Transsynaptic Assemblies Link Domains of Presynaptic and Postsynaptic Intracellular Structures across the Synaptic Cleft.

The chemical synapse is a complex machine separated into three parts: presynaptic, postsynaptic, and cleft. Super-resolution light microscopy has revealed alignment of presynaptic vesicle release machinery and postsynaptic neurotransmitter-receptors and scaffolding components in synapse spanning nanocolumns. Cryo-electron tomography confirmed that postsynaptic glutamate receptor-like structures align with presynaptic structures in proximity to synaptic vesicles into transsynaptic assemblies. In our electron tomographic renderings, nearly all transcleft structures visibly connect to intracellular structures through transmembrane structures to form transsynaptic assemblies, potentially providing a structural basis for transsynaptic alignment. Here, we describe the patterns of composition, distribution, and interactions of all assemblies spanning the synapse by producing three-dimensional renderings of all visibly connected structures in excitatory and inhibitory synapses in dissociated rat hippocampal neuronal cultures of both sexes prepared by high-pressure freezing and freeze-substitution. The majority of transcleft structures connect to material in both presynaptic and postsynaptic compartments. We found several instances of assemblies connecting to both synaptic vesicles and postsynaptic density scaffolding. Each excitatory synaptic vesicle within 30 nm of the active zone contacts one or more assembly. Further, intracellular structures were often shared between assemblies, entangling them to form larger complexes or association domains, often in small clusters of vesicles. Our findings suggest that transsynaptic assemblies physically connect the three compartments, allow for coordinated molecular organization, and may combine to form specialized functional association domains, resembling the light-level nanocolumns.SIGNIFICANCE STATEMENT A recent tomographic study uncovered that receptor-like cleft structures align across the synapse. These aligned structures were designated as transsynaptic assemblies and demonstrate the coordinated organization of synaptic transmission molecules between compartments. Our present tomographic study expands on the definition of transsynaptic assemblies by analyzing the three-dimensional distribution and connectivity of all cleft-spanning structures and their connected intracellular structures. While one-to-one component alignment occurs across the synapse, we find that many assemblies share components, leading to a complex entanglement of assemblies, typically around clusters of synaptic vesicles. Transsynaptic assemblies appear to form domains which may be the structural basis for alignment of molecular nanodomains into synapse spanning nanocolumns described by super-resolution light microscopy.

Development and Validation of a Machine Learning Algorithm Using Clinical Pages to Predict Imminent Clinical Deterioration.

BACKGROUND: Early detection of clinical deterioration among hospitalized patients is a clinical priority for patient safety and quality of care. Current automated approaches for identifying these patients perform poorly at identifying imminent events. OBJECTIVE: Develop a machine learning algorithm using pager messages sent between clinical team members to predict imminent clinical deterioration. DESIGN: We conducted a large observational study using long short-term memory machine learning models on the content and frequency of clinical pages. PARTICIPANTS: We included all hospitalizations between January 1, 2018 and December 31, 2020 at Vanderbilt University Medical Center that included at least one page message to physicians. Exclusion criteria included patients receiving palliative care, hospitalizations with a planned intensive care stay, and hospitalizations in the top 2% longest length of stay. MAIN MEASURES: Model classification performance to identify in-hospital cardiac arrest, transfer to intensive care, or Rapid Response activation in the next 3-, 6-, and 12-hours. We compared model performance against three common early warning scores: Modified Early Warning Score, National Early Warning Score, and the Epic Deterioration Index. KEY RESULTS: There were 87,783 patients (mean [SD] age 54.0 [18.8] years; 45,835 [52.2%] women) who experienced 136,778 hospitalizations. 6214 hospitalized patients experienced a deterioration event. The machine learning model accurately identified 62% of deterioration events within 3-hours prior to the event and 47% of events within 12-hours. Across each time horizon, the model surpassed performance of the best early warning score including area under the receiver operating characteristic curve at 6-hours (0.856 vs. 0.781), sensitivity at 6-hours (0.590 vs. 0.505), specificity at 6-hours (0.900 vs. 0.878), and F-score at 6-hours (0.291 vs. 0.220). CONCLUSIONS: Machine learning applied to the content and frequency of clinical pages improves prediction of imminent deterioration. Using clinical pages to monitor patient acuity supports improved detection of imminent deterioration without requiring changes to clinical workflow or nursing documentation.

Impact of inpatient addiction psychiatry consultation on opioid use disorder outcomes.

BACKGROUND AND OBJECTIVES: Addiction consultation services provide access to specialty addiction care during general hospital admission. This study assessed opioid use disorder (OUD) outcomes associated with addiction consultation. METHODS: Retrospective cohort study of individuals with OUD admitted to an academic medical center between 2018 and 2023. The exposure was addiction consultation. Outcomes included initiating medication for OUD (MOUD), hospital length of stay, before-medically-advised (BMA) discharge, and 30- and 90-day postdischarge acute care utilization. RESULTS: Of 26,766 admissions (10,501 patients) with OUD, 2826 addiction consultations were completed. Consultation cohort was more likely to be young, male, and White than controls. Consultation was associated with greater MOUD initiation (adjusted odds ratio [aOR], 5.07; 95% confidence interval [CI], 4.41-5.82), fewer emergency department visits at 30 (aOR, 0.78; 95% CI, 0.67-0.92) and 90 (aOR, 0.79; 95% CI, 0.69-0.89) days, and fewer hospitalizations at 30 (aOR, 0.65; 95% CI, 0.56 to 0.76) and 90 (aOR, 0.67; 95% CI, 0.59-0.76) days. Additionally, consultation patients were more likely to have a longer hospital stay and leave BMA. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Addiction consultation was associated with increased MOUD initiation and reduced postdischarge acute care utilization. This is the largest study to date showing a significant association between addiction psychiatry consultation and improved OUD outcomes when compared to controls. The observed reduction in postdischarge acute care utilization remains even after adjusting for MOUD initiation. Disparities in access to addiction consultation warrant further study.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration.

BACKGROUND: Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS: We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS: We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS: The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Evaluation in Life Cycle of Information Technology (ELICIT) framework: Supporting the innovation life cycle from business case assessment to summative evaluation.

OBJECTIVE: Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation. METHODS: The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies. RESULTS: The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment. DISCUSSION: Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation. CONCLUSION: As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations.

Coherent directed movement toward food modeled in Trichoplax, a ciliated animal lacking a nervous system.

Trichoplax adhaerens is a small, ciliated marine animal that glides on surfaces grazing upon algae, which it digests externally. It has no muscles or nervous system and only six cell types, all but two of which are embedded in its epithelium. The epithelial cells are joined by apical adherens junctions; neither tight junctions nor gap junctions are present. Monociliated epithelial cells on the lower surface propel gliding. The cilia beat regularly, but asynchronously, and transiently contact the substrate with each stroke. The animal moves in random directions in the absence of food. We show here that it exhibits chemotaxis, moving preferentially toward algae embedded in a disk of agar. We present a mathematical model to explain how coherent, directional movements could arise from the collective actions of a set of ciliated epithelial cells, each independently sensing and responding to a chemoattractant gradient. The model incorporates realistic values for viscoelastic properties of cells and produces coordinated movements and changes in body shape that resemble the actual movements of the animal. The model demonstrates that an animal can move coherently in search of food without any need for chemical signaling between cells and introduces a different approach to modeling behavior in primitive multicellular organisms.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry.

BACKGROUND: Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. METHODS: Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre. RESULTS: 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004). CONCLUSIONS: The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

A systematic review of theoretical constructs in CDS literature.

BACKGROUND: Studies that examine the adoption of clinical decision support (CDS) by healthcare providers have generally lacked a theoretical underpinning. The Unified Theory of Acceptance and Use of Technology (UTAUT) model may provide such a theory-based explanation; however, it is unknown if the model can be applied to the CDS literature. OBJECTIVE: Our overall goal was to develop a taxonomy based on UTAUT constructs that could reliably characterize CDS interventions. METHODS: We used a two-step process: (1) identified randomized controlled trials meeting comparative effectiveness criteria, e.g., evaluating the impact of CDS interventions with and without specific features or implementation strategies; (2) iteratively developed and validated a taxonomy for characterizing differential CDS features or implementation strategies using three raters. RESULTS: Twenty-five studies with 48 comparison arms were identified. We applied three constructs from the UTAUT model and added motivational control to characterize CDS interventions. Inter-rater reliability was as follows for model constructs: performance expectancy (κ = 0.79), effort expectancy (κ = 0.85), social influence (κ = 0.71), and motivational control (κ = 0.87). CONCLUSION: We found that constructs from the UTAUT model and motivational control can reliably characterize features and associated implementation strategies. Our next step is to examine the quantitative relationships between constructs and CDS adoption.

Iterative heuristic design of temporal graphic displays with clinical domain experts.

Conventional electronic health record information displays are not optimized for efficient information processing. Graphical displays that integrate patient information can improve information processing, especially in data-rich environments such as critical care. We propose an adaptable and reusable approach to patient information display with modular graphical components (widgets). We had two study objectives. First, reduce numerous widget prototype alternatives to preferred designs. Second, derive widget design feature recommendations. Using iterative human-centered design methods, we interviewed experts to hone design features of widgets displaying frequently measured data elements, e.g., heart rate, for acute care patient monitoring and real-time clinical decision-making. Participant responses to design queries were coded to calculate feature-set agreement, average prototype score, and prototype agreement. Two iterative interview cycles covering 64 design queries and 86 prototypes were needed to reach consensus on six feature sets. Interviewers agreed that line graphs with a smoothed or averaged trendline, 24-h timeframe, and gradient coloring for urgency were useful and informative features. Moreover, users agreed that widgets should include key functions: (1) adjustable reference ranges, (2) expandable timeframes, and (3) access to details on demand. Participants stated graphical widgets would be used to identify correlating patterns and compare abnormal measures across related data elements at a specific time. Combining theoretical principles and validated design methods was an effective and reproducible approach to designing widgets for healthcare displays. The findings suggest our widget design features and recommendations match critical care clinician expectations for graphical information display of continuous and frequently updated patient data.

Critical care information display approaches and design frameworks: A systematic review and meta-analysis.

OBJECTIVE: To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians. METHODS: We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author. RESULTS: Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible. CONCLUSION: Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.

Palmitoylation regulates glutamate receptor distributions in postsynaptic densities through control of PSD95 conformation and orientation.

Postsynaptic density protein 95 (PSD95) and synapse-associated protein 97 (SAP97) are homologous scaffold proteins with different N-terminal domains, possessing either a palmitoylation site (PSD95) or an L27 domain (SAP97). Here, we measured PSD95 and SAP97 conformation in vitro and in postsynaptic densities (PSDs) using FRET and EM, and examined how conformation regulated interactions with AMPA-type and NMDA-type glutamate receptors (AMPARs/NMDARs). Palmitoylation of PSD95 changed its conformation from a compact to an extended configuration. PSD95 associated with AMPARs (via transmembrane AMPAR regulatory protein subunits) or NMDARs [via glutamate ionotropic receptor NMDA-type subunit 2B (GluN2B) subunits] only in its palmitoylated and extended conformation. In contrast, in its extended conformation, SAP97 associates with NMDARs, but not with AMPARs. Within PSDs, PSD95 and SAP97 were largely in the extended conformation, but had different orientations. PSD95 oriented perpendicular to the PSD membrane, with its palmitoylated, N-terminal domain at the membrane. SAP97 oriented parallel to the PSD membrane, likely as a dimer through interactions of its N-terminal L27 domain. Changing PSD95 palmitoylation in PSDs altered PSD95 and AMPAR levels but did not affect NMDAR levels. These results indicate that in PSDs, PSD95 palmitoylation, conformation, and its interactions are dynamic when associated with AMPARs and more stable when associated with NMDARs. Altogether, our results are consistent with differential regulation of PSD95 palmitoylation in PSDs resulting from the clustering of palmitoylating and depalmitoylating enzymes into AMPAR nanodomains segregated away from NMDAR nanodomains.

PSD-95 family MAGUKs are essential for anchoring AMPA and NMDA receptor complexes at the postsynaptic density.

The postsynaptic density (PSD)-95 family of membrane-associated guanylate kinases (MAGUKs) are major scaffolding proteins at the PSD in glutamatergic excitatory synapses, where they maintain and modulate synaptic strength. How MAGUKs underlie synaptic strength at the molecular level is still not well understood. Here, we explore the structural and functional roles of MAGUKs at hippocampal excitatory synapses by simultaneous knocking down PSD-95, PSD-93, and synapse-associated protein (SAP)102 and combining electrophysiology and transmission electron microscopic (TEM) tomography imaging to analyze the resulting changes. Acute MAGUK knockdown greatly reduces synaptic transmission mediated by α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptors (AMPARs) and N-methyl-d-aspartate receptors (NMDARs). This knockdown leads to a significant rise in the number of silent synapses, diminishes the size of PSDs without changes in pre- or postsynaptic membrane, and depletes the number of membrane-associated PSD-95-like vertical filaments and transmembrane structures, identified as AMPARs and NMDARs by EM tomography. The differential distribution of these receptor-like structures and dependence of their abundance on PSD size matches that of AMPARs and NMDARs in the hippocampal synapses. The loss of these structures following MAGUK knockdown tracks the reduction in postsynaptic AMPAR and NMDAR transmission, confirming the structural identities of these two types of receptors. These results demonstrate that MAGUKs are required for anchoring both types of glutamate receptors at the PSD and are consistent with a structural model where MAGUKs, corresponding to membrane-associated vertical filaments, are the essential structural proteins that anchor and organize both types of glutamate receptors and govern the overall molecular organization of the PSD.

Interactive Visual Displays for Interpreting the Results of Clinical Trials: Formative Evaluation With Case Vignettes.

BACKGROUND: At the point of care, evidence from randomized controlled trials (RCTs) is underutilized in helping clinicians meet their information needs. OBJECTIVE: To design interactive visual displays to help clinicians interpret and compare the results of relevant RCTs for the management of a specific patient, and to conduct a formative evaluation with physicians comparing interactive visual versus narrative displays. METHODS: We followed a user-centered and iterative design process succeeded by development of information display prototypes as a Web-based application. We then used a within-subjects design with 20 participants (8 attendings and 12 residents) to evaluate the usability and problem-solving impact of the information displays. We compared subjects' perceptions of the interactive visual displays versus narrative abstracts. RESULTS: The resulting interactive visual displays present RCT results side-by-side according to the Population, Intervention, Comparison, and Outcome (PICO) framework. Study participants completed 19 usability tasks in 3 to 11 seconds with a success rate of 78% to 100%. Participants favored the interactive visual displays over narrative abstracts according to perceived efficiency, effectiveness, effort, user experience and preference (all P values <.001). CONCLUSIONS: When interpreting and applying RCT findings to case vignettes, physicians preferred interactive graphical and PICO-framework-based information displays that enable direct comparison of the results from multiple RCTs compared to the traditional narrative and study-centered format. Future studies should investigate the use of interactive visual displays to support clinical decision making in care settings and their effect on clinician and patient outcomes.

A Network of Three Types of Filaments Organizes Synaptic Vesicles for Storage, Mobilization, and Docking.

Synaptic transmission between neurons requires precise management of synaptic vesicles. While individual molecular components of the presynaptic terminal are well known, exactly how the molecules are organized into a molecular machine serving the storage and mobilization of synaptic vesicles to the active zone remains unclear. Here we report three filament types associated with synaptic vesicles in glutamatergic synapses revealed by electron microscope tomography in unstimulated, dissociated rat hippocampal neurons. One filament type, likely corresponding to the SNAREpin complex, extends from the active zone membrane and surrounds docked vesicles. A second filament type contacts all vesicles throughout the active zone and pairs vesicles together. On the third filament type, vesicles attach to side branches extending from the long filament core and form vesicle clusters that are distributed throughout the vesicle cloud and along the active zone membrane. Detailed analysis of presynaptic structure reveals how each of the three filament types interacts with synaptic vesicles, providing a means to traffic reserved and recycled vesicles from the cloud of vesicles into the docking position at the active zone. SIGNIFICANCE STATEMENT: The formation and release of synaptic vesicles has been extensively investigated. Explanations of the release of synaptic vesicles generally begin with the movement of vesicles from the cloud into the synaptic active zone. However, the presynaptic terminal is filled with filamentous material that would appear to limit vesicular diffusion. Here, we provide a systematic description of three filament types connecting synaptic vesicles. A picture emerges illustrating how the cooperative attachment and release of these three filament types facilitate the movement of vesicles to the active zone to become docked in preparation for release.

Neuropeptidergic integration of behavior in Trichoplax adhaerens, an animal without synapses.

Trichoplax adhaerens is a flat, millimeter-sized marine animal that adheres to surfaces and grazes on algae. Trichoplax displays a repertoire of different feeding behaviors despite the apparent absence of a true nervous system with electrical or chemical synapses. It glides along surfaces to find food, propelled by beating cilia on cells at its ventral surface, and pauses during feeding by arresting ciliary beating. We found that when endomorphin-like peptides are applied to an animal, ciliary beating is arrested, mimicking natural feeding pauses. Antibodies against these neuropeptides label cells that express the neurosecretory proteins and voltage-gated calcium channels implicated in regulated secretion. These cells are embedded in the ventral epithelium, where they comprise only 4% of the total, and are concentrated around the edge of the animal. Each bears a cilium likely to be chemosensory and used to detect algae. Trichoplax pausing during feeding or spontaneously in the absence of food often induce their neighbors to pause as well, even neighbors not in direct contact. Pausing behavior propagates from animal to animal across distances much greater than the signal that diffuses from just one animal, so we presume that the peptides secreted from one animal elicit secretion from nearby animals. Signal amplification by peptide-induced peptide secretion explains how a small number of sensory secretory cells lacking processes and synapses can evoke a wave of peptide secretion across the entire animal to globally arrest ciliary beating and allow pausing during feeding.

Anaphylaxis in children and adolescents: The European Anaphylaxis Registry.

BACKGROUND: Anaphylaxis in children and adolescents is a potentially life-threatening condition. Its heterogeneous clinical presentation and sudden occurrence in virtually any setting without warning have impeded a comprehensive description. OBJECTIVE: We sought to characterize severe allergic reactions in terms of elicitors, symptoms, emergency treatment, and long-term management in European children and adolescents. METHODS: The European Anaphylaxis Registry recorded details of anaphylaxis after referral for in-depth diagnosis and counseling to 1 of 90 tertiary allergy centers in 10 European countries, aiming to oversample the most severe reactions. Data were retrieved from medical records by using a multilanguage online form. RESULTS: Between July 2007 and March 2015, anaphylaxis was identified in 1970 patients younger than 18 years. Most incidents occurred in private homes (46%) and outdoors (19%). One third of the patients had experienced anaphylaxis previously. Food items were the most frequent trigger (66%), followed by insect venom (19%). Cow's milk and hen's egg were prevalent elicitors in the first 2 years, hazelnut and cashew in preschool-aged children, and peanut at all ages. There was a continuous shift from food- to insect venom- and drug-induced anaphylaxis up to age 10 years, and there were few changes thereafter. Vomiting and cough were prevalent symptoms in the first decade of life, and subjective symptoms (nausea, throat tightness, and dizziness) were prevalent later in life. Thirty percent of cases were lay treated, of which 10% were treated with an epinephrine autoinjector. The fraction of intramuscular epinephrine in professional emergency treatment increased from 12% in 2011 to 25% in 2014. Twenty-six (1.3%) patients were either admitted to the intensive care unit or had grade IV/fatal reactions. CONCLUSIONS: The European Anaphylaxis Registry confirmed food as the major elicitor of anaphylaxis in children, specifically hen's egg, cow's milk, and nuts. Reactions to insect venom were seen more in young adulthood. Intensive care unit admissions and grade IV/fatal reactions were rare. The registry will serve as a systematic foundation for a continuous description of this multiform condition.

NMDA-induced accumulation of Shank at the postsynaptic density is mediated by CaMKII.

Shank is a specialized scaffold protein present in high abundance at the postsynaptic density (PSD). Using pre-embedding immunogold electron microscopy on cultured hippocampal neurons, we had previously demonstrated further accumulation of Shank at the PSD under excitatory conditions. Here, using the same experimental protocol, we demonstrate that a cell permeable CaMKII inhibitor, tatCN21, blocks NMDA-induced accumulation of Shank at the PSD. Furthermore we show that NMDA application changes the distribution pattern of Shank at the PSD, promoting a 7-10 nm shift in the median distance of Shank labels away from the postsynaptic membrane. Inhibition of CaMKII with tatCN21 also blocks this shift in the distribution of Shank. Altogether these results imply that upon activation of NMDA receptors, CaMKII mediates accumulation of Shank, preferentially at the distal regions of the PSD complex extending toward the cytoplasm.

Prognostic information of serial plasma osteopontin measurement in radiotherapy of non-small-cell lung cancer.

BACKGROUND: Circulating baseline levels of the plasma-protein osteopontin (OPN) have been suggested as a prognostic indicator in chemotherapy and surgery for lung cancer. However, the role of this hypoxia-related protein in radiotherapy of lung cancer is unclear. We previously demonstrated the prognostic effect of baseline OPN plasma levels which was increased by co-detection with other hypoxia-related proteins in the radical radiotherapy of non-small-cell lung cancer (NSCLC). This prospective clinical study investigated whether serial OPN measurements during and after curative-intent radiotherapy for NSCLC provide additional or superior prognostic information. METHODS: Sixty-nine patients with inoperable NSCLC were prospectively enrolled (55 M0, 14 M1). OPN plasma levels were measured before (t0), at the end (t1) and four weeks after radiotherapy (t2) by ELISA, compared between M0 and M1 patients and correlated with clinicopathological parameters. OPN levels were monitored over time and correlated with prognosis in M0-stage patients treated by radical 66-Gy radiotherapy ± chemotherapy. RESULTS: Pre-treatment OPN levels were associated with T stage (p = .03), lung function (p = .002), weight loss (p = .01), tumor volume (p = .02) and hemoglobin concentration (p = 04). M1 patients had significantly elevated OPN levels at all time points (p < .001). Patients with increasing OPN levels after radiotherapy had inferior freedom from relapse (p = .008), overall survival (p = .004) and disease-free survival (p = .001) compared to patients with stable or decreasing OPN levels. The risk of relapse in patients with increasing or stable OPN levels after radiotherapy was increased by a factor of 2.9 (p = .01). Patients with increasing post-treatment OPN levels had a 3.1-fold increased risk of death (p = .003). In an exploratory multivariate model, post-treatment OPN level changes but not absolute baseline OPN levels remained an independent prognostic factor for overall survival (p = .002) with a 3.6-fold increased risk of death, as well as N stage (p = .006). CONCLUSIONS: Our results suggest that OPN level changes over time, particularly post-treatment, may yield additional prognostic information in curative-intent radiotherapy of NSCLC.