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Copper pollution is pervasive in aquatic habitats and is particularly harmful to invertebrates sensitive to environmental changes such as Daphnia pulex. Mechanisms of toxicity and tolerance to copper are not well understood. We used RNA-sequencing to investigate these mechanisms in three genetically distinct D. pulex clonal lineages with different histories of copper exposure. Upregulated genes after copper exposure were enriched with Gene Ontology (GO) categories involved in digestion, molting and growth, whereas downregulated genes after copper exposure were enriched in the metal-regulatory system, immune response and epigenetic modifications. The three D. pulex clones in our study show largely similar transcriptional patterns in response to copper, with only a total of twenty genes differentially expressed in a single clonal lineages. We also detected lower relative expression of some genes known to be important for copper tolerance, metallothionein and glutathione-S-transferase, in a sensitive lineage sampled from an uncontaminated habitat. Daphnia-specific genes (without orthologs outside the genus) and Daphnia-specific duplications (genes duplicated in the Daphnia lineage) were overrepresented in differentially expressed genes, highlighting an important role for newly emerged genes in tolerating environmental stressors. The results indicate that the D. pulex lineages tested in this study generally respond to copper stress using the same major pathways, but that the more resistant clone with previous copper exposure might be better able to regulate key genes. This finding highlights the important nuances in gene expression among clones, shaped by historical exposure and influencing copper tolerance.

In Bronze Aegean society, seals played an important role by authenticating, securing and marking. The study of the seals and their engraved motifs provides valuable insight into the social and political organization and administration of Aegean societies. A key research question is the determination of authorship and origin. Given several sets of similar impressions with a wide geographical distribution on Crete, and even beyond the island, the question arises as to whether all of them originated from the same seal and thus the same seal user. Current archaeological practice focuses on manually and qualitatively distinguishing visual features. In this work, we quantitatively evaluate and highlight visual differences between sets of seal impressions, enabling archaeological research to focus on measurable differences. Our data are plasticine and latex casts of original seal impressions acquired with a structured-light 3D scanner. Surface curvature of 3D meshes is computed with Multi-Scale Integral Invariants (MSII) and rendered into 2D images. Then, visual feature descriptors are extracted and used in a two-stage registration process. A rough rigid fit is followed by non-rigid fine-tuning on basis of thin-plate splines (TPS). We compute and visualize all pairwise differences in a set of seal impressions, making outliers easily visible showing significantly different impressions. To validate our approach, we construct a-priori synthetic deformations between impressions that our method reverses. Our method and its parameters is evaluated on the resulting difference. For testing real-world applicability, we manufactured two sets of physical seal impressions, with a-priori known manufactured differences, against which our method is tested.

Seals and sealings were widely used in Neopalatial Crete, primarily in community-wide administrative systems to manage the movement and storage of goods, but also to secure or control channels of intra-site communication using parchment documents. The main principle of this monitoring process was the use of the seal impression as an ‘indexical’ sign, that is, as a means of identifying a seal-user who was acting in an authorising or securing role. Given the fact that seal-users could be acting on their own behalf or, alternatively, as representatives of an institution, there is uncertainty in the literature still over whether the seal impression stood for a single identifiable individual or not. In this paper, we present a new computational methodology for identifying and quantifying similarity within sets of multiple seal impressions made by the same seal. Using a combination of visualisations derived from computational analysis of 3-D scans, experimental work to make seal impressions, and scrutiny of the relevant sealing casts within the Corpus of Minoan and Mycenaean Seals, Heidelberg, we are able to identify groups of sealings impressed in significantly similar ways. We consider it probable that seal impressions with a high degree of similarity were made by the same individual or by two or more people trained to work in a very specific way. This computational methodology is transferable and would prove valuable for other collections of material with identifiable repeated visual elements, such as coins. The implications of our research and the nuance it adds to reconstructions of Neopalatial sealing practices are of broader relevance for sphragistic studies, and provide a point of comparison with the contemporary sealing material of the Ancient Near East.

Background: The preferred timing of umbilical-cord clamping in preterm infants is unclear. Methods: We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births. Results: Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were available for 1497 infants (95.6%). There was no significant difference in the incidence of the primary outcome between infants assigned to delayed clamping (37.0%) and those assigned to immediate clamping (37.2%) (relative risk, 1.00; 95% confidence interval, 0.88 to 1.13; P=0.96). The mortality was 6.4% in the delayed-clamping group and 9.0% in the immediate-clamping group (P=0.03 in unadjusted analyses; P=0.39 after post hoc adjustment for multiple secondary outcomes). There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities. Conclusions: Among preterm infants, delayed cord clamping did not result in a lower incidence of the combined outcome of death or major morbidity at 36 weeks of gestation than immediate cord clamping. (Funded by the Australian National Health and Medical Research Council [NHMRC] and the NHMRC Clinical Trials Centre; APTS Australian and New Zealand Clinical Trials Registry number, ACTRN12610000633088. opens in new tab.)

Introduction In this study we investigated muscle magnetic resonance imaging in congenital myasthenic syndromes (CMS). Methods Twenty-six patients with 9 CMS subtypes and 10 controls were imaged. T1-weighted (T1w) and short-tau inversion recovery (STIR) 3-Tesla MRI images obtained at thigh and calf levels were scored for severity. Results Overall mean the T1w score was increased in GFPT1 and DPAGT1 CMS. T1w scans of the AChR-deficiency, COLQ, and CHAT subjects were indistinguishable from controls. STIR images from CMS patients did not differ significantly from those of controls. Mean T1w score correlated with age in the CMS cohort. Conclusions MRI appearances ranged from normal to marked abnormality. T1w images seem to be especially abnormal in some CMS caused by mutations of proteins involved in the glycosylation pathway. A non-selective pattern of fat infiltration or a normal-appearing scan in the setting of significant clinical weakness should suggest CMS as a potential diagnosis. Muscle MRI could play a role in differentiating CMS subtypes. Muscle Nerve, 2016

The human gastrointestinal microbiota is composed of a diverse and complex array of bacteria, fungi, and viruses that reside within our gastrointestinal (GI) tract. The microbiota plays a vital role in metabolism, vitamin production, and perhaps most importantly, protection from invasion by pathogenic microorganisms. The modern era of antibiotic use has resulted in unanticipated damage to the microbiota and the disruption of the delicate balance between the microorganisms of which it is composed. Over the last 15 years, there has been an alarming rise in the incidence and severity of Clostridium difficile infection (CDI), with accompanying increases in morbidity and significant mortality. Driven at least in part by the CDI epidemic, fecal microbiota transplantation (FMT) has emerged as an astonishingly effective cure of CDI and has gained widespread acceptance as the treatment of choice for recurrent or relapsing CDI (R-CDI) as well as severe CDI. With the increased practice of FMT in many hospitals, it is pertinent to discuss, from the surgeon׳s perspective, the use of FMT in the various clinical scenarios encountered on the surgical service.

Systemic reviews have shown that delaying the time of umbilical cord clamping can improve outcomes of preterm newborns. One such study found enhanced placental transfusion through delayed cord clamping, cord-palpation, or a combination of the 2 practices caused a lower infection and mortality rate when compared with immediate clamping. Despite this recent body of evidence, concerns exist about harm from delayed resuscitation and hyperbilirubinemia causing current professional guidelines to vary significantly.

The last 20 years has seen significant advances in our understanding and treatment of the congenital myasthenic syndromes. This article discusses individual syndromes, their management and how to distinguish the subtypes from each other as well as from other conditions that commonly mimic them. ### What are congenital myasthenic syndromes? Congenital myasthenic syndromes result from gene mutations affecting the neuromuscular junction structure and function. Unlike autoimmune myasthenia gravis, the immune system is not involved and there is no association with antibodies to the acetylcholine receptor (AChR) or muscle specific kinase. Although all congenital myasthenic syndromes share the feature of fatiguable muscle weakness, they are discrete syndromes each with their own, often distinct, phenotype. Significant advances in the last 20 years, mainly in molecular genetics, have enabled identification of at least 15 genes implicated in congenital myasthenic syndromes (table 1). About 80%–90% of patients with congenital myasthenia in the UK now have a confirmed genetic diagnosis. Thus, there are likely to be many unidentified associated genes. View this table: Table 1 Congenital myasthenic syndromes subtypes, associated genes and main pathology The delineation of these different genetic syndromes has enabled the development of a range of effective symptomatic treatments. The choice of treatment is governed by the underlying pathogenic mechanism. Importantly, the treatments routinely used for some subtypes can cause significant deterioration in others. In addition, a range of conditions can mimic congenital myasthenic syndromes and these too require different therapy. Therefore, a definitive genetic diagnosis is important and guides treatment, prognosis and genetic counselling. Most patients with congenital myasthenia present with symptoms at birth or early infancy, although in some subtypes, particularly those predominantly affecting proximal muscles such as downstream of kinase-7 (DOK7), onset is typically in childhood with walking difficulties. Patients with the slow channel syndrome may have symptom onset well into their second or third decades. While many patients are now identified …

Introduction: Slow channel congenital myasthenic syndrome is a dominant disorder characterized by prolonged acetylcholine receptor ion-channel activation. Methods: Molecular genetic techniques, electrophysiology, and binding studies in human embryonic kidney (HEK) 293 cells determined mutant function and expression levels. Patient response to treatment was measured by quantitative myasthenic gravis and Medical Research Council grade strength scores. Results: We report an unusual case due to heteroallelic mutations in CHRNE. The slow channel mutation, p.eS278del, is accompanied by a severe low-expression mutation, p.eR217L, on the second allele. Expression studies and cosegregation of p.eS278del with the disorder in the patient's offspring demonstrate robust expression of the p.eS278del mutation. The patient showed modest benefits from standard treatment with fluoxetine, but there was dramatic improvement when salbutamol was combined with fluoxetine. Conclusions: This case suggests that salbutamol, which is beneficial in some other congenital myasthenic syndromes, might also be considered in addition to fluoxetine in slow channel syndrome. Muscle Nerve, 2013

Congenital myasthenic syndromes (CMS) are a group of inherited disorders that arise from impaired signal transmission at the neuromuscular synapse. They are characterized by fatigable muscle weakness. This is a heterogenous group of disorders with 15 different genes implicated in the development of the disease. Using whole-exome sequencing we identified DPAGT1 as a new gene associated with CMS. DPAGT1 catalyses the first step of N-linked protein glycosylation. DPAGT1 patients are characterized by weakness of limb muscles, response to treatment with cholinesterase inhibitors, and the presence of tubular aggregates on muscle biopsy. We showed that DPAGT1 is required for glycosylation of acetylcholine receptor (AChR) subunits and efficient export of AChR to the cell surface. We suggest that the primary pathogenic mechanism of DPAGT1-associated CMS is reduced levels of AChRs at the endplate region. This finding demonstrates that impairment of the N-linked glycosylation pathway can lead to the development of CMS.

Congenital myasthenic syndromes are a heterogeneous group of inherited disorders that arise from impaired signal transmission at the neuromuscular synapse. They are characterized by fatigable muscle weakness. We performed whole-exome sequencing to determine the underlying defect in a group of individuals with an inherited limb-girdle pattern of myasthenic weakness. We identify DPAGT1 as a gene in which mutations cause a congenital myasthenic syndrome. We describe seven different mutations found in five individuals with DPAGT1 mutations. The affected individuals share a number of common clinical features, including involvement of proximal limb muscles, response to treatment with cholinesterase inhibitors and 3,4-diaminopyridine, and the presence of tubular aggregates in muscle biopsies. Analyses of motor endplates from two of the individuals demonstrate a severe reduction of endplate acetylcholine receptors. DPAGT1 is an essential enzyme catalyzing the first committed step of N-linked protein glycosylation. Our findings underscore the importance of N-linked protein glycosylation for proper functioning of the neuromuscular junction. Using the DPAGT1-specific inhibitor tunicamycin, we show that DPAGT1 is required for efficient glycosylation of acetylcholine-receptor subunits and for efficient export of acetylcholine receptors to the cell surface. We suggest that the primary pathogenic mechanism of DPAGT1 mutations is reduced levels of acetylcholine receptors at the endplate region. These individuals share clinical features similar to those of congenital myasthenic syndrome due to GFPT1 mutations, and their disorder might be part of a larger subgroup comprising the congenital myasthenic syndromes that result from defects in the N-linked glycosylation pathway and that manifest through impaired neuromuscular transmission. © 2012 The American Society of Human Genetics.

Summary Background In Australia 60–80% of all residents in aged care facilities have a cognitive impairment related to dementia with this figure predicted to increase. The associated behavioural and psychological disorders associated with dementia frequently result in the prescription of antipsychotic drugs to assist in limiting disruptive or concerning unmet needs behaviour. Antipsychotic prescription rates in aged care facilities are estimated to be as high as 80% despite the well known adverse effects in this population. Person centred care approaches to management of behavioural and psychological symptoms of dementia (BPSD) has not been widely implemented despite its reported effectiveness. Other interventions aimed at reducing antipsychotic use in aged care has been limited and the barriers to the use of non pharmacological strategies are poorly researched. Methodology In this study a 43 point questionnaire was distributed to 6 rural aged care facilities to assess nurses' knowledge of non pharmacological and pharmacological interventions, and the frequency, perceived barriers and efficacy of both strategies. Resources and information bases utilised in behaviour management was also explored. Findings The results indicated that staff have a good knowledge of possible underlying causes of BPSD, but a poor understanding of appropriate methods of management and resources available to assist them. Time constraints were frequently cited by respondents as problematic in managing behavioural problems. The results of this study suggest the need for utilisation of tools to assist nurses to identify target behaviours, implementation of appropriate management and access to the resources available.

OBJECTIVES: Clostridium difficile infection (CDI) in the elderly has a higher prevalence, greater morbidity and mortality, and lower response to conventional treatment than the general population. Fecal microbiota transplant (FMT) is highly effective therapy for CDI but has not been studied specifically in the elderly. This study aims to determine the long-term efficacy and safety of FMT for recurrent (RCDI), severe (SCDI), and complicated (CCDI) CDI in elderly patients. METHODS: A multicenter, long-term follow-up study was performed with demographic, pre-FMT, and post-FMT data collected from elderly patients with RCDI, SCDI, and CCDI, through a 47-item questionnaire. Outcome measures included primary and secondary cure rates, early (

Background Increasing demand for fecal microbiota transplantation (FMT) has created a need for stool banks sourced from long-term healthy donors. Here, we describe our experience in recruiting and screening fecal donors. Methods Mailbox, newspaper, and online advertisements were used. Potential donors were required to satisfy a prescreen telephone conversation, pass blood and stool investigations, then undertake a screening interview including medical history, physical examination, and evaluation of donor selection criteria. Results One hundred sixteen potential donors were prescreened of whom 74 failed-47 declined based on study donation requirements (primarily related to frequency and duration of donations), 13 had medical comorbidities, 6 variant Creutzfeldt-Jakob disease risk factors, 8 for other reasons. Thirty-eight completed stool and blood testing-1 failed blood testing (indeterminate hepatitis C serology), whereas 15 failed stool investigations (5 Dientamoeba fragilis, 5 Blastocystis hominis, 1 B. hominis and D. fragilis, 1 Giardia intestinalis plus D. fragilis, 1 Norovirus plus Clostridium difficile toxin positive, and 2 leucocytes or erythrocytes on stool microscopy). Of the 18 potential donors proceeding to screening interview, 6 were excluded (3 body mass index >30, 1 illicit drug use, 1 uncontrolled anxiety and concerns regarding compliance, 1 irregular bowel movements after new medication commencement). In total, only 12 of 116 (10%) potential donors were enrolled as study donors. Conclusions Recruitment of fecal donors for FMT is challenging with only a small percentage ultimately serving as donors. Many were unable or unwilling to meet the donor commitment requirements. A surprisingly large proportion of healthy asymptomatic donors failed stool testing, primarily due to gastrointestinal parasites.

Slow channel congenital myasthenic syndrome is a dominant disorder characterized by prolonged acetylcholine receptor ion-channel activation.Molecular genetic techniques, electrophysiology, and binding studies in human embryonic kidney (HEK) 293 cells determined mutant function and expression levels. Patient response to treatment was measured by quantitative myasthenic gravis and Medical Research Council grade strength scores.We report an unusual case due to heteroallelic mutations in CHRNE. The slow channel mutation, p.εS278del, is accompanied by a severe low-expression mutation, p.εR217L, on the second allele. Expression studies and cosegregation of p.εS278del with the disorder in the patient's offspring demonstrate robust expression of the p.εS278del mutation. The patient showed modest benefits from standard treatment with fluoxetine, but there was dramatic improvement when salbutamol was combined with fluoxetine.This case suggests that salbutamol, which is beneficial in some other congenital myasthenic syndromes, might also be considered in addition to fluoxetine in slow channel syndrome.

With the widespread implementation of screening programs internationally, there will be an increase in early stage cervical cancer cases. In response to this, the Ministry of Health in each country will need to plan strategies to provide care such as radical surgery or radiation for this potentially curable group of women.The Gynaecologic Oncologists of Canada created a teaching module to intensively train a small number of locally identified gynecologists to perform radical hysterectomy and pelvic lymphadenectomy. The process was based on adult learning principles; it involved a Canadian gynecologic oncologist working in the low- or middle-resource country with the gynecologists and problem-solving local issues in health care delivery.The teaching process included a pretest and a posttest on the basis of the objectives of the module. There were 7 modules including preoperative evaluation of the patient, cone biopsy, radical hysterectomy, pelvic lymphadenectomy, ureteric injury, vascular injury, and follow-up after surgery. Each module was divided into background information, techniques, and complications. There were video clips imbedded in the modules. After the educational modules had been reviewed, the learners were walked through the surgical procedures repeatedly including a detailed assessment of performance after each case. Participants had the opportunity to provide feedback on the training program. The module was reviewed in Mongolia and implemented in Kenya.In low- and middle-resource countries where there is an urgent need to provide a curative surgical option for the management of early cervical cancer, a focused high-intensity curriculum delivered by a trained surgeon can translate into immediate change in clinical and surgical practice.

Neurologists and paediatricians call for action on “massive” rises in the prices of orphan drugs We are writing to you as a group of clinicians treating patients with so called “orphan” diseases (and one representative of a patients’ group) to express our concern at an unintended effect of the European Union’s regulations on orphan drugs. The original purpose of this legislation, passed in 1999, was to encourage drug companies to conduct research into rare diseases and develop novel treatments. However, as the rules are currently enacted, many drug companies merely address their efforts to licensing drugs that are already available rather than developing new treatments. Once a company has obtained a licence, the legislation then gives the company sole rights to supply the drug. This in turn allows the company to set an exorbitant price for this supply and effectively to bar previous suppliers of the unlicensed preparation from further production and distribution. We believe that this behaviour is not in the best interests of patients or the NHS but is undoubtedly significantly advantageous to drug companies. We have made representations to …

The congenital myasthenic syndromes (CMS) are a group of rare inherited disorders causing abnormal neuromuscular junction signal transmission. They result from mutations in genes that encode proteins required for neuromuscular transmission or for the formation and maintenance of the neuromuscular synapse. Fast channel syndrome (FCS) comprises around 5% of genetically confirmed CMS in the UK and is autosomal recessive in inheritance. Here mutations in AChR subunits lead to a kinetic abnormality of the AChR ion channel pore whereby channel opening is abnormally brief (or fast). In the UK the majority of fast channel syndrome present as a severe form of CMS with associated sudden, life-threatening apnoeas on a background of persistent generalised muscle weakness. Patients may have an initial dramatic response to cholinesterase inhibitors but over time this reduces. Addition of 3, 4-Diaminopyridine can be beneficial. We will present 12 cases of FCS detailing underlying mutations and demonstrating the clinical features and discuss management strategies focussing on respiratory issues.