Isolation of the Stromal Vascular Fraction Using a New Protocol with All Clinical-Grade Drugs: From Basic Study to Clinical Application.

OBJECTIVE: The purpose of this study was to evaluate the yield, viability, clinical safety, and efficacy of the stromal vascular fraction (SVF) separated with a new protocol with all clinical-grade drugs. MATERIALS AND METHODS: SVF cells were isolated from lipoaspirate obtained from 13 participants aged from 30 to 56 years by using a new clinical protocol and the laboratory protocol. The cell yield, viability, morphology, mesenchymal stem cell (MSC) surface marker expression, and differentiation abilities of the SVF cells harvested from the two protocols were compared. Furthermore, three related clinical trials were conducted to verify the safety and efficiency of SVF cells isolated by the new clinical protocol. RESULTS: There were no significant differences in the yield, viability, morphology, and differentiation potential of the SVFs isolated with the clinical protocol and laboratory protocol. Adipose-derived mesenchymal stem cell (ASC) surface marker expression, including that of CD14, CD31, CD44, CD90, CD105, and CD133, was consistent between the two protocols. Clinical trials have demonstrated the effectiveness of the SVF isolated with the new clinical protocol in improving skin grafting, promoting mechanical stretch-induced skin regeneration and improving facial skin texture. No complications occurred. CONCLUSION: SVF isolated by the new clinical protocol had a noninferior yield and viability to that of the SVF separated by the laboratory protocol. SVFs obtained by the new protocol can be safely and effectively applied to improve skin grafting, promote mechanical stretch-induced skin regeneration, and improve facial skin texture. TRIAL REGISTRATION: The trials were registered with the ClinicalTrials.gov (NCT03189628), the Chinese Clinical Trial Registry (ChiCTR2000039317), and the ClinicalTrials.gov (NCT02546882). All the three trials were not patient-funded trials. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Incidence, severity, and temporal development of oral complications in pediatric allogeneic hematopoietic stem cell transplant patients - a multicenter study.

PURPOSE: Oral mucositis is a common complication for patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) and causes pain and difficulties in functions like eating and swallowing, resulting in lower quality of life and greater need of treatment with opioids and parenteral nutrition. This prospective multicenter study focused on pediatric recipients of HSCT in the neutropenic phase concerning oral complications, timing, severity, and patient experience. METHODS: The cohort comprised 68 patients, median age 11.1 years (IQR 6.3) receiving allogeneic HSCT at three clinical sites. Medical records were retrieved for therapy regimens, concomitant medications, oral and dental history, and subjective oral complaints. Calibrated dentists conducted an oral and dental investigation before HSCT. After HSCT graft infusion, study personnel made bedside assessments and patients filled out a questionnaire once or twice a week until neutrophil engraftment. RESULTS: We followed 63 patients through the neutropenic phase until engraftment. 50% developed oral mucositis of grades 2-4. Peak severity occurred at 8-11 days after stem cell infusion. Altogether, 87% had subjective oral complaints. The temporal distribution of adverse events is similar to the development of oral mucositis. The most bothersome symptoms were blisters and oral ulcerations, including mucositis; 40% reported severe pain and major impact on activities of daily living despite continuous use of opioids. CONCLUSION: This study highlights the burden of oral complications and their negative effect on the health and quality of life of HSCT recipients.

Identifying characteristics of dermal fibroblasts in skin homeostasis and disease.

Heterogeneous dermal fibroblasts are the main components that constitute the dermis. Distinct fibroblast subgroups show specific characteristics and functional plasticity that determine dermal structure during skin development and wound healing. Although researchers have described the roles of fibroblast subsets, this is not completely understood. We review recent evidence supporting understanding about the heterogeneity of fibroblasts. We summarize the origins and the identified profiles of fibroblast subpopulations. The characteristics of fibroblast subpopulations in both healthy and diseased states are highlighted, and the potential of subpopulations to be involved in wound healing in different ways was discussed. Additionally, we review the plasticity of subpopulations and the underlying signalling mechanisms. This review may provide greater insights into potential novel therapeutic targets and tissue regeneration strategies for the future.

Performance of portable objective wound assessment tools: a systematic review.

OBJECTIVE: Accurate wound assessment is crucial for determining the progression of healing and guides treatment strategies. Portable wound assessment devices can be useful in providing an accurate evaluation in the community where most cases are treated. The objective of this review was to compare the performance of various portable wound assessment techniques used for wound healing assessment described in the literature. METHOD: In April 2020, electronic databases were searched, using appropriate search terms, for all available publications on the use of portable wound assessment devices on human and artificial wounds. The primary outcome was the reliability and reproducibility of measurement while the secondary outcome was the feasibility of the instrument. All studies underwent quality assessment of diagnostic accuracy studies (QUADAS) to examine the quality of data. RESULTS: A total of 129 articles were identified and 24 were included in the final review; 17 articles discussed two-dimensional (2D) devices; three articles discussed three-dimensional (3D) devices; and four articles discussed application-based devices. Most studies (n=8) reported on a 2D device that had an ICC of 0.92-0.99 for area measurement and a coefficient of variance of 3.1% with an error of 2.3% in human wounds and 1.55-3.7% in artificial wounds. The inter/intra observer reliability was 0.998 and 0.985, respectively with a scan time of two minutes per wound. The median QUADAS score was 12. CONCLUSION: Based on the presented evidence, 2D-based portable wound assessment devices were the most studied and demonstrated good performance. Further studies are required for 3D and application-based measurement instruments.

Venous thromboembolism risk following temporary immobilisation after injury: evaluation of the Aberdeen VTE risk tool.

BACKGROUND: Temporary lower limb immobilisation following injury is a risk factor for symptomatic venous thromboembolism (VTE). Pharmacological thromboprophylaxis can mitigate this risk but it is unclear which patients benefit from this intervention. The Aberdeen VTE risk tool was developed to tailor thromboprophylaxis decisions in these patients and this evaluation aimed to describe its performance in clinical practice. Secondarily, diagnostic metrics were compared with other risk assessment methods (RAMs). METHODS: A prospective cohort service evaluation was conducted. Adult patients (≥16 years) managed with lower limb immobilisation for injury who were evaluated with the Aberdeen VTE risk tool prior to discharge from the ED were identified contemporaneously between February 2014 and December 2020. Electronic patient records were scrutinised up to 3 months after removal of immobilisation for the development of symptomatic VTE or sudden death due to pulmonary embolism (PE). Other RAMs, including the Thrombosis Risk Prediction for Patients with cast immobilisation (TRiP(cast)) and Plymouth scores, were assimilated retrospectively and diagnostic performance compared. RESULTS: Of 1763 patients (mean age 46 (SD 18) years, 51% women), 15 (0.85%, 95% CI 0.52% to 1.40%) suffered a symptomatic VTE or death due to PE. The Aberdeen VTE tool identified 1053 (59.7%) patients for thromboprophylaxis with a sensitivity of 80.0% (95% CI 54.8% to 93.0%) and specificity of 40.4% (95% CI 38.1% to 42.6%) for the primary outcome. In 1695 patients, fewer were identified as high risk by the TRiP(cast) (33.3%) and Plymouth (24.4%) scores, but with greater specificity, 67.0% and 75.6%, respectively, than dichotomous RAMs, including the Aberdeen VTE tool. CONCLUSION: Routine use of the Aberdeen VTE tool in our population resulted in an incidence of symptomatic VTE of less than 1%. Ordinal RAMs, such as the TRiP(cast) score, may more accurately reflect VTE risk and permit more individually tailored thromboprophylaxis decisions but prospective comparison is needed.

Switching to or Add-on Peginterferon in Patients on Nucleos(t)ide Analogues for Chronic Hepatitis B: The SWAP RCT.

BACKGROUND & AIMS: The optimal therapeutic strategy in nucleoside analogue (NA) experienced chronic hepatitis B (CHB) using peginterferon is still unclear; hence we explored a switch to or add-on peginterferon strategy versus continued NA. METHODS: We conducted a randomized controlled trial of CHB patients on NA >12 months with HBV DNA(-) randomized to switch or add-on peginterferon-alpha2b (1.5 µg/kg/weekly) for 48 weeks versus continuing NA (controls) (allocation 2:2:1; Clinicaltrial.gov: NCT01928511) in tertiary Singapore hospitals. The primary composite endpoint at week 72 was hepatitis B e antigen (HBeAg) loss or quantitative HBsAg (qHBsAg) >1 log IU/mL reduction, and secondary endpoints were HBsAg loss, HBsAg seroconversion, qHBsAg <200 IU/mL, qHBsAg <100 IU/mL, HBV DNA(-), viral relapse, and safety. Analysis was by intention-to-treat (ITT). RESULTS: A total of 253 patients (controls 51, switch 103, add-on 99) were randomized. The primary ITT endpoint was achieved in 3.9% of controls, 33.3% of switch, and 26.7% of add-on (P < .0001, switch/add-on versus controls). HBsAg loss occurred in 0% of controls, 7.8% of switch, and 10.1% of add-on (ITT, P < .001, switch/add-on versus controls). HBeAg(+) patients on peginterferon had higher HBeAg loss than controls but poor HBsAg responses, whereas HBeAg(-) patients on peginterferon achieved better HBsAg responses than controls. Reduction in qHBsAg in HBeAg(+) was 0.14 log IU/mL versus 0.51 log IU/mL in HBeAg(-) (P < .0001) in peginterferon-treated patients. Clinical relapse was higher in switch (13.6% overall, 27% in HBeAg(+)) versus 1% add-on and 0% controls. Adverse events were typically interferon-related symptoms, with one death (myocardial infarction unrelated to therapy). CONCLUSIONS: ITT analysis showed that either peginterferon strategies were superior to NA for the primary endpoint and HBsAg loss, but add-on peginterferon is preferred to switch due to improved safety and similar efficacy. ClincialTrials.gov number: NCT01928511.

Changes in Frequency and Patterns of Marital Sexual Activity During COVID-19: Evidence From Longitudinal Data Prior to, During and After Lockdown in Singapore.

BACKGROUND: The literature suggests that the pandemic has affected sexual activity and sexual desire around the world, potentially due to increased levels of stress, movement restrictions under lockdown conditions, and changes in relationship quality. AIM: To investigate changes in frequency and patterns of marital sexual activity and the role of potential factors underlying these changes, during and after COVID-19 lockdown. METHODS: This longitudinal study followed 409 heterosexual married female participants who completed a baseline survey in April-July 2018 and biweekly online surveys over the next 14 weeks; an online survey in May 2020 during the lockdown in Singapore; and an online survey in June 2020 after the lockdown was lifted. Participants were recruited in 2018 using street intercept and screened for inclusion and exclusion criteria. Logistic fixed-effects models were used to test for changes in frequency and patterns of marital sexual activity and assess underlying factors. Pseudo-design-based sample weights were applied. OUTCOMES: The 2018 in-person baseline survey collected information on demographic characteristics and ideal frequency of marital sex, while follow-up online questionnaires in May-June 2020 included items on exact dates of marital sexual activity of previous weeks; stress and fatigue levels; both spouses' stay-at-home statuses during lockdown; and marital satisfaction. RESULTS: 409 heterosexual married women were included in this study. Compared to pre-pandemic levels, the proportion of participants not having marital sex within a week remained stable while weekly sexual frequency increased, with more evenly distributed sexual activity on weekdays and weekends. Stress, fatigue, and marital satisfaction levels predicted probability of non-activity and sexual frequency. CLINICAL TRANSLATION: The increase in weekly sexual frequency has implications for sexual and reproductive health, including sexual satisfaction and prevalence of infertility and low birth weight associated with waiting time to pregnancy. STRENGTHS & LIMITATIONS: The longitudinal nature of the dataset provides unique insights into differences in frequency of marital sexual activity during compared to before the pandemic. Unlike previous studies, detailed data on exact dates of sexual activity allow for detection of differences in sexual activity by day of the week. However, dates of sexual activity were recorded retrospectively and may contain recall errors. Data were collected only from wives and hence dates of marital sexual activities were not cross-validated with husbands. CONCLUSION: Results point to more active and flexible marital sex lives during the pandemic, with effects that persisted after the lockdown ended. Tan PL. Changes in Frequency and Patterns of Marital Sexual Activity During COVID-19: Evidence From Longitudinal Data Prior to, During and After Lockdown in Singapore. J Sex Med 2022;19:188-200.

CT-based morphologic and radiomics features for the classification of MYCN gene amplification status in pediatric neuroblastoma.

PURPOSE: MYCN onco-gene amplification in neuroblastoma confers patients to the high-risk disease category for which prognosis is poor and more aggressive multimodal treatment is indicated. This retrospective study leverages machine learning techniques to develop a computed tomography (CT)-based model incorporating semantic and non-semantic features for non-invasive prediction of MYCN amplification status in pediatric neuroblastoma. METHODS: From 2009 to 2020, 54 pediatric patients treated for neuroblastoma at a specialized children's hospital with pre-treatment contrast-enhanced CT and MYCN status were identified (training cohort, n = 44; testing cohort, n = 10). Six morphologic features and 107 quantitative gray-level texture radiomics features extracted from manually drawn volume-of-interest were analyzed. Following feature selection and class balancing, the final predictive model was developed with eXtreme Gradient Boosting (XGBoost) algorithm. Accumulated local effects (ALE) plots were used to explore main effects of the predictive features. Tumor texture maps were also generated for visualization of radiomics features. RESULTS: One morphologic and 2 radiomics features were selected for model building. The XGBoost model from the training cohort yielded an area under the receiver operating characteristics curve (AUC-ROC) of 0.930 (95% CI, 0.85-1.00), optimized F1-score of 0.878, and Matthews correlation coefficient (MCC) of 0.773. Evaluation on the testing cohort returned AUC-ROC of 0.880 (95% CI, 0.64-1.00), optimized F1-score of 0.933, and MCC of 0.764. ALE plots and texture maps showed higher "GreyLevelNonUniformity" values, lower "Strength" values, and higher number of image-defined risk factors contribute to higher predicted probability of MYCN amplification. CONCLUSION: The machine learning model reliably classified MYCN amplification in pediatric neuroblastoma and shows potential as a surrogate imaging biomarker.

The impact of community nursing program on healthcare utilization: A program evaluation.

BACKGROUND: The role of nurses has evolved to meet the dynamic needs of an aging population. Community nursing has been established in Singapore with the aim to anchor population health and provide sustainable healthcare services beyond the hospital to the community. Community nurses provide health services to residents at the Community Nurse Posts (CNP) situated within the heartland residential estates. OBJECTIVE: To investigate the effect on healthcare utilization six months pre and post first community nurse visit in older adults, and if the effect is modified by the presence of two or more community nurse visits or absence of a polyclinic chronic disease diagnosis. DESIGN: A single-group pretest-posttest study SETTING(S): Fifty-one SingHealth CNPs at the southeast and east regions of Singapore PARTICIPANTS: Community-dwelling older adults aged ≥ 60 years, seen at any of the SingHealth CNPs between 1 April and 30 November 2019. METHODS: The number of emergency department (ED) visits, unplanned inpatient admissions, length of inpatient stay, specialist outpatient clinic (SOC) and polyclinic visits at SingHealth institutions six months from the first community nurse visit were compared to six months prior. Negative binomial generalized estimating equations were used to model healthcare utilization events, adjusting for baseline age, gender, and race. RESULTS: 1,600 community-dwelling participants were included, of whom 1,561 (median age of 71 years) survived the post-test period. There was a population-average 23% lower rate of ED visits (incidence rate ratio 0.77, 95% confidence interval 0.68 to 0.87, p<0.001) and 15% lower rate of unplanned inpatient admissions (0.85, 0.75 to 0.96, p=0.011). A trend towards a lower rate of inpatient length of stay and a higher rate of SOC and polyclinic visits was also observed. The reduction in acute care utilization may have been greater among adults with two or more community nurse visits. Participants with no recent polyclinic chronic disease diagnosis had a greater increase in SOC visits. CONCLUSIONS: Community nursing services are associated with reduced acute care utilization, especially for older adults with two or more community nurse visits. The trend of a higher rate of SOC visits could be attributed to the community nurses' referrals for undiagnosed/ new conditions and/or treatment of suboptimal health issues. There is a potential role for community nursing towards a sustainable healthcare system.

Identifying Patients With Cirrhosis Who Might Avoid Screening Endoscopy Based on Serum Albumin and Bilirubin and Platelet Counts.

The presence of gastroesophageal varices is a major complication of portal hypertension associated with significant morbidity and mortality.1 The Baveno VI criteria state that patients with liver stiffness measurement (LSM) <20 kPa by transient elastography (TE) and platelet count >150,000/µL can avoid screening endoscopy for high-risk varix (HRV).2 However, because TE is not widely available, the Baveno VI criteria could not be applied in many clinical settings. As such, we aim to determine a concise clinical criterion as an alternative noninvasive tool to predict absence of HRV among patients with compensated cirrhosis to avoid screening esophagogastroduodenoscopy (EGD).

Stress, Fatigue, and Sexual Spontaneity Among Married Couples in a High-Stress Society: Evidence from Sex Diary Data from Singapore.

This paper investigates the associations between stress and fatigue and sexual spontaneity among heterosexual married couples in Singapore, a high-income society with high work performance expectations and long working hours. Data on self-reported menstrual dates, sexual activity within the marriage, and stress and fatigue levels were collected from 657 married women aged 25-34 years through biweekly online diaries over 14 weeks. Using a two-way fixed effects logistic model which controlled for time-invariant individual fixed effects and menstrual cycle fixed effects, the paper tests three hypotheses: (1) sexual activity is significantly lower on weekdays compared to weekends and public holidays, (2) sexual activity is significantly lower during periods when women reported higher stress and fatigue, and (3) stress and fatigue are more predictive of sexual activity during weekdays than during weekends. Frequencies of marital sexual intercourse during the diary keeping period were 3.69 and 2.55 per 30 days among women aged 25-29 and 30-34 years, respectively, much lower than ideal frequencies of 6.40 and 5.23. Consistent with all three hypotheses, there was a strong positive weekend effect and a weak but positive public holiday effect, and strong negative effects of both stress and fatigue, especially during weekdays. There was no evidence of compensatory sex on weekends to make up for hectic workweeks. Increased support for work-life balance can contribute to more spontaneous marital sex lives and may reduce underachievement of ideals for sexual intimacy and childbearing in Singapore.

Fortunes of Dragons: Cohort size effects on life outcomes.

This paper examines the long-term effects of birth cohort size on life outcomes. Using administrative data from Singapore, we study the outcomes of large birth cohorts created by the Chinese superstitious practice of zodiac birth timing, where parents prefer to give birth in the year of the Dragon. This practice is followed exclusively by the Chinese majority, with no similar patterns detected among non-Chinese minorities, allowing us to differentiate cohort size effects from confounding year-of-birth effects. Despite government efforts to increase public educational resources for these cohorts, Chinese Dragons earn lower incomes and are less likely to gain admission to national universities. There is also evidence of negative externalities on non-practising populations who happen to enter the labour market at the same time as Chinese Dragons. Our analysis suggests that the adverse life outcomes are not due to selection, but rather reflect the aggregate resource implications of birth cohort size.Supplementary material is available for this article at: https://doi.org/10.1080/00324728.2020.1864458.

Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy - A Safe and Effective Low-Dose Protocol.

AIMS: Regional citrate anticoagulation (RCA) is the preferred mode of anticoagulation for continuous renal replacement therapy (CRRT). Conventional RCA-CRRT citrate dose ranges from 3 to 5 mmol/L of blood. This study explored the effectiveness of an RCA protocol with lower citrate dose and its impact on citrate-related complications. METHODS: This prospective observational study compared two RCA-CRRT protocols in the intensive care unit. RCA Protocol 1 used an initial citrate dose of 3.0 mmol/L while Protocol 2 started with 2.5 mmol/L. The citrate dose was titrated by sliding scale to target circuit-iCa 0.26-0.40 mmol/L. Calcium was re-infused post-dialyzer and titrated by protocol to target systemic-iCa 1.01-1.20 mmol/L. RESULTS: Two hundred RCA-CRRT sessions were performed (81 Protocol 1; 119 Protocol 2). The median age was 65.4 years and median APACHE-II score was 23. Citrate dose for Protocol 1 was significantly higher than Protocol 2 in the first 12 h. The circuit clotting rate was similar in both arms (Protocol 1: 9.9%; Protocol 2: 9.2%; P = 0.881). With Protocol 2, circuit-iCa levels were 2.42 times more likely to be on target (P = 0.003) while the odds of hypocalcaemia was 4.67 times higher with Protocol 1 (P < 0.001). There was a wider anion gap was noted with Protocol 1, which suggests a propensity for citrate accumulation with higher citrate exposure. CONCLUSION: The RCA protocol with a lower initial citrate dose of 2.5 mmol/L blood had less citrate-related complications with no loss of efficacy. A more precise RCA prescription at the start of treatment avoids unnecessary citrate exposure and improves safety.

Implementing advance care planning: A qualitative exploration of nurses' perceived benefits and challenges.

AIM: To explore nurses' perspectives on implementing advance care planning (ACP) in an acute setting. BACKGROUND: Advance care planning can assist patients to achieve peace of mind and a sense of control in decision-making. Nurses are well-positioned to integrate ACP into practice. METHODS: A descriptive, qualitative study using face-to-face semi-structured interviews was conducted among 16 nurses. A theoretical sampling strategy was used to inform data collection. Data were analysed using a thematic approach. RESULTS: Three major themes were found from nurses' narratives of implementing ACP: value of ACP, communicating ACP and barriers to advocating ACP. IMPLICATIONS FOR NURSING MANAGEMENT: Implementing ACP will require a multi-pronged approach, which includes specific training and changes in hospital policies. Findings from this study will enable hospital administrators to make informed decisions in preparing training programmes for ACP from nurses' perspectives. CONCLUSION: Advance care planning provides a clear direction for health care professionals in meeting patients' desired outcomes. However, a lack of understanding and acceptance among the public, as well as systematic clinical routine supporting nurses' roles and responsibilities in ACP, was recognized.

Does persistent anti-HBc positivity influence the prognosis of HBsAg-negative hepatocellular carcinoma? comparative outcomes of anti-Hbc positive versus anti-Hbc negative non-B non-C HCC.

BACKGROUND: To compare the presentations and outcomes of anti-HBc seropositive Hepatocellular Carcinoma (HBc-HCC) with anti-HBc seronegative (NHBc-HCC) patients in HBsAg negative Non-HBV Non-HCV (NBNC-HCC) HCC population. METHODS: 515 newly diagnosed HCC patients from January 2011 to September 2016 were retrospectively reviewed. 145 (66.5%) NHBc-HCC and 73 (33.5%) HBc-HCC patients were identified. Patient demographics, disease characteristics, details of treatments, recurrence and survival outcomes were analysed. RESULTS: A significantly lower proportion of HBc-HCC patients were diagnosed through surveillence (6.8% vs 26.2%, p = 0.001). HBc-HCC patients were less likely cirrhotic (p < 0.001), portal hypertensive (p < 0.001), ascitic (p = 0.008) and thrombocytopenic (p = 0.003). A higher proportion of HBc-HCC patients had treatment with curative intent (46.6% vs 30.3%, p = 0.018) and surgery (39.7% vs 16.6%, p < 0.001). Although HBc-HCC patients had larger median tumor size (74.0 mm vs 55.0 mm, p = 0.016) with a greater proportion of patients having tumors ≥5 cm, there was no difference in the overall median survival (19.0 months vs 22.0 months, p = 0.919) and recurrence rates (38.2% vs 40.9%). CONCLUSION: Isolated anti-HBc seropositivity in HbsAg negative patients tend to present incidentally with delayed diagnoses resulting in larger tumors, but their long-term survival remain comparable.

DNA hypomethylation induces a DNA replication-associated cell cycle arrest to block hepatic outgrowth in uhrf1 mutant zebrafish embryos.

UHRF1 (ubiquitin-like, containing PHD and RING finger domains, 1) recruits DNMT1 to hemimethylated DNA during replication and is essential for maintaining DNA methylation. uhrf1 mutant zebrafish have global DNA hypomethylation and display embryonic defects, including a small liver, and they die as larvae. We make the surprising finding that, despite their reduced organ size, uhrf1 mutants express high levels of genes controlling S-phase and have many more cells undergoing DNA replication, as measured by BrdU incorporation. In contrast to wild-type hepatocytes, which are continually dividing during hepatic outgrowth and thus dilute the BrdU label, uhrf1 mutant hepatocytes retain BrdU throughout outgrowth, reflecting cell cycle arrest. Pulse-chase-pulse experiments with BrdU and EdU, and DNA content analysis indicate that uhrf1 mutant cells undergo DNA re-replication and that apoptosis is the fate of many of the re-replicating and arrested hepatocytes. Importantly, the DNA re-replication phenotype and hepatic outgrowth failure are preceded by global loss of DNA methylation. Moreover, uhrf1 mutants are phenocopied by mutation of dnmt1, and Dnmt1 knockdown in uhrf1 mutants enhances their small liver phenotype. Together, these data indicate that unscheduled DNA replication and failed cell cycle progression leading to apoptosis are the mechanisms by which DNA hypomethylation prevents organ expansion in uhrf1 mutants. We propose that cell cycle arrest leading to apoptosis is a strategy that restricts propagation of epigenetically damaged cells during embryogenesis.

Impact of microbial Aetiology on mortality in severe community-acquired pneumonia.

BACKGROUND: The impact of different classes of microbial pathogens on mortality in severe community-acquired pneumonia is not well elucidated. Previous studies have shown significant variation in the incidence of viral, bacterial and mixed infections, with conflicting risk associations for mortality. We aimed to determine the risk association of microbial aetiologies with hospital mortality in severe CAP, utilising a diagnostic strategy incorporating molecular testing. Our primary hypothesis was that respiratory viruses were important causative pathogens in severe CAP and was associated with increased mortality when present with bacterial pathogens in mixed viral-bacterial co-infections. METHODS: A retrospective cohort study from January 2014 to July 2015 was conducted in a tertiary hospital medical intensive care unit in eastern Singapore, which has a tropical climate. All patients diagnosed with severe community-acquired pneumonia were included. RESULTS: A total of 117 patients were in the study. Microbial pathogens were identified in 84 (71.8%) patients. Mixed viral-bacterial co-infections occurred in 18 (15.4%) of patients. Isolated viral infections were present in 32 patients (27.4%); isolated bacterial infections were detected in 34 patients (29.1%). Hospital mortality occurred in 16 (13.7%) patients. The most common bacteria isolated was Streptococcus pneumoniae and the most common virus isolated was Influenza A. Univariate and multivariate logistic regression showed that serum procalcitonin, APACHE II severity score and mixed viral-bacterial infection were associated with increased risk of hospital mortality. Mixed viral-bacterial co-infections were associated with an adjusted odds ratio of 13.99 (95% CI 1.30-151.05, p = 0.03) for hospital mortality. CONCLUSIONS: Respiratory viruses are common organisms isolated in severe community-acquired pneumonia. Mixed viral-bacterial infections may be associated with an increased risk of mortality.

Imaging-based surrogate markers of transcriptome subclasses and signatures in hepatocellular carcinoma: preliminary results.

OBJECTIVES: In this preliminary study, we examined whether imaging-based phenotypes are associated with reported predictive gene signatures in hepatocellular carcinoma (HCC). METHODS: Thirty-eight patients (M/F 30/8, mean age 61 years) who underwent pre-operative CT or MR imaging before surgery as well as transcriptome profiling were included in this IRB-approved single-centre retrospective study. Eleven qualitative and four quantitative imaging traits (size, enhancement ratios, wash-out ratio, tumour-to-liver contrast ratios) were assessed by three observers and were correlated with 13 previously reported HCC gene signatures using logistic regression analysis. RESULTS: Thirty-nine HCC tumours (mean size 5.7 ± 3.2 cm) were assessed. Significant positive associations were observed between certain imaging traits and gene signatures of aggressive HCC phenotype (G3-Boyault, Proliferation-Chiang profiles, CK19-Villanueva, S1/S2-Hoshida) with odds ratios ranging from 4.44-12.73 (P <0.045). Infiltrative pattern at imaging was significantly associated with signatures of microvascular invasion and aggressive phenotype. Significant but weak associations were also observed between each enhancement ratio and tumour-to-liver contrast ratios and certain gene expression profiles. CONCLUSIONS: This preliminary study demonstrates a correlation between phenotypic imaging traits with gene signatures of aggressive HCC, which warrants further prospective validation to establish imaging-based surrogate markers of molecular phenotypes in HCC. KEY POINTS: • There are associations between imaging and gene signatures of aggressive hepatocellular carcinoma. • Infiltrative type is associated with gene signatures of microvascular invasion and aggressiveness. • Infiltrative type may be a surrogate marker of microvascular invasion gene signature.

Cutaneous Emboli of Invasive Basidiomycosis in a Child With Aplastic Anemia.

Invasive fungal diseases are a significant cause of mortality among the immunocompromised. This report documents an unusual case of disseminated fungal infection in a child with severe aplastic anemia. The offending fungus, a Basidiomycete, is rarely known to cause human infections. The patient presented acutely with multiple purpuric skin lesions in various parts of the body. The skin biopsy revealed septated fungal hyphae embolized within small dermal blood vessels. Molecular sequencing indicated Earliella scabrosa as the likely organism. The clinical course of the infection was inexorable despite systemic antifungal treatment, resulting in mortality. The literature of human infections due to Basidiomycetes, the usefulness of histopathology in the early diagnosis of the infection, and possible treatment options are discussed.