Is the Epworth Sleepiness scale a valid outcome measure to evaluate the effectiveness of positive airway pressure treatments on daytime sleepiness? Psychometric insights from measurement invariance and response shifts.

PURPOSE: Although the validity of the Epworth Sleepiness Scale (ESS) as an effectiveness measure for sleep apnea treatments such as continuous positive airway pressure (CPAP) has been supported by multiple studies, some researchers continue to challenge it. They suggest that in addition to its impact on relieving patients' daytime sleepiness, CPAP also alters the internal standards patients use to evaluate their sleepiness (i.e., response shift; RS), confounding the meaning of the difference in the ESS scores. We believe an issue yet to be addressed in this debate is that all existing evidence of RS has been obtained through the then-test approach, a retrospective method sensitive to various cognitive mechanisms. Thus, in the current study, we re-examined this issue using the structural equation modeling (SEM) approach, a method that can be directly applied to randomized clinical trial (RCT) data without retrospective measures. METHODS: With the ESS data from two independent RCTs, we conducted cross-sectional and longitudinal measure invariance tests in SEM to examine whether CPAP would lead to RS. RESULTS: The ESS demonstrated cross-sectional and longitudinal scalar invariance against CPAP treatments. Its factorial pattern, loadings, and thresholds were invariant between the treatment and control groups and pre- and post-treatment, supporting the comparability of the observed mean ESS scores across time and groups. CONCLUSION: Our results support the validity of the average difference scores of the ESS for quantifying the effectiveness of CPAP on group-level daytime sleepiness in RCTs with relatively large sample sizes.

Comparative Effectiveness of Focused Extracorporeal versus Radial Extracorporeal Shockwave Therapy for Knee Osteoarthritis-Randomized Controlled Study.

Both focused extracorporeal shockwave (f-ESWT) and radial extracorporeal shockwave therapy (r-ESWT) can alleviate symptoms in patients with knee osteoarthritis, but no trials have directly compared f-ESWT with r-ESWT for knee osteoarthritis. This study aimed to compare the effectiveness of f-ESWT and r-ESWT on knee osteoarthritis. Forty-two patients with bilateral knee osteoarthritis were randomly assigned to receive three sessions of either f-ESWT or r-ESWT at 1-week intervals. The patients were evaluated at baseline and at 4 and 8 weeks after the final treatment. The primary outcome was the change in pain intensity, as measured on the visual analog scale (VAS). Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion of the knee joint, and the 6-minute walk test. At the end of 4 weeks, the VAS score was substantially reduced in both groups (f-ESWT, -4.5 ± 2.5 points; r-ESWT, -2.6 ± 2.0 points), with a greater reduction in the f-ESWT group. Both groups showed significant improvement in secondary outcomes; however, the f-ESWT group yielded greater improvement in the VAS score, WOMAC score, and 6-minute walk test. Our results showed that f-ESWT was more effective than r-ESWT in improving pain and physical function in patients with knee osteoarthritis.

Gene Expression Profiling of Skeletal Muscles.

Next-generation sequencing provides an opportunity for an in-depth biocomputational analysis to identify gene expression patterns between soleus and tibialis anterior, two well-characterized skeletal muscles, and analyze their gene expression profiling. RNA read counts were analyzed for differential gene expression using the R package edgeR. Differentially expressed genes were filtered using a false discovery rate of less than 0.05 c, a fold-change value of more than twenty, and an association with overrepresented pathways based on the Reactome pathway over-representation analysis tool. Most of the differentially expressed genes associated with soleus are coded for components of lipid metabolism and unique contractile elements. Differentially expressed genes associated with tibialis anterior encoded mostly for glucose and glycogen metabolic pathway regulatory enzymes and calcium-sensitive contractile components. These gene expression distinctions partly explain the genetic basis for skeletal muscle specialization, and they may help to explain skeletal muscle susceptibility to disease and drugs and further refine tissue engineering approaches.

Fabrication and Characterization of Nylon 66/PAN Nanofibrous Film Used as Separator of Lithium-Ion Battery.

In recent years, portable electronic devices have flourished, and the safety of lithium batteries has received increasing attention. In this study, nanofibers were prepared by electrospinning using different ratios of nylon 66/polyacrylonitrile (PAN), and their properties were studied and compared with commercial PP separators. The experimental results show that the addition of PAN in nylon 66/PAN nanofibrous film used as separator of lithium-ion battery can enhance the porosity up to 85%. There is also no significant shrinkage in the shrinkage test, and the thermal dimensional stability is good. When the Li/LiFePO4 lithium battery is prepared by nylon 66/PAN nanofibrous film used as separator, the capacitor can be maintained at 140 mAhg-1 after 20 cycles at 0.1 C, and the coulombic efficiency is still maintained at 99%, which has excellent electrochemical performance.

Requirement of Pitx2 for skeletal muscle homeostasis.

Skeletal muscle is generated by the successive incorporation of primary (embryonic), secondary (fetal), and tertiary (adult) fibers into muscle. Conditional excision of Pitx2 function by an MCKCre driver resulted in animals with histological and ultrastructural defects in P30 muscles and fibers, respectively. Mutant muscle showed severe reduction in mitochondria and FoxO3-mediated mitophagy. Both oxidative and glycolytic energy metabolism were reduced. Conditional excision was limited to fetal muscle fibers after the G1-G0 transition and resulted in altered MHC, Rac1, MEF2a, and alpha-tubulin expression within these fibers. The onset of excision, monitored by a nuclear reporter gene, was observed as early as E16. Muscle at this stage was already severely malformed, but appeared to recover by P30 by the expansion of adjoining larger fibers. Our studies demonstrate that the homeodomain transcription factor Pitx2 has a postmitotic role in maintaining skeletal muscle integrity and energy homeostasis in fetal muscle fibers.

Extracorporeal Shock Waves Versus Botulinum Toxin Type A in the Treatment of Poststroke Upper Limb Spasticity: A Randomized Noninferiority Trial.

OBJECTIVE: To investigate whether extracorporeal shock wave therapy (ESWT) is noninferior to botulinum toxin type A (BoNT-A) for the treatment of poststroke upper limb spasticity. DESIGN: Randomized noninferiority trial. SETTING: Referral medical center. PARTICIPANTS: Patients (N=42) with chronic stroke (28 men; mean age, 61.0±10.6y). INTERVENTIONS: Patients received either ESWT or BoNT-A. During the study period, all patients continued their regular rehabilitation. MAIN OUTCOME MEASURES: Assessments were performed at baseline and at 1, 4, and 8 weeks after the intervention. The primary outcome was the change from baseline of the modified Ashworth scale (MAS) score of the wrist flexors at week 4. Secondary outcomes included the change of the MAS scores, Tardieu angles of the wrist and elbow flexors, wrist and elbow passive range of motion (PROM), and upper extremity Fugl-Meyer Assessment (UE-FMA) score during the study period, as well as the treatment response rate. RESULTS: The primary outcome result in the ESWT group (-0.80±0.41) was similar to that in the BoNT-A group (-0.90±0.44), with a higher confidence limit (0.4) for the difference between groups within the prespecified margin of 0.5, indicating the noninferiority of ESWT to BoNT-A. The response rate was not significantly different between the 2 groups. Both groups showed significant improvement in secondary outcomes relative to baseline; however, the ESWT group yielded greater improvement in wrist and elbow PROM and UE-FMA score. CONCLUSION: Our results suggest that ESWT is a noninferior treatment alternative to BoNT-A for poststroke upper limb spasticity. ESWT and BoNT-A caused similar reduction in spasticity of the wrist and elbow flexors; however, ESWT yielded greater improvement in wrist and elbow PROM and UE-FMA score.

Additional Vitamin and Mineral Support for Patients with Severe Burns: A Nationwide Experience from a Catastrophic Color-Dust Explosion Event in Taiwan.

Major burn injuries, which encompass ≥20% of the total body surface area (TBSA), are the most severe form of trauma because of the stress response they provoke, which includes hypermetabolism, muscle wasting, and stress-induced diabetes. In 2015, a color-dust explosion disaster occurred in the Formosa Fun Coast of Taiwan and injured 499 people, who were transferred via a nationwide emergency delivery system. Some recommendations are currently available regarding vitamin and mineral support for wound healing and recovery in severe burns, but there is a lack of evidence to confirm the benefits. Thus, the current study aimed to investigate the effects of additional vitamin and mineral support for patients with severe burn injuries. Sixty-one hospitalized individuals with major burns (full thickness and ≥20% TBSA) were classified into the supplement (n = 30) and control (n = 31) groups, according to whether they received supplementation with additional vitamins, calcium, and magnesium. There were significant differences between the supplement and control groups in the incidence of wound infection (30.0% vs. 77.4%, p < 0.001), sepsis (13.3% vs. 41.9%, p = 0.021), and hospitalization days (51.80 vs. 76.81, p = 0.025). After adjustment, logistic regression analysis revealed that, compared to those in the control group, patients in the supplement group had a lower risk for wound infection (OR 0.11; 95% CI 0.03⁻0.43; p = 0.002) and sepsis (OR 0.09; 95% CI 0.01⁻0.61; p = 0.014). Supplementation of multiple vitamins, calcium, and magnesium reduced the risk of wound infection and sepsis, shortened the time of hospitalization, and can be considered for use in major burns.

Quercetin and chrysin inhibit nickel-induced invasion and migration by downregulation of TLR4/NF-κB signaling in A549 cells.

Nickel exposure promotes the invasive potential of human lung cancer cells. Polyphenols such as quercetin, curcumin, chrysin, apigenin, and luteolin, present in many plant foods may suppress the development of cancers. However, whether these compounds inhibit the promoting effects of Nickel on cancer cell invasion and migration as well as the possible mechanisms are unclear. In the present study, we first showed that quercetin, curcumin, chrysin, apigenin, and luteolin at 5 µM, significantly suppressed the promoting effects of NiCl2 (Ni) on migration and invasion in H1975 and A549 human lung cancer cells. The five phytochemicals also significantly suppressed the secretion of cytokines, IL-1ß, IL-6, TNF-α and IL-10, induced by Ni in A549 cells. The overall efficiency of quercetin was the best, followed by chrysin and the other compounds. Furthermore, we found that quercetin and chrysin suppressed the mRNA and protein expression of TLR4 and Myd88. Consistently, quercetin and chrysin also decreased the phosphorylation of IKKß and IκB, the nuclear level of p65 (NF-κB) as well as the expression of MMP-9 in A549 cells exposed to Ni. In conclusion, these results suggest the potential preventive effects of the five phytochemicals on the promoting effect of Ni on human lung cancer cell invasion. In addition, the preventive effects are associated with downregulation of the TLR4/NF-κB signaling pathway, especially for quercetin and chrysin.

Location, Location, Location: Signals in Muscle Specification.

Muscles control body movement and locomotion, posture and body position and soft tissue support. Mesoderm derived cells gives rise to 700 unique muscles in humans as a result of well-orchestrated signaling and transcriptional networks in specific time and space. Although the anatomical structure of skeletal muscles is similar, their functions and locations are specialized. This is the result of specific signaling as the embryo grows and cells migrate to form different structures and organs. As cells progress to their next state, they suppress current sequence specific transcription factors (SSTF) and construct new networks to establish new myogenic features. In this review, we provide an overview of signaling pathways and gene regulatory networks during formation of the craniofacial, cardiac, vascular, trunk, and limb skeletal muscles.

FACS-Seq analysis of Pax3-derived cells identifies non-myogenic lineages in the embryonic forelimb.

Skeletal muscle in the forelimb develops during embryonic and fetal development and perinatally. While much is known regarding the molecules involved in forelimb myogenesis, little is known about the specific mechanisms and interactions. Migrating skeletal muscle precursor cells express Pax3 as they migrate into the forelimb from the dermomyotome. To compare gene expression profiles of the same cell population over time, we isolated lineage-traced Pax3+ cells (Pax3 EGFP ) from forelimbs at different embryonic days. We performed whole transcriptome profiling via RNA-Seq of Pax3+ cells to construct gene networks involved in different stages of embryonic and fetal development. With this, we identified genes involved in the skeletal, muscular, vascular, nervous and immune systems. Expression of genes related to the immune, skeletal and vascular systems showed prominent increases over time, suggesting a non-skeletal myogenic context of Pax3-derived cells. Using co-expression analysis, we observed an immune-related gene subnetwork active during fetal myogenesis, further implying that Pax3-derived cells are not a strictly myogenic lineage, and are involved in patterning and three-dimensional formation of the forelimb through multiple systems.

Comparison of the effect of focused and radial extracorporeal shock waves on spastic equinus in patients with stroke: a randomized controlled trial.

BACKGROUND: Recent studies have suggested that either focused or radial shock wave therapy is an effect method for the treatment of spasticity in patients with stroke. However, no previous study compared these two types of extracorporeal shock wave on spasticity in patients with stroke. This study aimed to compare the effect of focused and radial shock wave therapy for the treatment of spastic equinus in patients with stroke. DESIGN: Randomized control trial. SETTING: Outpatient rehabilitation center in a medical center. POPULATION: Thirty-two stroke patients with spastic equinus (18 males and 14 women; mean age, 60.1±10.6 years). METHODS: Patients were randomly assigned to receive three sessions of either focused or radial shock wave therapy at 1-week intervals. The intensities that were used during focused shock wave therapy (0.12 mJ/mm2) and radial shock wave therapy (2.4 bar) were comparable. The patients were evaluated at baseline and at 1, 4, and 8 weeks after the final shockwave treatment. The primary outcome measure was change of modified Ashworth Scale Score of gastrocnemius muscle. The secondary outcome measures were Tardieu Scale, ankle passive range of motion, dynamic foot contact area and gait speed. A linear mixed model with repeated measures was used to compare each outcome measure between the two groups. RESULTS: Both groups improved significantly in terms of modified Ashworth Scale Score and Tardieu Scale, and no differences were found between the two groups. In terms of ankle passive range of motion and plantar contact area during gait, the radial shock wave therapy yielded a significantly greater improvement than the focused shock wave therapy. No significant changes were observed in gait speed in either group. CONCLUSIONS: Our study suggested that focused and radial shock wave therapy resulted in similar significant improvements in the modified Ashworth scale score and Tardieu scale, but those in the radial shock wave therapy group experienced greater improvements in the ankle passive range of motion and plantar contact area during gait. CLINICAL REHABILITATION IMPACT: Both focused and radial shock wave therapy yielded similar improve the spasticity of gastrocnemius muscle. Radial shock wave therapy is superior to focused shock wave therapy in terms of improving the ankle passive range of motion and plantar contact area during gait in patients with stroke.

Phenotypic Screening of Drug Library in Actively Differentiating Mouse Embryonic Stem Cells.

Phenotypic screening enables the discovery of new drug leads with novel targets. ES cells differentiate into different lineages by successively making use of different subsets of the genome's possible macromolecular interactions. If a compound effectively targets just one of these interactions, it derails the developmental pathway to produce a phenotypical change. The OTRADI microsource spectrum library of 2000 approved drug components, natural products, and bioactive components was screened for compounds that can induce phenotypic changes in ES cell cultures at 10 µM after 3 days. Twenty-one compounds that induced specific morphologies also induced unique changes to an expression profile of a dozen markers of early embryonic development, indicating that each compound has derailed the molecular developmental process in a characteristic way. Phenotypic screens conducted with ES cultures differentiating along different lineages can be used to efficiently prescreen compounds able to regulate cell differentiation lineage.

TERT promoter mutation in resectable hepatocellular carcinomas: a strong association with hepatitis C infection and absence of hepatitis B infection.

INTRODUCTION: Mutation in the core promoter of the telomerase reverse transcriptase (TERT) gene was determined to be a frequent event in malignant melanoma and other cancers. However, the role of TERT promoter mutation in hepatocellular carcinomas (HCCs) remains largely unknown. METHODS: Genomic DNA samples from the tumor tissue of 195 HCCs were analyzed for TERT promoter mutation at 2 hotspots (-124 and -146 bp from the ATG start site, g.1,295,228 and g.1,295,250, respectively) through direct sequencing. RESULTS: The TERT promoter mutation was identified in 57 of the 195 HCCs (29.2%) and was associated with old age (P = 0.0122), presence of anti-hepatitis C (HCV; P = 0.0048), and absence of hepatitis B surface antigen (HBsAg; P = 0.0007). However, the TERT promoter mutation did not correlate with serum α-fetoprotein levels, liver cirrhosis, tumor size, tumor grade, tumor stage, early tumor recurrence, ß-catenin mutation or p53 mutation. A multivariate analysis confirmed that the absence of hepatitis B infection is an independent factor associated with TERT promoter mutation. Furthermore, among HCC patients infected with hepatitis C, those with concomitant hepatitis B infection exhibited infrequent TERT promoter mutation (P = 0.0435). Remarkably, patients presenting with TERT promoter mutation-positive and -negative HCCs exhibited similar disease-free and overall survival rates. CONCLUSIONS: Our study indicated that the TERT promoter mutation frequently occurred in HCV-associated HCCs. The absence of Hepatitis B infection was significantly associated with the TERT promoter mutation. These findings suggest that various etiological factors may be involved in differing mechanisms to preserve telomeres during the carcinogenesis of HCCs.

Morphological subclassification of intrahepatic cholangiocarcinoma: etiological, clinicopathological, and molecular features.

On the basis of morphological features, we subclassified 189 intrahepatic cholangiocarcinomas into two subtypes: bile duct and cholangiolar. The cholangiolar type is composed of cuboidal to low columnar tumor cells that contain scanty cytoplasm. The bile duct type is composed of tall columnar tumor cells arranged in a large glandular pattern. In this study, 77 (41%) tumors were classified as the cholangiolar type and 112 (59%) tumors were classified as the bile duct type. The cholangiolar-type intrahepatic cholangiocarcinoma was more frequently associated with viral hepatitis, whereas all but one intrahepatic cholangiocarcinoma associated with intrahepatic lithiasis were classified as the bile duct type. Biliary intraepithelial neoplasm or intraductal papillary neoplasm of the bile duct could be identified in 50 bile duct-type intrahepatic cholangiocarcinomas (45%), but in only 3 cholangiolar-type intrahepatic cholangiocarcinomas (4%). Cholangiolar-type intrahepatic cholangiocarcinomas frequently expressed N-cadherin, whereas bile duct intrahepatic cholangiocarcinomas were more likely to express S100P, Trefoil factor 1, and anterior gradient 2. KRAS is mutated in 23 of 98 (23%) bile duct-type intrahepatic cholangiocarcinomas and in only 1 of 76 (1%) cholangiolar-type intrahepatic cholangiocarcinomas. Cholangiolar-type intrahepatic cholangiocarcinomas had a higher frequency of IDH1 or 2 mutations than did the bile duct-type intrahepatic cholangiocarcinomas. The molecular features of the bile duct-type intrahepatic cholangiocarcinoma were similar to those of hilar cholangiocarcinoma. Patients with the cholangiolar-type intrahepatic cholangiocarcinoma had higher 5-year survival rates than those of patients with the bile duct-type intrahepatic cholangiocarcinoma. Our results indicated that intrahepatic cholangiocarcinoma was a heterogeneous tumor. Subclassification of intrahepatic cholangiocarcinomas based on cholangiocytic differentiation divides them into two groups with different etiologies, clinical manifestations, and molecular pathogeneses.

p15(PAF) is an Rb/E2F-regulated S-phase protein essential for DNA synthesis and cell cycle progression.

The p15(PAF)/KIAA0101 protein is a proliferating cell nuclear antigen (PCNA)-associated protein overexpressed in multiple types of cancer. Attenuation of p15(PAF) expression leads to modifications in the DNA repair process, rendering cells more sensitive to ultraviolet-induced cell death. In this study, we identified that p15(PAF) expression peaks during the S phase of the cell cycle. We observed that p15(PAF) knockdown markedly inhibited cell proliferation, S-phase progression, and DNA synthesis. Depletion of p15(PAF) resulted in p21 upregulation, especially chromatin-bound p21. We further identified that the p15(PAF) promoter contains 3 E2F-binding motifs. Loss of Rb-mediated transcriptional repression resulted in upregulated p15(PAF) expression. Binding of E2F4 and E2F6 to the p15(PAF) promoter caused transcriptional repression. Overall, these results indicate that p15(PAF) is tightly regulated by the Rb/E2F complex. Loss of Rb/E2F-mediated repression during the G1/S transition phase leads to p15(PAF) upregulation, which facilitates DNA synthesis and S-phase progression.

Hepatocyte growth factor activates Wnt pathway by transcriptional activation of LEF1 to facilitate tumor invasion.

Hepatocyte growth factor (HGF) is a secretory protein that plays important roles in cancer growth and metastasis. Lymphoid-enhancing factor 1 (LEF1) is a transcription factor mediating Wnt/ß-catenin signaling. Using microarray analysis, we found HGF induced expression of LEF1 in liver and breast cancer cell lines. HGF induced expression of LEF1 through phosphatidylinositol 3-kinase/Akt and nuclear factor-kappa B (NF-κB) signaling. Multiple NF-κB-binding sites were mapped within 3 kb upstream of LEF1 transcription initiation site. NF-κB binding to a site 2 kb upstream of LEF1 transcription initiation site was confirmed by chromatin immunoprecipitation assay. Knockdown of LEF1 inhibited the expression of Slug and Zinc finger E-box-binding homeobox 2 (ZEB2) and markedly attenuated HGF-induced tumor migration and invasion. Using immunohistochemical staining, we found LEF1 was frequently expressed in multiple types of carcinoma but not in the non-tumorous epithelial cells. Our finding suggest that transcriptional activation of LEF1 is a mechanism of cross talk between HGF/c-Met and Wnt/ß-catenin pathways and is essential for HGF-induced tumor invasion.

A novel DNA selection and direct extraction process and its application in DNA recombination.

In the conventional bench-top approach, the DNA recombination process is time- and effort-consuming due to laborious procedures lasting from several hours to a day. A novel DNA selection and direct extraction process has been proposed, integrated and tested on chip. The integrative microfluidic chip can perform the whole procedure of DNA recombination, including DNA digestion, gel electrophoresis, DNA extraction and insert-vector ligation within 1 h. In this high-throughput design, the manual gel cutting was replaced by an automatic processing system that performed high-quality and high-recovery efficiency in DNA extraction process. With no need of gel-dissolving reagents and manipulation, the application of selection and direct extraction process could significantly eliminate the risks from UV and EtBr and also facilitate DNA recombination. Reliable output with high success rate of cloning has been achieved with a significant reduction in operational hazards, required materials, efforts and time.