The membrane-associated ubiquitin ligase MARCHF8 stabilizes the human papillomavirus oncoprotein E7 by degrading CUL1 and UBE2L3 in head and neck cancer.

The human papillomavirus (HPV) oncoprotein E7 is a relatively short-lived protein required for HPV-driven cancer development and maintenance. E7 is degraded through ubiquitination mediated by cullin 1 (CUL1) and the ubiquitin-conjugating enzyme E2 L3 (UBE2L3). However, E7 proteins are maintained at high levels in most HPV-positive cancer cells. A previous proteomics study has shown that UBE2L3 and CUL1 protein levels are increased by the knockdown of the E3 ubiquitin ligase membrane-associated ring-CH-type finger 8 (MARCHF8). We have recently demonstrated that HPV16 upregulates MARCHF8 expression in HPV-positive keratinocytes and head and neck cancer (HPV+ HNC) cells. Here, we report that MARCHF8 stabilizes the HPV16 E7 protein by degrading the components of the S-phase kinase-associated protein 1-CUL1-F-box ubiquitin ligase complex in HPV+ HNC cells. We found that MARCHF8 knockdown in HPV+ HNC cells drastically decreases the HPV16 E7 protein level while increasing the CUL1 and UBE2L3 protein levels. We further revealed that the MARCHF8 protein binds to and ubiquitinates CUL1 and UBE2L3 proteins and that MARCHF8 knockdown enhances the ubiquitination of the HPV16 E7 protein. Conversely, the overexpression of CUL1 and UBE2L3 in HPV+ HNC cells decreases HPV16 E7 protein levels and suppresses tumor growth in vivo. Our findings suggest that HPV-induced MARCHF8 prevents the degradation of the HPV16 E7 protein in HPV+ HNC cells by ubiquitinating and degrading CUL1 and UBE2L3 proteins.IMPORTANCESince human papillomavirus (HPV) oncoprotein E7 is essential for virus replication; HPV has to maintain high levels of E7 expression in HPV-infected cells. However, HPV E7 can be efficiently ubiquitinated by a ubiquitin ligase and degraded by proteasomes in the host cell. Mechanistically, the E3 ubiquitin ligase complex cullin 1 (CUL1) and ubiquitin-conjugating enzyme E2 L3 (UBE2L3) components play an essential role in E7 ubiquitination and degradation. Here, we show that the membrane ubiquitin ligase membrane-associated ring-CH-type finger 8 (MARCHF8) induced by HPV16 E6 stabilizes the E7 protein by degrading CUL1 and UBE2L3 and blocking E7 degradation through proteasomes. MARCHF8 knockout restores CUL1 and UBE2L3 expression, decreasing E7 protein levels and inhibiting the proliferation of HPV-positive cancer cells. Additionally, overexpression of CUL1 or UBE2L3 decreases E7 protein levels and suppresses in vivo tumor growth. Our results suggest that HPV16 maintains high E7 protein levels in the host cell by inducing MARCHF8, which may be critical for cell proliferation and tumorigenesis.

HPV upregulates MARCHF8 ubiquitin ligase and inhibits apoptosis by degrading the death receptors in head and neck cancer.

The membrane-associated RING-CH-type finger ubiquitin ligase MARCHF8 is a human homolog of the viral ubiquitin ligases Kaposi's sarcoma herpesvirus K3 and K5 that promote host immune evasion. Previous studies have shown that MARCHF8 ubiquitinates several immune receptors, such as the major histocompatibility complex II and CD86. While human papillomavirus (HPV) does not encode any ubiquitin ligase, the viral oncoproteins E6 and E7 are known to regulate host ubiquitin ligases. Here, we report that MARCHF8 expression is upregulated in HPV-positive head and neck cancer (HNC) patients but not in HPV-negative HNC patients compared to normal individuals. The MARCHF8 promoter is highly activated by HPV oncoprotein E6-induced MYC/MAX transcriptional activation. The knockdown of MARCHF8 expression in human HPV-positive HNC cells restores cell surface expression of the tumor necrosis factor receptor superfamily (TNFRSF) death receptors, FAS, TRAIL-R1, and TRAIL-R2, and enhances apoptosis. MARCHF8 protein directly interacts with and ubiquitinates the TNFRSF death receptors. Further, MARCHF8 knockout in mouse oral cancer cells expressing HPV16 E6 and E7 augments cancer cell apoptosis and suppresses tumor growth in vivo. Our findings suggest that HPV inhibits host cell apoptosis by upregulating MARCHF8 and degrading TNFRSF death receptors in HPV-positive HNC cells.

Gender differences in presentation, management, and outcomes among Egyptian patients with acute coronary syndrome: a single-centre registry.

BACKGROUND: Despite a significant rise in cardiovascular disease (CVD)-related mortality in low- and middle-income countries (LMICs), data are scarce regarding the quality of care provided, particularly for women. METHODS: This is a prospective observational, cross-sectional study. Acute coronary syndrome (ACS) patients presented to the Cardiology Department at Tanta University, Egypt, between September 1, 2023, and December 31, 2023, were enrolled. The study assessed gender disparities by comparing men and women regarding presentation, management, and major adverse cardiovascular events (MACE) occurrence during hospitalization and 30 days after discharge. RESULTS: A total of 400 ACS patients were included, with 29.5% being women. Women were comparatively older (59 ± 9 years vs. 55 ± 13 years), with a significantly higher prevalence of hypertension (70.3% vs. 47.5%) and diabetes (55% vs. 36.8%). Non-ST-segment elevation myocardial infarction (Non-STEMI) was more common in women (35.29% vs. 21%). Dyspnea was expressed by 34.4% of women (vs. 21.35% of men). Women were hospitalized later (9.29 h vs. 6.74 h). In-hospital outcomes were poorer for women with worse NYHA classes III and IV. Additionally, the odds ratio (OR) for in-hospital cardiac mortality was 0.303 (95% CI 0.103-0.893) for women compared to men. However, a one-month follow-up for MACE post-hospital discharge did not indicate significant gender differences. CONCLUSIONS: The current study suggests that women with ACS in Egypt exhibit a higher risk profile for CVD compared to men and tend to present later with atypical symptoms. Women additionally experience poorer in-hospital MACE and higher cardiac mortality. Therefore, increasing awareness about ACS syndrome and eliminating obstacles that delay hospital admission are imperative.

Suicide and depressive symptoms possible correlates among a sample of Egyptian physicians: observational cross-sectional study (online survey).

BACKGROUND: Compared to other occupations, physicians are more susceptible to depression and suicide. Suicide among physicians in some countries reached up to 1.5- to threefold higher than the general population. However, this rate was not homogenous in all countries. Most of the Egyptian studies were related to the stressful pandemic event, but the actual prevalence of depression among physicians is still under research. To the best of the researcher's knowledge, no other study has been conducted to evaluate the risk of suicide among Egyptian physicians. AIM: The study aimed to screen for depressive symptoms and suicide among Egyptian physicians and to investigate the correlates associated with suicide ideations. METHODS: This cross-sectional survey included Egyptian physicians recruited online by Google Forms. Depressive symptoms were screened using the Beck Depression Scale (BDI-II), while suicidal ideas were assessed using the Suicidal Ideation Attributes Scale (SIDAS). RESULTS: Six hundred sixty Egyptian physicians completed the survey following a two-week pilot study between January 10 and July 16, 2023. The average age was 39.1 years, and 71.4% were married. 49.1% were medical specialists. The median daily working hours were eight, and 27.7% of the physicians attended night shifts. 22.3% had a psychiatric illness, and 34.3% had a chronic disease. Younger and single physicians of both sexes were more prone to suicide risk (p-value = 0.019 and 0.021, respectively). Those with psychiatric or chronic medical disorders had a higher suicidal risk (p-values < 0.001 and 0.004, respectively). Physicians with fewer academic degrees and those who work longer hours or night shifts had more depressive symptoms (p-values < 0.001 and 0.009, respectively). The risk of depression and suicide is almost the same in all medical specialties. The SIDAS suicide score and the Beck depression score revealed a statistically significant association (r = 0.288, p-value < 0.001). CONCLUSION: Suicide risk is higher among younger, single physicians of both sexes, as well as those with psychiatric or chronic medical disorders. More depressive symptoms are seen in physicians who have more extended hours or night shifts and who have fewer academic degrees. Almost all medical specialties carry the same risk of depression and suicide. Longitudinal research is recommended for regular follow-up of suicidal thoughts and depressive symptoms.

In-Ovo injection of melittin into Alexandria chicken eggs: a way for early immune acceleration.

This study intended to assess the properties of in-ovo administration of Melittin (MLT) on hatchability, chick yield, hematology, immunological indices and relative organs weight of Alexandria chickens at hatch. A total of 600 eggs with an average weight of (45.12 g), were gathered and split into five groups: a non-injected group or negative control (NC), a saline injection group or positive control (PC), and three concentrations of MLT (5, 10 and 15 µg of MLT per egg, respectively). On day 18 of incubation, eggs from the injection groups were injected into the amniotic fluid from the large end with the in-ovo injection solutions (0.2 ml per egg). Results indicated that 10 µg MLT/egg positively affected the weight and yield of chicks. In addition, our findings indicated that the in-ovo administration with 10 or 15 µg MLT/egg was superior in most of the immunological indicators (spleen and bursa relative weights, immunoglobulins IgG and IgM, T cells and B cells). In conclusion, in order to improve the immune efficiency (early immune acceleration) of Alexandria chicks, which may contribute to offering a significant boost to their future performance, this study suggests injecting eggs with 5 or 10 µg MLT/egg.

Optimum heparin dose in off-pump coronary artery bypass grafting: A systematic review and meta-analysis.

INTRODUCTION: Off-pump coronary artery bypass grafting (OPCABG) was introduced many years ago aiming to reduce the known complications of conventional on-pump coronary surgeries. Heparin is required during the procedures, but the available protocols have diverse dosage regimens. The primary objective of this systematic review is to examine the effect of different heparin doses on the outcomes of OPCABG. EVIDENCE ACQUISITION: MEDLINE and EMBASE were searched. Four reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias using Cochrane tool. The primary outcome was the activated clotting time (ACT) at three minutes. The secondary outcomes were proportion of patients requiring blood products and the length of hospital stay. An aggregate data approach was used. EVIDENCE SYNTHESIS: Three single-center randomized studies recruiting 256 patients were included. The studies compared low-dose (1.5-2 mg/kg) and high-dose (3 mg/kg) heparin boluses. The overall mean difference for ACT after three minutes between low- and high-dose heparin is - 126.16 (95% CI: - 142.19, - 110.14). The proportion of patients requiring blood products after surgery [odd ratio 1.27 (95% CI: 0.69, 2.32)] or the overall length of stay [mean difference -0.15 (95% CI: -0.84, 0.53)] did not differ between the heparin doses. CONCLUSIONS: In OPCABG, high-dose compared with low-dose heparin did not affect the utilization of more blood products or increased the overall length of stay. Unsurprisingly, ACT values were higher in the high-dose heparin group. Larger and adequately powered randomized clinical trials are indicated to resolve the uncertainty.

Effects of norepinephrine infusion during cardiopulmonary bypass on perioperative changes in lactic acid level (Norcal).

INTRODUCTION: Hyperlactatemia, a problem reported in up to 30% of cardiac surgery patients, results from excessive production of or decreased clearance of lactate. It is typically a symptom of tissue hypoperfusion and may be associated with the prevalence of postoperative acute mesenteric ischemia and renal failure, or prolonged intensive care unit (ICU) and hospital stay, and increased 30-day mortality. METHODS AND MEASUREMENTS: Eighty cardiac surgery patients using cardiopulmonary bypass (CPB) were randomly assigned into either a placebo (n = 39) or norepinephrine 0.05-0.2 µg/kg/min (n = 41) as well as norepinephrine boluses during CPB to maintain mean arterial blood pressure (MAP) at 65 to 80 mm Hg. Patient assignments were done after receiving ethical approval to proceed. The primary result was the perioperative changes in lactic acid level. Secondary findings were also recorded, including hemodynamic variables, the incidence of vasoplegia, intraoperative hypotension, myocardial ischemia, the need for vasopressor support, postoperative complications, and mortality. RESULTS: The peak levels and perioperative changes in blood lactate during the first 24 postoperative hours, the number of patients who experienced early hyperlactatemia on admission to the ICU (Placebo: 46.2%, Norepinephrine: 51.2%, p = .650), vasoplegia, hemodynamic changes, incidences of intraoperative hypotension, myocardial ischemia, postoperative complications, and mortality rates were similar in the two groups. Patients in the norepinephrine group received lower intraoperative rescue norepinephrine boluses to maintain the target MAP (p = .039) and had higher MAP values during the CPB and intraoperative blood loss [mean difference [95% confidence interval]; 177 [20.9-334.3] ml, p = .027]. CONCLUSION: norepinephrine and placebo infusions during the CPB with the maintenance of MAP from 65 to 80 mmHg had comparative effects on the changes in blood lactate and incidence of vasoplegia after cardiac surgery. Norepinephrine infusion maintained higher MAP values during the CPB.

Migraine in bipolar disorder and schizophrenia: The hidden pain.

OBJECTIVE: This study examined the prevalence of comorbid migraine in patients with bipolar disorder and those with schizophrenia and also examined the association between migraine comorbidity and disease characteristics in both disorders. METHODS: In this cross-sectional study, 150 patients with bipolar disorder and 150 with schizophrenia were evaluated for migraine diagnosis using the International Classification of Headache Disorders (3rd ed). Patients were selected from psychiatry outpatient clinics at Kasr Al Ainy hospitals, Cairo University.  The Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS) were administered to the bipolar group, whereas the Positive and Negative Syndrome Scale (PANSS) was administered to the schizophrenia group. Both groups were evaluated by the Clinical Global Impressions (CGI) scale. RESULTS: The diagnosis of migraine was made in 34 (22.7%) of the bipolar group and 24 (16.0%) of the schizophrenia group. Patients with schizophrenia showed a significantly higher frequency and intensity of migraine attacks on the Migraine Disability Assessment scale than did the bipolar group (p < 0.001). In the bipolar group, there was no significant difference between patients with and without migraine on the YMRS, HDRS, and CGI. Among patients with schizophrenia, the duration of the migraine attacks was positively correlated with CGI scores (r = 0.40, p = 0.02). CONCLUSION: Migraine was found to be a significant comorbidity in patients with bipolar disorder and schizophrenia. However, the intensity and frequency of migraine attacks were higher in the schizophrenia than in the bipolar group.

Treatment of hazardous landfill leachate containing 1,4 dioxane by biochar-based photocatalysts in a solar photo-oxidation reactor.

This study investigates a combined photocatalytic and adsorption system to maximize the removal of 1,4 dioxane from hazardous landfill leachate (HLL). The production of transformation products was also investigated to obtain a comprehensive evaluation of the treatment system. Copper/iron doped zinc oxide (Cu-Fe-ZnO) was introduced to biochar to form a hybrid materials and used to treat HLL contaminated with 1,4 dioxane of 355.0 ± 11.7 mg/L. The Cu-Fe-ZnO/biochar removed 93.1 ± 8.7% of 1,4 dioxane at a dose of 0.6 g/L within 90 min, as compared with only 42.7 ± 3.3% by 1.2 g/L of bare biochar within 210 min. The Cu-Fe-ZnO/biochar degraded 1,4 dioxane into ethylene glycol, glycolic acid, and formic acid. The 1,4 dioxane removal mechanisms were investigated using the density functional theory, demonstrating that doping of ZnO with metal atoms (Cu-Fe) narrowed the bandgap from 3.307 eV to 2.736 eV. The enhanced photocatalytic activity of ZnO was also supported by the role of biochar in increasing the reactive species and adsorbing the pollutant molecules. The high degradation efficiency of 1,4 dioxane using small catalyst doses with short reaction times would reduce the treatment cost and improve the system's applicability for treating HLL and industrial effluents.

A retrospective study of the correlation between duration of monitoring in the epilepsy monitoring unit and diagnostic yield.

OBJECTIVE: Long-term video-electroencephalographic (LTVEM) monitoring is a valuable tool in the evaluation of paroxysmal clinical events. However, vEEG itself is costly. Hence, we aimed to establish if longer duration of monitoring (DOM) is associated with higher diagnostic yield. METHOD: A retrospective review of patients admitted into the epilepsy monitoring unit (EMU) for the diagnostic evaluation of paroxysmal events was performed. Patients' demographic, clinical characteristics, and vEEG data were analyzed. In the cohort of patients with DOM > 7 days, the reasons for prolonged DOM were identified and the differences in clinical characteristics and vEEG data between conclusive and inconclusive studies were analyzed. RESULT: A total of 501 patients were included. Four hundred and thirty-six (87 %) patients had conclusive studies. Of these patients, 67.9 % patients with conclusive studies received diagnosis within the first 7 days of monitoring with the highest on day 7. The likelihood of conclusive studies decreased beyond 7 days. A total of 175 had DOM > 7 days, of which 140 (80 %) had conclusive studies. In the cohort with DOM > 7 days, patients with previous abnormal routine EEG, previous vEEG monitoring, first event recorded before day 5 of admission and ≥1 events recorded during vEEG monitoring were more likely to have conclusive studies. The most common reason for prolonging DOM beyond 7 days was to adequately record multiple semiologically distinctive events (76 %). CONCLUSION: Our study supports that longer DOM is associated with an increase in diagnostic yield. More than one-third of our cohort were monitored beyond 7 days with majority (80 %) being conclusive. Our findings may guide clinicians in planning the DOM and predicting the likelihood of conclusive vEEG studies in patients with prolonged DOM based on the clinical characteristics and vEEG data.

Stigma, Uncertainty, and Coping at the Time of COVID-19 Pandemic Amid Health Care Professionals: How Far Have We Gone?

ABSTRACT: Stigma and uncertainty are noticed in global pandemics. Their impacts on health care providers tend to persist notably during and after the outbreaks. Our objective was to assess stigma, uncertainty, and coping among health care providers through an online survey using the Discrimination and Stigma Scale Version 12 (DISC-12) modified version to assess stigma related to treating COVID-19, the Intolerance of Uncertainty Scale, and the Brief Resilient Coping Scale (BRCS). Of the respondents (n = 65), 63.1% treated patients with COVID-19, and 21.5% worked in isolation hospitals. Physicians who treated patients with COVID-19 had significantly higher scores in all DISC subscales: unfair treatment (8.73 ± 6.39, p = 0.001), stopping self from doing things (2.05 ± 1.41, p = 0.019), overcoming stigma (1.17 ± 0.80, p = 0.035), and positive treatment (1.90 ± 1.65, p = 0.005). Unfair treatment was negatively correlated with BRCS (r = -0.279, p = 0.024). On the other hand, physicians who did not treat patients with COVID-19 had significantly higher BRCS scores. We concluded that frontline physicians experienced greater stigma associated with lower resilient coping strategies.

Warm saline effectiveness for pain relief in office hysteroscopy: A systematic review and meta-analysis of randomized controlled trials.

AIM: To evaluate the impact of warm distension medium versus room temperature distension medium on pain control among patients undergoing office hysteroscopy. METHODS: A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI web of science from inception to October 2021. We selected randomized clinical trials (RCTs) compared warmed saline distension medium in the intervention group versus room temperature distension medium in the control group among women undergoing diagnostic and/or operative office hysteroscopy. Revman software was utilized for performing our meta-analysis. Our primary outcomes were pain scores evaluated by the visual analog scale (VAS) during and after the procedure. Our secondary outcome was the patient satisfaction between both groups. RESULTS: Five RCTs met our inclusion criteria with a total number of 441 patients. We found warm saline was linked to a significant reduction in the VAS pain score during the procedure compared to the control group (mean difference [MD] = -1.12, 95% confidence interval [CI] [-1.80, -0.45], p = 0.001). Moreover, the VAS pain score after the procedure was significantly declined among the warm saline group (MD = -0.62, 95% CI [-0.97, -0.27], p = 0.005). Interestingly, more patients were significantly satisfied with warm saline distension medium application compared to room temperature group (odds ratio [OR] = 3.71, 95% CI [2.01, 6.86], p < 0.001). CONCLUSIONS: Warm saline application in office hysteroscopy is effective in reducing pain during and after the procedure as well as improvement in patient satisfaction.

Brain-Derived neurotrophic factor (BDNF) plasma level increases in patients with resistant schizophrenia treated with electroconvulsive therapy (ECT).

OBJECTIVES: The study aimed to assess the effect of Electroconvulsive Therapy (ECT) on plasma BDNF levels in patients with resistant schizophrenia. METHODS: It was a cohort study that included 60 patients with resistant schizophrenia fulfilling the DSM-5 criteria of schizophrenia and APA criteria of resistant schizophrenia. They were divided into two groups, followed over 4 weeks, and compared to their baseline assessment. Group (A) included 45 patients who received 4-10 sessions of ECT while Group (B) included 15 patients who received the usual treatment with antipsychotics without ECT. The assessment included the severity of psychotic symptoms assessed by the Positive and Negative Symptom Scale (PANSS) in addition to plasma BDNF level. RESULTS: Patients in Group (A) had an increased level of BDNF after treatment with a statistically significant difference in comparison to their baseline BDNF level (P = 0.027). Meanwhile, patients in group (B) showed a non-significant increase in BDNF. Patients in both groups improved significantly in all PANSS subscales after treatment. CONCLUSIONS: It was concluded that plasma BDNF levels in patients with resistant schizophrenia increase after electroconvulsive therapy in association with clinical improvement.Key pointsBDNF increases after ECT treatment of resistant schizophrenia.BDNF is not correlated with the severity of psychotic symptomsPatients treated with ECT showed a better response.

Elevated blood purine levels as a biomarker of seizures and epilepsy.

OBJECTIVE: There is a major unmet need for a molecular biomarker of seizures or epilepsy that lends itself to fast, affordable detection in an easy-to-use point-of-care device. Purines such as adenosine triphosphate and adenosine are potent neuromodulators released during excessive neuronal activity that are also present in biofluids. Their biomarker potential for seizures and epilepsy in peripheral blood has, however, not yet been investigated. The aim of the present study was to determine whether blood purine nucleoside measurements can serve as a biomarker for the recent occurrence of seizures and to support the diagnosis of epilepsy. METHODS: Blood purine concentrations were measured via a point-of-care diagnostic technology based on the summated electrochemical detection of adenosine and adenosine breakdown products (inosine, hypoxanthine, and xanthine; SMARTChip). Measurements of blood purine concentrations were carried out using samples from mice subjected to intra-amygdala kainic acid-induced status epilepticus and in video-electroencephalogram (EEG)-monitored adult patients with epilepsy. RESULTS: In mice, blood purine concentrations were rapidly increased approximately two- to threefold after status epilepticus (2.32 ± .40 µmol·L-1 [control] vs. 8.93 ± 1.03 µmol·L-1 [after status epilepticus]), and levels correlated with seizure burden and postseizure neurodegeneration in the hippocampus. Blood purine concentrations were also elevated in patients with video-EEG-diagnosed epilepsy (2.39 ± .34 µmol·L-1 [control, n = 13] vs. 4.35 ± .38 µmol·L-1 [epilepsy, n = 26]). SIGNIFICANCE: Our data provide proof of concept that the measurement of blood purine concentrations may offer a rapid, low-volume bedside test to support the diagnosis of seizures and epilepsy.

30 day predicted outcome in undifferentiated chest pain: multicenter validation of the HEART score in Tunisian population.

BACKGROUND: Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physcian effectively progrnosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. However, most validation studies of HEART score were not performed in populations different from those included in the original one. OBJECTIVE: To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain. METHODS: Our prospective, multicenter study enrolled adult patients presenting with chest pain at chest pain units. Patients over 30 years of age with a primary complaint of chest pain were enrolled. HEART score was calculated for every patient. The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. The discriminative power of HEART score was evaluated by the area under the ROC curve. A calibration analysis of the HEART score in this population was performed using Hosmer-Lemeshow goodness of test. RESULTS: We enrolled 3880 patients (age 56.3; 59.5% males). The application of HEART score showed that most patients were in intermediate risk category (55.3%). Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group. The area under receiver operating characteristic curve was 0.87 (95% CI 0.85-0.88). HEART score was not well calibrated (χ2 statistic = 12.34; p = 0.03). CONCLUSION: HEART score showed a good discrimination performance in predicting MACE occurrence at 30 days for Tunisian patients with undifferentiated acute chest pain. Heart score was not well calibrated in our population.

Characterization of CRLF2 Expression in Pediatric B-Cell Precursor Acute Lymphoblastic Leukemia.

BACKGROUND: Acute lymphoblastic leukemia (ALL) is a heterogeneous disease with several underlying genetic ab-normalities. Several studies have tried to elucidate the prognostic significance of cytokine receptor-like factor 2 (CRLF2) overexpression in pediatric B-cell precursor (BCP)-ALL; however, it is still controversial. METHODS: CRLF2 expression was assessed by flow cytometry in 87 newly diagnosed BCP-ALL pediatric patients, and 80 age and gender-matched control group. Janus Kinase2 (JAK2) (R683) mutation analysis was also performed in those identified to have CRLF2 overexpression with adequate DNA samples by direct sequencing. RESULTS: CRLF2 overexpression was identified in 26/87 (29.9%) of our patients with cutoff set at mean fluorescence intensity (MFI = 3.8) using the Receiver Operating Characteristic (ROC) curve. There were no significant differences in the clinical and laboratory features between patients with high and low-CRLF2 expression, apart from thrombocytopenia which showed statistically significant association with the low-expression group (p = 0.041). Sequence analysis of samples with high CRLF2 expression (n = 23) revealed that 2/23 (8.7%) cases harbored the mutation JAK2 (R683). CRLF2 levels did not have a significant impact on either overall survival (OS) or disease free survival (DFS) (p = 0.601; p = 0.212, respectively). CONCLUSIONS: CRLF2 overexpression was not an adverse parameter in pediatric BCP-ALL patients. However, patients with CRLF2 overexpression may harbor the JAK2 mutation presenting a group that can benefit from targeted therapy by kinase inhibitors. The usage of CRLF2 expression to monitor minimal residual disease of BCP-ALL would be an area of interest for further evaluation.

A Comparison of Different Remifentanil Effect-Site Concentrations to Allow for Early Extubation After Cardiac Surgery.

OBJECTIVES: Assess different remifentanil effect-site concentrations (Ce) for readiness for extubation time after cardiac surgery. DESIGN: Prospective, randomized, blinded, controlled study. DESIGN: Single university hospital. PARTICIPANTS: Seventy-three patients scheduled for cardiac surgery. INTERVENTIONS: After ethical approval, patients scheduled for cardiac surgery with target-controlled propofol infusion were randomly assigned to receive remifentanil effect-site concentrations (Ce) of 1, 2, or 3 ng/mL (n = 25, 25, and 23, respectively). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was readiness for extubation. Secondary outcomes were also recorded, including the cumulative doses and number of changes of propofol and remifentanil, hemodynamic variables, time to spontaneous eye opening and breathing, actual extubation, incidences of light anesthesia and myocardial ischemia, need for vasopressors and inotropes, and intensive care unit (ICU) and hospital stays. There was no difference in the time to readiness for extubation in any of the groups (0.1 ng/mL: 11.5 min (5-37); 0.2 ng/mL: 22 min (10-35); and 0.3 ng/mL: 21 min (10-49), p < 0.532); however, there was a significant difference among the 3 groups regarding the cumulative remifentanil doses (p < 0.001). Time to spontaneous eye opening and breathing, actual extubation, use of vasopressors and inotropes, incidences of light anesthesia and myocardial ischemia, and length of ICU and hospital stay were similar for all groups. Forty-six of the 73 patients were extubated on-table. CONCLUSION: Remifentanil Ce 1, 2, and 3 ng/mL produced comparative effects on time to extubation and hemodynamic responses to cardiac surgery. The 3 Ce resulted in immediate on-table extubation in 50% of patients.

Non-functional water clear cell parathyroid carcinoma masquerading as medullary thyroid carcinoma.

Parathyroid carcinoma is a rare neuroendocrine tumor. Non-functional parathyroid carcinomas are exceedingly rare neoplasms which generally present at an advanced disease stage, and occasionally can masquerade as medullary thyroid carcinoma.

Eleven Cases of Hb J-Paris-I [HBA2: c.38C>A (or HBA1)]: A Stable α Chain Variant Elutes in the P3 Window on High-Performance Liquid Chromatography.

Hb J-Paris-I [HBA2: c.38C>A (or HBA1)] is a stable fast-moving hemoglobin (Hb) that elutes in the P3 window on high performance liquid chromatography (HPLC). The mutation can happen on either the α1- or α2-globin gene. Codon 12 changes from GCC to GAC to replace the alanine amino acid with aspartic acid. This change is external with no clinical significance. The elution in the P3 wave on HPLC can interfere with the glycated Hb assay by HPLC. In this study, data of 11 cases of Hb J-Paris-I were thoroughly presented. The majority of the cases were of Indian ethnicity. The mean value of Hb J-Paris-I on HPLC was 26.7 ± 2.0%. The retention time (RT) was 1.75 ± 0.03 min. The isoelectric focusing (IEF) mean value was -5.6 (range -6.1 to -4.9). Hb A2 was consistently reduced to 1.8 ± 0.3%. A fraction of 0.8% corresponding to the Hb A2-J-Paris-I (α2J-Paris-Iδ2) is likely to be concealed within the A0 peak of Hb A on HPLC. Interestingly, two cases were associated with two different polymorphisms [HBA2: c.-24C>G or Cap +14 (C>G) and HBA2: c.*136A>G polymorphism] without apparent effect on the variant expression.

Eight Cases of Hb Winnipeg [HBA2: c.226G>T (or HBA1)]: A Detailed Study.

Hb Winnipeg [α75(EF4)Asp→Tyr (α2); HBA2: c.226G>T (or HBA1)] is a stable α-globin chain variant described in a few articles. The majority of reported cases in older articles were clustered in Canada. It can occur on both α1- and α2-globin genes and in different populations. In this study, eight cases of Hb Winnipeg were characterized by DNA sequencing during a wide-spectrum study of suspected α-globin gene variants collected in the United Kingdom. All cases detected peaked in the S window between 4.4 and 4.54 min. on high performance liquid chromatography (HPLC). The isoelectric focusing (IEF) averaged at 6.21 below Hb A. All the mutations were detected on the α1-globin gene except in one case. The ethnic origin of the majority of the patients was Canadian. Only one case was associated with the common polymorphism HBA2: c.-24C>G (or HBA1) [Cap +14 (C>G)] on both α-globin genes without any apparent effect on the variant expression. All cases were detected in a heterozygous state. Hb Winnipeg expression was consistently lower than the theoretical value for α chain variants, ranging between 11.8 and 15.8% of total hemoglobin (Hb). This study gave more details about Hb Winnipeg that may help in presumptive diagnosis, especially in routine laboratories.