Systems biology approach to functionally assess the Clostridioides difficile pangenome reveals genetic diversity with discriminatory power.

Combatting Clostridioides difficile infections, a dominant cause of hospital-associated infections with incidence and resulting deaths increasing worldwide, is complicated by the frequent emergence of new virulent strains. Here, we employ whole-genome sequencing, high-throughput phenotypic screenings, and genome-scale models of metabolism to evaluate the genetic diversity of 451 strains of C. difficile. Constructing the C. difficile pangenome based on this set revealed 9,924 distinct gene clusters, of which 2,899 (29%) are defined as core, 2,968 (30%) are defined as unique, and the remaining 4,057 (41%) are defined as accessory. We develop a strain typing method, sequence typing by accessory genome (STAG), that identifies 176 genetically distinct groups of strains and allows for explicit interrogation of accessory gene content. Thirty-five strains representative of the overall set were experimentally profiled on 95 different nutrient sources, revealing 26 distinct growth profiles and unique nutrient preferences; 451 strain-specific genome scale models of metabolism were constructed, allowing us to computationally probe phenotypic diversity in 28,864 unique conditions. The models create a mechanistic link between the observed phenotypes and strain-specific genetic differences and exhibit an ability to correctly predict growth in 76% of measured cases. The typing and model predictions are used to identify and contextualize discriminating genetic features and phenotypes that may contribute to the emergence of new problematic strains.

The Impact of Extracellular Histones and Absence of Toll-like Receptors on Cardiac Functional and Electrical Disturbances in Mouse Hearts.

In polymicrobial sepsis, the extracellular histones, mainly released from activated neutrophils, significantly contribute to cardiac dysfunction (septic cardiomyopathy), as demonstrated in our previous studies using Echo-Doppler measurements. This study aims to elucidate the roles of extracellular histones and their interactions with Toll-like receptors (TLRs) in cardiac dysfunction. Through ex vivo assessments of ECG, left ventricle (LV) function parameters, and in vivo Echo-Doppler studies in mice perfused with extracellular histones, we aim to provide comprehensive insights into the mechanisms underlying sepsis-induced cardiac dysfunction. Langendorff-perfused hearts from both wild-type and TLR2, TLR3, or TLR4 knockout (KO) mice were examined. Paced mouse hearts were perfused with histones to assess contractility and relaxation. Echo-Doppler studies evaluated cardiac dysfunction after intravenous histone injection. Histone perfusion caused defects in contractility and relaxation, with TLR2 and TLR3 KO mice being partially protected. Specifically, TLR2 KO mice exhibited the greatest reduction in Echo-Doppler abnormalities, while TLR4 KO exacerbated cardiac dysfunction. Among individual histones, H1 induced the most pronounced abnormalities in cardiac function, apoptosis of cardiomyocytes, and LDH release. Our data highlight significant interactions between histones and TLRs, providing insights into histones especially H1 as potential therapeutic targets for septic cardiomyopathy. Further studies are needed to explore specific histone-TLR interactions and their mechanisms.

Knowledge, attitudes, and factors associated with vegetarianism in the Saudi Population.

BACKGROUND: In recent years, there has been great interest in the dietary practices of vegetarians in addition to an increasing awareness of the potential benefits of vegetarian diets. However, there are insufficient data on the spread of vegetarianism in Arab countries. The aim of this study was to investigate knowledge and attitudes about vegetarianism and associated factors in the Saudi population and to understand the reasons for its growing prevalence. METHOD: This is a cross-sectional study began in May 2020 and ended in September 2020. Researchers distributed the questionnaire electronically through social media. Data were collected electronically and exported to Excel by the researchers .The electronic questionnaire comprised three sections: sociodemographic questions, reasons for following a vegetarian diet, and beliefs and knowledge about vegetarianism. RESULTS: There were 3,035 responses, of which 80.2% of respondents were female and 19.8% were male. Participant were aged 18-65. Vegetarians represented 37.5% (15.7% semivegetarians, 8.1% pescovegetarians, 64.3% lacto-ovo-vegetarians, and 11.3% vegans), and the rest were nonvegetarians. The majority of the vegetarian participants (92.9%) had a low vegetarianism knowledge level. Health issues, followed by ethical and environmental concerns, were the most common motivators for adopting a vegetarian diet; these reasons were cited by 72.5%, 59.3%, and 47.9% of participants, respectively. Factors associated with increased vegetarianism were engaging in exercise for half an hour to two hours, while factors associated with decreased vegetarianism were male, aged 51-64 years, being married, having a higher education, working in the health sector, being a housewife, and having an income between 5,000 and 10,000 SR/month. CONCLUSION: Vegetarianism appears to be a growing phenomenon among the Saudi population. Increased awareness of health issues and the desire to live a healthy lifestyle might be the strongest motives. This study offers an opportunity to better understand vegetarianism in Saudi Arabia along with the possibility of expanding vegetarian food choices for the general public.

EVALUATION OF ANTIOXIDANTS ENZYMES AND AUTOPHAGY GENES IN THE BLOOD OF IRAQI SMOKER VOLUNTEERS.

OBJECTIVE: The aim: In this study, we investigated the expression level of LC3A, LC3B, Beclin1, and ATG5 in the blood of smokers as well as non-smokers volunteers. On the other hand, total antioxidant status (TAS), catalase (CAT), and superoxide dismutase (SOD) in the same individuals were measured. PATIENTS AND METHODS: Material and methods: About 5 ml of blood was collected from 55 smokers (workers in a coffee shop) and 24 non-smokers volunteers. The blood was divided into two parts: 2.5 ml collected in a K2-EDTA tube that was used for RNA extraction to estimate the autophagic genes including LC3A, LC3B, Beclin1, and ATG5 by using of qRT-PCR and for hematological studies. The other part - was centrifuged to obtain the serum samples to measure TAS, CAT, and SOD by spectrophotometrical method. RESULTS: Results: The fold expression of autophagy genes was significantly increased in the blood of smokers as compared to non-smokers' individuals at (p ≤ 0.05). On the other hand, TAS, CAT, and SOD were significantly increased in smokers as compared with non-smokers individuals at (p ≤ 0.05). The hematological study revealed increased hemoglobin concentration and hematocrit in the smoker's blood as compared to nonsmokers' individuals. No significant variation was found in other hematological parameters in the smoker's individual as compared to non-smokers at (p ≤ 0.05). CONCLUSION: Conclusions: Our results indicate that smoke exposure may induce autophagy genes through increased antioxidant status and antioxidant enzymes, and the better way to be healthy is to quitting smoking.

Requirement of Complement C6 for Intact Innate Immune Responses in Mice.

Over the first days of polymicrobial sepsis, there is robust activation of the innate immune system, causing the appearance of proinflammatory cytokines and chemokines, along with the appearance of extracellular histones, which are highly proinflammatory and prothrombotic. In the current study, we studied different innate immune responses in mice with knockout (KO) of complement protein 6 (C6). Polymorphonuclear neutrophils (PMNs) from these KO mice had defective innate immune responses, including defective expression of surface adhesion molecules, generation of superoxide anion, and appearance of reactive oxygen species and histone release after activation of PMNs, along with defective phagocytosis. In addition, in C6-/- mice, the NLRP3 inflammasome was defective both in PMNs and in macrophages. When these KO mice were subjected to polymicrobial sepsis, their survival was improved, associated with reduced levels in the plasma of proinflammatory cytokines and chemokines and lower levels of histones in plasma. In addition, sepsis-induced cardiac dysfunction was attenuated in these KO mice. In a model of acute lung injury induced by LPS, C6-/- mice showed reduced PMN buildup and less lung epithelial/endothelial cell dysfunction (edema and hemorrhage). These data indicate that C6-/- mice have reduced innate immune responses that result in less organ injury and improved survival after polymicrobial sepsis.

Predicting Vibrio cholerae Infection and Disease Severity Using Metagenomics in a Prospective Cohort Study.

BACKGROUND: Susceptibility to Vibrio cholerae infection is affected by blood group, age, and preexisting immunity, but these factors only partially explain who becomes infected. A recent study used 16S ribosomal RNA amplicon sequencing to quantify the composition of the gut microbiome and identify predictive biomarkers of infection with limited taxonomic resolution. METHODS: To achieve increased resolution of gut microbial factors associated with V. cholerae susceptibility and identify predictors of symptomatic disease, we applied deep shotgun metagenomic sequencing to a cohort of household contacts of patients with cholera. RESULTS: Using machine learning, we resolved species, strains, gene families, and cellular pathways in the microbiome at the time of exposure to V. cholerae to identify markers that predict infection and symptoms. Use of metagenomic features improved the precision and accuracy of prediction relative to 16S sequencing. We also predicted disease severity, although with greater uncertainty than our infection prediction. Species within the genera Prevotella and Bifidobacterium predicted protection from infection, and genes involved in iron metabolism were also correlated with protection. CONCLUSION: Our results highlight the power of metagenomics to predict disease outcomes and suggest specific species and genes for experimental testing to investigate mechanisms of microbiome-related protection from cholera.

Comparing RECIST 1.1 and iRECIST in advanced melanoma patients treated with pembrolizumab in a phase II clinical trial.

OBJECTIVES: To compare tumor best overall response (BOR) by RECIST 1.1 and iRECIST, to explore the incidence of pseudoprogression in melanoma treated with pembrolizumab, and to assess the impact of pseudoprogression on overall survival (OS). METHODS: A total of 221 patients with locally advanced/unresectable melanoma who received pembrolizumab as part of KEYNOTE-002 trial were included in this study. Radiological assessment of imaging was centrally reviewed to assess tumor response. Incidence of discordance in BOR between RECIST 1.1 and iRECIST as well as rate of pseudoprogression were measured. OS of patients with pseudoprogression was compared with that of those with uncontrolled disease. RESULTS: Of the 221 patients in this cohort, 136 patients developed PD as per RECIST v1.1 and 78 patients with PD continued treatment and imaging beyond initial RECIST 1.1-defined PD. Among the 78 patients who continued therapy and imaging post-progression, RECIST 1.1 and iRECIST were discordant in 10 patients (12.8%) and pseudoprogression was encountered in 14 patients (17.9%). OS of patients with pseudoprogression was longer than that of patients with uncontrolled disease/true progression (29.9 months versus 8.0 months, p value < 0.001). CONCLUSIONS: Effectiveness of immunotherapy in clinical trials depends on the criterion used to assess tumor response (RECIST 1.1 vs iRECIST) with iRECIST being more appropriate to detect pseudoprogression and potentially prevent premature termination of effective therapy. Pseudoprogression was associated with improved OS in comparison with that of patients with uncontrolled disease. KEY POINTS: • Discordance between iRECIST and RECIST 1.1 was found in 12.8% of unresectable melanoma patients on pembrolizumab who continued therapy beyond initial RECIST 1.1-defined progression. • Pseudoprogression, captured with iRECIST, occurred in 17.9% and was significantly associated with improved overall survival in comparison with uncontrolled disease.

The Negative Predictive Value of a PI-RADS Version 2 Score of 1 on Prostate MRI and the Factors Associated With a False-Negative MRI Study.

OBJECTIVE. The purpose of this study was to calculate the negative predictive value of a prostate MRI study with a Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) score of 1 (hereafter referred to as a PI-RADS 1 MRI study) and to explore the patient characteristics and MRI-based factors associated with an MRI study with false-negative results. MATERIALS AND METHODS. A total of 542 consecutive patients with a PI-RADS 1 MRI study obtained between January 2016 and July 2019 were retrospectively identified. Patient charts were examined to identify those patients who subsequently underwent systematic prostate biopsy within 1 year of undergoing MRI or at any later date if the biopsy was negative. Patient characteristics and MRI-specific factors were recorded. Two blinded radiologists evaluated the quality of the axial T2-weighted, DWI, and apparent diffusion coefficient sequences; measured the volume of the bladder, the prostate gland, and rectal gas; and determined whether the peripheral zone was avidly enhancing and whether low signal intensity was seen in 50% or more of the peripheral zone on T2-weighted images. Interobserver agreement was tested. Univariable and multivariable logistic regression models were built. RESULTS. A total of 150 patients (median age, 63 years; interquartile range, 56-70 years) were included. Of these patients, 19 (13%) had prostate cancer with a Gleason score of 3 + 4 or greater, yielding a negative predictive value of 87%. Both low T2 signal intensity in the peripheral zone and the prostate-specific antigen level were associated with a false-negative PI-RADS 1 assessment (odds ratio, 4.9 [95% CI, 1.6-14.9; p = 0.006] and 1.1 [95% CI, 1.0-1.2; p = 0.03], respectively). A cutoff prostate-specific antigen level of 3.97 ng/mL resulted in sensitivity and specificity of 89% and 21%, respectively. There was moderate interobserver agreement for low T2 signal intensity in the peripheral zone (κ coefficient = 0.75). CONCLUSION. Even among select patients who undergo subsequent biopsy because of a high clinical suspicion of prostate cancer, a PI-RADS 1 prostate MRI study has a high negative predictive value. A T2-hypointense peripheral zone and an elevated prostate-specific antigen level are significantly associated with a false-negative MRI study.

Ulnar Collateral Ligament Insertional Injuries in Pediatric Overhead Athletes: Are MRI Findings Predictive of Symptoms or Need for Surgery?

OBJECTIVE: The purpose of this study was to determine whether ulnar collateral ligament (UCL) insertion below the articular margin (so-called T sign) exists in the pediatric population and whether MRI features can be used to identify insertional UCL injuries in overhead athletes that are symptomatic or require surgery. MATERIALS AND METHODS: Retrospective review of elbow MR images of patients younger than 21 years from 2011 to 2017 yielded 26 control subjects who were not overhead athletes and 97 overhead athletes. According to the clinical diagnosis, 50 of the overhead athletes had symptoms. Two radiologists evaluated the UCL for thickness, abnormal insertional signal intensity, insertion distance, and adjacent marrow or soft-tissue edema. Insertion distance was defined as the coronal length of any T sign measured from the articular margin. RESULTS: Mean insertion distance was greater in overhead athletes than in control subjects (1.42 vs 0.23 mm, p = 0.001) but not significantly different in athletes with symptoms compared with those without symptoms or in those who underwent operative treatment compared with those who did not. Mean UCL thickness was greater in overhead athletes than in control subjects (2.64 vs 1.74 mm, p < 0.0001), athletes with than those without symptoms (2.84 vs 2.41 mm, p = 0.005), and athletes who did versus those who did not undergo operative treatment (3.40 vs 2.73 mm, p = 0.011). Marrow (p = 0.002) and soft-tissue (p = 0.016) edema were found more frequently in athletes with symptoms. ROC analysis of UCL thickness and insertion distance as predictors of symptoms showed AUCs of 0.69 and 0.49, respectively. CONCLUSION: The T sign is likely not an anatomic variation but is a poor predictor of symptoms and need for surgery. Soft-tissue and marrow edema are more frequently seen in overhead athletes with symptomatic injuries and can aid in the diagnosis of clinically relevant injury.

Anterior Inferior Iliac Spine Morphology: Comparison of Symptomatic Hips With Femoroacetabular Impingement and Asymptomatic Hips.

OBJECTIVE: The objective of our study was to compare anterior inferior iliac spine (AIIS) morphology in symptomatic hips with femoroacetabular impingement (FAI) and in asymptomatic hips, determine the prevalence of impingement morphology in patients with a radiographic "crossover" sign, and identify potential risk factors for having impingement morphology. MATERIALS AND METHODS: For this retrospective study, we identified consecutive symptomatic hips with FAI (n = 54) and asymptomatic hips (n = 35) in patients who underwent CT from 2015 to 2017. Two radiologists blindly and independently evaluated 3D CT images of each hip and graded the AIIS morphology according to the Hetsroni classification scheme. The prevalence of AIIS morphology types was calculated. Associations of AIIS morphology types with symptoms and the crossover sign were evaluated with a chi-square test. A multivariable logistic regression determined risk factors for abnormal AIIS morphology (i.e., type 2 or 3). RESULTS: There was no difference in the prevalence of AIIS morphology types for symptomatic hips with FAI versus asymptomatic hips (p = 0.44) or for hips with a positive versus those with a negative crossover sign (p = 0.21). There was moderate interobserver agreement (κ = 0.44) and good-to-excellent intraobserver agreement (κ = 0.67 and 0.90) for grading AIIS morphology. Age, sex, femoral version, acetabular version, alpha angle, lateral center edge angle, and the crossover sign were not significant risk factors for abnormal AIIS morphology in patients with FAI (p = 0.11-0.79). CONCLUSION: There is no difference in AIIS morphology between symptomatic hips with FAI versus asymptomatic hips or between hips with and those without the radiographic crossover sign. Age, sex, and other FAI parameters are not risk factors for developing AIIS impingement morphology.

Diffuse Peripheral Zone T2 Hypointensity: When to Worry About Prostate Cancer.

OBJECTIVE: Evaluate the accuracy of an obscured surgical capsule (OSC) for detecting diffuse prostate cancer (PCa) in the setting of diffusely T2 hypointense peripheral zones (PZs) on prostate magnetic resonance imaging. METHODS: Axial T2-weighted sequences of prostate magnetic resonance imaging performed on July 1, 2015, to August 1, 2017, were blindly assessed for diffusely T2 hypointense PZs, OSC, and focal diffusion abnormalities by 2 radiologists. Diffuse PCa was defined by the presence of bilateral PCa on at least 4 contiguous biopsy cores involving 2/3 levels. Interobserver agreement and multivariate analysis were performed. RESULTS: Seven (10%) of 70 patients had diffuse PCa. There was weak interreader agreement for OSC (κ coefficient = 0.58). Obscured surgical capsule was 57% sensitive and 89% specific for the presence of diffuse PCa and was associated with it (odds ratio, 17.6; P = 0.0008). Multivariate logistic regression demonstrated that OSC was the only significant predictor for the presence of diffuse PCa. CONCLUSION: Obscured surgical capsule is a strong independent predictor for diffuse PCa in T2 hypointense PZs.

Nonenhancing Component of Clear Cell Renal Cell Carcinoma on Computed Tomography Correlates With Tumor Necrosis and Stage and Serves as a Size-Independent Prognostic Biomarker.

OBJECTIVES: This study aimed to quantify nonenhancing tumor (NT) component in clear cell renal cell carcinoma (ccRCC) and assess its association with histologically defined tumor necrosis, stage, and survival outcomes. METHODS: Among 183 patients with ccRCC, multi-institutional changes in computed tomography attenuation of tumor voxels were used to quantify percent of NT. Associations of NT with histologic tumor necrosis and tumor stage/grade were tested using Wilcoxon signed rank test and with survival outcomes using Kaplan-Meier curves/Cox regression analysis. RESULTS: Nonenhancing tumor was higher in ccRCC with tumor necrosis (11% vs 7%; P = 0.040) and higher pathological stage (P = 0.042 and P < 0.001, respectively). Patients with greater NT had higher incidence of cancer recurrence after resection (P < 0.001) and cancer-specific mortality (P < 0.001). CONCLUSION: Nonenhancing tumor on preoperative computed tomographic scans in patients with ccRCC correlates with tumor necrosis and stage and may serve as an independent imaging prognostic biomarker for cancer recurrence and cancer-specific survival.

Determinants of breast cancer in Saudi women from Makkah region: a case-control study (breast cancer risk factors among Saudi women).

BACKGROUND: There are various factors that play a major role in influencing the overall health conditions of women diagnosed with breast cancer. The population of women in Makkah region are diverse, therefore it is significant to highlight the possible determinants of breast cancer in this population. This is a case-control study that assessed determinants of breast cancer including socioeconomic factors, health-related characteristics, menstrual histories and breastfeeding among postmenopausal women in Makkah region in Saudi Arabia. METHODS: A total of 432 female participants (214 cases and 218 controls) were recruited for this study. A validated questionnaire was completed by trained dietitians at King Abdullah Medical City Hospital in the Makkah region of Saudi Arabia. RESULTS: Results displayed that determinants of breast cancer were associated significantly (P < 0.05) with unemployment, large family size, lack of knowledge and awareness about breast cancer, obesity, sedentary lifestyle, smoking, starting menarche at an early age, as well as hormonal and non-hormonal contraceptive use. There was no effect of diabetes, hypertension, hyperlipidemia, and duration of breastfeeding on the incidence of breast cancer. CONCLUSION: In summary, the results of this study accentuate the possible effect of socioeconomic factors, health-related characteristics and menstrual history on the incidence of breast cancer in postmenopausal women in the Makkah region. Education programs should be applied to increase breast cancer awareness and possibly decrease its incidence.

A comparative study of gut microbiomes in captive nocturnal strepsirrhines.

Feeding strategy and diet are increasingly recognized for their roles in governing primate gut microbiome (GMB) composition. Whereas feeding strategy reflects evolutionary adaptations to a host's environment, diet is a more proximate measure of food intake. Host phylogeny, which is intertwined with feeding strategy, is an additional, and often confounding factor that shapes GMBs across host lineages. Nocturnal strepsirrhines are an intriguing and underutilized group in which to examine the links between these three factors and GMB composition. Here, we compare GMB composition in four species of captive, nocturnal strepsirrhines with varying feeding strategies and phylogenetic relationships, but nearly identical diets. We use 16S rRNA sequences to determine gut bacterial composition. Despite similar husbandry conditions, including diet, we find that GMB composition varies significantly across host species and is linked to host feeding strategy and phylogeny. The GMBs of the omnivorous and the frugivorous species were significantly more diverse than were those of the insectivorous and exudativorous species. Across all hosts, GMBs were enriched for bacterial taxa associated with the macronutrient resources linked to the host's respective feeding strategy. Ultimately, the reported variation in microbiome composition suggests that the impacts of captivity and concurrent diet do not overshadow patterns of feeding strategy and phylogeny. As our understanding of primate GMBs progresses, populations of captive primates can provide insight into the evolution of host-microbe relationships, as well as inform future captive management protocols that enhance primate health and conservation.

Stressors contributing to burnout amongst pediatric radiologists: results from a survey of the Society for Pediatric Radiology.

BACKGROUND: A recent study showed a high prevalence of burnout in pediatric radiology. OBJECTIVE: The purpose of this study is to evaluate potential stressors contributing to burnout in pediatric radiology. MATERIALS AND METHODS: Society for Pediatric Radiology members received an invitation for an anonymous survey evaluating stressors contributing to burnout. Stressors evaluated included call burden, financial stress, work-life balance, health care evolution and job market changes, and radiology as a career choice. Additional questions regarding demographics were obtained. RESULTS: The response rate was 460/1,453 (32%). The prevalence of emotional exhaustion was 66% (286/435), depersonalization was 61% (265/433) and perceived lack of personal accomplishment was 15% (67/436). In a backward selective logistic regression model, work-life imbalance and call burden were the only significant factors predicting higher emotional exhaustion (P<0.001). Using a similar model, work-life imbalance, call burden and decreased rate of reimbursement were significantly associated with higher probability of depersonalization (P=0.033, 0.0002 and 0.015, respectively). Emotional exhaustion and depersonalization were significantly associated with higher odds of a radiologist's wish to work in another medical specialty (P=0.011 and 0.002, respectively). CONCLUSION: Key stressors contributing to burnout in pediatric radiology include work-life imbalance, pediatric call burden and a decreased rate of reimbursement. Burnout in pediatric radiology is a serious issue that needs to be addressed and prioritized on the individual and departmental/institutional levels and further investigated to develop effective interventions to mitigate it.

Human Gut Microbiota Predicts Susceptibility to Vibrio cholerae Infection.

Background: Cholera is a public health problem worldwide, and the risk factors for infection are only partially understood. Methods: We prospectively studied household contacts of patients with cholera to compare those who were infected to those who were not. We constructed predictive machine learning models of susceptibility, using baseline gut microbiota data. We identified bacterial taxa associated with susceptibility to Vibrio cholerae infection and tested these taxa for interactions with V. cholerae in vitro. Results: We found that machine learning models based on gut microbiota, as well as models based on known clinical and epidemiological risk factors, predicted V. cholerae infection. A predictive gut microbiota of roughly 100 bacterial taxa discriminated between contacts who developed infection and those who did not. Susceptibility to cholera was associated with depleted levels of microbes from the phylum Bacteroidetes. By contrast, a microbe associated with cholera by our modeling framework, Paracoccus aminovorans, promoted the in vitro growth of V. cholerae. Gut microbiota structure, clinical outcome, and age were also linked. Conclusion: These findings support the hypothesis that abnormal gut microbial communities are a host factor related to V. cholerae susceptibility.

Cerebrovascular Accidents During Mechanical Circulatory Support: New Predictors of Ischemic and Hemorrhagic Strokes and Outcome.

BACKGROUND AND PURPOSE: Left ventricular assist devices (LVADs) have emerged as an effective treatment for patients with advanced heart failure refractory to medical therapy. Post-LVAD strokes are an important cause of morbidity and reduced quality of life. Data on risks that distinguish between ischemic and hemorrhagic post-LVAD strokes are limited. The aim of this study was to determine the incidence of post-LVAD ischemic and hemorrhagic strokes, their association with stroke risk factors, and their effect on mortality. METHODS: Data are collected prospectively on all patients with LVADs implanted at Brigham and Women's Hospital. We added retrospectively collected clinical data for these analyses. RESULTS: From 2007 to 2016, 183 patients (median age, 57; 80% male) underwent implantation of HeartMate II LVAD as a bridge to transplant (52%), destination therapy (39%), or bridge to transplant candidacy (8%). A total of 48 strokes occurred in 39 patients (21%): 28 acute ischemic strokes in 24 patients (13%) and 20 intracerebral hemorrhages in 19 patients (10.3%). First events occurred at a median of 238 days from implantation (interquartile range, 93-515) among those who developed post-LVAD stroke. All but 9 patients (4.9%) were on warfarin (goal international normalized ratio, 2-3.5) and all received aspirin (81-325 mg). Patients with chronic obstructive pulmonary disease were more likely to have an ischemic stroke (odds ratio, 2.96; 95% confidence interval, 1.14-7.70). Dialysis-dependent patients showed a trend toward a higher risk of hemorrhagic stroke (odds ratio, 6.31; 95% confidence interval, 0.99-40.47). Hemorrhagic stroke was associated with higher mortality (odds ratio, 3.92; 95% confidence interval, 1.34-11.45) than ischemic stroke (odds ratio, 3.17; 95% confidence interval, 1.13-8.85). CONCLUSIONS: Stroke is a major cause of morbidity and mortality in patients on LVAD support. Chronic obstructive pulmonary disease increases the risk of ischemic stroke, whereas dialysis may increase the risk of hemorrhagic stroke. Although any stroke increases mortality, post-LVAD hemorrhagic stroke was associated with higher mortality compared with ischemic stroke.

Complement-induced activation of MAPKs and Akt during sepsis: role in cardiac dysfunction.

Polymicrobial sepsis in mice causes myocardial dysfunction after generation of the complement anaphylatoxin, complement component 5a (C5a). C5a interacts with its receptors on cardiomyocytes (CMs), resulting in redox imbalance and cardiac dysfunction that can be functionally measured and quantitated using Doppler echocardiography. In this report we have evaluated activation of MAPKs and Akt in CMs exposed to C5a in vitro and after cecal ligation and puncture (CLP) in vivo In both cases, C5a in vitro caused activation (phosphorylation) of MAPKs and Akt in CMs, which required availability of both C5a receptors. Using immunofluorescence technology, activation of MAPKs and Akt occurred in left ventricular (LV) CMs, requiring both C5a receptors, C5aR1 and -2. Use of a water-soluble p38 inhibitor curtailed activation in vivo of MAPKs and Akt in LV CMs as well as the appearance of cytokines and histones in plasma from CLP mice. When mouse macrophages were exposed in vitro to LPS, activation of MAPKs and Akt also occurred. The copresence of the p38 inhibitor blocked these activation responses. Finally, the presence of the p38 inhibitor in CLP mice reduced the development of cardiac dysfunction. These data suggest that polymicrobial sepsis causes cardiac dysfunction that appears to be linked to activation of MAPKs and Akt in heart.-Fattahi, F., Kalbitz, M., Malan, E. A., Abe, E., Jajou, L., Huber-Lang, M. S., Bosmann, M., Russell, M. W., Zetoune, F. S., Ward, P. A. Complement-induced activation of MAPKs and Akt during sepsis: role in cardiac dysfunction.

Complement Destabilizes Cardiomyocyte Function In Vivo after Polymicrobial Sepsis and In Vitro.

There is accumulating evidence during sepsis that cardiomyocyte (CM) homeostasis is compromised, resulting in cardiac dysfunction. An important role for complement in these outcomes is now demonstrated. Addition of C5a to electrically paced CMs caused prolonged elevations of intracellular Ca(2+) concentrations during diastole, together with the appearance of spontaneous Ca(2+) transients. In polymicrobial sepsis in mice, we found that three key homeostasis-regulating proteins in CMs were reduced: Na(+)/K(+)-ATPase, which is vital for effective action potentials in CMs, and two intracellular Ca(2+) concentration regulatory proteins, that is, sarcoplasmic/endoplasmic reticulum calcium ATPase 2 and the Na(+)/Ca(2+) exchanger. Sepsis caused reduced mRNA levels and reductions in protein concentrations in CMs for all three proteins. The absence of either C5a receptor mitigated sepsis-induced reductions in the three regulatory proteins. Absence of either C5a receptor (C5aR1 or C5aR2) diminished development of defective systolic and diastolic echocardiographic/Doppler parameters developing in the heart (cardiac output, left ventricular stroke volume, isovolumic relaxation, E' septal annulus, E/E' septal annulus, left ventricular diastolic volume). We also found in CMs from septic mice the presence of defective current densities for Ik1, l-type calcium channel, and Na(+)/Ca(2+) exchanger. These defects were accentuated in the copresence of C5a. These data suggest complement-related mechanisms responsible for development of cardiac dysfunction during sepsis.

Normal Patterns of Nasometric Values in Adult Jordanian Speakers of Arabic.

PURPOSE: The study sought to establish normative nasometric values for adult Jordanian speakers of Arabic. Gender-related differences and intraspeaker variability of nasalance scores were investigated. METHODS: A total of 113 adult speakers of Jordanian Arabic (56 men and 57 women) without speech-language and hearing impairments or craniofacial anomalies ranging in age between 18 and 55 participated in the study. Nasometer II, Model 6400 was used to obtain nasalance scores as speakers produced 3 recitations for each of the 3 standardized passages consisting of an oral passage, an oronasal passage, and nasal sentences. Descriptive statistics of nasalance scores for each passage were obtained and gender-related differences were determined by ANOVA. Standard deviation for the 3 repetitions for each passage was considered an index for intraspeaker variability. RESULTS: Average nasalance for each passage was (11.23%) for the oral passage, (25.48%) for the oronasal passage, and (51.92%) for the nasal sentence. There was no gender effect on nasalance on the oral passage, however women exhibited higher nasalance scores than men on the both oronasal passage (P = 0.002) and nasal sentences (P = 0.017). Intraspeaker variability for all speakers fell below 4.5% with repeated readings. CONCLUSION: The study provides normative nasometric data for Arabic speaking Jordanian adults to serve as references for the assessment of velopharyngeal dysfunction in craniofacial clinics. Arabic speakers demonstrated different nasalance scores than speakers of other languages. Gender differences can be attributed to variations in anatomical structure and velopharyngeal function between men and women.