric striated muscle-specific gigantic protein titin, although not directed to the NJ, are invaluable biomarkers for thymoma and MG disease severity. Thymus and thymoma are critical in MG mechanisms and management. Titin autoantibodies bind to a 30 KDa titin segment, the main immunogenic region (MIR), consisting of an Ig-FnIII-FnIII 3-domain tandem, termed I109-I111. In this work, we further resolved the localization of titin epitope(s) to facilitate the development of more specific anti-titin diagnostics. For this, we expressed protein samples corresponding to 8 MIR and non-MIR titin fragments and tested 77 anti-titin sera for antibody binding using ELISA, competition experiments and Western blots. All anti-MIR antibodies were bound exclusively to the central MIR domain, I110, and to its containing titin segments. Most antibodies were bound also to SDS-denatured I110 on Western blots, suggesting that their epitope(s) are non-conformational. No significant difference was observed between thymoma and non-thymoma patients or between early- and late-onset MG. In addition, atomic 3D-structures of the MIR and its subcomponents were elucidated using X-ray crystallography. These immunological and structural data will allow further studies into the atomic determinants underlying titin-based autoimmunity, improved diagnostics and how to eventually treat titin autoimmunity associated co-morbidities.

Circular Economy Electrochemistry: Creating Additive Manufacturing Feedstocks for Caffeine Detection from Post-Industrial Coffee Pod Waste.

The recycling of post-industrial waste poly(lactic acid) (PI-PLA) from coffee machine pods into electroanalytical sensors for the detection of caffeine in real tea and coffee samples is reported herein. The PI-PLA is transformed into both nonconductive and conductive filaments to produce full electroanalytical cells, including additively manufactured electrodes (AMEs). The electroanalytical cell was designed utilizing separate prints for the cell body and electrodes to increase the recyclability of the system. The cell body made from nonconductive filament was able to be recycled three times before the feedstock-induced print failure. Three bespoke formulations of conductive filament were produced, with the PI-PLA (61.62 wt %), carbon black (CB, 29.60 wt %), and poly(ethylene succinate) (PES, 8.78 wt %) chosen as the most suitable for use due to its equivalent electrochemical performance, lower material cost, and improved thermal stability compared to the filaments with higher PES loading and ability to be printable. It was shown that this system could detect caffeine with a sensitivity of 0.055 ± 0.001 µA µM-1, a limit of detection of 0.23 µM, a limit of quantification of 0.76 µM, and a relative standard deviation of 3.14% after activation. Interestingly, the nonactivated 8.78% PES electrodes produced significantly better results in this regard than the activated commercial filament toward the detection of caffeine. The activated 8.78% PES electrode was shown to be able to detect the caffeine content in real and spiked Earl Grey tea and Arabica coffee samples with excellent recoveries (96.7-102%). This work reports a paradigm shift in the way AM, electrochemical research, and sustainability can synergize and feed into part of a circular economy, akin to a circular economy electrochemistry.

Circular Economy Electrochemistry: Recycling Old Mixed Material Additively Manufactured Sensors into New Electroanalytical Sensing Platforms.

Recycling used mixed material additively manufactured electroanalytical sensors into new 3D-printing filaments (both conductive and non-conductive) for the production of new sensors is reported herein. Additively manufactured (3D-printed) sensing platforms were transformed into a non-conductive filament for fused filament fabrication through four different methodologies (granulation, ball-milling, solvent mixing, and thermal mixing) with thermal mixing producing the best quality filament, as evidenced by the improved dispersion of fillers throughout the composite. Utilizing this thermal mixing methodology, and without supplementation with the virgin polymer, the filament was able to be cycled twice before failure. This was then used to process old sensors into an electrically conductive filament through the addition of carbon black into the thermal mixing process. Both recycled filaments (conductive and non-conductive) were utilized to produce a new electroanalytical sensing platform, which was tested for the cell's original application of acetaminophen determination. The fully recycled cell matched the electrochemical and electroanalytical performance of the original sensing platform, achieving a sensitivity of 22.4 ± 0.2 µA µM-1, a limit of detection of 3.2 ± 0.8 µM, and a recovery value of 95 ± 5% when tested using a real pharmaceutical sample. This study represents a paradigm shift in how sustainability and recycling can be utilized within additively manufactured electrochemistry toward promoting circular economy electrochemistry.

All-in-One Single-Print Additively Manufactured Electroanalytical Sensing Platforms.

This manuscript provides the first report of a fully additively manufactured (AM) electrochemical cell printed all-in-one, where all the electrodes and cell are printed as one, requiring no post-assembly or external electrodes. The three-electrode cell is printed using a standard non-conductive poly(lactic acid) (PLA)-based filament for the body and commercially available conductive carbon black/PLA (CB/PLA, ProtoPasta) for the three electrodes (working, counter, and reference; WE, CE, and RE, respectively). The electrochemical performance of the cell is evaluated first against the well-known near-ideal outer-sphere redox probe hexaamineruthenium(III) chloride (RuHex), showing that the cell performs well using an AM electrode as the pseudo-RE. Electrochemical activation of the WE via chronoamperometry and NaOH provides enhanced electrochemical performances toward outer-sphere probes and for electroanalytical performance. It is shown that this activation can be completed using either an external commercial Ag|AgCl RE or through simply using the internal AM CB/PLA pseudo-RE and CE. This all-in-one electrochemical cell (AIOEC) was applied toward the well-known detection of ascorbic acid (AA) and acetaminophen (ACOP), achieving linear trends with limits of detection (LODs) of 13.6 ± 1.9 and 4.5 ± 0.9 µM, respectively. The determination of AA and ACOP in real samples from over-the-counter effervescent tablets was explored, and when analyzed individually, recoveries of 102.9 and 100.6% were achieved against UV-vis standards, respectively. Simultaneous detection of both targets was also achieved through detection in the same sample exhibiting 149.75 and 81.35% recoveries for AA and ACOP, respectively. These values differing from the originals are likely due to electrode fouling due to the AA oxidation being a surface-controlled process. The cell design produced herein is easily tunable toward different sample volumes or container shapes for various applications among aqueous electroanalytical sensing; however, it is a simple example of the capabilities of this manufacturing method. This work illustrates the next step in research synergising AM and electrochemistry, producing operational electrochemical sensing platforms in a single print, with no assembly and no requirements for exterior or commercial electrodes. Due to the flexibility, low-waste, and rapid prototyping of AM, there is scope for this work to be able to span and impact a plethora of research areas.

Interventions for latent autoimmune diabetes (LADA) in adults.

BACKGROUND: Latent autoimmune diabetes in adults (LADA) is a slowly developing type 1 diabetes. OBJECTIVES: To compare interventions used for LADA. SEARCH STRATEGY: Studies were obtained from searches of electronic databases, supplemented by handsearches, conference proceedings and consultation with experts. Date of last search was December 2010. SELECTION CRITERIA: Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating interventions for LADA or type 2 diabetes with antibodies were included. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed risk of bias. Studies were summarised using meta-analysis or descriptive methods. MAIN RESULTS: Searches identified 13,306 citations. Fifteen publications (ten studies) were included, involving 1019 participants who were followed between three months to 10 years (1060 randomised). All studies had a high risk of bias. Sulphonylurea (SU) with insulin did not improve metabolic control significantly more than insulin alone at three months (one study, n = 15) and at 12 months (one study, n = 14) of treatment and follow-up. SU (with or without metformin) gave poorer metabolic control compared to insulin alone (mean difference in glycosylated haemoglobin A1c (HbA1c) from baseline to end of study, for insulin compared to oral therapy: -1.3% (95% confidence interval (CI) -2.4 to -0.1; P = 0.03, 160 participants, four studies, follow-up/duration of therapy: 12, 30, 36 and 60 months; however, heterogeneity was considerable). In addition, there was evidence that SU caused earlier insulin dependence (proportion requiring insulin at two years was 30% in the SU group compared to 5% in conventional care group (P < 0.001); patients classified as insulin dependent was 64% (SU group) and 12.5% (insulin group, P = 0.007). No intervention influenced fasting C-peptide, but insulin maintained stimulated C-peptide better than SU (one study, mean difference 7.7 ng/ml (95% CI 2.9 to 12.5)). In a five year follow-up of GAD65 (glutamic acid decarboxylase formulated with aluminium hydroxide), improvements in fasting and stimulated C-peptide levels (20 µg group) were maintained after five years. Short term (three months) follow-up in one study (n = 74) using Chinese remedies did not demonstrate a significant difference in improving fasting C-peptide levels compared to insulin alone (0.07 µg/L (95% CI -0.05 to 0.19). One study using vitamin D with insulin showed steady fasting C-peptide levels in the vitamin D group but declining fasting C-peptide levels (368 to 179 pmol/L, P = 0.006) in the insulin alone group at 12 months follow-up. Comparing studies was difficult as there was a great deal of heterogeneity in the studies and in their selection criteria. There was no information regarding health-related quality of life, complications of diabetes, cost or health service utilisation, mortality and limited evidence on adverse events (studies on oral agents or insulin reported no adverse events in terms of severe hypoglycaemic episodes). AUTHORS' CONCLUSIONS: Two studies show SU leading to earlier insulin dependence and a meta-analysis of four studies with considerable heterogeneity showed poorer metabolic control if SU is prescribed for patients with LADA compared to insulin. One study showed that vitamin D with insulin may protect pancreatic beta cells in LADA. Novel treatments such as GAD65 in certain doses (20 µg) have been suggested to maintain fasting and stimulated C-peptide levels. However, there is no significant evidence for or against other lines of treatment of LADA.

Roles of ATM and ATR in DNA double strand breaks and replication stress.

The maintenance of genome integrity is critical for the faithful replication of the genome during cell division and for protecting cells from accumulation of DNA damage, which if left unrepaired leads to a loss of genetic information, a breakdown in cell function and ultimately cell death and cancer. ATM and ATR are master kinases that are integral to homologous recombination-mediated repair of double strand breaks and preventing accumulation of dangerous DNA structures and genome instability during replication stress. While the roles of ATM and ATR are heavily intertwined in response to double strand breaks, their roles diverge in the response to replication stress. This review summarises our understanding of the players and their mode of actions in recruitment, activation and activity of ATM and ATR in response to DNA damage and replication stress and discusses how controlling localisation of these kinases and their activators allows them to orchestrate a stress-specific response.

Roles of ATM and ATR in DNA double strand breaks and replication stress.

The maintenance of genome integrity is critical for the faithful replication of the genome during cell division and for protecting cells from accumulation of DNA damage, which if left unrepaired leads to a loss of genetic information, a breakdown in cell function and ultimately cell death and cancer. ATM and ATR are master kinases that are integral to homologous recombination-mediated repair of double strand breaks and preventing accumulation of dangerous DNA structures and genome instability during replication stress. While the roles of ATM and ATR are heavily intertwined in response to double strand breaks, their roles diverge in the response to replication stress. This review summarises our understanding of the players and their mode of actions in recruitment, activation and activity of ATM and ATR in response to DNA damage and replication stress and discusses how controlling localisation of these kinases and their activators allows them to orchestrate a stress-specific response.

Use of sodium zirconium cyclosilicate for up-titration of renin-angiotensin-aldosterone system inhibitor therapy in patients with heart failure: a case series.

BACKGROUND: Patients often receive suboptimal dosing of renin-angiotensin-aldosterone system inhibitor (RAASi) therapy over concerns of hyperkalaemia. However, studies have shown associations between suboptimal dosing or interruptions to therapy and adverse clinical events. Therefore, effective treatments for hyperkalaemia that can enable optimal RAASi therapy are needed. This case series examines eight patients whose commencement on the novel potassium binder sodium zirconium cyclosilicate (SZC) allowed for the initiation and/or up-titration of RAASi therapy. CASE SUMMARY: Eight patients aged 64-87 years with heart failure (HF) with reduced ejection fraction all developed hyperkalaemia (serum potassium (sK+) >5.0 mmol/L) while receiving RAASi therapy. Following initiation of SZC, all patients experienced eventual stabilization of sK+ levels. All patients were able to initiate, restart, or up-titrate RAASi therapy with five patients achieving optimal medical therapy. Left ventricular ejection fraction improved in four patients, two patients are now re-classified as New York Heart Association Class I, and an additional patient had improved exercise tolerance. Follow-up for Patient 8 is still ongoing. DISCUSSION: These real-world cases demonstrate that use of SZC to manage hyperkalaemia in patients with HF is feasible and allows optimization of RAASi therapy.

Health-Related Quality of Life Among Patients With HR+/HER2- Early Breast Cancer.

PURPOSE: The goal of this study was to characterize health-related quality of life (HRQOL) among patients diagnosed with early-stage, hormone receptor-positive (HR+)/human epidermal growth factor receptor 2 negative (HER2-) breast cancer. METHODS: A multinational (United States, Japan, France, Germany, Italy, Spain, and United Kingdom) study of patients diagnosed with stage I to III HR+/HER2- breast cancer, either receiving adjuvant treatment or under postadjuvant surveillance, was conducted between June and October 2019. Patients were identified by their consulting physician and invited to complete the Functional Assessment of Cancer Therapy-Breast (FACT-B) and the EQ-5D-5L pen and paper questionnaires. EQ-5D-5L index scores were derived by using available country-specific health state value sets, where available, and numerically compared with general population scores derived from published normative and population data. Descriptive summary statistics were reported for FACT-B, Functional Assessment of Cancer Therapy-General (FACT-G) (total and specific subscales), the EQ-5D index scores, and the EQ-VAS scores for each country. Results were stratified according to disease-free treatment status (active adjuvant treatment or postadjuvant surveillance), age (25-44, 45-54, 55-64, or ≥65 years), stage (I, II, or III), and menopausal status at the time of questionnaire completion (pre-/peri-menopausal or postmenopausal). FINDINGS: Overall, 1110 patients completed the HRQOL questionnaires (mean age, 59 years; 79% active adjuvant treatment, and 21% under surveillance postadjuvant treatment at time of questionnaire administration; 31% stage I, 48% stage II, and 20% stage III at diagnosis). Of these, 1102 completed the FACT-B and 1083 completed the EQ-5D-5L questionnaires. The mean (SD) FACT-B total score was 99.0 (21.9). The mean FACT-G total score was 72.5 (17.8), which was comparable to the published normative score. The mean EQ-5D index and EQ-VAS scores for each country were similar to corresponding population means; EQ-5D index scores ranged from 0.842 (0.098) in Japan to 0.916 (0.109) in France, and EQ-VAS scores from 68.0 (18.4) in Germany to 78.6 (16.4) in the United States. In addition, mean scores were comparable between the active adjuvant treatment and postadjuvant surveillance groups for the FACT-B total (99.4 [22.5] and 97.7 [19.7], respectively), FACT-G total (72.8 [18.3] and 71.3 [16.0]), EQ-5D index score (0.868 [0.135] and 0.869 [0.142]), and EQ-VAS (74.9 [17.2] and 74.4 [16.1]). IMPLICATIONS: Patient-reported HRQOL among patients with HR+/HER2- early breast cancer who were disease-free was high, with reported scores comparable to normative scores. These results improve our understanding of HRQOL among patients with early disease and may facilitate future studies examining the potential impact of adjuvant treatment and disease recurrence, including metastasis.

Conformational changes in twitchin kinase in vivo revealed by FRET imaging of freely moving C. elegans.

The force-induced unfolding and refolding of proteins is speculated to be a key mechanism in the sensing and transduction of mechanical signals in the living cell. Yet, little evidence has been gathered for its existence in vivo. Prominently, stretch-induced unfolding is postulated to be the activation mechanism of the twitchin/titin family of autoinhibited sarcomeric kinases linked to the mechanical stress response of muscle. To test the occurrence of mechanical kinase activation in living working muscle, we generated transgenic Caenorhabditis elegans expressing twitchin containing FRET moieties flanking the kinase domain and developed a quantitative technique for extracting FRET signals in freely moving C. elegans, using tracking and simultaneous imaging of animals in three channels (donor fluorescence, acceptor fluorescence, and transmitted light). Computer vision algorithms were used to extract fluorescence signals and muscle contraction states in each frame, in order to obtain fluorescence and body curvature measurements with spatial and temporal precision in vivo. The data revealed statistically significant periodic changes in FRET signals during muscle activity, consistent with a periodic change in the conformation of twitchin kinase. We conclude that stretch-unfolding of twitchin kinase occurs in the active muscle, whereby mechanical activity titrates the signaling pathway of this cytoskeletal kinase. We anticipate that the methods we have developed here could be applied to obtaining in vivo evidence for force-induced conformational changes or elastic behavior of other proteins not only in C. elegans but in other animals in which there is optical transparency (e.g., zebrafish).

Population based absolute and relative survival to 1 year of people with diabetes following a myocardial infarction: a cohort study using hospital admissions data.

BACKGROUND: People with diabetes who experience an acute myocardial infarction (AMI) have a higher risk of death and recurrence of AMI. This study was commissioned by the Department for Transport to develop survival tables for people with diabetes following an AMI in order to inform vehicle licensing. METHODS: A cohort study using data obtained from national hospital admission datasets for England and Wales was carried out selecting all patients attending hospital with an MI for 2003-2006 (inclusion criteria: aged 30+ years, hospital admission for MI (defined using ICD 10 code I21-I22). STATA was used to create survival tables and factors associated with survival were examined using Cox regression. RESULTS: Of 157,142 people with an MI in England and Wales between 2003-2006, the relative risk of death or recurrence of MI for those with diabetes (n = 30,407) in the first 90 days was 1.3 (95%CI: 1.26-1.33) crude rates and 1.16 (95%CI: 1.1-1.2) when controlling for age, gender, heart failure and surgery for MI) compared with those without diabetes (n = 129,960). At 91-365 days post AMI the risk was 1.7 (95% CI 1.6-1.8) crude and 1.50 (95%CI: 1.4-1.6) adjusted. The relative risk of death or re-infarction was higher at younger ages for those with diabetes and directly after the AMI (Relative risk; RR: 62.1 for those with diabetes and 28.2 for those without diabetes aged 40-49 [compared with population risk]). CONCLUSIONS: This is the first study to provide population based tables of age stratified risk of re-infarction or death for people with diabetes compared with those without diabetes. These tables can be used for giving advice to patients, developing a baseline to compare intervention studies or developing license or health insurance guidelines.

Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial.

BACKGROUND: Recent literature supports surgical intervention for shortened, displaced, mid-shaft clavicle fractures. We present the results of a randomized clinical trial comparing locked intramedullary fixation and plate fixation for short, displaced, mid-shaft clavicle fractures. MATERIALS AND METHODS: Local ethical approval was obtained and power analysis and sample size calculations were performed prior to commencement. Patients randomized to 2 groups to be treated with either locked intramedullary fixation or plating. Patients regularly followed up to clinical and radiographic union. The primary outcome measure was the Constant score, secondary outcome measures included the Oxford shoulder score, union rate, and complication rates. RESULTS: Seventeen patients were randomized to locked intramedullary fixation and 15 randomized to plating. Mean age was 29.3 years. Mean follow-up was 12.4 months. There was no significant difference in either Constant scores (P = .365) or Oxford scores (P = .773). There was 100% union in both groups. In the intramedullary group, 1 case of soft tissue irritation settled after the pin removal; 1 pin backed out and was revised. Three superficial wound infections resulted in plate removal and 8 plates (53%) were removed. DISCUSSION: Intramedullary fixation has the theoretical advantage of preserving the periosteal blood supply, but carries the morbidity of pin removal. Clavicle plates are not routinely removed but require greater exposure and may compromise periosteal blood supply. CONCLUSION: Both locked intramedullary fixation and plating produce good functional results; however, metalwork may need to be removed as a second procedure.

Systemic capillary leak syndrome: a rare but potentially life-threatening cause of protein loss and oedema in B cell prolymphocytic leukaemia.

A 64-year-old man had a several year history of B prolymphocytic leukaemia (PLL) which behaved indolently and had not required any treatment. Five years after diagnosis, he developed hypoalbuminaemia associated with severe lower-limb oedema, consistent with systemic capillary leak syndrome (SCLS). He recovered spontaneously but went on to have three further increasingly severe and protracted episodes over the subsequent 18 months. There was no identifiable precipitating factor for these episodes, but his peripheral lymphocyte count continued to increase slowly. The start of treatment for his PLL with chemoimmunotherapy was followed by a rapid resolution of residual oedema and normalisation of serum albumin. He has had no further attacks of SCLS in the 14 months since he started therapy for PLL. SCLS is a rare consequence of haematological malignancy which may show an excellent response to treatment of the haematological disease.

Structures and regulations of ATM and ATR, master kinases in genome integrity.

Homologous recombination (HR) is a faithful repair mechanism for double stranded DNA breaks. Two highly homologous master kinases, the tumour suppressors ATM and ATR (Tel1 and Mec1 in yeast), coordinate cell cycle progression with repair during HR. Despite their importance, our molecular understanding of these apical coordinators has been limited, in part due to their large sizes. With the recent development in cryo-electron microscopy, significant advances have been made in structural characterisation of these proteins in the last two years. These structures, combined with new biochemical studies, now provide a more detailed understanding of how a low basal activity is maintained and how activation may occur. In this review, we summarize recent advances in the structural and molecular understanding of these key components in HR, compare the common and distinct features of these kinases and suggest aspects of structural components that are likely to be involved in regulating its activity.