Reversibly Reactive Affinity Selection-Mass Spectrometry Enables Identification of Covalent Peptide Binders.

Covalent peptide binders have found applications as activity-based probes and as irreversible therapeutic inhibitors. Currently, there is no rapid, label-free, and tunable affinity selection platform to enrich covalent reactive peptide binders from synthetic libraries. We address this challenge by developing a reversibly reactive affinity selection platform termed ReAct-ASMS enabled by tandem high-resolution mass spectrometry (MS/MS) to identify covalent peptide binders to native protein targets. It uses mixed disulfide-containing peptides to build reversible peptide-protein conjugates that can enrich for covalent variants, which can be sequenced by MS/MS after reduction. Using this platform, we identified covalent peptide binders against two oncoproteins, human papillomavirus 16 early protein 6 (HPV16 E6) and peptidyl-prolyl cis-trans isomerase NIMA-interacting 1 protein (Pin1). The resulting peptide binders efficiently and selectively cross-link Cys58 of E6 at 37 °C and Cys113 of Pin1 at room temperature, respectively. ReAct-ASMS enables the identification of highly selective covalent peptide binders for diverse molecular targets, introducing an applicable platform to assist preclinical therapeutic development pipelines.

Branched Multimeric Peptides as Affinity Reagents for the Detection of α-Klotho Protein.

α-Klotho, an aging-related protein found in the kidney, parathyroid gland, and choroid plexus, acts as an essential co-receptor with the fibroblast growth factor 23 receptor complex to regulate serum phosphate and vitamin D levels. Decreased levels of α-Klotho are a hallmark of age-associated diseases. Detecting or labeling α-Klotho in biological milieu has long been a challenge, however, hampering the understanding of its role. Here, we developed branched peptides by single-shot parallel automated fast-flow synthesis that recognize α-Klotho with improved affinity relative to their monomeric versions. These peptides were further shown to selectively label Klotho for live imaging in kidney cells. Our results demonstrate that automated flow technology enables rapid synthesis of complex peptide architectures, showing promise for future detection of α-Klotho in physiological settings.

Triple-threat quantitative multiplexed plasma proteomics analysis on immune complex disease MRL-lpr mice.

Systemic lupus erythematosus is a common autoimmune inflammatory disease which is associated with increases in autoantibodies and immune complexes that deposit in the kidney. The MRL-lpr mouse is a common mouse model used for the study of lupus and immune complex glomerulonephritis but very little is known about the plasma proteome changes in this model. We performed in-depth quantitative proteome profiling on MRL-lpr and control (strain MpJ) mice to investigate the changes in the proteome, immunoglobulins and their glycoproteome as well as protein and immune complexes. Methodologies used included immunohistochemistry, immunoglobulin isotyping, multiplexed proteome profiling, immunoglobulin immunoprecipitation with glycoproteome profiling, and size exclusion chromatography (SEC) profiling to enable a comprehensive proteome profiling of proteins and protein complexes. We also used a novel native multiplexed plasma proteome profiling (NativeMP3) method that relies on native enrichment of plasma proteins enabling ultra-deep single shot profiling where we identified 922 plasma proteins at 1% false discovery rate (FDR) in a single shot mass spectrometry run. We observed many large plasma protein differences between the MRL-lpr and control strain including differences in the immunoglobulins, immunoglobulins against specific antigens, chemokines, and proteases as well as changes in protein complexes such as the immunoproteasome.

Impact of left ventricular outflow tract calcium on valve geometry in self-expanding transcatheter aortic-valve replacement.

OBJECTIVES: Evaluate transcatheter heart valve (THV) geometry according to left ventricular outflow tract (LVOT) calcium degree and its impact on hemodynamics and outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) with a contemporary self-expanding THV. BACKGROUND: LVOT calcium remains challenging for contemporary THVs. LVOT calcium location and degree may affect THV deployment and impact flow patterns and shear stress, accelerating THV degeneration. METHODS: EPROMPT (CoreValve Evolut Pro Prospective Registry; NCT03423459) is a prospective, investigator-initiated, multicenter registry of patients undergoing TAVR using CoreValve Evolut PRO/PRO + THVs. A total of 107 patients were enrolled in EPROMPT's computed tomography (CT) cohort between January 2018 and October 2021. These patients underwent follow-up CT scan 30 days post-TAVR. We analyzed THV geometry and its interaction with the aortic root following deployment using 30-day post-TAVR CT in patients with none/mild versus moderate/severe LVOT calcium. RESULTS: Thirty-day THV inflows were less eccentric in the short axis in patients with none/mild versus moderate/severe LVOT calcium (1.16 ± 0.09 vs. 1.21 ± 0.12; p = 0.007). THV became more circular and was similar between both cohorts at the THV waist (1.08 ± 0.06 vs. 1.09 ± 0.11; p = 0.551), leaflet tips (1.03 ± 0.04 vs. 1.05 ± 0.09; p = 0.299), and THV outflow (1.04 ± 2.2 vs. 1.03 ± 2.7; p = 0.143). Thirty-day > mild paravalvular leak was low in both cohorts (1.5% vs. 2.4%; p = 0.724); mean gradients were similar (7.7 ± 3.6 vs. 7.7 ± 3.4 mmHg; p = 0.955). CONCLUSIONS: Despite inflow deformities observed in patients with moderate/severe LVOT calcium, Evolut PRO/PRO + conforms to elliptical aortic annuli, maintaining circularity and proper function at the leaflets and outflow, even in patients with moderate/severe LVOT calcium.

Small-vessel PCI outcomes in men, women, and minorities following platinum chromium everolimus-eluting stents: Insights from the pooled PLATINUM Diversity and PROMUS Element Plus Post-Approval studies.

OBJECTIVE: We evaluated 1-year outcomes after platinum chromium everolimus-eluting stents (PtCr-EES) in small versus non-small coronary arteries within a large, diverse sample of men, women, and minorities. BACKGROUND: There exists limited outcomes data on the use of second-generation drug-eluting stent to treat small diameter coronary arteries. METHODS: We pooled patients from the PLATINUM Diversity and PROMUS Element Plus stent registries. Small-vessel percutaneous coronary intervention (SV-PCI) was defined as ≥1 target lesion with reference vessel diameter (RVD) ≤2.5 mm. Endpoints included major adverse cardiac event (MACE; death, myocardial infarction [MI] or target vessel revascularization [TVR]), target vessel failure (TVF; death related to the target vessel, target vessel MI or TVR) and definite/probable stent thrombosis (ST). Multivariable Cox regression was used to risk-adjust outcomes. RESULTS: We included 4,155/4,182 (99%) patients with available RVD, of which 1,607 (39%) underwent small-vessel PCI. SV-PCI was not associated with increased MACE (adjHR 1.02; 95%CI 0.81-1.30) or TVF (adjHR 1.07; 95%CI 0.82-1.39). MI risk was lower in white men compared to women and minorities, both in the setting of SV-PCI (adjHR 0.41; 95%CI 0.23-0.74 and adjHR 0.39; 95%CI 0.20-0.75, respectively) and for non-SV-PCI (adjHR 0.61; 95%CI 0.38-0.99 and adjHR 0.45; 95%CI 0.27-0.74, respectively). There was no significant interaction between RVD and sex or minority status for any endpoint. CONCLUSION: In a large diverse contemporary PCI outcomes database, SV-PCI with PtCr-EES was not associated with increased MACE or TVR and did not account for the increased MI risk noted in women and minorities compared to white men.

Aggressive Video Games are Not a Risk Factor for Future Aggression in Youth: A Longitudinal Study.

The issue of whether video games with aggressive or violent content (henceforth aggressive video games) contribute to aggressive behavior in youth remains an issue of significant debate. One issue that has been raised is that some studies may inadvertently inflate effect sizes by use of questionable researcher practices and unstandardized assessments of predictors and outcomes, or lack of proper theory-driven controls. In the current article, a large sample of 3034 youth (72.8% male Mage = 11.2) in Singapore were assessed for links between aggressive game play and seven aggression or prosocial outcomes 2 years later. Theoretically relevant controls for prior aggression, poor impulse control, gender and family involvement were used. Effect sizes were compared to six nonsense outcomes specifically chosen to be theoretically unrelated to aggressive game play. The use of nonsense outcomes allows for a comparison of effect sizes between theoretically relevant and irrelevant outcomes, to help assess whether any statistically significant outcomes may be spurious in large datasets. Preregistration was employed to reduce questionable researcher practices. Results indicate that aggressive video games were unrelated to any of the outcomes using the study criteria for significance. It would take 27 h/day of M-rated game play to produce clinically noticeable changes in aggression. Effect sizes for aggression/prosocial outcomes were little different than for nonsense outcomes. Evidence from this study does not support the conclusion that aggressive video games are a predictor of later aggression or reduced prosocial behavior in youth.

Simulation of carotid artery stenting reduces training procedure and fluoroscopy times.

OBJECTIVE: Outcomes from carotid artery stenting (CAS) are related to experience and technical expertise of the operator. Simulation of CAS may enhance clinical proficiency. We interrogated the impact of endovascular simulation of CAS procedures in operators who are at various stages of training. METHODS: Twelve trainees (students [n = 4]; junior surgery residents, postgraduate year [PGY] 1-3 [n = 4]; and senior surgery residents or fellows, PGY 4-7 [n = 4]) were apprised of characteristics of an endovascular simulator and CAS procedures. This was followed by four independent sessions that were assessed for objective measures including procedure and fluoroscopy times and contrast agent use. A qualitative analysis grading steps of CAS by two observers using a Likert scale was performed. One-way analysis of variance and paired t-tests were employed for data analysis. RESULTS: For all participants (n = 12), procedure times (mean, 920 ± 279 seconds for the first session vs 454 ± 156 seconds for the fourth session; P < .01; confidence interval [CI], 315-621) and fluoroscopy cumulative times (mean, 421 ± 230 seconds for the first session vs 222 ± 102 seconds for the fourth session; P < .01; CI, 78-285) decreased with progression of cases. Students and PGY 1-3 residents decreased their procedure times significantly in comparison of initial and final sessions (P < .05 and P < .01, respectively). For all groups, fluoroscopy cumulative times were reduced, and this decrement was significant in the PGY 1-3 cohort (mean, 444 ± 8 seconds for the first session vs 265 ± 51 seconds for the fourth session; P < .01; CI, 81-276). Initial CAS procedure times were significantly different between groups (P < .05), but this was observed to resolve by the final case at study completion. Qualitatively, the Likert scores of students and PGY 1-3 residents significantly improved with case repetition, specifically in the following steps: (1) cannulation of common carotid artery and (2) sizing and deployment of embolic protection device. Senior operators (PGY 4-7) demonstrated consistently better performance overall with minimal change in scoring with case repetition. CONCLUSIONS: Practice leads to improvements in endovascular simulator procedure and fluoroscopy times, especially for more novice trainees. Initial operator performance gaps can be approximated with a few sessions to expected proficiency. Incorporation of endovascular simulators in residency training may assist in shortening the learning curve in rarer endovascular procedures.

Open surgical or endovascular revascularization for acute limb ischemia.

Acute limb ischemia (ALI) is one of the most common vascular emergencies, with high risk for limb loss if it is not treated expediently. Endovascular therapy is less invasive and used increasingly because of patient factors that disfavor open surgery despite limited quality data to support its safety and efficacy. This evidence summary reviews literature from 1990 to 2014, comparing contemporary surgical and endovascular revascularization. Systematic review was performed with emphasis on acuity of presentation, study design, revascularization techniques, limb salvage and mortality rates, and complications. There were 2999 articles identified and 563 abstracts reviewed; 68 articles were reviewed fully and 26 critically appraised. Limb salvage, amputation-free survival, overall survival and mortality, and treatment complications were elucidated, including Medicare outcomes data. Risk factors for amputation and mortality were identified. Surgical or endovascular revascularization for ALI is achievable with acceptable limb salvage and amputation rates, which are not markedly different between the two modalities in the short term. Endovascular therapy and surgery are complementary rather than competing strategies for ALI. Further good-quality clinical trial data are needed to define longer term outcomes.

Endovascular aneurysm repair simulation can lead to decreased fluoroscopy time and accurately delineate the proximal seal zone.

BACKGROUND: The use of simulators for endovascular aneurysm repair (EVAR) is not widespread. We examined whether simulation could improve procedural variables, including operative time and optimizing proximal seal. For the latter, we compared suprarenal vs infrarenal fixation endografts, right femoral vs left femoral main body access, and increasing angulation of the proximal aortic neck. METHODS: Computed tomography angiography was obtained from 18 patients who underwent EVAR at a single institution. Patient cases were uploaded to the ANGIO Mentor endovascular simulator (Simbionix, Cleveland, Ohio) allowing for three-dimensional reconstruction and adapted for simulation with suprarenal fixation (Endurant II; Medtronic Inc, Minneapolis, Minn) and infrarenal fixation (C3; W. L. Gore & Associates Inc, Newark, Del) deployment systems. Three EVAR novices and three experienced surgeons performed 18 cases from each side with each device in randomized order (n = 72 simulations/participant). The cases were stratified into three groups according to the degree of infrarenal angulation: 0° to 20°, 21° to 40°, and 41° to 66°. Statistical analysis used paired t-test and one-way analysis of variance. RESULTS: Mean fluoroscopy time for participants decreased by 48.6% (P < .0001), and total procedure time decreased by 33.8% (P < .0001) when initial cases were compared with final cases. When stent deployment accuracy was evaluated across all cases, seal zone coverage in highly angulated aortic necks was significantly decreased. The infrarenal device resulted in mean aortic neck zone coverage of 91.9%, 89.4%, and 75.4% (P < .0001 by one-way analysis of variance), whereas the suprarenal device yielded 92.9%, 88.7%, and 71.5% (P < .0001) for the 0° to 20°, 21° to 40°, and 41° to 66° cases, respectively. Suprarenal fixation did not increase seal zone coverage. The side of femoral access for the main body did not influence proximal seal zone coverage regardless of infrarenal angulation. CONCLUSIONS: Simulation of EVAR leads to decreased fluoroscopy times for novice and experienced operators. Side of femoral access did not affect precision of proximal endograft landing. The angulated aortic neck leads to decreased proximal seal zone coverage regardless of infrarenal or suprarenal fixation devices.

Elevated Peak Systolic Velocity and Velocity Ratio from Duplex Ultrasound are Associated with Hemodynamically Significant Lesions in Arteriovenous Access.

BACKGROUND: Duplex ultrasound (DUS) is reliably used to detect lesions in the peripheral and carotid arterial beds and venous system. Although commonly used in clinical practice, duplex criteria to define lesions in arteriovenous access are not well characterized. This study will define the optimal Doppler-derived peak systolic velocity (PSV) and velocity ratio (VR) to identify >50% lesions in arteriovenous fistulas (AVF) and arteriovenous grafts (AVG). METHODS: This retrospective analysis includes patients with both DUS and fistulogram within 30 days. DUS-derived PSV and VR were recorded for 3 segments of each access and compared with fistulograms of the same 3 segments of each AV access. Receiver operating characteristic (ROC) was used to determine the optimal DUS criteria for diagnosis of >50% stenosis. RESULTS: Fifty pairs of imaging in 40 patients were available for analysis. Mean PSV and VR for segments with greater than 50% stenosis were significantly greater than those without; mean PSV of 480 cm/sec vs. 297 cm/sec (P < 0.001) and mean VR of 3.81 vs. 2.09 (P < 0.001). The ROC analysis demonstrated an optimal PSV of 404 and VR of 2.2 to diagnose >50% stenosis with area under the curve of 0.825 and 0.821 for PSV and VR, respectively. PSV of 500 had sensitivity (Se) of 0.60, specificity (Sp) of 0.86, positive predictive value (PPV) of 0.72, and negative predictive value (NPV) of 0.78. VR of 3.0 had Se of 0.52, Sp of 0.91, PPV of 0.77, and NPV of 0.75. CONCLUSIONS: DUS-derived PSV of 400 cm/sec and VR of 2.25 have good discrimination to predict greater than 50% stenosis in AVFs and AVGs. Given the broad range of velocities in AV accesses, a threshold of PSV greater than 500 cm/sec and VR greater than 3.0, will reliably identify graft-threatening lesions. Se and Sp of PSV 500 are 0.596 and 0.854, respectively. Se and Sp for VR 3.0 are 0.519 and 0.894, respectively.

Students' Motivational Profiles in the Physical Education Context.

The purpose of the current study is to test the self-determination theory (SDT) continuum hypothesis of motivation using latent profile analysis (LPA). A total of 3,220 school students took part in the study. We compared LPA solutions estimated using the four motivation types versus the two higher-order dimensions to assess their degree of correspondence to the SDT continuum hypothesis. To examine the concurrent validity of the profiles, we also verified their associations with three predictors (age, gender, perception of physical education teachers' autonomy-supportive behaviors) and two outcomes variables (perceived competence and intentions to be physically active). The results showed that profiling using the four motivation types provides more differentiated and meaningful description of responses to the Perceived Locus of Causality Scale, compared with profiling using two higher-order factors. In general, the results of the current study were consistent with the SDT continuum hypothesis of human motivation.

Principal considerations for the contemporary high-fidelity endovascular simulator design used in training and evaluation.

BACKGROUND: The simulation and rehearsal of virtual endovascular procedures are anticipated to improve the outcomes of actual procedures. Contemporary, high-fidelity simulation is based on feedback systems that combine concepts of mechanical, electrical, computer, and control systems engineering to reproduce an interactive endovascular case. These sophisticated devices also include psychometric instruments for objective surgical skill assessment. The goal of this report is to identify the design characteristics of commercially available simulators for endovascular procedures and to provide a cross-section comparison across all devices to aid in the simulator selection process. METHODS: Data were obtained (1) by a standard questionnaire issued to four simulator companies prompting for relevant design details of each model for the expressed purpose of publication, (2) from each manufacturer's respective website including appended sales brochures and specification sheets, and (3) by an evaluation of peer-reviewed literature. Focus topics include haptic technology, vessel segmentation, physiologic feedback, performance feedback, and physical logistics (ie, weight, dimensions, and portability). All data sources were surveyed between January 1, 2012, and June 30, 2013. RESULTS: All of the commercially available, high-fidelity endovascular simulators use interactive virtual environments with preprogrammed physics and physiology models for accurate reproduction of surgical reality. The principal differences between devices are the number of access sites and haptic devices, the ability to reconstruct patient-specific anatomy for preprocedural rehearsal, and the available peripheral training modalities. Hardware and software options can also vary within the same device in comparing patient-specific with generic cases. CONCLUSIONS: Despite our limited knowledge about the potential of high-fidelity simulation within the endovascular world, today's currently available simulators successfully provide high-fidelity reproductions of the endovascular environment. We have found that all of the commercially available devices incorporate the necessary features for a high-fidelity experience: (1) haptic technology, (2) vessel reconstruction, (3) physiology feedback, and (4) performance feedback. Significant variations in design do exist and may influence differences in skill development, evaluation, or cost. However, further validation of these differences is still needed and would benefit program directors interested in expanding these platforms for vascular training and certification as this technology matures.

Development of an α-Klotho Recognizing High-Affinity Peptide Probe from In-Solution Enrichment.

The kidney, parathyroid gland, and choroid plexus express the aging-related transmembrane protein α-Klotho, a coreceptor of the fibroblast growth factor 23 (FGF23) receptor complex. Reduced α-Klotho levels are correlated with chronic kidney disease and other age-related diseases, wherein they are released from membranes into circulation. Klotho's potential physiological action as a hormone is of current scientific interest. Part of the challenges associated with advancing these studies, however, has been the long-standing difficulty in detecting soluble α-Klotho in biofluids. Here, we describe the discovery of peptides that recognize α-Klotho with high affinity and selectivity by applying in-solution size-exclusion-based affinity selection-mass spectrometry (AS-MS). After two rounds of AS-MS and subsequent N-terminal modifications, the peptides improved their binding affinity to α-Klotho by approximately 2300-fold compared to the reported starting peptide Pep-10, previously designed based on the C-terminal region of FGF23. The lead peptide binders were shown to enrich α-Klotho from cell lysates and to label α-Klotho in kidney cells. Our results further support the utility of in-solution, label-free AS-MS protocols to discover peptide-based binders to target proteins of interest with high affinity and selectivity, resulting in functional probes for biological studies.

Electrophile Scanning Reveals Reactivity Hotspots for the Design of Covalent Peptide Binders.

Protein-protein interactions (PPIs) are intriguing targets in drug discovery and development. Peptides are well suited to target PPIs, which typically present with large surface areas lacking distinct features and deep binding pockets. To improve binding interactions with these topologies and advance the development of PPI-focused therapeutics, potential ligands can be equipped with electrophilic groups to enable binding through covalent mechanisms of action. We report a strategy termed electrophile scanning to identify reactivity hotspots in a known peptide ligand and demonstrate its application in a model PPI. Cysteine mutants of a known ligand are used to install protein-reactive modifiers via a palladium oxidative addition complex (Pd-OAC). Reactivity hotspots are revealed by cross-linking reactions with the target protein under physiological conditions. In a model PPI with the 9-mer peptide antigen VL9 and major histocompatibility complex (MHC) class I protein HLA-E, we identify two reactivity hotspots that afford up to 87% conversion to the protein-peptide conjugate within 4 h. The reactions are specific to the target protein in vitro and dependent on the peptide sequence. Moreover, the cross-linked peptide successfully inhibits molecular recognition of HLA-E by CD94-NKG2A possibly due to structural changes enacted at the PPI interface. The results illustrate the potential application of electrophile scanning as a tool for rapid discovery and development of covalent peptide binders.

Structure of the p53 degradation complex from HPV16.

Human papillomavirus (HPV) is a significant contributor to the global cancer burden, and its carcinogenic activity is facilitated in part by the HPV early protein 6 (E6), which interacts with the E3-ligase E6AP, also known as UBE3A, to promote degradation of the tumor suppressor, p53. In this study, we present a single-particle cryoEM structure of the full-length E6AP protein in complex with HPV16 E6 (16E6) and p53, determined at a resolution of ~3.3 Å. Our structure reveals extensive protein-protein interactions between 16E6 and E6AP, explaining their picomolar binding affinity. These findings shed light on the molecular basis of the ternary complex, which has been pursued as a potential therapeutic target for HPV-driven cervical, anal, and oropharyngeal cancers over the last two decades. Understanding the structural and mechanistic underpinnings of this complex is crucial for developing effective therapies to combat HPV-induced cancers. Our findings may help to explain why previous attempts to disrupt this complex have failed to generate therapeutic modalities and suggest that current strategies should be reevaluated.

Everolimus-eluting versus paclitaxel-eluting stents in coronary artery disease.

BACKGROUND: Previous studies have established the superiority of coronary everolimus-eluting stents over paclitaxel-eluting stents with respect to angiographic findings. However, these trials were not powered for superiority in clinical end points. METHODS: We randomly assigned 3687 patients at 66 U.S. sites to receive everolimus-eluting stents or paclitaxel-eluting stents without routine follow-up angiography. The primary end point was the 1-year composite rate of target-lesion failure (defined as cardiac death, target-vessel myocardial infarction, or ischemia-driven target-lesion revascularization). RESULTS: Everolimus-eluting stents were superior to paclitaxel-eluting stents with respect to the primary end point of target-lesion failure (4.2% vs. 6.8%; relative risk, 0.62; 95% confidence interval, 0.46 to 0.82; P=0.001). Everolimus-eluting stents were also superior with respect to the major secondary end point of the 1-year rate of ischemia-driven target-lesion revascularization (P=0.001) and were noninferior with respect to the major secondary end point of the 1-year composite rate of cardiac death or target-vessel myocardial infarction (P<0.001 for noninferiority; P=0.09 for superiority). The 1-year rates of myocardial infarction and stent thrombosis were also lower with everolimus-eluting stents than with paclitaxel-eluting stents (1.9% vs. 3.1%, P=0.02 for myocardial infarction; 0.17% vs. 0.85%, P=0.004 for stent thrombosis). Target-lesion failure was consistently reduced with everolimus-eluting stents as compared with paclitaxel-eluting stents in 12 prespecified subgroups, except in the subgroup of patients with diabetes (6.4% vs. 6.9%, P=0.80). CONCLUSIONS: Everolimus-eluting stents, as compared with paclitaxel-eluting stents, resulted in reduced rates of target-lesion failure at 1 year, results that were consistent in all patients except those with diabetes, in whom the results were nonsignificantly different. (ClinicalTrials.gov number, NCT00307047.)

Everolimus-eluting stents in patients undergoing percutaneous coronary intervention: final 3-year results of the Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Subjects With de Novo Native Coronary Artery Lesions trial.

OBJECTIVES: We compared the outcomes of patients treated with everolimus-eluting stents (EES) versus paclitaxel-eluting stents (PES) at 3 years from the large-scale randomized SPIRIT IV trial. BACKGROUND: SPIRIT IV is the largest randomized trial comparing the outcomes of EES and PES. The present report represents the final long-term follow-up analysis from this study. METHODS: A total of 3,687 patients were randomized 2:1 to EES or PES, stratified by presence of diabetes mellitus and lesion characteristics. Prespecified subgroups were compared for interaction with stent allocation. The primary end point was target lesion failure (TLF) (the composite of cardiac death, target vessel-related myocardial infarction [MI], or ischemia-driven target lesion revascularization). RESULTS: At 3 years, TLF occurred in 9.2% versus 11.7% of EES- and PES-treated patients (hazard ratio [HR] 0.78 [0.63-0.97], P = .02). The incidence of death or MI was 5.9% versus 9.1%, respectively (HR 0.67 [0.52-0.85], P = .001), and there was a 64% reduction in stent thrombosis (Academic Research Consortium definite or probable definition) with EES (0.59% vs 1.60%, HR 0.36 [0.18-0.72], P = .003). The difference in target lesion revascularization at 3 years did not reach statistical significance (6.2% vs 7.8%, respectively, HR 0.78 [0.60-1.01], P = .06). There was no significant interaction between treatment allocation and any of the subgroups, including diabetes. CONCLUSIONS: When compared with PES, EES provides durable and significant reduction in TLF, especially due to its enhanced safety profile, with lower rates of death or MI and stent thrombosis up to 3 years.

Pathological gaming: a longitudinal study from the perspectives of mental health problems and social stress model.

Debates about pathological gaming continues in the wake of the World Health Organization's (WHO) decision to establish a gaming disorder diagnosis. Questions persist whether gaming disorder is best conceived as a stand-alone psychiatric disorder, or whether it heralds or accompanies other, more established conditions, such as depression or ADHD. We tested these hypotheses in a sample of 3,034 youth from Singapore. Evidence suggests that pathological gaming is a somewhat unstable construct, often remitting spontaneously. Youth with preexisting ADHD or depression were more likely to develop later pathological gaming problems, while the inverse was not true, with neither early pathological gaming nor gaming time predictive of later mental health problems. Results suggest that, whenever there is any need to conduct robust evidence-based studies, more evidence should be collected before new disorders are recognized by means of "expert consensus".