Differences in Achilles tendon stiffness in people with gout: a pilot study.

BACKGROUND: Gout has been associated with weaker foot/leg muscles and altered gait patterns. There is also evidence of on-going foot pain and an increased risk of tendinopathy, with the Achilles and patella tendons most frequently affected in gout. Additionally, the inflammation associated with gout may change tissue elasticity. Ultrasound imaging utilising shear wave elastography (SWE) offers a non-invasive method of quantifying changes in tendon stiffness. SWE findings have not previously been reported in individuals with gout. We sought to determine differences in Achilles tendon stiffness in people with gout compared to controls (non-gout). METHODS: A cross sectional study comparing 24 people with gout and 26 age/sex-matched controls. Clinical and demographic data were collated, and US imaging used to determine tendon thickness, presence of gouty tophi and/or aggregates and levels of angiogenesis. Ten shear wave elastography (SWE) measures were taken along the centre of a longitudinal section of the mid-portion of each Achilles tendon. Prior to data collection, intra-observer error was good (>0.69). Data were summarised using descriptive statistics and a repeated measures ANCOVA was used to compare SWE measures between the two groups for the left and right foot separately after accounting for Body Mass Index (BMI). RESULTS: A small proportion of those with gout presented with intra-tendon aggregates and/or intra-tendon tophi in one or both tendons. There was no statistically significant difference in tendon thickness between groups. Neo-vascularity was present in a third of gout participants. SWE findings demonstrated significantly reduced tendon stiffness in those with gout compared to controls: right Achilles mdiff =1.04 m/s (95% CI (0.38 to 1.7) p = 0.003 and left Achilles mdiff = 0.7 m/s (95% CI 0.09 to 1.32) p = 0.025. No relationship between the presence of tophi and SWE values were detected. CONCLUSION: Subjects with chronic gout show significantly reduced Achilles tendon stiffness compared to non-gout controls. From a clinical standpoint, our findings were similar to SWE measurements in subjects with Achilles tendinopathy and who did not have gout.

Reproducibility of shear wave elastography measuresof the Achilles tendon.

OBJECTIVE: To assess the reproducibility of shear wave elastography (SWE) measures in the Achilles tendon (AT) in vivo. MATERIALS AND METHODS: Shear wave velocity (SWV) of 14 healthy volunteers [7 males, 7 females; mean age 26.5 ± 3.8 years, mean height 171.6 ± 10.9 cm, mean Victorian Institute of Sports Assessment Achilles questionnaire (VISA-A) score 99.4 ± 1.2] was measured with the foot relaxed and fixed at 90°. Data were collected over five consecutive measures and 5 consecutive days. RESULTS: Mean SWV values ranged from 7.91 m/s-9.56 m/s ± 0.27-0.50 m/s. Coefficient of variation (CV), correlations and intra-class correlation coefficient (ICC) scores ranged from 2.9%-6.3%, 0.4-0.7 and 0.54-0.85 respectively. No significant differences were noted for longitudinal or transverse data with respect to protocol or time and no significant differences were noted for foot position in transverse data. Significant differences in SWV values were noted between foot positions for longitudinal scanning (p = <0.05), with a relaxed foot position providing SWV values on average 0.47 m/s faster than a fixed position. Increased reproducibility was obtained with the foot relaxed. ICC between operators was 0.70 for transverse and 0.80 for longitudinal scanning. CONCLUSIONS: Reproducible SWE measures were obtained over a 1-h period as well as a period of 5 consecutive days with more reliable measures obtained from a longitudinal plane using a relaxed foot position. SWE also has a high level of agreement between operators making SWE a reproducible technique for quantitatively assessing the mechanical properties of the human AT in vivo.

Poor reproducibility of compression elastography in the Achilles tendon: same day and consecutive day measurements.

OBJECTIVE: To determine the reproducibility of compression elastography (CE) when measuring strain data, a measure of stiffness of the human Achilles tendon in vivo, over consecutive measures, consecutive days and when using different foot positions. MATERIALS AND METHODS: Eight participants (4 males, 4 females; mean age 25.5 ± 2.51 years, range 21-30 years; height 173.6 ± 11.7 cm, range 156-189 cm) had five consecutive CE measurements taken on one day and a further five CE measures taken, one per day, at the same time of day, every day for a consecutive 5-day period. These 80 measurements were used to assess both the repeatability and reproducibility of the technique. Means, standard deviations, coefficient of variation (CV), Pearson correlation analysis (R) and intra-class correlation coefficients (ICC) were calculated. RESULTS: For CE data, all CVs were above 53%, R values indicated no-to-weak correlations between measures at best (range 0.01-0.25), and ICC values were all classified in the poor category (range 0.00-0.11). CVs for length and diameter measures were acceptably low indicating a high level of reliability. CONCLUSIONS: Given the wide variation obtained in the CE results, it was concluded that CE using this specific system has a low level of reproducibility for measuring the stiffness of the human Achilles tendon in vivo over consecutive days, consecutive measures and in different foot positions.

Why do captive pied tamarins give birth during the day?

Diurnal primates typically give birth at night, when it is presumed that they are safer at a very vulnerable time, and this is reflected in an overwhelmingly nocturnal pattern of delivery in most species of Callitrichidae. However, over half (51.1%) of 88 births to pied tamarins (Saguinus bicolor) at Durrell Wildlife Park occurred during the day (0800-1700), almost always in the afternoon. Nearly three quarters of breeding females (17/23) had at least one diurnal birth, including females from all generations in captivity from wild-caught to fifth captive-born generation, and from all six matrilines represented at Durrell. The proportion of diurnal births has remained relatively stable over time despite management changes. We used generalized linear mixed modeling to investigate several factors that we hypothesized could affect time of birth: maternal experience, season, female rearing history, and whether or not the group was on public display. We fitted all possible models to the data, but none explained more than 7.5% of the variation. Daytime delivery had few statistically significant detrimental effects, although infant survival was somewhat lower and parental rejection increased in diurnal births. Pied tamarins do not seem to fit any of the hypotheses previously put forward to explain exceptions to the typical primate circadian pattern of delivery. Zoo Biol. 35:487-494, 2016. © 2016 Wiley Periodicals, Inc.

Anticonvulsant hypersensitivity syndrome (AHS): a case report.

Anticonvulsant Hypersensitivity Syndrome (AHS) is a rare complication of common drugs used today. It is unusual in that it occurs later than most other drug reactions, about two to six weeks after initiation of the offending agent. It also has a hereditary background unlike most other drug reactions. This reaction is caused by the aromatic amines and causes hepatitis, skin rash, fever, and other systemic organ involvement can occur. The reaction is rare but often fatal, thus the observer should be acutely aware of this in the months following initiation of the agents.

Generation of functional human hepatic endoderm from human induced pluripotent stem cells.

UNLABELLED: With the advent of induced pluripotent stem cell (iPSC) technology, it is now feasible to generate iPSCs with a defined genotype or disease state. When coupled with direct differentiation to a defined lineage, such as hepatic endoderm (HE), iPSCs would revolutionize the way we study human liver biology and generate efficient "off the shelf" models of human liver disease. Here, we show the "proof of concept" that iPSC lines representing both male and female sexes and two ethnic origins can be differentiated to HE at efficiencies of between 70%-90%, using a method mimicking physiological relevant condition. The iPSC-derived HE exhibited hepatic morphology and expressed the hepatic markers albumin and E-cadherin, as assessed by immunohistochemistry. They also expressed alpha-fetoprotein, hepatocyte nuclear factor-4a, and a metabolic marker, cytochrome P450 7A1 (Cyp7A1), demonstrating a definitive endodermal lineage differentiation. Furthermore, iPSC-derived hepatocytes produced and secreted the plasma proteins, fibrinogen, fibronectin, transthyretin, and alpha-fetoprotein, an essential feature for functional HE. Additionally iPSC-derived HE supported both CYP1A2 and CYP3A4 metabolism, which is essential for drug and toxicology testing. CONCLUSION: This work is first to demonstrate the efficient generation of hepatic endodermal lineage from human iPSCs that exhibits key attributes of hepatocytes, and the potential application of iPSC-derived HE in studying human liver biology. In particular, iPSCs from individuals representing highly polymorphic variants in metabolic genes and different ethnic groups will provide pharmaceutical development and toxicology studies a unique opportunity to revolutionize predictive drug toxicology assays and allow the creation of in vitro hepatic disease models.

Persistence of functional hepatocyte-like cells in immune-compromised mice.

BACKGROUND: Human embryonic stem cells (hESCs) can be efficiently differentiated to hepatocyte-like cells (HLCs) in vitro and demonstrate many of the functions and gene expression found in the adult liver. AIMS: In this study, we assess the therapeutic value of HLCs in long-term cell-based therapies in vivo. METHODS: hESC-derived HLCs were injected into the spleen of acutely injured NODscid(IL-2Rγ) null mice and analysed at various time points post-transplantation up to 3 months. RESULTS: Large clusters of human cells engrafted in the spleen after 3 days and had expanded considerably by 31 days. At these time points, we identified human cells expressing parenchymal hepatocyte markers, exhibiting biliary duct-like structures and expressing myofibroblast markers. Three months after transplantation, we could detect human HLCs that were positive for albumin and CK18 by immunostaining and human DNA by fluorescent in situ hybridisation. Moreover, we could detect secretion of human serum albumin by enzyme-linked immunoabsorbant assay. CONCLUSIONS: We observed the persistence, engraftment and function of HLCs in vivo up to 3 months post-translation; however, all murine recipients developed large splenic and liver tumours that contained endodermal and mesodermal cell types. Although our studies demonstrate that hESC-derived HLCs have the potential to play an important role in cell-based therapies, current methodologies and transplantation strategies require substantial refinement before they can be deployed safely.

Highly efficient differentiation of hESCs to functional hepatic endoderm requires ActivinA and Wnt3a signaling.

Human embryonic stem cells (hESCs) are a valuable source of pluripotential primary cells. To date, however, their homogeneous cellular differentiation to specific cell types in vitro has proven difficult. Wnt signaling has been shown to play important roles in coordinating development, and we demonstrate that Wnt3a is differentially expressed at critical stages of human liver development in vivo. The essential role of Wnt3a in hepatocyte differentiation from hESCs is paralleled by our in vitro model, demonstrating the importance of a physiologic approach to cellular differentiation. Our studies provide compelling evidence that Wnt3a signaling is important for coordinated hepatocellular function in vitro and in vivo. In addition, we demonstrate that Wnt3a facilitates clonal plating of hESCs exhibiting functional hepatic differentiation. These studies represent an important step toward the use of hESC-derived hepatocytes in high-throughput metabolic analysis of human liver function.

Side population cells in developing human liver are primarily haematopoietic progenitor cells.

Side population (SP) cells have recently been identified in a number of tissues although their phenotype and functional abilities are poorly understood. Surface marker characterisation and functional assessment of developing liver SP cells might allow for their isolation and manipulation using clinically relevant techniques. It was hypothesised that SP cells are present early during human liver development and contribute to haematopoietic and epithelial lineage generation. Whilst the SP population remained positive for CD34 during the 1st and 2nd trimester, 1st trimester SP cells were more highly enriched for haematopoietic and epithelial progenitor activity than those from the 2nd trimester in vitro. Marker expression and functional similarities indicate that SP cells in developing human liver may share a temporal relationship with oval/progenitor cells, responsible for liver regeneration after massive or chronic hepatic injury. Furthermore, modification of SP integrin expression during development suggests a potential adaptive interaction with niche components such as fibronectin. Improved understanding of developing human liver SP cells will contribute to the generation of novel cell-based therapies for liver disease.

Novel immortalized human fetal liver cell line, cBAL111, has the potential to differentiate into functional hepatocytes.

BACKGROUND: A clonal cell line that combines both stable hepatic function and proliferation capacity is desirable for in vitro applications that depend on hepatic function, such as pharmacological or toxicological assays and bioartificial liver systems. Here we describe the generation and characterization of a clonal human cell line for in vitro hepatocyte applications. RESULTS: Cell clones derived from human fetal liver cells were immortalized by over-expression of telomerase reverse transcriptase. The resulting cell line, cBAL111, displayed hepatic functionality similar to the parental cells prior to immortalization, and did not grow in soft agar. Cell line cBAL111 expressed markers of immature hepatocytes, like glutathione S transferase and cytokeratin 19, as well as progenitor cell marker CD146 and was negative for lidocaine elimination. On the other hand, the cBAL111 cells produced urea, albumin and cytokeratin 18 and eliminated galactose. In contrast to hepatic cell lines NKNT-3 and HepG2, all hepatic functions were expressed in cBAL111, although there was considerable variation in their levels compared with primary mature hepatocytes. When transplanted in the spleen of immunodeficient mice, cBAL111 engrafted into the liver and partly differentiated into hepatocytes showing expression of human albumin and carbamoylphosphate synthetase without signs of cell fusion. CONCLUSION: This novel liver cell line has the potential to differentiate into mature hepatocytes to be used for in vitro hepatocyte applications.

The inhibitory role of stromal cell mesenchyme on human embryonic stem cell hepatocyte differentiation is overcome by Wnt3a treatment.

Pluripotent stem cells are derived from the inner cell mass of preimplantation embryos, and display the ability of the embryonic founder cells by forming all three germ lineages in vitro. It is well established that the cellular niche plays an important role in stem cell maintenance and differentiation. Stem cells generally have limited function without the specialized microenvironment of the niche that provides key cell-cell contact, soluble mediators, and extracellular matrices. We were interested in the role that Wnt signaling, in particular Wnt3a, played in human embryonic stem cell (hESC) differentiation to hepatic endoderm in vitro. hESC differentiation to hepatic endoderm was efficient in pure stem cell populations. However, in younger hESC lines, generating stromal cell mesenchyme, our model was very inefficient. The negative effect of stroma could be reversed by pretreating hESCs with Wnt3a prior to the onset of hepatocyte differentiation. Wnt3a pretreatment reinstated efficient hESC differentiation to hepatic endoderm. These studies represent an important step in understanding hepatocyte differentiation from hESCs and the role played by the cellular niche in vitro.

Clinical Significance of Persistent Global and Focal Computed Tomography Nephrograms After Cardiac Catheterization and Their Relationships to Urinary Biomarkers of Kidney Damage and Procedural Factors: Pilot Study.

OBJECTIVES: We evaluate the relationships between persistent computed tomography (CT) nephrograms and acute kidney injury after cardiac catheterization (CC). We compare changes in urinary biomarkers kidney injury molecule 1 (KIM-1), cystatin C, and serum creatinine to procedural factors. MATERIALS AND METHODS: From 159 eligible patients without renal insufficiency (estimated glomerular filtration rate >60 mL/min), 40 random patients (age range, 42-81 years; mean age, 64 years; 25 men, 15 women) gave written informed consent to undergo unenhanced CT limited to their kidneys 24 hours after CC. Semiquantitative assessment for global nephrograms and quantitative assessment of focal nephrograms in each kidney was performed. Computed tomography attenuation (Hounsfield units) of the renal cortex was measured. Serum creatinine, KIM-1, and cystatin C were measured before and 24 hours after CC. RESULTS: Robust linear regression showed that both relative changes in KIM-1 and cystatin C had positive relationships with kidney CT attenuation (P = 0.012 and 0.002, respectively). Spearman rank correlation coefficient showed that both absolute changes and relative changes in KIM-1 and cystatin C had positive correlations with global nephrogram grades (P = 0.025 and 0.040, respectively, for KIM-1; P = 0.013 and 0.019, respectively, for cystatin C). CONCLUSIONS: Global nephrograms on unenhanced CT in patients who have undergone CC are significantly correlated with changes in urinary biomarkers for kidney damage.

Does fire influence the landscape-scale distribution of an invasive mesopredator?

Predation and fire shape the structure and function of ecosystems globally. However, studies exploring interactions between these two processes are rare, especially at large spatial scales. This knowledge gap is significant not only for ecological theory, but also in an applied context, because it limits the ability of landscape managers to predict the outcomes of manipulating fire and predators. We examined the influence of fire on the occurrence of an introduced and widespread mesopredator, the red fox (Vulpes vulpes), in semi-arid Australia. We used two extensive and complimentary datasets collected at two spatial scales. At the landscape-scale, we surveyed red foxes using sand-plots within 28 study landscapes - which incorporated variation in the diversity and proportional extent of fire-age classes - located across a 104 000 km2 study area. At the site-scale, we surveyed red foxes using camera traps at 108 sites stratified along a century-long post-fire chronosequence (0-105 years) within a 6630 km2 study area. Red foxes were widespread both at the landscape and site-scale. Fire did not influence fox distribution at either spatial scale, nor did other environmental variables that we measured. Our results show that red foxes exploit a broad range of environmental conditions within semi-arid Australia. The presence of red foxes throughout much of the landscape is likely to have significant implications for native fauna, particularly in recently burnt habitats where reduced cover may increase prey species' predation risk.

Accounting for professionalism: an innovative point system to assess resident professionalism.

BACKGROUND: Professionalism is a core competency for residency required by the Accreditation Council of Graduate Medical Education. We sought a means to objectively assess professionalism among internal medicine and transitional year residents. INNOVATION: We established a point system to document unprofessional behaviors demonstrated by internal medicine and transitional year residents along with opportunities to redeem such negative points by deliberate positive professional acts. The intent of the policy is to assist residents in becoming aware of what constitutes unprofessional behavior and to provide opportunities for remediation by accruing positive points. A committee of core faculty and department leadership including the program director and clinic nurse manager determines professionalism points assigned. Negative points might be awarded for tardiness to mandatory or volunteered for events without a valid excuse, late evaluations or other paperwork required by the department, non-attendance at meetings prepaid by the department, and inappropriate use of personal days or leave. Examples of actions through which positive points can be gained to erase negative points include delivery of a mentored pre-conference talk, noon conference, medical student case/shelf review session, or a written reflection. RESULTS: Between 2009 and 2012, 83 residents have trained in our program. Seventeen categorical internal medicine and two transitional year residents have been assigned points. A total of 55 negative points have been assigned and 19 points have been remediated. There appears to be a trend of fewer negative points and more positive points being assigned over each of the past three academic years. CONCLUSION: Commitment to personal professional behavior is a lifelong process that residents must commit to during their training. A professionalism policy, which employs a point system, has been instituted in our programs and may be a novel tool to promote awareness and underscore the merits of the professionalism competency.

Population, behavioural and physiological responses of an urban population of black swans to an intense annual noise event.

Wild animals in urban environments are exposed to a broad range of human activities that have the potential to disturb their life history and behaviour. Wildlife responses to disturbance can range from emigration to modified behaviour, or elevated stress, but these responses are rarely evaluated in concert. We simultaneously examined population, behavioural and hormonal responses of an urban population of black swans Cygnus atratus before, during and after an annual disturbance event involving large crowds and intense noise, the Australian Formula One Grand Prix. Black swan population numbers were lowest one week before the event and rose gradually over the course of the study, peaking after the event, suggesting that the disturbance does not trigger mass emigration. We also found no difference in the proportion of time spent on key behaviours such as locomotion, foraging, resting or self-maintenance over the course of the study. However, basal and capture stress-induced corticosterone levels showed significant variation, consistent with a modest physiological response. Basal plasma corticosterone levels were highest before the event and decreased over the course of the study. Capture-induced stress levels peaked during the Grand Prix and then also declined over the remainder of the study. Our results suggest that even intensely noisy and apparently disruptive events may have relatively low measurable short-term impact on population numbers, behaviour or physiology in urban populations with apparently high tolerance to anthropogenic disturbance. Nevertheless, the potential long-term impact of such disturbance on reproductive success, individual fitness and population health will need to be carefully evaluated.

The role of activin/nodal and Wnt signaling in endoderm formation.

Human embryonic stem cells (hESCs) are located within the inner cell mass of the preimplantation blastocysts. hESCs exhibit two important properties, the ability to generate exact copies of themselves, termed self-renewal, and pluripotency, the ability of stem cells to differentiate into every cell type of the embryo. This means that in theory it may be possible to generate an inexhaustible supply of primary human somatic cells in vitro which are suitable for application in regenerative medicine. Maintaining stem cell self-renewal and eliciting differentiation are dependent on the coordination of a number of signaling pathways which include members of the transforming growth factor beta (TGFß) and Wnt families. The work in our laboratory has focused on the efficient generation of hepatocyte-like cells (HLCs) from hESCs and induced pluripotent stem cells (iPSCs). In order to mimic signaling during primitive streak and endoderm development, we have utilized TGFß and Wnt signaling pathways in vitro. This has resulted in the generation of homogeneous populations of HLCs exhibiting liver specific function. This chapter will focus on TGFß and Wnt signaling pathways and their role in primitive streak, endoderm, and HLC development.

Transient binocular visual loss: a rare presentation of ventriculoperitoneal shunt malfunction.

The authors report the case of a 27-year-old male with ventriculoperitoneal shunt (VPS) for hydrocephalus presenting with episodic transient binocular visual loss (TBVL) and headache. Complete physical, bedside shunt examination and funduscopy were unremarkable. Laboratory investigation, shunt series and imaging studies failed to reveal any acute abnormalities. Interrogation of the shunt system identified a valve malfunction which was corrected with resultant symptomatic relief and the patient was discharged home in stable condition. VPS malfunction occurs secondary to infection or mechanical failure such as obstruction, tubing fracture, shunt migration and over drainage. Resultant raised intracranial pressure leads to symptoms of headache, nausea, vomiting and gait abnormalities. Visual defects including blindness has been occasionally reported from shunt malfunction. Rare complications include cerebrospinal fluid oedema, colonic perforation, paraparesis and parkinsonism. TBVL due to shunt malfunction remains an uncommon presentation and requires a high index of clinical suspicion while evaluating these patients.

Life threatening retroperitoneal haemorrhage due to therapeutic fondaparinux.

We report the case of a patient with pulmonary embolism, treated with fondaparinux as bridging therapy until therapeutic levels were achieved on warfarin, who developed a non-traumatic massive retroperitoneal haematoma requiring substantial resuscitation with blood products and arterial embolisation. To our knowledge, this condition has not been reported with therapeutic doses of fondaparinux. Our patient, however, may have been more predisposed to bleeding due to the unpredictable pharmacokinetics of fondaparinux secondary to his morbid obesity, reduced clearance of the drug due to renal insufficiency and concomitant treatment with low dose aspirin and warfarin. Another consideration was the lack of a specific reversing agent for fondaparinux in the setting of a life threatening haemorrhage.

Induction of tachykinin production in airway epithelia in response to viral infection.

BACKGROUND: The tachykinins are implicated in neurogenic inflammation and the neuropeptide substance P in particular has been shown to be a proinflammatory mediator. A role for the tachykinins in host response to lung challenge has been previously demonstrated but has been focused predominantly on the release of the tachykinins from nerves innervating the lung. We have previously demonstrated the most dramatic phenotype described for the substance P encoding gene preprotachykinin-A (PPT-A) to date in controlling the host immune response to the murine gammaherpesvirus 68, in the lung. METHODOLOGY/PRINCIPAL FINDINGS: In this study we have utilised transgenic mice engineered to co-ordinately express the beta-galactosidase marker gene along with PPT-A to facilitate the tracking of PPT-A expression. Using a combination of these mice and conventional immunohistology we now demonstrate that PPT-A gene expression and substance P peptide are induced in cells of the respiratory tract including tracheal, bronchiolar and alveolar epithelial cells and macrophages after viral infection. This induction was observed 24h post infection, prior to observable inflammation and the expression of pro-inflammatory chemokines in this model. Induced expression of the PPT-A gene and peptide persisted in the lower respiratory tract through day 7 post infection. CONCLUSIONS/SIGNIFICANCE: Non-neuronal PPT-A expression early after infection may have important clinical implications for the progression or management of lung disease or infection aside from the well characterised later involvement of the tachykinins during the inflammatory response.