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Clinical trial enrollment provides various benefits to study participants including early access to novel therapies that may potentially alter the trajectory of disease states. Trial sponsors benefit from enrolling demographically diverse trial participants enabling the trial outcomes to be generalizable to a larger proportion of the community at large. Despite these and other well-documented benefits, clinical trial enrollment for Black and Hispanic Americans as well as women continues to be low. Specific disease states such as peripheral artery disease (PAD) have a higher prevalence and clinical outcomes are relatively worse in Black Americans compared with non-Hispanic white Americans. The recruitment process for PAD clinical trials can be costly and challenging and usually comes at the expense of representation. Participant willingness and trust, engagement, and socioeconomic status play essential roles in the representation of under-represented minority (URM) groups. Despite the contrary belief, URM groups such as Blacks and Hispanics are just as willing to participate in a clinical trial as non-Hispanic Whites. However, financial burdens, cultural barriers, and inadequate health literacy and education may impede URMs' access to clinical trials and medical care. Clinical trials' enrollment sites often pose transportation barriers and challenges that negatively impact creating a diverse study population. Lack of diversity among a trial population can stem from the stakeholder level, where corporate sponsors of academic readers do not consider diversity in clinical trials a priority due to false cost-benefit assumptions. The funding source may also impact the racial reporting or the results of a given trial. Industry-based trials have always been criticized for over-representing non-Hispanic White populations, driven by the desire to reach high completion rates with minimum financial burdens. Real efforts are warranted to ensure adequate minorities' representation in the PAD clinical trials and to the process toward the ultimate goal of developing more durable and effective PAD treatments that fit the needs of real-world populations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Whole genome sequencing (WGS) is being used in diagnostic testing for certain clinical indications within the NHS Genomic Medicine Service (GMS) in England. Letter writing is an integral part of delivering results. However, no national guidelines for writing results from WGS exist. This multi-centre service evaluation used mixed methods to understand the content and readability of letters returning diagnostic, variant of uncertain significance (VUS), and no-finding results to paediatric rare disease patients. Eight Regional Genetics Services (response rate 47%) in England provided a total of 37 letters returning diagnostic (n = 13), VUS (n = 10), and no-finding (n = 14) results. Diagnostic and VUS results were usually delivered during an appointment; no-finding results were typically delivered by letter only. Letters were diverse in which content topics they covered and level of detail. No-finding letters (14/14) explained the result but were less likely to cover other topics. Diagnostic letters discussed the result (13/13), the condition (13/13), clinical genetics follow-up (13/13), clinical management (10/13), and adapting to the result (9/13). VUS letters explained the result (10/10), diagnostic uncertainty (10/10), and clinical genetics follow-up (10/10). Uncertainty was a common component of letters (33/37), irrespective of the result. Reanalysis or review after one or more years was suggested in 6/13 diagnostic, 7/10 VUS, and 6/14 no-finding letters. The mean reading level of letters corresponded to 15-17 years. Understanding how WGS results are conveyed to families during appointments, as well as how families interpret that information, is needed to provide a more comprehensive overview of results communication and inform best practices., Competing Interests: Competing interests The authors declare no competing interests. Ethical approval Multi-centre governance approval was gained from the University College London Great Ormond Street Institute of Child Health Research & Development department on 10th June 2021 (reference 21PP11). A review by an ethics committee was not required for a service evaluation study., (© 2024. The Author(s).)

Objective: Mental health issues increased during the COVID - 19 pandemic, especially among children. Our past research efforts found that surveillance data can address a variety of health concerns; that personal psychological awareness impacted ability to cope, and mental health outcomes were improved when survivors were triaged to mental health countermeasures. To build upon our public health efforts, we wanted to see if increased screen time due to remote learning caused by the pandemic influenced school aged children's mental health., Methods: With the hypothesis that excessive time spent isolated during remote learning increased the amount of mental health events in children, we conducted a public health surveillance project on actual diagnoses rather than just symptoms, controlling for historical mental health and emotional disorders., Results: The entire cohort of children aged 6 to 17 years were studied over time before and during the pandemic for their medically diagnosed mental health and emotional outcomes by the amount of pandemic induced social isolation., Conclusions: After controlling for historical diagnoses and the rate of COVID - 19, the effect of pandemic - induced social isolation had a linear increase on the amount of anxiety, resulting in a 4-fold increase in pandemic social isolation - induced anxiety.

Background: Children with intellectual disability frequently have multiple co-morbid neuropsychiatric conditions and poor physical health. Genomic testing is increasingly recommended as a first-line investigation for these children. We aim to determine the effect of genomics, inheritance, and socioeconomic deprivation on neuropsychiatric risk in children with intellectual disability of genetic origin as compared with the general population., Methods: IMAGINE is a prospective cohort study using online mental health and medical assessments in a cohort of 3407 UK participants with intellectual disability and pathogenic genomic variants as identified by the UK's National Health Service (NHS). Our study is on a subset of these participants, including all children aged 4-19 years. We collected diagnostic genomic reports from NHS records and asked primary caregivers to provide an assessment of their child using the Development and Well-Being Assessment (DAWBA), the Strengths and Difficulties Questionnaire (SDQ), the Adaptive Behaviour Assessment System 3 (ABAS-3), and a medical history questionnaire. Each child was assigned a rank based on their postcode using the index of multiple deprivation (IMD). We compared the IMAGINE cohort with the 2017 National Survey of Children's Mental Health in England. The main outcomes of interest were mental health and neurodevelopment according to the DAWBA and SDQ., Findings: We recruited 2770 children from the IMAGINE study between Oct 1, 2014 and June 30, 2019, of whom 2397 (86·5%) had a basic assessment of their mental health completed by their families and 1277 (46·1%) completed a medical history questionnaire. The mean age of participants was 9·2 years (SD 3·9); 1339 (55·9%) were boys and 1058 (44·1%) were girls. 355 (27·8%) of 1277 reported a seizure disorder and 814 (63·7%) reported movement or co-ordination problems. 1771 (73·9%) of 2397 participants had a pathogenic copy number variant (CNV) and 626 (26·1%) had a pathogenic single nucleotide variant (SNV). Participants were representative of the socioeconomic spectrum of the UK general population. The relative risk (RR) of co-occurring neuropsychiatric diagnoses, compared with the English national population, was high: autism spectrum disorder RR 29·2 (95% CI 23·9-36·5), ADHD RR 13·5 (95% CI 11·1-16·3). In children with a CNV, those with a familial variant tended to live in more socioeconomically deprived areas than those with a de novo variant. Both inheritance and socioeconomic deprivation contributed to neuropsychiatric risk in those with a CNV., Interpretation: Children with genomic variants and intellectual disability are at an increased risk of neuropsychiatric difficulties. CNV variant inheritance and socioeconomic deprivation also contribute to the risk. Early genomic investigations of children with intellectual disability could facilitate the identification of the most vulnerable children. Additionally, harnessing parental expertise using online DAWBA assessments could rapidly identify children with exceptional needs to child mental health services., Funding: UK Medical Research Council and Medical Research Foundation., Competing Interests: Declaration of interests FLR and ERM were supported by Cambridge National Institute of Health Research (NIHR) Biomedical Research Centre. SJRAC is supported by an Institutional Strategic Support Fund Wellcome Trust Fellowship (204824/Z/16/Z) and RS from a Wellcome Trust grant (211163/Z/18/Z). EM and FLR receive salary support through the University of Cambridge from the NHS in the East of England through the Clinical Academic Reserve. All other authors declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Traumatic brain injury (TBI) is a global health problem, whose management in low-resource settings is hampered by fragile health systems and lack of access to specialist services. Improvement is complex, given the interaction of multiple people, processes and institutions. We aimed to develop a mixed-method approach to understand the TBI pathway based on the lived experience of local people, supported by quantitative methodologies and to determine potential improvement targets., Design: We describe a systems approach based on narrative exploration, participatory diagramming, data collection and discrete event simulation (DES), conducted by an international research collaborative., Setting: The study is set in the tertiary neurotrauma centre in Yangon General Hospital, Myanmar, in 2019-2020 (prior to the SARS-CoV2 pandemic)., Participants: The qualitative work involved 40 workshop participants and 64 interviewees to explore the views of a wide range of stakeholders including staff, patients and relatives. The 1-month retrospective admission snapshot covered 85 surgical neurotrauma admissions., Results: The TBI pathway was outlined, with system boundaries defined around the management of TBI once admitted to the neurosurgical unit. Retrospective data showed 18% mortality, 71% discharge to home and an 11% referral rate. DES was used to investigate the system, showing its vulnerability to small surges in patient numbers, with critical points being CT scanning and observation ward beds. This explorative model indicated that a modest expansion of observation ward beds to 30 would remove the flow-limitations and indicated possible consequences of changes., Conclusions: A systems approach to improving TBI care in resource-poor settings may be supported by simulation and informed by qualitative work to ground it in the direct experience of those involved. Narrative interviews, participatory diagramming and DES represent one possible suite of methods deliverable within an international partnership. Findings can support targeted improvement investments despite coexisting resource limitations while indicating concomitant risks., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The aim of this quality improvement project was to reduce the rate of severe intraventricular hemorrhage (sIVH) by 50% within 3 years for extremely preterm infants born at a children's teaching hospital., Methods: A multidisciplinary team developed key drivers for the development of intraventricular hemorrhage in preterm infants. Targeted interventions included the development of potentially better practice guidelines, promoting early noninvasive ventilation, consistent use of rescue antenatal betamethasone, and risk-based indomethacin prophylaxis. The outcome measure was the rate of sIVH. Process measures included the rate of intubation within 24 hours and receipt of rescue betamethasone and risk-based indomethacin prophylaxis. Common markers of morbidity were balancing measures. Data were collected from a quarterly chart review and analyzed with statistical process control charts. The preintervention period was from January 2012 to March 2016, implementation period was from April 2016 to December 2018, and sustainment period was through June 2020., Results: During the study period, there were 268 inborn neonates born at <28 weeks' gestation or <1000 g (127 preintervention and 141 postintervention). The rate of sIVH decreased from 14% to 1.2%, with sustained improvement over 2 and a half years. Mortality also decreased by 50% during the same time period. This was associated with adherence to process measures and no change in balancing measures., Conclusions: A multipronged quality improvement approach to intraventricular hemorrhage prevention, including evidence-based practice guidelines, consistent receipt of rescue betamethasone and indomethacin prophylaxis, and decreasing early intubation was associated with a sustained reduction in sIVH in extremely preterm infants., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: The effectiveness of occupation-based hand therapy and the barriers to the use of occupation-based interventions (OBIs) have been established, but the current experience of hand therapists using OBIs and the extent of the use of OBIs in practice is unknown., Objective: This study aimed to identify the frequency that occupational therapists who are Certified Hand Therapists (CHTs) utilized OBIs, how occupational therapists who are CHTs described their application of OBIs, and identify the supports and barriers to the application of OBIs., Methods: Twenty-nine participants completed a survey that included 27 questions. The questions consisted of close ended, Likert scale, and multiple-choice questions which were analyzed quantitatively, and open-ended questions which were analyzed qualitatively., Results: The majority of the participants, 57.7%, reported implementing OBI at least 75% of the time. Barriers and supports to the use of OBIs reported include a lack of equipment and therapist creativity, and support for the use of OBIs included the therapist's creativity, support from the facility, the availability of equipment, and the intrinsic motivation of therapists. Descriptions of OBI application included activity simulation, adaptive equipment use, and participation in meaningful activity., Conclusion: Although the use of OBIs in hand therapy may be expanding, occupational therapy practitioners and educators have a role to play in overcoming the remaining barriers to occupation-based hand therapy. Additional research is needed to gain further insight into use of occupation-based intervention by occupational therapists who are CHTs and explore the effect of education on promoting the use of OBIs.

Background: Early skin-to-skin care (SSC) has been shown to improve outcomes after preterm birth, including improved clinical stability and establishment of breastfeeding. Recent evidence suggests the most unstable infants get the most benefit, yet these infants are not consistently offered opportunities for SSC because of safety concerns and discomfort of the care team., Purpose: To identify barriers and implement a multidimensional approach to increase SSC within the first 72 hours of life among infants born less than 28 weeks' gestation and less than 1,000 g in a Level IV university-based regional intensive care nursery., Methods: Using Institute of Healthcare Improvement quality improvement methodology, a multidisciplinary team identified barriers to SSC and developed targeted interventions, including a unit-specific protocol; widespread parent, staff, and provider education; and an infant readiness checklist. The primary outcome was the rate of SSC within 72 hours. The balancing measure was the rate of severe intraventricular hemorrhage (IVH). Data were collected from monthly chart review and analyzed with statistical process control charts. The aim was to increase SSC within 72 hours of birth from 7 percent to greater than 80 percent within 12 months for infants born less than 28 weeks' gestation or less than 1,000 g., Results: Between June 2017 and December 2019, there were 52 extremely preterm infants included in the project (15 preintervention and 37 postintervention). The rate of SSC within the first 72 hours increased from 7 to 84 percent. There has been no increase in any or severe IVH during the project period despite the increased rate of SSC., Implications for Practice: Implementation of multidimensional, multidisciplinary interventions for reducing barriers to early SSC in extremely preterm infants resulted in rapid adoption of SSC in the first 72 hours of life without increasing severe IVH in this high-risk population., (© Copyright 2021 Springer Publishing Company, LLC.)

The notochord drives longitudinal growth of the body axis by convergent extension, a highly conserved developmental process that depends on non-canonical Wnt/planar cell polarity (PCP) signaling. However, the role of cell-matrix interactions mediated by integrins in the development of the notochord is unclear. We developed transgenic Cre mice, in which the β1 integrin gene ( Itgb1 ) is ablated at E8.0 in the notochord only or in the notochord and tail bud. These Itgb1 conditional mutants display misaligned, malformed vertebral bodies, hemi-vertebrae and truncated tails. From early somite stages, the notochord was interrupted and displaced in these mutants. Convergent extension of the notochord was impaired with defective cell movement. Treatment of E7.25 wild-type embryos with anti-β1 integrin blocking antibodies, to target node pit cells, disrupted asymmetric localization of VANGL2. Our study implicates pivotal roles of β1 integrin for the establishment of PCP and convergent extension of the developing notochord, its structural integrity and positioning, thereby ensuring development of the nucleus pulposus and the proper alignment of vertebral bodies and intervertebral discs. Failure of this control may contribute to human congenital spine malformations., Competing Interests: Competing interestsThe authors declare no competing or financial interests., (© 2020. Published by The Company of Biologists Ltd.)

Background: Goals-of-care conversations are a central component of high-quality patient-centered care. However, clinicians may not engage in such conversations until patients are critically ill., Objective: To assess the frequency and quality of goals-of-care conversation documentation among patients who died in an intensive care unit, and then to develop and implement mechanisms to improve the quantity and quality of such conversations., Methods: A baseline retrospective medical records review of intensive care unit deaths that occurred within 1 year was conducted to assess the barriers to high-quality goals-of-care conversations. A nurse-led inter-professional task force was formed to address possible solutions., Interventions: A new electronic health record tab, note type, and preformatted template known as a SmartPhrase for goals-of-care conversations were created. Nurses and physicians were educated and encouraged to perform and document goals-of-care conversations., Results: Before implementation of the initiative, the electronic health record lacked a consistent place to document goals-of-care conversations, and such conversations were not occurring until patients required intensive care. Moreover, the content of documentation of the conversations was inconsistent. Three years after implementation of the initiative, the goals-of-care conversation documentation tab was used for 75% of hospital deaths, and 67% of goals-of-care conversation notes included use of the SmartPhrase template., Conclusions: Electronic health record platforms can be used to improve the frequency, consistency of documentation, and quality of goals-of-care conversations. A standardized process coupled with effective work tools can foster a culture of advance care planning., (©2020 American Association of Critical-Care Nurses.)

Advances in cancer therapeutics have dramatically improved the survival rate and quality of life in patients affected by various cancers, but have been accompanied by treatment-related cardiotoxicity, e.g. left ventricular (LV) dysfunction and/or overt heart failure (HF). Cardiologists thus need to assess cancer treatment-related cardiotoxic risks and have close followups for cancer survivors and patients undergoing cancer treatments using serial echocardiography exams and cardiovascular biomarkers testing. Unfortunately, the cost-prohibitive nature of echocardiography has made these routine follow-ups difficult and not accessible to the growing number of cancer survivors and patients undergoing cancer treatments. There is thus a need to develop a wearable system that can yield similar information at a minimal cost and can be used for remote monitoring of these patients. In this proof-of-concept study, we have investigated the use of wearable seismocardiography (SCG) to monitor LV function non-invasively for patients undergoing cancer treatment. A total of 12 subjects (six with normal LV relaxation, five with impaired relaxation and one with pseudo-normal relaxation) underwent routine echocardiography followed by a standard six-minute walk test. Wearable SCG and electrocardiogram signals were collected during the six-minute walk test and, later, the signal features were compared between subjects with normal and impaired LV relaxation. Pre-ejection period (PEP) from SCG decreased significantly (p < 0.05) during exercise for the subjects with impaired relaxation compared to the subjects with normal relaxation, and changes in PEP/LV ejection time (LVET) were also significantly different between these two groups (p < 0.05). These results suggest that wearable SCG may enable monitoring of patients undergoing cancer treatments by assessing cardiotoxicity.

We investigated the effect of parity number on the dry matter intake (DMI) of cows during the first week after calving. Eighty-three cows were evaluated from 14 days before to 7 days after calving. DMI and milk yield were measured for 7 days after calving, and the calving score was measured. Blood samples were collected throughout the experiment. The average DMI during the first week after calving was reduced in the first-lactation heifers and high-parity number cows. A quadratic relationship between the parity number and the DMI was observed. The first-lactation heifers had lower prepartum serum total protein (TP) concentration and milk yield, higher prepartum serum nonesterified fatty acid (NEFA) concentration and calving score than the multiparous cows. The recovery rate of serum calcium (Ca) after calving was slow in the cows in the parity 6. The DMI was positively affected by the serum Ca concentration after calving, milk yield, and prepartum serum TP concentration and was negatively affected by the calving score and prepartum serum NEFA concentration. We conclude that the DMI immediately after calving tends to be lower in first-lactation heifers and high-parity number cows, but factors that reduce the DMI differ according to parity number., (© 2019 Japanese Society of Animal Science.)

The latest United Kingdom (UK) strategy for rare diseases emphasises the need to empower affected populations to improve diagnosis, intervention, and coordination of care. Families who have a child with a rare chromosome disorder (RCD) are a challenging group to include. We report the findings of 2 large-scale surveys, undertaken by the UK RCD Support Group Unique, of these families' experiences over a 10-year period. Seven stages of the patient journey were examined. From pre-testing, through diagnosis, genetics consultation, clinical follow-up and peer support. Overall, 1158 families replied; 36.4% response rate (2003) and 53.6% (2013). Analysis of responses identifies significant differences (P < .001) over time with a decrease in results reported face to face (76%-62%), doubling by telephone (12%-22%), improved explanation of chromosome disorder (57%-75%), and increased signposting to peer support group (34%-62%). However, conduct of the consultation raises a number of important questions. Overall, 28 aspects of the patient journey are recognised as requiring improvement; only 12/28 are currently incorporated in UK service specifications. Involvement of RCD families has identified key service improvements. This approach can empower those affected by such extremely rare disorders, and also enable professionals to design improved services in partnership with "expert families." Further surveys are planned., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Acute kidney injury (AKI) is common in critically ill patients and is associated with high morbidity and mortality. Early identification of high-risk patients provides an opportunity to develop strategies for prevention, early diagnosis and treatment of AKI., Methods: We undertook this multicenter prospective cohort study to develop and validate a risk score for predicting AKI in patients admitted to an intensive care unit (ICU). Patients were screened for predictor variables within 48 h of ICU admission. Baseline and acute risk factors were recorded at the time of screening and serum creatinine was measured daily for up to 7 days. A risk score model for AKI was developed with multivariate regression analysis combining baseline and acute risk factors in the development cohort (573 patients) and the model was further evaluated on a test cohort (144 patients). Validation was performed on an independent prospective cohort of 1300 patients. The discriminative ability of the risk model was assessed by the area under the receiver operating characteristic curve (AUROC) and model calibration was evaluated by Hosmer-Lemeshow statistic. AKI was defined by the Kidney Disease: Improving Global Outcomes criteria (absolute change of 0.3 mg/dL or relative change of 50% from baseline serum creatinine in 48 h to 7 days, respectively)., Results: AKI developed in 754 (37.2%) patients. In the multivariate model, chronic kidney disease, chronic liver disease, congestive heart failure, hypertension, atherosclerotic coronary vascular disease, pH ≤ 7.30, nephrotoxin exposure, sepsis, mechanical ventilation and anemia were identified as independent predictors of AKI and the AUROC for the model in the test cohort was 0.79 [95% confidence interval (CI) 0.70-0.89]. On the external validation cohort, the AUROC value was 0.81 (95% CI 0.78-0.83). The risk model demonstrated good calibration in both cohorts. Positive and negative predictive values for the optimal cutoff value of ≥ 5 points in test and validation cohorts were 22.7 and 96.1% and 31.8 and 95.4%, respectively., Conclusions: A risk score model integrating chronic comorbidities and acute events at ICU admission can identify patients at high risk to develop AKI. This risk assessment tool could help clinicians to stratify patients for primary prevention, surveillance and early therapeutic intervention to improve care and outcomes of ICU patients., (© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Sex chromosome trisomies (SCTs) are frequently diagnosed, both prenatally and postnatally, but the highly variable childhood outcomes can leave parents at a loss on whether, when and how to disclose genetic status. In two complementary studies, we detail current parental practices, with a view to informing parents and their clinicians. Study 1 surveyed detailed qualitative data from focus groups of parents and affected young people with either Trisomy X or XYY (N=34 families). These data suggested that decisions to disclose were principally affected by the child's level of cognitive, social and emotional functioning. Parents reported that they were more likely to disclose when a child was experiencing difficulties. In Study 2, standardised data on cognitive, social and emotional outcomes in 126 children with an SCT and 63 sibling controls highlighted results that converged with Study 1: logistic regression analyses revealed that children with the lowest levels of functioning were more likely to know about their SCT than those children functioning at a higher level. These effects were also reflected in the likelihood of parents to disclose to unaffected siblings, schools and general practitioners. In contrast, specific trisomy type and the professional category of the clinician providing the original diagnosis did not affect likelihood of disclosure. Our study emphasises the complex weighing up of costs and benefits that parents engage in when deciding whether to disclose a diagnosis.

Federal directives, nursing and nursing education associations, as well as accrediting bodies emphasize the importance of integrating health information technology and EHRs into nursing practice. Additionally, informatics is a required competency of baccalaureate nursing graduates. Nursing education's efforts to enhance students' learning in the area of electronic documentation is at its peak. The goal of enabling nurses to make healthcare safer, more effective, efficient, patient-centered, timely and equitable can only be achieved if a variety of technologies are clearly integrated into nursing education. Therefore, some schools have developed educational innovations to incorporate academic EHRs. As the mental health setting is unique, extraordinary attention has to be provided during the education of electronic documentation. Nursing education efforts must focus on interventions that provide resources that enhance the participant's knowledge and skills related to electronic documentation in a variety of clinical settings. Additionally, implementing academic EHRs in clinical settings offers nursing educators an opportunity to note the benefits. The state of nursing education depends on the accessibility to utilize academic EHRs in the nursing curriculum within the clinical setting to effectively prepare students for real-word practice.

The incidence of hypocalcemia increases in high-parity dairy cows because resorption of bone Ca is delayed in these animals, and they appear to have a reduced ability to absorb Ca from the intestine during the early postpartum period. Difructose anhydride (DFA) III has been shown to promote the absorption of intestinal Ca via a paracellular pathway. However, past studies have not reported this effect in peripartum dairy cows. Therefore, we investigated the effect of DFA III supplementation on Ca metabolism during the peripartum period to determine whether DFA III promotes intestinal Ca absorption via this route. Seventy-four multiparous Holstein cows were separated into DFA and control groups based on their parity and body weight. The feed of the DFA group was supplemented with 40g/d of DFA III from -14 to 6d relative to calving. The control group did not receive DFA III. At calving (0h relative to calving), serum Ca declined below 9mg/dL in both groups. However, serum Ca concentrations were greater in the DFA group than in the control group at 6, 12, 24, and 48h relative to calving, and the time required for serum Ca to recover to 9mg/dL during the postpartum period was shorter in the high-parity cows in the DFA group than in those in the control group. Parathyroid hormone concentrations increased immediately after calving in both groups and were greater in the control group than in the DFA group at 12 and 24h relative to calving. Serum 1,25-dihydroxyvitamin D concentrations increased at 0 and 12h relative to calving in both groups and were higher in the control group than in the DFA group at 72h relative to calving. Serum concentrations of the bone-resorption marker cross-linked N-telopeptide of type I collagen (NTX) were not different between the groups during peripartum period, and serum NTX in all cows was lower at 0, 6, 12, 24, 48, and 72h relative to calving than at -21, 4, and 5d relative to calving. Thus, DFA treatment induced faster recovery of serum Ca, although bone resorption was restrained. In conclusion, DFA III promotes intestinal passive Ca absorption via the paracellular pathway during the early postpartum period; this absorption is unaffected by aging., (Copyright © 2015 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

A small number of recent papers have described individuals with intellectual disabilities and microdeletions in chromosome band 19p13.2. However, little is known about the behavioral characteristics of individuals with microdeletions in this area. The current study examines behavioral characteristics of a series of 10 participants ranging in age from 2 to 20 years with 19p13.2 microdeletions. Parents/caregivers completed a series of established behavioral measures which have aided the elucidation of the behavioral phenotypes of a number of genetic neurodevelopmental syndromes. All but the youngest two participants (aged 2 and 3 years) were verbal, ambulant, and classified as "partly able" or "able" with regard to self-help skills. Six of eight participants for whom a screening measure for autism spectrum disorders (ASD) could be deployed met criteria for an ASD. Six of the 10 participants had displayed self-injurious behavior in the month prior to assessment, eight had displayed destruction/disruption of property, and eight had shown physically aggressive behaviors. Repetitive behaviors were prevalent in the sample (with all participants displaying at least one repetitive behavior to a clinically relevant level), as were problems with sleep. Low mood was not prevalent in this group, and nor were overactivity or impulsivity. Full determination of a behavioral phenotype for this group would require a larger sample size, distinguishing between genetic subtypes. However, the current data suggest that ASD characteristics, repetitive, and challenging behaviors (such as aggression and self-injury) might be associated with 19p13.2 microdeletions, providing a basis for future investigation., (© 2015 Wiley Periodicals, Inc.)

Requirements to control the large decrease in serum calcium (Ca) due to parturition and to increase the feed intake soon after parturition have been well accepted in dairy cows. This study was aimed to investigate the feed intake affected by serum Ca concentration with difructose anhydride (DFA) III supplement in dairy cows soon after parturition. Fourteen transition Holstein cows were divided into DFA and control (CONT) groups within 1 to 5 parity variations in each group. Measurement schedule for an individual cow was from 14 d before parturition to 7 d following parturition. The cows in DFA group were supplied 0.2 kg/head/d of DFA III feed containing 40 g of pure DFA III while the cows in CONT group received no DFA III. Other feeding procedures were the same for all cows in both groups. At parturition (d 0), serum Ca concentration sharply declined in both groups (p<0.05). Time interval for recovery from decreased serum Ca to its normal range (>9.0 mg/dL) tended to be faster in DFA group (12 h) than in the CONT group (48 h), but the differences were not significant. Active ruminal contraction was observed in DFA group at following parturition of d 1 (p<0.05), d 3 (p<0.05), and d 5 (p<0.01). Dry matter (DM) intake did not differ between the groups. However, positive correlations were observed between serum Ca concentration and ruminal contraction (p<0.001), and between ruminal contraction and DM intake (p<0.001) during following parturition. According to multiple regression analysis (R(2) = 0.824, p<0.001), the DM intake was positively affected by serum Ca concentration and ruminal contraction. These results suggest that feed intake soon after parturition in dairy cows can be increased by improvement of serum Ca concentration and active ruminal contraction, but DFA III supplementation in this study did not improve the lower serum Ca concentration due to parturition.

Introduction: In April and June 2012, two outbreaks of Campylobacter gastroenteritis were investigated in an Australian aged-care facility (ACF); a Campylobacter-positive puppy was identified as a potential source of infection., Methods: An expert panel was convened to assess transmission risk from the puppy to elderly residents and to guide further public health action. Criteria considered as part of the panel's assessment included the puppy's infectivity, the bacterium's transmissibility, puppy-resident contact, infection control and cleaning practices and animal management at the facility. A literature review was used to assist the panel, with a final risk being determined using a likelihood and consequence matrix., Results: The panel determined that the setting and low infective dose made transmission likely despite varying degrees of contact between the puppy and cases. While infection control practices were generally appropriate, the facility's animal policy did not adequately address potential zoonotic risk., Conclusion: In summary, puppies should not be considered as companion animals in ACFs due to high rates of Campylobacter carriage and the underlying susceptibility of the elderly. Infection control and animal policies in ACFs should reflect an awareness of zoonotic disease potential.

Background: Despite improvements in the diagnosis and management of acute kidney injury (AKI), posttraumatic renal dysfunction continues to be associated with increased morbidity and mortality. Intravenous (IV) contrast is known to induce AKI in high-risk groups including the elderly and critically ill. We sought to determine whether IV contrast exposure among high-risk trauma patients resulted in renal dysfunction as defined by the Acute Kidney Injury Network criteria., Methods: We performed a 3-year retrospective analysis of all patients admitted to our Level I trauma center surgical intensive care unit for >48 hours. Patients with preexisting chronic renal dysfunction were excluded. We performed univariate and bivariate analyses to identify risk factors for AKI. Multivariable logistic regression analysis identified independent predictors for AKI. Subgroup analysis was undertaken among high-risk groups to include elderly patients (aged ≥65 years) with admission hypotension (systolic blood pressure <90 mm Hg) and an Injury Severity Score (ISS) ≥25., Results: Of the 6,317 patients, 571 (9.0%) patients met the inclusion criteria; 170 (29.8%) patients developed AKI. Age ≥65 years (odds ratio [OR] 2.26, 95% confidence interval [CI] = 1.06-4.80, p <0.034) and ISS ≥25 (OR 1.86, 95% CI = 1.12-3.07, p <0.015) were determined to be independent predictors of AKI. IV contrast was not identified to be a predictor of AKI. Upon subgroup analysis, IV contrast exposure was not a predictor of AKI among the elderly, hypotensive, or severely injured patients (ISS ≥25)., Conclusion: A complete trauma workup including studies requiring IV contrast exposure should be considered safe even among high-risk trauma patients.

Dysregulation of tissue development pathways can contribute to cancer initiation and progression. In murine embryonic prostate epithelia, the transcription factor SOX9 is required for proper prostate development. In this study, we examined a role for SOX9 in prostate cancer in mouse and human. In Pten and Nkx3.1 mutant mice, cells with increased levels of SOX9 appeared within prostate epithelia at early stages of neoplasia, and higher expression correlated with progression at all stages of disease. In transgenic mice, SOX9 overexpression in prostate epithelia increased cell proliferation without inducing hyperplasia. In transgenic mice that were also heterozygous for mutant Pten, SOX9 overexpression quickened the induction of high-grade prostate intraepithelial neoplasia. In contrast, Sox9 attenuation led to a decrease proliferating prostate epithelia cells in normal and homozygous Pten mutant mice with prostate neoplasia. Analysis of a cohort of 880 human prostate cancer samples showed that SOX9 expression was associated with increasing Gleason grades and higher Ki67 staining. Our findings identify SOX9 as part of a developmental pathway that is reactivated in prostate neoplasia where it promotes tumor cell proliferation.

As adults age, many changes in functioning occur, and dementia and/or depression may develop. Medications used to manage dementia and depression include selective serotonin reuptake inhibitors. The challenge for nurses is recognizing which behaviors, signs, and symptoms are the result of the dementia or depression and which are the result of the drug therapy. The purpose of this article is to present information to increase awareness of the complexities of care for older adults with dementia and/or depression and identify possible implications for practicing nurses.

Background: Acute renal failure (ARF) in trauma patients is associated with high mortality rates. There is currently no consensus definition for renal failure, however, the American College of Surgeons' Committee on Trauma (ACSCOT) defines ARF as a serum creatinine > or =3.5, blood urea nitrogen > 100, or renal replacement therapy. We hypothesize that by using the Acute Kidney Injury Network (AKIN) staging system we would identify smaller changes in renal function that may impact outcome, and may serve as a marker for mortality and other organ dysfunction., Methods: We retrospectively identified all trauma patients admitted to the surgical intensive care unit (SICU) for >48 hours during a 3-year period ending December 2007. Hourly urine output, serum creatinine, demographic data, trauma scores, admission vital signs, ICU and hospital length of stay, need for renal replacement therapy, organ failure, and death were collected and were stratified according to AKIN and ACSCOT renal dysfunction criteria. Trauma patients admitted to the SICU who did not develop renal dysfunction were used as controls., Results: A total of 571 patients were studied. Of those, only 17 patients (3.0%) were classified as having ARF by the ACSCOT criteria, whereas 170 (29.8%) had kidney injury using the AKIN criteria (146, stage 1; 15, stage 2; 9, stage 3). Compared with patients admitted to the ICU for > or =48 hours with normal renal function, patients meeting AKIN criteria had longer hospital and ICU length of stay (p < 0.001). Patients meeting AKIN criteria also had an increased incidence of multiple organ failure and death (p < 0.03)., Conclusions: Stratification using the AKIN criteria for acute kidney injury identifies an increased number of patients with renal dysfunction compared with the current ACSCOT criteria. Importantly, these patients have an increased risk of multiple organ failure and death. Inclusion into the AKIN criteria may be a marker for later morbidity and mortality.

Background: The double-bundle technique has recently gained much interest in ligament reconstruction. In addition to potential kinematic advantages, perhaps double tunnels have the potential for faster and more secure tendon-to-bone healing., Hypothesis: Placement of tendons in 2 osseous tunnels, as opposed to 1, will enhance tendon fixation as determined biomechanically and histologically., Study Design: Controlled laboratory study., Methods: Fourteen sheep were used, and an extra-articular tendon graft reconstruction was performed on both knees of each sheep. In 1 randomly selected knee, the long digital extensor tendon was released from the femur and placed into a single tunnel in the proximal tibia. In the contralateral knee, the tendon was split and placed into 2 tibial tunnels. Ten sheep were analyzed by mechanical testing, and the remaining 4 were subjected to histologic evaluation at 6 weeks after surgery. Paired t tests were used for statistical analysis., Results: Mechanical testing demonstrated that the peak load (981.8 +/- 143.2 N, mean +/- SD) and stiffness (570.9 +/- 114.6 N/mm) at 6 weeks after surgery in the double-tunnel group were significantly greater than for the single-tunnel group (714.8 +/- 94.2 N and 432.2 +/- 56.7 N/mm, respectively; load, P = .007; stiffness, P = .03). Histologic analysis suggested similar tendon-to-bone healing for both groups., Conclusion: This study demonstrated enhanced biomechanical fixation of the tendon to the surrounding bone in the double-tunnel compared with the single-tunnel technique in this ovine model., Clinical Relevance: The double-tunnel technique may provide better fixation and healing in human ligament reconstruction.

Purpose: The purpose of this study was to quantify the changes in the arc of digital flexion before and after metacarpophalangeal (MCP) silicone arthroplasty with a 30 degrees preflexed design., Methods: Index, middle, and ring fingers of 4 fresh-frozen cadaver hands were used. Each hand was attached (palmar side up) to a custom test apparatus. The tendon was drawn by a small winch-type servomotor. Micropotentiometers that were attached to the centers of rotation of the MCP, distal interphalangeal, and proximal interphalangeal joints measured angular displacement before and after MCP arthroplasty as a function of tendon excursion. The data were analyzed comparing the angle of flexion initiation and the angular displacement as a function of tendon excursion before and after joint arthroplasty., Results: There were no statistical differences in the angles of the MCP joints at rest, the order of initiation of joint flexion, and the overall degree of flexion between the unoperated fingers and the fingers that had surgery. There was, however, a trend toward delay in flexion initiation, an increase in the MCP angle at rest, and a decrease in torque after implant arthroplasty., Conclusions: The decrease in initiation of flexion of the MCP joint, although not statistically significant, probably was related to the 30 degrees of preflexion built into the implant. We also noted a trend of decreased flexion at the MCP joint and increased flexion at the proximal interphalangeal and distal interphalangeal joints. This trend may be advantageous in the reconstruction of hands that initially have an MCP joint flexion deformity., Type of Study/level of Evidence: to come.

This article reviews basic concepts in fundamental elbow biomechanics, particularly how they relate to the skeletally immature elbow in throwing athletes. Adult phases of throwing and the forces generated in each phase are compared with the developmental phases of throwing in children. The impact of elevated forces, poor mechanics, and poor coordination are emphasized as they relate to potential areas of injury in the skeletally immature. Finally, concepts in prevention focused on biomechanics are offered.

Background: This study was designed to resolve uncertainty concerning whether the position of the examiner is associated with variability in the results of the nearpoint alternate cover test (NACT). Two previous studies have shown that when the examiner is positioned to the side of the patient, rather than directly in front of the patient, the NACT shows greater exophoria in the range of 1.3 to 4.4 prism diopters. In the current study, we sought to determine if proximal cues or effective prism power might be the source of the apparent exo shift associated with examiner position., Methods: Three conditions of the NACT were performed on 52 young adults with normal visual function. Two measurements using the method of limits were made in each condition and averaged. In all conditions, the fixation target remained on the subject's midline at a distance of 40 cm., Results: Our results showed a small significant increase in measured exophoria when the examiner administered the NACT from a position to the side of the subject. The magnitude of the increase, 0.98 prism diopter, was less than in the previous studies, probably due to the control for proximal effect that was used. Intentionally rotating the measuring prism had a nominal effect on the measured phoria value, consistent with error induced due to effective prism power., Discussion: It appears that examiner position does affect the outcome of the NACT, but that the magnitude of the effect is not clinically significant. A change in proximal cues may contribute to the effect.

The more a critical look at the medicinal properties of plants is undertaken, the more it will be realized that nature does not make it easy to find all there is to know about them and the complexities of their interactions. An illustration of this can be found in one of the earlier scientific studies on phytomedicines, the Nobel laureate Albert Szent-Györgyi and his colleagues [170] found that flavanone extracts from the Capsicum spp contain an ascorbate-protective factor. It has now been repeatedly shown that the electron-donating properties of the phytochemical flavonoids, providing both nutritive and chemotherapeutic benefits, are the basis of their antioxidant action [171-175]. Studies by zoologists have demonstrated that animals, by selectively choosing specific plants, soils, and clays, maintain their health and treat themselves in times of ill health. The term zoopharmacognosy, now well researched, has been coined to describe the study of this recognized phenomenon. Long ago, Isaac Newton stated that for every action, there is an equal and opposite reaction. The same may be seen in plants and plant material. The same may be said of life in general. At the most basic concept, we are talking of electrons and their activities.

Tabular information of proposed cellular effects regarding the use of certain nutraceuticals (including antioxidants, phytonutrients, and other biologic therapies) and herbs, compiled from scientific sources and experimental research, is provided.

Tabular information of proposed cellular effects regarding the use of certain nutraceuticals (including antioxidants, phytonutrients, and other biological therapies) and herbs, compiled from scientific sources and experimental research, is provided.

The 27-kDa heat shock protein (HSP27) has a potent ability to increase cell survival in response to a wide range of cellular challenges. In order to investigate the mode of action of HSP27 in vivo, we have developed transgenic lines, which express human HSP27 at high levels throughout the brain, spinal cord, and other tissues. In view of the particular property of HSP27 compared with other HSPs to protect neurons against apoptosis, we have tested these transgenic lines in a well established in vivo model of neurotoxicity produced by kainic acid, where apoptotic cell death occurs. Our results demonstrate for the first time the marked protective effects of HSP27 overexpression in vivo, which significantly reduces kainate-induced seizure severity and mortality rate (>50%) in two independent lines and markedly reduces neuronal cell death in the CA3 region of hippocampus. This reduced seizure severity in HSP27 transgenic animals was associated with a marked attenuation of caspase 3 induction and apoptotic features. These studies clearly demonstrate that HSP27 has a major neuroprotective effect in the central nervous system in keeping with its properties demonstrated in culture and highlight an early stage in the cell death pathway that is affected by HSP27.

Objectives: To explore women's attitudes and practices related to douching., Methods: We conducted focus groups between July and December 1999 with 34 black and 27 white women enrolled in a managed care plan in Memphis, Tennessee. Participants were at least 18 years of age and had douched at some time in their lives. Five groups were held with black women and five with white women., Results: The focus groups identified 13 themes that fell in four broad categories: general perceptions about feminine hygiene, douching behavior, factors perpetuating douching, and health information. Each of these categories is briefly discussed with supporting evidence., Conclusions: First, women have deeply-rooted beliefs about the critical role of douching in making them feel clean. Second, douching generally starts at a young age and is reinforced by family, friends, and the media. Third, douching is a very difficult behavior to change; any efforts to influence this behavior must consider women's beliefs and the media marketing efforts that promote douching. Finally, simplistic interventions that only provide risk information about douching are not likely to result in behavior change.

Diabetes mellitus can be frustrating to treat in veterinary practice, but botanical and nutritional supplements may offer assistance in stabilizing difficult patients. While dogs are typically subject to type 1 diabetes, cats develop type 2 diabetes as much as 70 percent of the time. Whereas treatment adjuncts to insulin may address carbohydrate metabolism from glucose absorption to insulin receptor function, success may depend on the type of diabetes present in the patient.

To formulate a 'logic' for how a single immunoglobulin variable region gene generates antibodies with different antigen specificity and polyreactivity, we analysed chimeric antibodies produced in transgenic mice carrying the germ-line human V3-23 gene, multiple diversity (D) and joining (J) gene segments. Hybridomas producing antibodies encoded by the V3-23 gene in combination with different mouse Vkappa genes were obtained by fusion of splenocytes from transgenic mice. All antibodies had human mu-chains and mouse light chains, were multimeric in structure and expressed the human V3-23 gene. Nucleotide sequence analyses of genes encoding the heavy and light chains of 12 antibodies in relation to antigen specificity highlighted the importance of heavy chain variable region CDR3 in determining reactivity with different antigens. However, the results also suggest that non-CDR3 sequences intrinsic to the V3-23 gene itself may be involved in, or determine, the binding of the chimeric antibodies to some of the antigens tested in the current study.

The SON gene, which maps to human chromosome 21q22.1-q22.2, encodes a novel regulatory protein. Here we describe the organization of the Son locus in the mouse genome. The mouse Son gene spans a region of approximately 35 kb. The coding region is more than 8 kb in length and has been completely sequenced. The gene is organized into 11 coding exons and 1 noncoding 3'UTR exon, with over 70% of the coding region residing in one 5.7-kb exon. The gene contains at least one alternative exon, N/C exon 1, which can be used, by splicing, to generate a truncated form of the SON protein. Further investigation of the mouse Son locus has identified the genes directly flanking Son. The glycinamide ribonucleotide formyltransferase gene, Gart, is encoded 5' of Son in a head-to-head arrangement, with the start of both genes lying within 899 bp. Sequence comparison with the expressed sequence tagged database identified a novel gene within 65 bp of the 3' end of Son, which we have named Donson. In this unusually compact gene cluster, we have found overlap in the pattern of expression between Gart, Son, and Donson. However, at least two of these genes have very different functions. While GART is involved in purine biosynthesis, we find that SON shows the characteristics of "SR- type" proteins, which are involved in mRNA processing and gene expression., (Copyright 2000 Academic Press.)

Neuroendocrine differentiation in the neoplastic prostate varies from foci of adenocarcinoma showing immunoreactivity to the pure small cell carcinoma, which correlates with poor prognosis. Widely metastatic disease in unusual sites is reported for small cell carcinoma, and rarely is the serum prostate-specific antigen level elevated. We report a case of recurrent prostate adenocarcinoma presenting as bowel obstruction due to widespread metastatic disease in the omentum and peritoneum. The histopathology of the omental metastasis was that of a large cell neuroendocrine carcinoma, without evidence of an adenocarcinoma. The absence of a clinically evident second primary tumor, the concomitant elevated serum prostate-specific antigen level, and the positive tissue immunoreactivities to prostatic markers all supported the prostatic origin of the omental tumor. Review of the importance of prostatic neuroendocrine differentiation and its unusual metastatic patterns is presented.

The purpose of this study was to determine the extent to which refusal skills and norm setting mediated the impact of a school-based prevention program from the Alcohol Misuse Prevention Study (AMPS) on adolescent alcohol overindulgence. The AMPS is a randomized, pre-post, experimental-control study. Respondents in the present study included 6th through 10th graders (ns ranged from 232 to 371). Structural equation modeling analyses using EQS indicated that norm setting mediated the effect of the intervention on alcohol overindulgence at the 7th through the 8th grade and at the 8th through the 10th grade. In contrast, although the prevention program served to increase refusal skills, refusal skills did not mediate the effect of the program on alcohol misuse.

The aim of this project is to develop a common homeopathic terminology to improve communication. A questionnaire was sent by email to an international group of experts. As a result of an iterative process we propose that a number of terms which are inaccurate, unclear or have become outdated should be replaced by new terms. The main areas in which terminology should be updated are: concepts relating to: homeopathic pharmacology, research, homeopathic medicine, the principle of similarity, homeostasis and disease imitation, miasms, experimental homeopathy, provings and pathogenic trials.

Bleeding is very rare in patients with lupus anticoagulants in the absence of associated hemostatic abnormalities. Few cases have been reported with attention given to work-up for other coagulation defects. We report a case of spontaneous hematoma in a patient with lupus anticoagulant, immunoglobulin (Ig)M anticardiolipin antibodies, and no other associated abnormalities.

Warfarin-induced skin necrosis is a rare complication of therapy with warfarin or other coumarin derivatives. When it occurs it usually appears 3 to 6 days after initiation of therapy and almost always between days 1 and 10. We report a case of late-onset (16 days after initiation of therapy) warfarin-induced skin necrosis and review the literature on this rarely reported variant of warfarin-induced skin necrosis. The skin lesion in our patient was not associated with either deficiency of protein C or resistance to activated protein C.

The purpose of prophylactic vaccination is to reduce morbidity and mortality in a population. Many questions related to the design of vaccines and vaccination programs require a population standpoint for their sharp formulation and laboratory and field studies to understand their immunologic background. Practical suggestions of the workshop included increased studies of age-specific immunity, better immunoepidemiologic surveillance, better design of efficacy studies, and more systematic sampling of parasite strains to study the evolutionary pressure exerted by vaccines. Theoretical immunology has much to contribute. One of the realizations of the workshop was the value of a strong interdisciplinary approach in vaccine development, utilizing relevant contributions from immunology, population biology, mathematical modeling, epidemiology, molecular biology, and virology.

Alcohol is the most frequently used psycho-active substance during adolescence. Adolescents who misuse or overindulge in alcohol are at risk for serious social and psychological consequences. Several preventive approaches can help adolescents deal with peer pressure that contributes to alcohol use experimentation and escalation. One promising approach involves teaching adolescents skills to refuse offers of alcohol and other drugs. Few studies, however, have examined how this approach works; that is, the connection between the prevention effort, refusal skills, and drinking behavior. This paper investigates the relationships among the intervention, refusal skills, and alcohol misuse in the Alcohol Misuse Prevention Study, a randomized, pre/post experimental study. Based on data from sixth through tenth graders (average N per grade = approximately 400), regression analyses indicate that refusal skills are significant mediators of the effect of the intervention on alcohol misuse.

Warfarin-induced skin necrosis is a rare complication of warfarin therapy. It appears between days 1 and 10 of therapy while the patient is receiving warfarin. Warfarin-induced skin necrosis occurring several days after cessation of therapy has not been reported. We report an atypical case of warfarin-induced skin necrosis which occurred 96 h after the last dose of warfarin was given while the prothrombin time was still elevated.

Currently, adenovirus (Ad) is being considered as a vector for the treatment of cystic fibrosis as well as other diseases. However, the cytotoxic T lymphocyte (CTL) response to Ad could limit the effectiveness of such approaches. Since the CTL response to virus infection is often focused on one or a few immunodominant epitopes, one approach to circumvent this response is to create vectors that lack these immunodominant epitopes. The effectiveness of this approach was tested by immunizing mice with human group C adenoviruses. Three mouse strains (C57BL/10SnJ [H-2b], C3HeB/FeJ [H-2k], and BALB/cByJ [H-2d]) were immunized with wild-type Ad or Ad vectors lacking the immunodominant antigen(s), and the CTL responses were measured. In C57BL/10 (B10) mice, a single inoculation intraperitoneally (i.p.) led to the recognition of an immunodominant antigen in E1A. When B10 mice were inoculated multiple times either i.p. or intranasally with wild-type Ad or an Ad vector lacking most of the E1 region, subdominant epitopes outside this region were recognized. In contrast, C3H mice inoculated with wild-type Ad recognized an epitope mapping within E1B. When inoculated twice with Ad vectors lacking both E1A and E1B, no immunorecessive epitopes were recognized. The immune response to Ad in BALB/c mice was more complex. CTLs from BALB/c mice inoculated i.p. with wild-type Ad recognized E1B in the context of the major histocompatibility complex (MHC) class I Dd allele and a region outside E1 associated with the Kd allele. When BALB/c mice were inoculated with E1-deleted Ad vectors, only the immunodominant Kd-restricted epitope was recognized, and Dd-restricted CTLs did not develop. This report indicates that the emergence of CTLs against immunorecessive epitopes following multiple administrations of Ad vectors lacking immunodominant antigens is dependent on haplotype and could present an obstacle to gene therapy in an MHC-diverse human population.

One potential limitation of adenovirus (Ad)-based vectors for the gene therapy of cystic fibrosis (CF) and other genetic diseases is the transience of expression observed in most in vivo systems. In this study, the influence of various factors on persistence of transgene expression in the lung was investigated. In the absence of immune pressure, such as in the nude mouse, the genomic structure of the vector was found to be predominant in determining the persistence of expression; Ad vector constructs with an E1-E3+E4ORF6+ backbone encoding beta-galactosidase (beta-Gal) or the cystic fibrosis transmembrane conductance regulator (CFTR) produced declining levels of expression while an Ad/CMV beta Gal vector with an E1-E3+E4+ backbone gave rise to sustained, long-term reporter gene expression. The ability of the latter vector to persist was in turn limited in part by the presence of cytotoxic T lymphocytes (CTLs). Adoptive transfer experiments indicated that CTLs directed against either viral proteins or the beta-Gal reporter gene product were able to reduce expression in nude C57BL/6 mice stably expressing beta-Gal from the E4+ vector. Finally, the specificity and strength of the CTL response elicited by Ad vector was found to vary considerably depending on mouse strain haplotype. These results indicate that persistence of transgene expression in a given system is determined by the interplay between several factors including genomic structure of the vector, host background, and immune response.