Arteriovenous Fistulae for Haemodialysis: A Systematic Review and Meta-analysis of Efficacy and Safety Outcomes.

BACKGROUND: Arteriovenous fistulae are the currently recommended gold standard vascular access modality for haemodialysis because of their prolonged patency, improved durability, and low risk of infection for those that mature. However, notable disadvantages are observed in terms of protracted maturation time, associated high rates of catheter use, and substantial abandonment rates. The aim of this study was to quantitatively summarize the outcomes of fistula patency, infection, maturation, and abandonment published in the scientific literature. METHODS: This was a systematic review and meta-analyses of studies evaluating fistula outcomes. Literature searches were conducted in multiple databases to identify observational and interventional studies of mean fistula patency rates at 1 year, infection risk, maturation time, and abandonment. Digitisation software was used to simulate individual patient level data from Kaplan-Meier survival plots. RESULTS: Over 8000 studies were reviewed, and from these, 318 studies were included comprising 62,712 accesses. For fistulas the primary unassisted, primary assisted, and secondary patency rates at one year were 64%, 73% and 79% respectively, however not all fistulas reported as patent could be confirmed as being clinically useful for dialysis (i.e. functional patency). For fistulas that were reported as mature, mean time to maturation was 3.5 months, however only 26% of created fistulas were reported as mature at 6 months and 21% of fistulas were abandoned without use. Overall risk of infection in fistula patients was 4.1% and the overall rate per 100 access days was 0.018. CONCLUSIONS: Reported fistula patency rates may overstate their potential clinical utility when time to maturation, maturation rate, abandonment and infection are considered. Protracted maturation times, abandonment and infection all have a significant impact on evaluating the clinical utility of fistula creation. A rigorous and consistent set of outcomes definitions for hemodialysis access are necessary to clarify factors contributing to fistula success and the clinical consequence of fistula failure.

Exploiting coherence for real-time studies by single-bunch imaging.

First real-time studies of ultra-fast processes by single-bunch imaging at the European Synchrotron Radiation Facility are reported. By operating the storage ring of the ESRF in single-bunch mode with its correspondingly increased electron bunch charge density per singlet, the polychromatic photon flux density at insertion-device beamlines is sufficient to capture hard X-ray images exploiting the light from a single bunch (the corresponding bunch length is 140 ps FWHM). Hard X-ray imaging with absorption contrast as well as phase contrast in combination with large propagation distances is demonstrated using spatial samplings of 11 µm and 35 µm pixel size. The images acquired allow one to track crack propagation in a bursting piece of glass, breaking of an electrical fuse as well as cell wall rupture in an aqueous foam. Future developments and their potential in the frame of the proposed Phase II of the ESRF Upgrade Program are discussed.

Structure and Volta potential of lipid multilayers: effect of X-ray irradiation.

The effect of hard X-ray radiation on the structure and electrostatics of solid-supported lipid multilayer membranes is investigated using a scanning Kelvin probe (SKP) integrated with a high-energy synchrotron beamline to enable in situ measurements of the membranes' local Volta potential (V(p)) during X-ray structural characterization. The undulator radiation employed does not induce any detectable structural damage, but the V(p) of both bare and lipid-modified substrates is found to undergo strong radiation-induced shifts, almost immediately after X-ray exposure. Sample regions that are macroscopically distant (~cm) from the irradiated region experience an exponential V(p) growth with a characteristic time constant of several minutes. The V(p) variations occurring upon periodic on/off X-ray beam switching are fully or partially reversible depending on the location and time-scale of the SKP measurement. The general relevance of these findings for synchrotron-based characterization of biomolecular thin films is critically reviewed.

Variation in organ quality between liver transplant centers.

A wide spectrum of quality exists among deceased donor organs available for liver transplantation. It is unknown whether some transplant centers systematically use more low quality organs, and what factors might influence these decisions. We used hierarchical regression to measure variation in donor risk index (DRI) in the United States by region, organ procurement organization (OPO) and transplant center. The sample included all adults who underwent deceased donor liver transplantation between January 12, 2005 and February 1, 2009 (n = 23,810). Despite adjusting for the geographic region and OPO, transplant centers' mean DRI ranged from 1.27 to 1.74, and could not be explained by differences in patient populations such as disease severity. Larger volume centers and those having competing centers within their OPO were more likely to use higher risk organs, particularly among recipients with lower model for end-stage liver disease (MELD) scores. Centers using higher risk organs had equivalent waiting list mortality rates, but tended to have higher post-transplant mortality (hazard ratio 1.10 per 0.1 increase in mean DRI). In conclusion, the quality of deceased donor organ patients receive is variable and depends in part on the characteristics of the transplant center they visit.

Checkerboard self-patterning of an ionic liquid film on mercury.

Å-resolution studies of room temperature ionic liquid (RTIL) interfaces are scarce, in spite of their long-recognized importance for the science and many applications of RTILs. We present an Å-resolution x-ray study of a Langmuir film of an RTIL on mercury. At low (high) coverage [90 (50) Å2/molecule] a mono-(bi)layer of surface-parallel molecules is found. The molecules self-assemble in a lateral ionic checkerboard pattern, unlike the uniform-charge, alternate-ion layers of this RTIL at its bulk-solid interface. A 2D-smectic order is found, with molecules packed in parallel stripes, forming long-range order normal to, but none along, the stripes.

Unifying interfacial self-assembly and surface freezing.

X-ray investigations reveal that the monolayers formed at the bulk alkanol-sapphire interface are densely packed with the surface-normal molecules hydrogen bound to the sapphire. About 30-35 °C above the bulk, these monolayers both melt reversibly and partially desorb. This system exhibits balanced intermolecular and molecule-substrate interactions which are intermediate between self-assembled and surface-frozen monolayers, each dominated by one interaction. The phase behavior is rationalized within a thermodynamic model comprising interfacial interactions, elasticity, and entropic effects. Separating the substrate from the melt leaves the monolayer structurally intact.

Flight interneurons in the locust and the origin of insect wings.

Interneurons involved in the generation of motor activity for flight in the locust were found in the first three abdominal ganglia as well as in thoracic ganglia. The evidence that sets of homologous flight interneurons occur in abdominal and thoracic ganglia supports theories that insect wings originated from movable appendages which were serially distributed along the thorax and abdomen and which were under central nervous control.

Developmental defects in brain segmentation caused by mutations of the homeobox genes orthodenticle and empty spiracles in Drosophila.

We have studied the roles of the homeobox genes orthodenticle (otd) and empty spiracles (ems) in embryonic brain development of Drosophila. The embryonic brain is composed of three segmental neuromeres. The otd gene is expressed predominantly in the anterior neuromere; expression of ems is restricted to the two posterior neuromeres. Mutation of otd eliminates the first (protocerebral) brain neuromere. Mutation of ems eliminates the second (deutocerebral) and third (tritocerebral) neuromeres. otd is also necessary for development of the dorsal protocerebrum of the adult brain. We conclude that these homeobox genes are required for the development of specific brain segments in Drosophila, and that the regionalized expression of their homologs in vertebrate brains suggests an evolutionarily conserved program for brain development.

Building a brain: developmental insights in insects.

Understanding the cellular, molecular and genetic mechanisms involved in building the brain remains one of the most challenging problems of neurobiology. In this article, we review recent work on the developmental mechanisms that generate the embryonic brain in insects. We compare some of the early developmental events that occur in the insect brain with those that operate during brain development in vertebrates and find that numerous parallels are present at both the cellular and the molecular levels. Thus, the roles of glial cells in prefiguring axon pathways, the function of pioneer neurons in establishing axon pathways, and the formation of a primary axon scaffolding are features of embryonic brain development in both insects and vertebrates. Moreover, at the molecular genetic level homologous regulatory genes control morphogenesis, regionalization and patterning during embryonic brain development in both insects and vertebrates. This indicates that there might be universal mechanisms for brain development, and that knowledge gained from Drosophila and other insects is relevant to our understanding of brain development in other more complex organisms, including man.

Conserved usage of gap and homeotic genes in patterning the CNS.

The homeotic and cephalic gap genes play central roles in the specification of the anteroposterior animal body axis. Genetic studies carried out in Drosophila and mouse now demonstrate that these genes are also involved in embryonic brain development. The homeotic genes act in posterior brain patterning, and the cephalic gap genes act in anterior brain patterning. Moreover, striking cross-phylum gene replacement experiments show that invertebrate and vertebrate members of the orthodenticle gene family can functionally replace each other. These findings indicate that the genetic mechanisms involved in embryonic brain development are conserved and suggest a common evolutionary origin of the insect and vertebrate brain.

Interaction of gap genes in the Drosophila head: tailless regulates expression of empty spiracles in early embryonic patterning and brain development.

Unlike gap genes in the trunk region of Drosophila embryos, gap genes in the head were presumed not to regulate each other's transcription. Here, we show that in tailless (tll) loss-of-function mutants the empty spiracles (ems) expression domain in the head expands, whereas it retracts in tll gain-of-function embryos. We have identified a 304bp element in the ems-enhancer which is sufficient to drive expression in the head and brain and which contains two TLL and two BCD binding sites. Transgenic reporter gene lines containing mutations of the TLL binding sites demonstrate that tll directly inhibits the expression of ems in the early embryonic head and the protocerebral brain anlage. These results are the first demonstration of direct transcriptional regulation between gap genes in the head.

Expression, regulation and function of the homeobox gene empty spiracles in brain and ventral nerve cord development of Drosophila.

We analyse the role of the empty spiracles (ems) gene in embryonic brain and ventral nerve cord development. ems is differentially expressed in the neurectoderm of the anterior head versus the trunk region of early embryos. A distal enhancer region drives expression in the deutocerebral brain anlage and a proximal enhancer region drives expression in the VNC and tritocerebral brain anlage. Mutant analysis indicates that in the anterior brain ems is necessary for regionalized neurogenesis in the deutocerebral and tritocerebral anlagen. In the posterior brain and VNC ems is necessary for correct axonal pathfinding of specific interneurons. Rescue experiments indicate that the murine Emx2 gene can partially replace the fly ems gene in CNS development.

Differential expression and function of the Drosophila Pax6 genes eyeless and twin of eyeless in embryonic central nervous system development.

We analyzed the expression and function of eyeless (ey) and twin of eyeless (toy) in the embryonic central nervous system (CNS) of Drosophila. Both genes are differentially expressed in specific neuronal subsets (but not in glia) in every CNS neuromere, and in the brain, specific cell populations co-expressing both proteins define a longitudinal domain which is intercalated between broad exclusive expression domains of ey and toy. Studies of genetic null alleles and dsRNA interference did not reveal any gross neuroanatomical effects of ey, toy, or ey/toy elimination in the embryonic CNS. In contrast, targeted misexpression of ey, but not of toy, resulted in profound axonal abnormalities in the embryonic ventral nerve cord and brain.

Molecular correlates of neuronal specificity in the developing insect nervous system.

The development of the nervous system in insects, as in most other higher animals, is characterized by the high degree of precision and specificity with which synaptic connectivity is established. Multiple molecular mechanisms are involved in this process. In insects a number of experimental methods and model systems can be used to analyze these mechanisms, and the modular organization of the insect nervous system facilitates this analysis considerably. Well characterized molecular elements involved in axogenesis are the cell-cell adhesion molecules that underlie selective fasciculation. These are cell-surface molecules that are expressed in a regional and dynamic manner on developing axon fascicles. Secreted molecules also appear to be involved in directing axonal navigation. Nonneuronal cells, such as glia, provide cellular and noncellular substrates that are important pathway cues for neuronal outgrowth. Once outgrowing processes reach their general target regions they make synapses with the appropriate postsynaptic cells. The molecular mechanisms that allow growth cones to recognize their correct target cells are essential for neuronal specificity and are being analyzed in neuromuscular and brain interneuron systems of insects. Candidate synaptic recognition molecules with remarkable and highly restricted expression patterns in the developing nervous system have recently been discovered.

Early development of the Drosophila mushroom bodies, brain centres for associative learning and memory.

We have studied the formation of Drosophila mushroom bodies using enhancer detector techniques to visualize specific components of these complex intrinsic brain structures. During embryogenesis, neuronal proliferation begins in four mushroom body neuroblasts and the major axonal pathways of the mushroom bodies are pioneered. During larval development, neuronal proliferation continues and further axonal projections in the pedunculus and lobes are formed in a highly structured manner characterized by spatial heterogeneity of reporter gene expression. Enhancer detector analysis identifies many genomic locations that are specifically activated in mushroom body intrinsic neurons (Kenyon cells) during the transition from embryonic to postembryonic development and during metamorphosis.

Early embryonic expression of a 60-kD glycoprotein in the developing nervous system of the lobster.

To investigate the developmental processes that generate the crustacean nervous system, we used a monoclonal antibody that recognises an antigen that is expressed in the developing embryonic nervous system of the lobster, Homarus gammarus. Expression of this antigen commences early in embryogenesis, occurs in all parts of the embryonic central and peripheral nervous systems, and continues into adulthood. Initial expression in the central nervous system correlates with the onset of neuronal process outgrowth. Light microscopic analysis shows that the antigen is found surrounding the cell bodies and processes of all neurons. Biochemical analysis indicates that the antigen is a glycoprotein with an apparent molecular weight of 60 kD. Due to the early embryonic onset of its expression, this antigen is a useful cellular label for visualisation of pattern formation in the developing nervous system; this is documented in detail for the developing stomatogastric nervous system. The fact that the 60-kD antigen is expressed early in embryogenesis throughout the nervous system suggests that it might play an important role in the development of the lobster nervous system.

Serially homologous development of the peripheral nervous system in the mouthparts of the grasshopper.

Segmentally homologous neurogenesis and neuronal differentiation processes characterize the formation of the peripheral nervous system in the developing mouthparts of the grasshopper embryo. The peripherally located neurons derive from the ectoderm in each of the embryonic mouthparts. The major nerve branches serving the mandibles, maxillae, and labium are established by peripheral pioneer neurons, which project their axons into the central nervous system via a set of guidepost cells. The two secondary nerve branches in each appendage are established by fasciculation of peripheral afferent pioneers and central efferent pioneers or by efferent pioneers alone. Sensory cells differentiate and connect with the peripheral nerve branches after a basic peripheral nerve scaffold has been established. The serial homology of these developmental processes in the mouthparts and in the thoracic legs is striking and can be documented at the level of individual identified cells. Thus despite the enormous differences in gross structure and function among cephalic mouthparts and true thoracic legs, many aspects of neurogenesis and early neuronal differentiation are remarkably conserved in all of these appendages.

Morphogenetic reorganization of the brain during embryogenesis in the grasshopper.

We have studied the morphogenetic reorganization that occurs in the grasshopper brain during embryogenesis. We find that morphogenetic movements occur at three organizational levels during brain development. First, the entire developing brain changes its orientation with respect to the segmental chain of ventral ganglia. A 90 degrees shift in the attitude of the brain neuraxis occurs during embryogenesis due to a gradual upward movement of the cerebral structures in the head. Second, the clusters of proliferating neuroblasts and progeny that generate the neuroarchitecture of the mature brain move relative to one another and to nonneural structures such as the stomodeum. This is especially pronounced for the pars intercerebralis and for the tritocerebrum, as shown by annulin and engrailed immunoreactivity. Third, individual neuroblasts within a given proliferative cluster undergo positional reorganization during embryogenesis. Identified neuroblasts of the tritocerebrum and the pars intercerebralis are displaced within the brain. We conclude that the transformation of the simple sheet-like structure of the early embryonic brain into the highly differentiated structure of the mature brain involves a series of morphogenetic movements that occur in virtually all parts of the brain.

Primary commissure pioneer neurons in the brain of the grasshopper Schistocerca gregaria: development, ultrastructure, and neuropeptide expression.

The bilaterally paired primary commissure pioneer neurons in the median domain of the grasshopper brain are large, descending interneurons that uniquely express the TERM-1 antigen, even in the adult. After pioneering the primary interhemispheric brain commissure, these neurons extend TERM-1-immunoreactive collaterals into most parts of the brain except the mushroom bodies. In this report, the authors show that the TERM-1 antigen is located in the cell body cytoplasm of these neurons and not on the membranes. Screening with antisera to insect neuropeptides reveals that an antiserum recognizing peptides of the leucokinin family labels the cell body cytoplasm of the primary commissure neurons. Leucokinin-related peptides are known to modulate motility of visceral muscle, play a role in diuresis, and are likely to be neuromodulators in the insect nervous system. The primary commissure neurons differ ultrastructurally from median neurosecretory cells in that their cell body cytoplasm is more extensive, contains high numbers of mitochondria and extensive endoplasmic reticulum, but does not contain neurosecretory granules. In the adult, the cell somata are enveloped by multiple glia membranes and associated trophospongia. According to these ultrastructural characteristics, the primary commissure pioneers are not classical neurosecretory cells.

Neurogenesis in the median domain of the embryonic brain of the grasshopper Schistocerca gregaria.

Embryonic development in the median domain of the brain of the grasshopper Schistocerca gregaria was investigated with immunohistochemical, histological, and intracellular dye injection techniques. The early head midline is divisible into a dorsal median domain and a ventral median domain based on the orientation of cell somata in each region. At 25% of embryogenesis, a single large midline precursor differentiates in the dorsal median domain and produces a lineage of six neuronal progeny before degenerating. No further precursors arise. In addition, the primary commissure pioneers and a pair of lateral neurons differentiate directly from the ectoderm in this region. Lucifer yellow dye injected into the midline precursor stains only this cell and its progeny. Similarly, there is no dye coupling from the primary commissure pioneers to the midline lineage or to neuroblasts of the brain hemispheres. Neurogenesis in the dorsal median domain therefore proceeds separately within each subset of cells, and is not related to development in the brain hemispheres. Beginning at 42% of embryogenesis, the primary commissure pioneers undergo a morphological transformation and concomittantly express the Term-1 antigen. Expression continues throughout embryogenesis and into the adult, where the midline primary commissure pioneer cells are the only ones labeled by Term-1 in the entire brain. The cellular organization of the dorsal median domain therefore remains remarkably conserved throughout embryogenesis, even as the brain undergoes extensive morphological transformation.