Development of the Addenbrooke's MSK screening tool (AMST) for children and adolescents with cystic fibrosis.

Background: Musculoskeletal (MSK) issues are common in the paediatric population and in people with CF. There is currently no MSK screening tool for children and adolescents with CF. Methods: The protocol to develop the pGALS (paediatric Gait, Arms, Legs, Spine) was followed to create this screening tool. Paediatric respiratory and MSK physiotherapists, and paediatric respiratory doctors at a large teaching hospital were involved in the creation of this tool. This was then reviewed by paediatric respiratory doctors and physiotherapists at a second large teaching hospital with amendments added. One year data of this screening tool used on children over 7 was collected and analysed as a secondary outcome of this project. Results: There were 81.8 % more positive screens for MSK issues in the newly developed screening tool compared to the year using Manchester MSK screening tool; there were also 6 more referrals all deemed as appropriate by the services referred to. Almost half of the population screened using the developed tool were positive for an MSK issue, this was commonly related to poor posture or correctable kyphosis. Kyphosis, as measured by plumb line, appeared to be associated with negative health outcomes in this population; pectoralis major length was also associated with kyphosis and these negative health outcomes. Conclusion: The development of this tool has followed the protocol set out by the PGALs and has shown some promise with interesting initial results. This tool will need further validation before it is used in the wider paediatric CF population.

A distinct and reproducible teleconnection pattern over North America during extreme El Niño events.

El Niño-Southern Oscillation (ENSO) teleconnections are an important predictability source for extratropical seasonal climate forecasts. Previous studies suggest that the ENSO teleconnection pattern depends on the ENSO phase (El Niño vs. La Niña) and/or Sea Surface Temperature (SST) pattern (central Pacific vs. eastern Pacific El Niño events). Observations and ensemble simulations with the CNRM-CM6.1 atmospheric general circulation model indicate that only extreme El Niño events (e.g. 1982-1983, 1997-1998, 2015-2016) display a statistically significant eastward shift relative to the well-known Pacific-North American teleconnection pattern that occurs during both central and eastern Pacific moderate El Niño or during La Niña. This specific teleconnection pattern emerges when equatorial SST anomalies are both eastward-shifted and sufficiently large to exceed the deep atmospheric convection threshold over most of the eastern Pacific, resulting in a basin-wide reorganization of tropospheric heat sources. It yields> 0.5 std wet conditions over Western United States (74% likelihood) as well as> 0.5 std warm anomalies over Canada and the Northern United States (71% likelihood), with more consistency across events and ensemble members than for any other El Niño or La Niña type. These findings hold important implications for the seasonal forecasting of El Niño's impacts on the North American climate.

Heterogeneous splicing patterns resulting from KIF5A variants associated with amyotrophic lateral sclerosis.

Single-nucleotide variants (SNVs) in the gene encoding Kinesin Family Member 5A (KIF5A), a neuronal motor protein involved in anterograde transport along microtubules, have been associated with amyotrophic lateral sclerosis (ALS). ALS is a rapidly progressive and fatal neurodegenerative disease that primarily affects the motor neurons. Numerous ALS-associated KIF5A SNVs are clustered near the splice-site junctions of the penultimate exon 27 and are predicted to alter the carboxy-terminal (C-term) cargo-binding domain of KIF5A. Mis-splicing of exon 27, resulting in exon exclusion, is proposed to be the mechanism by which these SNVs cause ALS. Whether all SNVs proximal to exon 27 result in exon exclusion is unclear. To address this question, we designed an in vitro minigene splicing assay in human embryonic kidney 293 cells, which revealed heterogeneous site-specific effects on splicing: only 5' splice-site (5'ss) SNVs resulted in exon skipping. We also quantified splicing in select clustered, regularly interspaced, short palindromic repeats-edited human stem cells, differentiated to motor neurons, and in neuronal tissues from a 5'ss SNV knock-in mouse, which showed the same result. Moreover, the survival of representative 3' splice site, 5'ss, and truncated C-term variant KIF5A (v-KIF5A) motor neurons was severely reduced compared with wild-type motor neurons, and overt morphological changes were apparent. While the total KIF5A mRNA levels were comparable across the cell lines, the total KIF5A protein levels were decreased for v-KIF5A lines, suggesting an impairment of protein synthesis or stability. Thus, despite the heterogeneous effect on ribonucleic acid splicing, KIF5A SNVs similarly reduce the availability of the KIF5A protein, leading to axonal transport defects and motor neuron pathology.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. OUTCOMES AND ANALYSIS: We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. RESULTS: We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. CONCLUSIONS: Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Ex-vivo articular cartilage removal from equine proximal interphalangeal joints using cannulated drill bits.

Objective: This report evaluates the use of 4.5- and 5.5-mm cannulated drill bits for articular cartilage removal from the proximal interphalangeal joints of equine cadaver limbs. Animals: Limbs from 8 equine cadavers, all with normal proximal interphalangeal joints. Procedure: Proximal interphalangeal joints of 32 limbs from 8 equine cadavers were drilled using either 4.5- or 5.5-mm cannulated drill bits. Pastern joints were then disarticulated, and intra-articular drilling was evaluated by visual inspection. Results: Post-drilling evaluation revealed complete intra-articular drilling occurred in all 32 joints. Conclusion: Canulated 4.5- and 5.5-mm drill bits resulted in consistent accurate intra-articular drilling in the proximal interphalangeal joint of horses. Clinical relevance: Cannulated drill bits provided an effective and consistent modality for articular cartilage removal with potential for improved accuracy of articular drilling and applications in minimally invasive proximal interphalangeal joint arthrodesis.

Objectif: Ce rapport évalue l'utilisation de forets canulés de 4,5 et 5,5 mm pour l'élimination du cartilage articulaire des articulations interphalangiennes proximales des membres de cadavres équins. Animaux: Membres provenant de huit cadavres équins, tous avec des articulations interphalangiennes proximales normales. Procédure: Les articulations interphalangiennes proximales de 32 membres de huit cadavres équins ont été percées à l'aide de forets canulées de 4,5 ou 5,5 mm. Les articulations du paturon ont ensuite été désarticulées et le forage intraarticulaire a été évalué par inspection visuelle. Résultats: L'évaluation post-forage a révélé qu'un forage intra-articulaire complet s'était produit dans les 32 articulations. Conclusion: Les forets canulés de 4,5 et 5,5 mm ont permis un forage intra-articulaire précis et constant dans l'articulation interphalangienne proximale des chevaux. Pertinence clinique: Les forets canulés ont fourni une modalité efficace et constante pour l'élimination du cartilage articulaire avec un potentiel d'amélioration de la précision du forage articulaire et des applications dans l'arthrodèse de l'articulation interphalangienne proximale de manière minimalement invasive.(Traduit par Dr Serge Messier).

Near Infrared Fluorescence Imaging to Demonstrate Reflux in the Superficial Microvenous Network of the Leg.

OBJECTIVE: Reflux within the superficial microvenous network may play a critical role in the development of skin changes which can be associated with chronic venous insufficiency. This study aimed to determine if near infrared fluorescence (NIRF) imaging could be used to accurately determine superficial venous reflux in the leg. METHODS: A total of nine limbs were examined ex vivo from patients undergoing limb amputation for peripheral arterial disease. Cannulation of the distal great saphenous vein was used to sequentially perform Xray contrast enhanced venography, NIRF imaging, and venous corrosion casts. RESULTS: Fluorescence imaging visualised a range of different microvenous reflux patterns ex vivo, which were generally not evident by Xray venography but were consistent with retrograde resin vascular casts. These included both focal and diffuse regions of fluorescence within the skin and, consistent with previous observations, the vascular casts indicated that regions of venous reflux were typically associated with incompetent valves. CONCLUSION: The findings from this study suggest a potential method for investigating early stage superficial venous disease, prior to the appearance of visible signs of advanced venous disease, such as skin changes. However, further studies are required to confirm the in vivo clinical utility of these observations.

The procoagulant effects of extracellular vesicles derived from hypoxic endothelial cells can be selectively inhibited by inorganic nitrite.

BACKGROUND: Extracellular vesicles (EVs) derived from endothelial cells are elevated in cardiovascular disease and promote inflammation and coagulation. Hypoxia is often a key feature and is itself a potent stimulator of increased EV production. Inorganic nitrite (NO2-) has beneficial and protective effects that are enhanced in hypoxia. OBJECTIVES: Investigate the impact of hypoxia on the functional capacity of EV derived from endothelial cells under hypoxia, and assess whether pre-treatment of endothelial cells with NO2- can alter EV function. METHODS: Differential ultracentrifugation was used to isolate EV from the cultured endothelial cell line HECV (CEV), and from primary human umbilical cord derived endothelial cells (PEV), with time-resolved fluorescence used to assess EV protein composition. Clot formation was induced by thrombin and calcium in two assays; using an Alexa Fluor 594 human fibrinogen conjugate assay and standard turbidometry. Platelet aggregation was determined using multiple electrode aggregometry. Scanning electron microscopy was used to visualise fibrin clots. RESULTS: Hypoxia exposure (1% O2) significantly increased CEV production in comparison to normoxia (21% O2) (1825 ± 72 EVs/cell vs 117 ± 9 EVs/cell, p < 0.001, respectively) but had no effect on CEV mean size (221 ± 6 nm vs 203 ± 4 nm, p > 0.05). Hypoxia-derived PEVs contained significantly more tissue factor than normoxia-derived EVs (Relative Fluorescence Units (RFU) = 7666 ± 1698 vs 5958 ± 1644, p < 0.001, respectively) and less tissue factor pathway inhibitor (RFU = 9799 ± 2353 vs 19723 ± 2698, p < 0.05). Hypoxia significantly increased CEV induced fibrin polymer formation compared to normoxia (% area = 46.98 ± 0.97 vs 36.36 ± 0.72, p < 0.05). Pre-treatment of endothelial cells with NO2- in hypoxia abrogated this effect (% area = 15.70 ± 1.99, p < 0.001). Hypoxia derived CEV non-significantly increased the maximum clot formed, shortened time to max clot, and increased time to clot lysis by turbidometry. ADP-mediated platelet aggregation was significantly elevated with PEV derived from hypoxia compared to normoxia (888.0 ± 32.2 AU*min vs 671.5.2 ± 28.3 AU*min, p < 0.01). This was abrogated by pre-treatment of hypoxic endothelial cells with NO2- (716.5 ± 744.3 AU*min, p < 0.001). CONCLUSIONS: Hypoxia-derived PEVs and CEVs exhibit increased procoagulant activity compared to normoxia-derived EVs, which we confirm to be mediated by an imbalance of TF/TFPI. Pre-treatment of endothelial cells with NO2- reduces the pro-coagulant activity of EVs via a mechanism that is Hypoxia-inducible factor 1 (HIF-1) dependent, but independent of TF/TFPI.

Enhanced fluorescence from semiconductor quantum dot-labelled cells excited at 280 nm.

Semiconductor quantum dots (QDs) have significant advantages over more traditional fluorophores used in fluorescence microscopy including reduced photobleaching, long-term photostability and high quantum yields, but due to limitations in light sources and optics, are often excited far from their optimum excitation wavelengths in the deep-UV. Here, we present a quantitative comparison of the excitation of semiconductor QDs at a wavelength of 280 nm, compared to the longer wavelength of 365 nm, within a cellular environment. We report increased fluorescence intensity and enhanced image quality when using 280 nm excitation compared to 365 nm excitation for cell imaging across multiple datasets, with a highest average fluorescence intensity increase of 3.59-fold. We also find no significant photobleaching of QDs associated with 280 nm excitation and find that on average, ∼80% of cells can tolerate exposure to high-intensity 280 nm irradiation over a 6-hour period.

Wavefront-sensorless adaptive optics with a laser-free spinning disk confocal microscope.

Adaptive optics is being applied widely to a range of microscopies in order to improve imaging quality in the presence of specimen-induced aberrations. We present here the first implementation of wavefront-sensorless adaptive optics for a laser-free, aperture correlation, spinning disk microscope. This widefield method provides confocal-like optical sectioning through use of a patterned disk in the illumination and detection paths. Like other high-resolution microscopes, its operation is compromised by aberrations due to refractive index mismatch and variations within the specimen. Correction of such aberrations shows improved signal level, contrast and resolution.

Python-Microscope - a new open-source Python library for the control of microscopes.

Custom-built microscopes often require control of multiple hardware devices and precise hardware coordination. It is also desirable to have a solution that is scalable to complex systems and that is translatable between components from different manufacturers. Here we report Python-Microscope, a free and open-source Python library for high-performance control of arbitrarily complex and scalable custom microscope systems. Python-Microscope offers simple to use Python-based tools, abstracting differences between physical devices by providing a defined interface for different device types. Concrete implementations are provided for a range of specific hardware, and a framework exists for further expansion. Python-Microscope supports the distribution of devices over multiple computers while maintaining synchronisation via highly precise hardware triggers. We discuss the architectural features of Python-Microscope that overcome the performance problems often raised against Python and demonstrate the different use cases that drove its design: integration with user-facing projects, namely the Microscope-Cockpit project; control of complex microscopes at high speed while using the Python programming language; and use as a microscope simulation tool for software development.

Treatment of temporohyoid osteoarthropathy in horses with a basihyoid-ceratohyoid disarticulation technique: 6 cases (2018-2019).

OBJECTIVE: To describe a technique for basihyoid-ceratohyoid disarticulation (BCD) in standing sedated horses affected by temporohyoid osteoarthropathy (THO) and report outcomes for horses that underwent the procedure. ANIMALS: 6 client-owned horses. PROCEDURES: Electronic medical records of a veterinary teaching hospital were searched to identify horses that underwent BCD for treatment of THO from 2018 to 2019. Signalment, clinical data, use of the horse, and complications were recorded. Follow-up data obtained by telephone interview with owners included the clinical outcome and time to improvement after surgery, any persistent clinical signs, horse's activity level before onset of clinical signs and after BCD, subsequent use of the horse, and whether they would pursue the same treatment again. RESULTS: All horses tolerated the procedure well, with no complications and improved neurologic function after BCD. Five of 6 horses had a reported activity level equal to or greater than that prior to having signs of THO. Three of 3 horses with acute ataxia prior to BCD reportedly had full resolution of this sign; 3 of 4 horses with facial nerve deficits prior to BCD had mild residual facial nerve deficits at follow-up. All owners indicated they would pursue BCD again. CONCLUSIONS AND CLINICAL RELEVANCE: The BCD procedure was performed safely in this sample of THO-affected horses that were sedated while standing, avoiding risks associated with general anesthesia and resulting in no adverse effects such as iatrogenic injury to neurovascular structures.

Microscope-Cockpit: Python-based bespoke microscopy for bio-medical science.

We have developed "Microscope-Cockpit" (Cockpit), a highly adaptable open source user-friendly Python-based Graphical User Interface (GUI) environment for precision control of both simple and elaborate bespoke microscope systems. The user environment allows next-generation near instantaneous navigation of the entire slide landscape for efficient selection of specimens of interest and automated acquisition without the use of eyepieces. Cockpit uses "Python-Microscope" (Microscope) for high-performance coordinated control of a wide range of hardware devices using open source software. Microscope also controls complex hardware devices such as deformable mirrors for aberration correction and spatial light modulators for structured illumination via abstracted device models. We demonstrate the advantages of the Cockpit platform using several bespoke microscopes, including a simple widefield system and a complex system with adaptive optics and structured illumination. A key strength of Cockpit is its use of Python, which means that any microscope built with Cockpit is ready for future customisation by simply adding new libraries, for example machine learning algorithms to enable automated microscopy decision making while imaging.

Grandiose narcissists and decision making: Impulsive, overconfident, and skeptical of experts-but seldom in doubt.

A substantial body of research has documented that grandiose narcissists are characterized by high self-esteem, a sense of personal superiority and entitlement, overconfidence, a willingness to exploit others for self-gain, and hostility and aggression when challenged. We report two studies (N = 452) that explore how these dispositions affect their decision making. We show that grandiose narcissists' overconfidence, impulsivity, and a willingness to ignore expert advice results in a higher likelihood of making a bad decision. In addition, after getting the wrong answer, grandiose narcissists are more likely to blame others and remain self-confident in their judgment.

Microscope-AOtools: a generalised adaptive optics implementation.

Aberrations arising from sources such as sample heterogeneity and refractive index mismatches are constant problems in biological imaging. These aberrations reduce image quality and the achievable depth of imaging, particularly in super-resolution microscopy techniques. Adaptive optics (AO) technology has been proven to be effective in correcting for these aberrations, thereby improving the image quality. However, it has not been widely adopted by the biological imaging community due, in part, to difficulty in set-up and operation of AO. The methods for doing so are not novel or unknown, but new users often waste time and effort reimplementing existing methods for their specific set-ups, hardware, sample types, etc. Microscope-AOtools offers a robust, easy-to-use implementation of the essential methods for set-up and use of AO elements and techniques. These methods are constructed in a generalised manner that can utilise a range of adaptive optics elements, wavefront sensing techniques and sensorless AO correction methods. Furthermore, the methods are designed to be easily extensible as new techniques arise, leading to a streamlined pipeline for new AO technology and techniques to be adopted by the wider microscopy community.

Targeted Delivery of Doxorubicin Liposomes for Her-2+ Breast Cancer Treatment.

The adverse side effects and toxicity caused by the non-targeted delivery of doxorubicin has emphasized the demand of emerging a targeted delivery system. The goal of this study is to enhance the delivery of doxorubicin by formulating an aptamer-labeled liposomal nanoparticle delivery system that will carry and deliver doxorubicin specifically into Her-2+ breast cancer cells. Twelve liposomal batches were prepared using different saturated (HSPC and DPPC) and unsaturated (POPC and DOPC) lipids by thin film hydration. The liposomes were characterized for their particle size, zeta potential, and drug encapsulation efficiency. The particles were also assessed for in vitro toxicity and DOX delivery into the breast cancer cells. The formulations, F1 through F12, had a small particle size of less than 200 nm and a high entrapment efficiency of about 88 ± 5%. The best formulation, F5, had a particle size of 101 ± 14nm, zeta potential of + 5.63 ± 0.46 mV, and entrapment efficiency of ≈ 93%. The cytotoxicity studies show that the DOX-loaded liposomal formulations are more effective in killing cancer cells than the free DOX in both MCF-7 and SKBR-3 cells. The uptake studies show a significant increase in the uptake of the aptamer-labeled liposomes (i.e., F5) by more than 60% into Her-2+ MCF-7 and SKBR-3 breast cancer cells compare to non-aptamer-labeled nanoparticles. F5 also shows ≈ 1.79-fold increase in uptake of DOX in the Her-2+ cells compared to the Her-2- cells. This preliminary study indicates that aptamer-labeled F5 nanoparticles among several batches showed the highest uptake as well as the targeted delivery of doxorubicin into Her-2+ breast cancer cells. Thus, aptamer targeted approach results in substantial reduction in the dose of DOX and improves the therapeutic benefits by promoting the target specificity.

Aptamer-functionalized Hybrid Nanoparticles to Enhance the Delivery of Doxorubicin into Breast Cancer Cells by Silencing P-glycoprotein.

OBJECTIVE: The MDR of metastatic breast cancer cells is accompanied by the overexpression of P-gp transporter. This study has been focused to determine whether silencing the expression of P-gp by aptamer-labeled siRNA nanoparticles could enhance the delivery of doxorubicin into breast cancer cells in culture. METHODOLOGY: The nanoparticle F-31 was prepared using DOTAP, cholesterol, and PLGA, and then incorporating Mal-PEG to facilitate aptamer-binding. The nanoparticles were surface-functionalized with aptamer A6, which targets Her-2 receptors overexpressed on the surface of breast cancer cells. RESULTS: This study has shown that the uptake of Dox by Dox-resistant 4T1-R is significantly less than Dox-sensitive 4T1-S which is partly attributed to the higher expression of drug-efflux pump P-gp on the surface of the resistant cells. The targeted knockdown of P-gp has been enhanced when the particles carrying P-gp siRNA was labeled with aptamer. Concurrently, the uptake of Dox into the Dox-resistant 4T1-R breast cancer cells has increased significantly when the P-gp was silenced by P-gp siRNA-encapsulated aptamer-labeled nanoparticles. CONCLUSIONS: This preliminary study concludes that downregulating P-gp expression by targeted delivery of P-gp siRNA using aptamer-labeled lipid-based hybrid nanoparticles could effectively increase the intracellular trafficking of doxorubicin in Dox-resistant mouse breast cancer cells.

Repeated spontaneous intra-tumoural and subarachnoid haemorrhage in an anticoagulated patient with a previously-irradiated vestibular Schwannoma: Case report.

Subarachnoid hemorrhage caused by vestibular schwannomas (VS) is rare with no clear pathological mechanism supported in the existing literature. However, anticoagulation treatment as well as previous radiation therapy appear to be a crucial risk factor for subarachnoid haemorrhage from a VS. We report an unusual case of both intratumoural and subarachnoid haemorrhage in a patient with a VS on anticoagulation treatment previously treated with stereotactic radiosurgery. We emphasize the need for caution when considering the use of radiation therapy for treatment of VS in patients on chronic anticoagulation therapy.

When Ventricular Cerebrospinal Fluid Assessment Misleads: Basal Meningitis and the Importance of Lumbar Puncture Sampling.

The diagnosis of central nervous system (CNS) infection relies upon analysis of cerebrospinal fluid (CSF). We present 4 cases of CNS infections associated with basal meningitis and hydrocephalus with normal ventricular CSF but grossly abnormal lumbar CSF. We discuss CSF ventricular-lumbar composition gradients and putative pathophysiological mechanisms and highlight clinical clues for clinicians.

Dietary Nitrate Supplementation Reduces Circulating Platelet-Derived Extracellular Vesicles in Coronary Artery Disease Patients on Clopidogrel Therapy: A Randomised, Double-Blind, Placebo-Controlled Study.

Extracellular vesicles (EVs) are implicated in the pathogenesis of cardiovascular disease (CVD). Specifically, platelet-derived EVs are highly pro-coagulant, promoting thrombin generation and fibrin clot formation. Nitrate supplementation exerts beneficial effects in CVD, via an increase in nitric oxide (NO) bioavailability. Clopidogrel is capable of producing NO-donating compounds, such as S-nitrosothiols (RSNO) in the presence of nitrite and low pH. The aim of this study was to assess the effect of nitrate supplementation with versus without clopidogrel therapy on circulating EVs in coronary artery disease (CAD) patients. In this randomized, double-blind, placebo-controlled study, CAD patients with (n = 10) or without (n = 10) clopidogrel therapy received a dietary nitrate supplement (SiS nitrate gel) or identical placebo. NO metabolites and platelet activation were measured using ozone-based chemiluminescence and multiple electrode aggregometry. EV concentration and origin were determined using nanoparticle tracking analysis and time-resolved fluorescence. Following nitrate supplementation, plasma RSNO was elevated (4.7 ± 0.8 vs 0.2 ± 0.5 nM) and thrombin-receptor mediated platelet aggregation was reduced (-19.9 ± 6.0 vs 4.0 ± 6.4 U) only in the clopidogrel group compared with placebo. Circulating EVs were significantly reduced in this group (-1.183e11 ± 3.15e10 vs -9.93e9 ± 1.84e10 EVs/mL), specifically the proportion of CD41+ EVs (-2,120 ± 728 vs 235 ± 436 RFU [relative fluorescence unit]) compared with placebo. In vitro experiments demonstrated clopidogrel-SNO can reduce platelet-EV directly (6.209e10 ± 4.074e9 vs 3.94e11 ± 1.91e10 EVs/mL). In conclusion, nitrate supplementation reduces platelet-derived EVs in CAD patients on clopidogrel therapy, increasing patient responsiveness to clopidogrel. Nitrate supplementation may represent a novel approach to moderating the risk of thrombus formation in CAD patients.

Evaluating Management and Change in Glycemic Control After Discontinuation of Metformin in Patients With Elevated Serum Creatinine.

Recently revised FDA labeling allows many patients with mild-to-moderate kidney disease to benefit from treatment with metformin.