Standard terminology is critical to advancing rehabilitation and assistive technology: a call to action.

This perspective piece discusses inconsistencies in assistive technology (AT) language as a barrier to communication in AT provision, research, development, trade, and policy. The imperative to improve communication is explored in relation to AT stakeholder endeavours. This commentary is a call for action to develop a terminology standard through the aggregation of evidence-based concepts and terms to inform and optimize stakeholder outcomes. IMPLICATIONS FOR REHABILITATIONStandardized terminology supports the gathering, aggregation, analysis, and interpretation of valid data and the development of tools used for needs and outcomes assessment.Standardized terminology also supports effective and efficient documentation, practice, collaboration, and capacity building by stakeholders in both national and international contexts.

Digital Whole Slide Imaging Compared With Light Microscopy for Primary Diagnosis in Surgical Pathology.

CONTEXT.­: The adoption of digital capture of pathology slides as whole slide images (WSI) for educational and research applications has proven utility. OBJECTIVE.­: To compare pathologists' primary diagnoses derived from WSI versus the standard microscope. Because WSIs differ in format and method of observation compared with the current standard glass slide microscopy, this study is critical to potential clinical adoption of digital pathology. DESIGN.­: The study enrolled a total of 2045 cases enriched for more difficult diagnostic categories and represented as 5849 slides were curated and provided for diagnosis by a team of 19 reading pathologists separately as WSI or as glass slides viewed by light microscope. Cases were reviewed by each pathologist in both modalities in randomized order with a minimum 31-day washout between modality reads for each case. Each diagnosis was compared with the original clinical reference diagnosis by an independent central adjudication review. RESULTS.­: The overall major discrepancy rates were 3.64% for WSI review and 3.20% for manual slide review diagnosis methods, a difference of 0.44% (95% CI, -0.15 to 1.03). The time to review a case averaged 5.20 minutes for WSI and 4.95 minutes for glass slides. There was no specific subset of diagnostic category that showed higher rates of modality-specific discrepancy, though some categories showed greater discrepancy than others in both modalities. CONCLUSIONS.­: WSIs are noninferior to traditional glass slides for primary diagnosis in anatomic pathology.

Assistive technology products: a position paper from the first global research, innovation, and education on assistive technology (GREAT) summit.

This paper is based on work from the Global Research, Innovation, and Education on Assistive Technology (GREAT) Summit that was coordinated by WHO's Global Cooperation on Assistive Technology (GATE). The purpose of this paper is to describe the needs and opportunities embedded in the assistive product lifecycle as well as issues relating to the various stages of assistive product mobilization worldwide. The paper discusses assistive technology product terminology and the dangers of focusing on products outside the context and rolling out products without a plan. Additionally, the paper reviews concepts and issues around technology transfer, particularly in relation to meeting global needs and among countries with limited resources. Several opportunities are highlighted including technology advancement and the world nearing a state of readiness through a developing capacity of nations across the world to successfully adopt and support the assistive technology products and applications. The paper is optimistic about the future of assistive technology products reaching the people that can use it the most and the excitement across large and small nations in increasing their own capacities for implementing assistive technology. This is expressed as hope in future students as they innovate and in modern engineering that will enable assistive technology to pervade all corners of current and potential marketplaces. Importantly, the paper poses numerous topics where discussions are just superficially opened. The hope is that a set of sequels will follow to continue this critical dialog. Implications for Rehabilitation Successful assistive technology product interventions are complex and include much more than the simple selection of the right product. Assistive technology product use is highly context sensitive in terms of an individual user's environment. The development of assistive technology products is tricky as it must be contextually sensitive to the development environment and market as well. As a field we have much to study and develop around assistive technology product interventions from a global perspective.

Atopic Eczema: Genetic Associations and Potential Links to Developmental Exposures.

Atopic eczema (AE), or atopic dermatitis (AD), is a common inflammatory skin disease with a disrupted epidermal barrier and an allergic immune response. AD/AE is prominently characterized by a symptomatic itch and transient skin lesions. Infants compose a significant percentage affected. Two models have been proposed to explain AD/AE skin pathology: the gut microbiome-focused inside-outside model and the outside-inside model concentrating on the disrupted skin barrier/skin microbiome. Gene disruptions contributing to epidermal structure, as well as those in immune system genes, are implicated. Over 30 genes have been linked to AD/AE with Flg and Tmem79/Matt alterations being common. Other linked disruptions are in the interleukin-1 family of cytokines/receptors and the TH2 gene family of cytokines. Inheritable epigenetic modifications of the genes or associated proteins may also be involved. Skin barrier disruption and the allergic immune response have been the main foci in mechanistic studies of AD/AE, but the role of the environment is becoming more apparent. Thus, an examination of in utero exposures could be very helpful in understanding the heterogeneity of AD/AE. Although research is limited, there is evidence that developmental exposure to environmental tobacco smoke or phthalates may impact disease. Management for AD/AE includes topical corticosteroids and calcineurin inhibitors, which safely facilitate improvements in select individuals. Disease heterogeneity warrants continued research not only into elucidating disease mechanism(s), via identification of contributing genetic alterations, but also research to understand how/when these genetic alterations occur. This may lead to the cure that those affected by AD/AE eagerly await.

A survey of assistive technology service providers in the USA.

This study investigates perspectives of assistive technology service (ATS) providers regarding their education and training, interdisciplinary standards of practice, use of a common language framework, funding policies, utilization of evidence and outcomes measurement. A survey underpinned by AT legislations and established guidelines for practice was completed by 318 certified AT providers. More than 30% of the providers reported their education and training as inadequate to fulfil four of the seven primary roles of ATS. Nearly 90% of providers expressed awareness of the International Classification of Functioning, Disability and Health (ICF) domains for interdisciplinary communication. However, only 45% felt that they could effectively utilize the ICF in their documentation. About 75% of the providers acknowledged the lack of a recognized standard for the provision of services. Prevailing inadequacies in funding were negatively impacting the quality of ATS, as expressed by 88% of respondents. Translation of evidence to practice was identified as a major challenge by 41% of service providers. Providers were predominantly documenting outcomes through informal interviews (54%) or non-standard instruments (26%). Findings support the need for strengthening professional curriculum, pre-service and in-service training and an established standard to support effective, interdisciplinary AT services and data collection to support public policy decisions. Implications for Rehabilitation This study validates the need to strengthen education and training of AT service providers by enhancing professional curriculum as well as their engagement in pre-service and in-service training activities. This study draws attention to health care funding policies and practices that critically impact the quality of AT services. This study signifies the need for an established interdisciplinary standard among AT professionals to support effective communication, service coordination and outcomes measurement.

Cardiac evaluation and management before vascular surgery.

PURPOSE OF REVIEW: The most common and significant morbidity and mortality of vascular surgical procedures remain coronary artery disease, arrhythmia, and heart failure. Cardiac evaluation and medical optimization provide the groundwork for best medical practice in an otherwise high-risk surgical population. The goal of this study is to review the most current literature and guidelines for evaluating patients prior to vascular surgical interventions. From this, we have made our own recommendations regarding both the preoperative and perioperative management of vascular surgical patients. RECENT FINDINGS: Risk stratification using a modified Lee index may be best to assess perioperative cardiac risk. Coronary revascularization should be reserved for those patients with significant coronary disease irrespective of symptoms. ß-blockers, statins, and antiplatelet agents should be considered for all patients with peripheral vascular disease. SUMMARY: The preoperative management of vascular surgical patients requires a complete understanding of the patient's medical history as it relates to their perioperative cardiac risk. Overwhelming data support the use of medical therapy as adjunct to minimize or prevent the risk of future cardiovascular events. As vascular surgery transitions to the outpatient setting, further studies will be required to better elucidate cardiac evaluation in this patient population.

Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies.

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient's responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

Important medical decisions: Using brief motivational interviewing to enhance patients' autonomous decision-making.

GOALS: The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. BACKGROUND: As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. METHOD: A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. DISCUSSION: The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient's best interests by psychotherapeutically addressing his anxious, fear-based ambivalence.

Utility of the digital rectal examination in the emergency department: a review.

BACKGROUND: The digital rectal examination (DRE) has been reflexively performed to evaluate common chief complaints in the Emergency Department without knowing its true utility in diagnosis. OBJECTIVE: Medical literature databases were searched for the most relevant articles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive rate of fecal occult blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the correlation between DRE and anal manometry in determining anal tone. DISCUSSION: Sixteen articles met our inclusion criteria; there were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was shown to add no additional diagnostic information and confounded the diagnosis in acute, undifferentiated abdominal pain. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children and adults. No statistical differences in the number of colonic pathologies were found between stool collection methods in those with positive FOBT. The DRE correlation with anal manometry in determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, respectively. CONCLUSION: We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis. Stool obtained by DRE doesn't seem to increase the false-positive rate of FOBTs, and the DRE correlated moderately well with anal manometric measurements in determining anal sphincter tone.

The effects of maternal exposure to bisphenol A on allergic lung inflammation into adulthood.

Bisphenol A (BPA) is a high-production volume chemical classified as an environmental estrogen and used primarily in the plastics industry. BPA's increased usage correlates with rising BPA levels in people and a corresponding increase in the incidence of asthma. Due to limited studies, the contribution of maternal BPA exposure to allergic asthma pathogenesis is unclear. Using two established mouse models of allergic asthma, we examined whether developmental exposure to BPA alters hallmarks of allergic lung inflammation in adult offspring. Pregnant C57BL/6 dams were gavaged with 0, 0.5, 5, 50, or 500 µg BPA/kg/day from gestational day 6 until postnatal day 21. To induce allergic inflammation, adult offspring were mucosally sensitized with inhaled ovalbumin containing low-dose lipopolysaccharide or ip sensitized using ovalbumin with alum followed by ovalbumin aerosol challenge. In the mucosal sensitization model, female offspring that were maternally exposed to ≥ 50 µg BPA/kg/day displayed enhanced airway lymphocytic and lung inflammation, compared with offspring of control dams. Peritoneally sensitized, female offspring exposed to ≤ 50 µg BPA/kg/day presented dampened lung eosinophilia, compared with vehicle controls. Male offspring did not exhibit these differences in either sensitization model. Our data demonstrate that maternal exposure to BPA has subtle and qualitatively different effects on allergic inflammation, which are critically dependent upon route of allergen sensitization and sex. However, these subtle, yet persistent changes due to developmental exposure to BPA did not lead to significant differences in overall airway responsiveness, suggesting that early life exposure to BPA does not exacerbate allergic inflammation into adulthood.

Developmental exposure to bisphenol A modulates innate but not adaptive immune responses to influenza A virus infection.

Bisphenol A (BPA) is used in numerous products, such as plastic bottles and food containers, from which it frequently leaches out and is consumed by humans. There is a growing public concern that BPA exposure may pose a significant threat to human health. Moreover, due to the widespread and constant nature of BPA exposure, not only adults but fetuses and neonates are also exposed to BPA. There is mounting evidence that developmental exposures to chemicals from our environment, including BPA, contribute to diseases late in life; yet, studies of how early life exposures specifically alter the immune system are limited. Herein we report an examination of how maternal exposure to a low, environmentally relevant dose of BPA affects the immune response to infection with influenza A virus. We exposed female mice during pregnancy and through lactation to the oral reference dose for BPA listed by the US Environmental Protection Agency, and comprehensively examined immune parameters directly linked to disease outcomes in adult offspring following infection with influenza A virus. We found that developmental exposure to BPA did not compromise disease-specific adaptive immunity against virus infection, or reduce the host's ability to clear the virus from the infected lung. However, maternal exposure to BPA transiently reduced the extent of infection-associated pulmonary inflammation and anti-viral gene expression in lung tissue. From these observations, we conclude that maternal exposure to BPA slightly modulates innate immunity in adult offspring, but does not impair the anti-viral adaptive immune response, which is critical for virus clearance and survival following influenza virus infection.

Integrating medical, assistive, and universally designed products and technologies: assistive technology device classification (ATDC).

INTRODUCTION: ISO26000:2010 International Guidance Standard on Organizational Social Responsibility requires that effective organizational performance recognize social responsibility, including the rights of persons with disabilities (PWD), engage stakeholders and contribute to sustainable development. Millennium Development Goals 2010 notes that the most vulnerable people require special attention, while the World Report on Disability 2011 identifies improved data collection and removal of barriers to rehabilitation as the means to empower PWD. BACKGROUND: The Assistive Technology Device Classification (ATDC), Assistive Technology Service Method (ATSM) and Matching Person and Technology models provide an evidence-based, standardized, internationally comparable framework to improve data collection and rehabilitation interventions. The ATDC and ATSM encompass and support universal design (UD) principles, and use the language and concepts of the International Classification of Functioning, Disability and Health (ICF). PURPOSE: Use ATDC and ICF concepts to differentiate medical, assistive and UD products and technology; relate technology "types" to markets and costs; and support provision of UD products and technologies as sustainable and socially responsible behavior. CONCLUSION: Supply-side and demand-side incentives are suggested to foster private sector development and commercialization of UD products and technologies. Health and health-related professionals should be knowledgeable of UD principles and interventions.

Integrating medical, assistive, and universal design products and technologies: Assistive Technology Service Method (ATSM).

INTRODUCTION: ISO26000 provides guidance on effective organizational performance that recognizes social responsibility (including rights of persons with disabilities (PWD)), engages stakeholders, and contributes to sustainable development [1]. Millennium Development Goals 2010 state: while progress has been made, insufficient dedication to sustainable development, and inequalities to the most vulnerable people require attention [2]. World Report on Disability 2011 recommendations includes improved data collection and removal of barriers to rehabilitation that empower PWD [3]. BACKGROUND: The Assistive Technology Service Method (ATSM), Assistive Technology Device Classification (ATDC) and Matching Person and Technology (MPT) provide an evidence-based, standardized, internationally comparable framework to improve rehabilitation interventions [4-6]. The ATSM and ATDC support universal design (UD) principles and provision of universal technology. The MPT assures interventions are effective and satisfactory to end-users [7]. The ICF conceptual framework and common language are used throughout [8]. METHOD: Research findings on healthcare needs are translated. ATSM applications in support of these findings are presented. RESULTS: National initiatives demonstrate the need and value of the ATSM as an evidence-based, user-centric, interdisciplinary method to improve individual and organizational performance for rehabilitation [including AT] services. CONCLUSION: Two Disability & Rehabilitation: Assistive Technology articles demonstrate ATSM and ATDC use to strengthen rehabilitation services and integrate Universal Design principles for socially responsible behavior.

Assistive technology device classification based upon the World Health Organization's, International Classification of Functioning, Disability and Health (ICF).

PURPOSE: To develop an assistive technology device classification (ATDC) consistent with the Assistive Technology Act (ATA2004), Americans with Disabilities Act (ADA2008), International Classification System of Functioning, Disability and Health (ICF), International Classification of Disease, Ninth Revision-Clinical Modification (ICD-9-CM) and American Medical Association's Current Procedural Terminology (CPT). BACKGROUND: Current assistive technology device (ATD) classifications include: the National Classification System for Assistive Technology Devices and ATSs (RTI/NCS) published in 2000; ISO 9999: technical aids for persons with disabilities - classification and terminology (ISO 9999) published in 1992, 1998, 2002 and 2007 and ICF-based AT classification (ICF/AT2007) published in 2009. OBJECTIVES: To derive 'requirements' for ATD classification from the ATA2004, ADA2008, ICF, ICD-9-CM and CPT. Review the ATD classifications and online databases against requirements. Construct the ATDC to be consistent with all requirements and demonstrate with examples. RESULTS: Existing ATD classifications and online databases are inconsistent with requirements. The ATDC is consistent and has inclusion and exclusion criteria, classification rules, employs ICF coding, extendable hierarchy and language and uses standard device naming conventions. Conclusion. The ATDC has broad application to: provision of AT ATSs (ATSs), characterisation and analysis of AT industries, Federally sponsored research pertaining to AT development and commercialisation, and Federal health insurance scope of benefits.

Provision of assistive technology services method (ATSM) according to evidence-based information and knowledge management.

PURPOSE. This article develops a standardised method for assistive technology service (ATS) provision and a logical basis for research to improve health care quality. The method is 'interoperable' across disabilities, disciplines, assistive technology devices and ATSs. BACKGROUND. Absence of a standardised and interoperable method for ATS provision results in ineffective communication between providers, manufacturers, researchers, policy-makers and individuals with disabilities (IWD), a fragmented service delivery system, inefficient resource allocation and sub-optimal outcomes. OBJECTIVES. Synthesise a standardised, interoperable AT service method (ATSM) fully consistent with key guidelines, systems, models and Federal legislation. Express the ATSM using common and unambiguous language. RESULTS. Guidelines, systems, models and Federal legislation relevant to ATS provision are reviewed. These include the RESNA Guidelines for Knowledge and Skills for Provision of Assistive Technology Products and Services (RESNA Guidelines), IMPACT2 model, international classification of functioning, disability and health (ICF) and AT device classification (ATDC). Federal legislation includes the Assistive Technology Act of 2004, Americans with Disabilities Act of 2008 and Social Security Act. Based on these findings, the ATSM is synthesised and translated into common and accessible language. CONCLUSION. ATSM usage will improve communication between stakeholders, service delivery coherence, resource allocation and intervention outcomes.

Activation of pulmonary dendritic cells and Th2-type inflammatory responses on instillation of engineered, environmental diesel emission source or ambient air pollutant particles in vivo.

The biological effects of acute particulate air pollution exposure in host innate immunity remain obscure and have relied largely on in vitro models. We hypothesized that single acute exposure to ambient or engineered particulate matter (PM) in the absence of other secondary stimuli would activate lung dendritic cells (DC) in vivo and provide information on the early immunological events of PM exposure and DC activation in a mouse model naïve to prior PM exposure. Activation of purified lung DC was studied following oropharyngeal instillation of ambient particulate matter (APM). We compared the effects of APM exposure with that of diesel-enriched PM (DEP), carbon black particles (CBP) and silver nanoparticles (AgP). We found that PM species induced variable cellular infiltration in the lungs and only APM exposure induced eosinophilic infiltration. Both APM and DEP activated pulmonary DC and promoted a Th2-type cytokine response from naïve CD4+ T cells ex vivo. Cultures of primary peribronchial lymph node cells from mice exposed to APM and DEP also displayed a Th2-type immune response ex vivo. We conclude that exposure of the lower airway to various PM species induces differential immunological responses and immunomodulation of DC subsets. Environmental APM and DEP activated DC in vivo and provoked a Th2 response ex vivo. By contrast, CBP and AgP induced altered lung tissue barrier integrity but failed to stimulate CD4+ T cells as effectively. Our work suggests that respirable pollutants activate the innate immune response with enhanced DC activation, pulmonary inflammation and Th2-immune responsiveness.

Female patients undergoing TEVAR may have an increased risk of postoperative spinal cord ischemia.

BACKGROUND: There is a paucity of literature regarding thoracic endovascular aneurysm repair (TEVAR) in women. We report our institutional experience with TEVAR. METHODS: Retrospective chart review was performed from 2004 to 2008. TEVAR was performed in 59 patients; 29 (49%) were female. RESULTS: Mean age was 73.5 years. Mean thoracic aortic aneurysm (TAA) diameter was larger for women (5.9 cm vs 4.7 cm). A trend toward an increase in paraplegia was noted in women, 10.3% vs 4.8%. This may be related to increase in length of aortic coverage in women, 18.2 cm vs 15.2 cm (P < .05). CONCLUSION: TEVAR in women is safe and effective. The length of aortic coverage is greater in women, which may be related to larger aneurysms and more diffuse disease. This may be associated with a concerning increase in postoperative paraplegia. Women undergoing TEVAR should be considered for prophylactic maneuvers to prevent spinal cord ischemia (SCI), including minimizing length of coverage.

Deletion of the mucin-like molecule muc1 enhances dendritic cell activation in response to toll-like receptor ligands.

Dendritic cells (DC) are potent professional antigen-presenting cells that drive primary immune responses to infections or other agonists perceived as 'dangerous'. Muc1 is the only cell surface mucin or MUC gene product that is expressed in DC. Unlike other members of this glycoprotein family, Muc1 possesses a unique cytosolic region capable of signal transduction and attenuating toll-like receptor (TLR) activation. The expression and function of Muc1 has been intensively investigated on epithelial and tumor cells, but relatively little is known about its function on DC. We hypothesized that Muc1 would influence in vitro generation and primary DC activation in response to the TLR4 and TLR5 ligands lipopolysaccharide and flagellin. Compared with Muc1(+/+) DC, we found that Muc1(-/-) DC were constitutively activated, as determined by higher expression of co-stimulatory molecules (CD40, CD80 and CD86), greater secretion of immunoregulatory cytokines (TNF-alpha and VEGF), and better stimulation of allogeneic naïve CD4+ T cell proliferation. After activation by either LPS or flagellin and co-culture with allogeneic CD4+ T cells, Muc1(-/-) DC also induced greater secretion of TNF-alpha and IFN-gamma compared to similarly activated Muc1(+/+) DC. Taken together, our results indicate that deletion of Muc1 promotes a heightened functional response of DC in response to TLR4 and TLR5 signaling pathways, and suggests a previously under-appreciated role for Muc1 in regulating innate immune responses of DC.

Nuclear erythroid 2 p45-related factor 2 inhibits the maturation of murine dendritic cells by ragweed extract.

Oxidative stress plays an important role in immune regulation and dendritic cell (DC) maturation. Recent studies indicate that allergens, including ragweed extract (RWE), possess prooxidant activities, but how RWE interacts with DCs is not well understood. Nuclear erythroid 2 p45-related factor 2 (Nrf2) is a key transcription factor that regulates constitutive and coordinated induction of a battery of antioxidant genes. We hypothesized that RWE would activate DCs and that this response would be augmented in the absence of Nrf2. We generated bone marrow-derived DCs (BM-DCs) and isolated lung DCs from Nrf2(+/+) and Nrf2(-/-) mice and studied the effects of RWE on DCs in vitro. Under resting conditions, Nrf2(-/-) BM-DCs exhibited constitutively greater levels of inflammatory cytokines and costimulatory molecules than Nrf2(+/+) BM-DCs. Exposure to RWE impaired endocytic activity, significantly induced oxidative stress, and enhanced the expression of CD80, CD86, and MHCII in Nrf2(-/-) BM-DCs when compared with Nrf2(+/+) BM-DC, in association with reduced expression of Nrf2-regulated antioxidant genes. RWE significantly induced the secretion of inflammatory cytokines IL-6 and TNF-alpha in BM-DCs and lung DCs from Nrf2(-/-) mice than Nrf2(+/+) mice and significantly inhibited the secretion of IL-12 in Nrf2(+/+) BM-DCs and IL-18 in Nrf2(+/+) and Nrf2(-/-) BM-DCs. The stimulatory effects of RWE on DC activation were inhibited to varying degrees by the antioxidant N-acetyl cysteine. Our findings indicate that a defect in Nrf2-mediated signaling mechanisms alters the response of DCs to a common environmental allergen, which may contribute to the susceptibility to allergic diseases.

New developments in the preoperative evaluation and perioperative management of coronary artery disease in patients undergoing vascular surgery.

BACKGROUND: Preoperative evaluation and perioperative management of cardiac disease in patients undergoing vascular surgery (VS) is important for patients and vascular surgeons. Recent evidence has emerged that has allowed us to develop contemporary paradigms for evaluating and managing coronary artery disease in VS patients perioperatively. METHODS: The utility of stress testing, the role of preoperative coronary revascularization, the optimal use of beta-blockers and statins, and the role of antiplatelet therapy in VS patients were reviewed in the literature. RESULTS: The revised Lee cardiac risk index, based on the number of risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, renal failure, hypertension, and age >75) quantitates cardiac risk. Stress testing is not predictive of myocardial ischemia/infarction (MI) or death and is only recommended in patients with unstable angina or an active arrhythmia. Stress testing for patients with 0 to 2 risk factors delays VS up to 3 weeks. In high-risk patients (>or=3 risk factors), it helps to identify patients who may develop myocardial ischemia and would benefit from a 30-day period to optimize medical therapy before VS. Stress testing and coronary catheterization do not predict which coronary artery to revascularize to prevent MI or death. Revascularization does not decrease MI or death rates at 1 month or 6 years. Although beta-blocker treatment decreases cardiac risk with VS, timing and dosage (titration) influence outcomes, improper usage may increase stroke and death rate, and not all VS patients should be taking these drugs. Patients with >or=1 risk factor should be considered to begin a low dose beta-blocker 1 month before VS. Preoperative statin use sharply decreases MI, stroke, and death perioperatively and long-term postoperatively. CONCLUSION: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication.