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The γδ T-cell receptor (TCR)-positive lymphocytes are a major circulating lymphocyte population in cattle, especially in young calves. In contrast, human and mice have low levels of circulating γδ TCR(+) T cells (γδ T cells). The majority of the circulating γδ T cells in ruminants express the workshop cluster 1 (WC1) molecule and are of the phenotype WC1(+) CD2(-) CD4(-) CD8(-). WC1 is a 220000 molecular weight glycoprotein with homology to the scavenger receptor cysteine-rich (SRCR) family, closely related to CD163. The existence of 13 members in the bovine WC1 gene family has recently been demonstrated and although murine and human orthologues to WC1 genes exist, functional gene products have not been identified in species other than ruminants and pigs. Highly diverse TCRδ usage has been reported, with expanded variable genes in cattle compared to humans and mice. Differential γ chain usage is evident between populations of bovine γδ T cells, this may have implications for functionality. There is a growing body of evidence that WC1(+) γδ T cells are important in immune responses to mycobacteria and may have important roles in T cell regulation and antigen presentation. In this review, we will summarize recent observations in γδ T cell biology and the importance of γδ T cells in immune responses to mycobacterial infections in cattle., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Patients with coal workers' pneumoconiosis (CWP) can develop chronic respiratory failure and require lung transplantation. A retrospective review was performed of the 712 referrals and 143 patients undergoing unilateral or bilateral lung transplantation at the University of Kentucky Medical Center between January 1999 and July 2009. Twenty-one of the 712 referrals (3%) had a diagnosis of CWP with eight patients eventually undergoing lung transplant (six single, two bilateral). The mean age of the cohort was 53 ± 5 (mean ± SD) yr (range 45-59). There was no increased risk of perioperative or postoperative complications. Six patients (75%) remain alive after a mean follow-up of 1013 ± 857 d with the two deaths attributable to sepsis 683 and 145 d after transplant, respectively. There were no pulmonary complications because of the native lung in patients after a single lung transplant, with otherwise good clinical outcomes seen after lung transplantation., (© 2012 John Wiley & Sons A/S.)

Dendritic cells (DC) are potent antigen-presenting cells and central to the induction of immune responses following infection or vaccination. The collection of DC migrating from peripheral tissues by cannulation of the afferent lymphatic vessels provides DC which can be used directly ex vivo without extensive in vitro manipulations. We have previously used bovine migrating DC to show that recombinant human adenovirus 5 vectors efficiently transduce afferent lymph migrating DEC-205(+) CD11c(+) CD8(-) DC (ALDC). We have also shown that recombinant modified vaccinia virus Ankara (MVA) infects ALDC in vitro, causing downregulation of costimulatory molecules, apoptosis, and cell death. We now show that in the bovine system, modified vaccinia virus Ankara-induced apoptosis in DC draining from the skin occurs soon after virus binding via the caspase 8 pathway and is not associated with viral gene expression. We also show that after virus entry, the caspase 9 pathway cascade is initiated. The magnitude of T cell responses to mycobacterial antigen 85A (Ag85A) expressed by recombinant MVA-infected ALDC is increased by blocking caspase-induced apoptosis. Apoptotic bodies generated by recombinant MVA (rMVA)-Ag85A-infected ALDC and containing Ag85A were phagocytosed by noninfected migrating ALDC expressing SIRPα via actin-dependent phagocytosis, and these ALDC in turn presented antigen. However, the addition of fresh ALDC to MVA-infected cultures did not improve on the magnitude of the T cell responses; in contrast, these noninfected DC showed downregulation of major histocompatibility complex class II (MHC-II), CD40, CD80, and CD86. We also observed that MVA-infected ALDC promoted migration of DEC-205(+) SIRPα(+) CD21(+) DC as well as CD4(+) and CD8(+) T cells independently of caspase activation. These in vitro studies show that induction of apoptosis in DC by MVA vectors is detrimental to the subsequent induction of T cell responses.

Objectives: The objectives of this study were to determine the current staffing models of practice and the frequency of 24/7 coverage in academic medical centers in the United States and to assess the perceptions of critical care trainees and program directors toward these models., Methods: A cross-sectional national survey was conducted using an Internet-based survey platform. The survey was distributed to fellows and program directors of 374 critical care training programs in US academic medical centers., Results: We received 518 responses: 138 from program directors (PDs) (37% of 374 programs) and 380 fellow responses. Coverage by a board-certified or board-eligible intensivist physician 24/7 was reported by 33% of PD respondents and was more common among pediatric and surgical critical care programs. Mandatory in-house call for critical care trainees was reported by 48% of the PDs. Mandatory call was also more common among pediatric-critical care programs compared with the rest (P < .001). Advanced nurse practitioners with critical care training were reported available by 27% of the PDs. The majority of respondents believed that 24/7 coverage would be associated with better patient care in the ICU and improved education for the fellows, although 65% of them believed this model would have a negative impact on trainees' autonomy., Conclusions: Intensivist coverage 24/7 was not commonly used in US academic centers responding to our survey. Significant differences in coverage models among critical care medicine specialties appear to exist. Program director and trainee respondents believed that 24/7 coverage was associated with better outcomes and education but also expressed concerns about the impact of this model on fellows' autonomy.

Understanding how pathogens or vaccine antigens are targeted to dendritic cell (DC) subsets is important for disease pathogenesis studies and vaccine design. We characterised the sub-populations of migrating bovine DC with functional and phenotypic diversity present in pseudoafferent lymph draining the skin. These skin draining DC exist as a series of maturation dependent subsets with differential capacities for antigen uptake and cytokine expression, and include both Langerhans' cells (LC) and dermal derived cells. Furthermore, Mycobacterium bovis Bacille Calmette Guerin, a vaccine which is administered by the intradermal route, was only taken up by a small number of the migrating DC, which were SIRPα(+) and expressed the mannose receptor and CD1b. This was evident following in vitro infection and also in vivo following inoculation of green fluorescent BCG over the lymphatic cannulation site. Only the SIRPα(+) DC were able to present antigen to T cells isolated from BCG vaccinated calves. Furthermore, presentation of BCG antigens by DC to T lymphocytes was ineffective compared to mycobacterial proteins. However, mycobacterial antigen 85 was delivered more effectively to DC via an adenoviral vector and the magnitude of the subsequent antigen-specific T cell response was significantly increased. This study further extends our understanding of the biology of migrating DC, identifies potential explanations for the modest success of BCG vaccination and demonstrates that targeted delivery of antigens via adenoviruses to DC can improve antigen presentation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Aim: Individually, statins and thiazolidinediones (TZDs) show positive effects on atherosclerosis progression in cellular and animal models as well as patients with diabetes; however, their combined effects have not been studied. This study examines the effects of simvastatin combined with rosiglitazone on vascular inflammation, oxidant stress, ambulatory blood pressure (BP) and other atherosclerotic factors in patients with the metabolic syndrome., Methods: This is a randomized, double blind, placebo-controlled study in 53 subjects with the metabolic syndrome. Participants were randomized to simvastatin 40 mg/day plus placebo vs. simvastatin 40 mg/day plus rosiglitazone 4 mg/day for 6 months. The primary endpoint was the between-group difference in high-sensitivity C-reactive protein (hs-CRP) and secondary variables including urinary isoprostanes, serum malondialdehyde (MDA), ambulatory BP, adiponectin, and lipid and glycaemic profiles., Results: At study end, the group randomized to the simvastatin/rosiglitazone combination had a greater reduction in hs-CRP of 1.33 mg/dl, (p = 0.029) and showed a trend for a greater reduction in urinary isoprostane (-39%), (p = 0.056) compared to simvastatin/placebo group. Changes in MDA levels did not differed between groups (p = 0.81). 24-h systolic blood pressure (SBP) also showed a 4.5 mmHg reduction at 6 months (p = 0.06). Adiponectin levels increased by 3.91 µg/ml in the combination group over placebo, (p = 0.03) and blood glucose decreased in combination group vs. placebo., Conclusion: Our data show that patients with the metabolic syndrome given a statin/TZD combination manifest greater reductions in markers of vascular inflammation and oxidant stress, 24-h ambulatory BP and increases in adiponectin as well as improved glycaemic indices., (© 2011 Blackwell Publishing Ltd.)

Background: The GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages for COPD use a fixed ratio of the postbronchodilator FEV(1)/FVC ratio of 0.70 as a threshold to define obstruction. Others advocate using the lower limit of normal (LLN) for the FEV(1)/FVC ratio, FEV(1), and FVC to define abnormality. This study investigated mortality in a representative sample of the US adult population with COPD by comparing abnormality determined using GOLD criteria to that determined using LLN criteria., Methods: We used baseline data from the Third National Health and Nutrition Examination Survey and follow-up mortality data. We classified subjects as obstructed, restricted, or normal based on GOLD vs LLN criteria and used Cox proportional hazards models to determine the relation between lung function impairment and mortality, adjusting for covariates., Results: The study sample included 13,847 subjects, of whom 3,774 died during the follow-up period. Of subjects classified as obstructed and restricted using GOLD criteria, 20.9% and 18.0%, respectively, were classified as normal using LLN criteria. Compared with people with normal lung function, mortality was increased in the obstructed (hazard ratio, 1.46; 95% CI, 1.21-1.86) and restricted (hazard ratio, 1.94; 95% CI, 1.58-2.39) subjects classified as normal using the LLN., Conclusions: In the nationally representative Third National Health and Nutrition Examination Survey data, subjects classified as normal using LLN criteria but obstructed or restricted using GOLD criteria have a higher risk of mortality.

Background. There are modes of mechanical ventilation that can select ventilator settings with computer controlled algorithms (targeting schemes). Two examples are adaptive support ventilation (ASV) and mid-frequency ventilation (MFV). We studied how different clinician-chosen ventilator settings are from these computer algorithms under different scenarios. Methods. A survey of critical care clinicians provided reference ventilator settings for a 70 kg paralyzed patient in five clinical/physiological scenarios. The survey-derived values for minute ventilation and minute alveolar ventilation were used as goals for ASV and MFV, respectively. A lung simulator programmed with each scenario's respiratory system characteristics was ventilated using the clinician, ASV, and MFV settings. Results. Tidal volumes ranged from 6.1 to 8.3 mL/kg for the clinician, 6.7 to 11.9 mL/kg for ASV, and 3.5 to 9.9 mL/kg for MFV. Inspiratory pressures were lower for ASV and MFV. Clinician-selected tidal volumes were similar to the ASV settings for all scenarios except for asthma, in which the tidal volumes were larger for ASV and MFV. MFV delivered the same alveolar minute ventilation with higher end expiratory and lower end inspiratory volumes. Conclusions. There are differences and similarities among initial ventilator settings selected by humans and computers for various clinical scenarios. The ventilation outcomes are the result of the lung physiological characteristics and their interaction with the targeting scheme.

The complement anaphylatoxin C5a has a pathogenetic role in endotoxin-induced lung inflammatory injury by regulating phagocytic cell migration and activation. Endotoxin and C5a activate the enzyme sphingosine kinase (Sphk) 1 to generate the signaling lipid sphingosine-1-phosphate (S1P), a critical regulator of phagocyte function. We assessed the function of Sphk1 and S1P in experimental lung inflammatory injury and determined their roles in anaphylatoxin receptor signaling and on the expression of the two C5a receptors, C5aR (CD88) and C5L2, on phagocytes. We report that Sphk1 gene deficient (Sphk1(-/-)) mice had augmented lung inflammatory response to endotoxin compared to wild type mice. Sphk1 was required for C5a-mediated reduction in cytokine and chemokine production by macrophages. Moreover, neutrophils from Sphk1(-/-) mice failed to upregulate the anaphylatoxin receptor C5L2 in response to LPS. Exogenous S1P restored C5L2 cell surface expression of Sphk1(-/-) mouse neutrophils to wild type levels but had no effect on cell surface expression of the other anaphylatoxin receptor, CD88. These results provide the first genetic evidence of the crucial role of Sphk1 in regulating the balance between expression of CD88 and C5L2 in phagocytes. S1P-mediated up-regulation of C5L2 is a novel therapeutic target for mitigating endotoxin-induced lung inflammatory injury.

Background: COPD and asthma are common diseases in the U.S. population and can coexist. Our goal was to determine the prevalence of self-reported, physician-diagnosed asthma and COPD in a sample of the U.S. population and their association with lung function impairment and mortality., Methods: We used baseline data from NHANES III and the follow-up mortality data. We used logistic regression and Cox Proportional Hazards models, adjusting for age, sex, race/ethnicity, education level, smoking status, and disease stage., Results: The sample consisted of 15,203 subjects, of whom 4,542 died during the follow-up period. Coexisting COPD and asthma was reported by 357 (2.7%), COPD by 815 (5.3%), and asthma by 709 (5.3%). Subjects with both conditions had a higher proportion of obstruction (30.9%) than those with COPD (24.3%), asthma (13.3%), or no lung disease (5.4%). In survival models adjusting for all factors except baseline lung function, coexisting COPD and asthma had the highest risk for mortality (Hazard Ratio [HR] 1.83, 95% confidence interval [CI] 1.34, 2.49), followed by COPD only (HR 1.44, 95% CI 1.28, 1.62), and asthma only (HR 1.16, 95% CI 0.94, 1.42). These affects were attenuated after controlling for baseline lung function: coexisting asthma and COPD (HR 1.45, 95% CI 1.06, 1.98), COPD only (1.28, 95% CI 1.13, 1.45), and asthma only (HR 1.04, 95% CI 0.85, 1.27)., Conclusion: In this analysis, subjects who report coexisting asthma and COPD have a higher risk of obstruction on spirometry and a higher risk of death during follow-up.

Background: Chronic obstructive pulmonary disease (COPD) is supposed to be classified on the basis of post-bronchodilator lung function. Most longitudinal studies of COPD, though, do not have post-bronchodilator lung function available. We used pre-and post bronchodilator lung function data from the Lung Health Study to determine whether these measures differ in their ability to predict mortality., Methods: We limited our analysis to subjects who were of black or white race, on whom we had complete data, and who participated at either the 1 year or the 5 year follow-up visit. We classified subjects based on their baseline lung function, according to COPD Classification criteria using both pre- and post-bronchodilator lung function. We conducted a survival analysis and logistic regression predicting death and controlling for age, sex, race, treatment group, smoking status, and measures of lung function (either pre- or post-bronchodilator. We calculated hazard ratios (HR) with 95% confidence intervals (CI) and also calculated area under the curve for the logistic regression models., Results: By year 15 of the study, 721 of the original 5,887 study subjects had died. In the year 1 sample survival models, a higher FEV1 % predicted lower mortality in both the pre-bronchodilator (HR 0.87, 95% CI 0.81, 0.94 per 10% increase) and post-bronchodilator (HR 0.84, 95% CI 0.77, 0.90) models. The area under the curve for the respective models was 69.2% and 69.4%. Similarly, using categories, when compared to people with "normal" lung function, subjects with Stage 3 or 4 disease had similar mortality in both the pre- (HR 1.51, 95% CI 0.75, 3.03) and post-bronchodilator (HR 1.45, 95% CI 0.41, 5.15) models. In the year 5 sample, when a larger proportion of subjects had Stage 3 or 4 disease (6.4% in the pre-bronchodilator group), mortality was significantly increased in both the pre- (HR 2.68, 95% CI 1.51, 4.75) and post-bronchodilator (HR 2.46, 95% CI 1.63, 3.73) models., Conclusions: Both pre- and post-bronchodilator lung function predicted mortality in this analysis with a similar degree of accuracy. Post-bronchodilator lung function may not be needed in population studies that predict long-term outcomes.

Neural retina leucine zipper (NRL) is an essential transcription factor for cell fate specification and functional maintenance of rod photoreceptors in the mammalian retina. In the Nrl(-/-) mouse retina, photoreceptor precursors fail to produce rods and generate functional cone photoreceptors that predominantly express S-opsin. Previous global expression analysis using microarrays revealed dramatically reduced expression of myocyte enhancer factor Mef2c in the adult Nrl(-/-) retina. We undertook this study to examine the biological relevance of Mef2c expression in retinal rod photoreceptors. Bioinformatics analysis, rapid analysis of cDNA ends (5'-RACE), and reverse transcription coupled with qPCR using splice site-specific oligonucleotides suggested that Mef2c is expressed in the mature retina from an alternative promoter. Chromatin immunoprecipitation (ChIP) studies showed the association of active RNA polymerase II and acetylated histone H3 just upstream of Mef2c exon 4, providing additional evidence for the utilization of an alternative promoter in the retina. In concordance, we observed the binding of NRL to a putative NRL-response element (NRE) at this location by ChIP-seq and electrophoretic mobility shift assays. NRL also activated the Mef2c alternative promoter in vitro and in vivo. Notably, MEF2C could support Rhodopsin promoter activity in rod photoreceptors. We conclude that Mef2c expression from an alternative promoter in the retina is regulated by NRL. Our studies also implicate MEF2C as a transcriptional regulator of homeostasis in rod photoreceptor cells.

Rhodococcus equi is an emerging opportunistic pathogen in immunocompromised patients. A lung-transplant recipient developed weight loss, nonproductive cough, dyspnea, and somnolence. Computed tomogram showed a pulmonary nodule and pleural changes in the right allograft that was due to R. equi infection. Alteration of cell-mediated immunity is a predisposing risk factor for R. equi infection in humans. Our patient developed R. equi infection soon after a course of high-dose corticosteroids for acute allograft infection and animal exposure. A course of intravenous vancomycin followed by single-agent long-term therapy with oral ciprofloxacin was successful.

During the last 5 years, new randomized trials in critically ill patients have challenged a number of traditional treatment strategies in intensive care. The authors review eight studies that helped change their medical practices.

Targeting dendritic cells (DC) is key to driving effective immune responses. Lymphatic cannulation provides access to the heterogeneous populations of DC draining peripheral sites in rodents and ruminants. Afferent lymph DEC-205(+) CD11c(+) SIRPα(+) DC were preferentially infected ex vivo with three vaccine viral vectors: recombinant human replication-defective human adenovirus 5 (rhuAdV5), recombinant modified vaccinia virus Ankara (rMVA), and recombinant fowlpox virus (rFPV), all expressing green fluorescent protein (GFP). The rhuAdV5-infected cells remained viable, and peak GFP expression was observed 16 to 24 h posttransduction. Increasing the incubation period of DC with rhuAdV5 enhanced GFP expression. In contrast, DC infected with rMVA-GFP or rFPV-GFP became rapidly apoptotic and GFP expression peaked at 6 h postinfection. Delivery of foot-and-mouth disease virus (FMDV) A(22) antigen to DC by rhuAdV5-FMDV-A(22) ex vivo resulted in significantly greater CD4(+) T cell proliferation than did delivery by rFPV-FMDV-A(22). Delivery of rhuAdV5-GFP in oil adjuvant in vivo, to enhance DC-vector contact, resulted in increased GFP expression in migrating DC compared to that with vector alone. Similarly, CD4(+) T cell responses were significantly enhanced when using rhuAdV5-FMDV-A(22) in adjuvant. Therefore, the interaction between viral vectors and afferent lymph DC ex vivo can predict the outcome of in vivo immunization and provide a means of rapidly assessing the effects of vector modification.

Hemophagocytic lymphohistiocytosis is a rare and often fatal disease that may occur in solid organ transplant recipients. Here, we describe 2 patients who developed hemophagocytic lymphohistiocytosis after having a lung transplant and present a review of all cases of hemophagocytic lymphohistiocytosis occurring in solid organ transplant recipients. Diagnosis of hemophagocytic lymphohistiocytosis relies on the association of clinical findings and the presence of hemophagocytosis. Clinical presentation is nonspecific and patients may present with unexplained sepsis or multiple organ failure. Management consists of treating the underlying process; but unfortunately, the prognosis is poor.

Objective: Inguinal hernia repair is thought to be a relatively low morbidity operation. This study examined whether this tenet hold true in patients who are elderly with significant comorbidity., Design: Case series. Retrospective review of a prospectively collected database., Setting: Single surgeon practicing in Vermont over a period of 9 years., Patients: Consecutive sample of 2,145 inguinal herniorraphies in 1,889 patients., Intervention: Patients underwent an open inguinal hernia repair with mesh placement. A total of 81% of the repairs were performed under local anesthesia with intravenous sedation., Main Outcome Measure: Presence of comorbid conditions and complications were compared between patients younger and older than 65 years., Results: A total of 2,145 herniorraphies were performed on 1,889 patients (1,646 in younger patients and 499 in older patients). Hernia repairs in older patients were more likely associated with comorbid conditions than in their younger counterparts (74 vs 39%; OR = 4.55, P < 0.0001). Specifically, hypertension (26 vs 9%; OR = 3.5, P < 0.0001), coronary artery disease (34 vs 6%; OR = 8.4, P < 0.0001) and benign prostatic hypertrophy (26 vs 4%; OR = 8.2, P < 0.0001) were more commonly present in older individuals. The commonest postoperative complications in both groups were recurrence (3%), hematoma (1%) and nerve entrapment (1%). There were no deaths. There was no significant difference in the rate of postoperative complications (6 vs 7%; OR = 0.95, P = 0.88) or recurrence rates (2 vs 3%; OR = 0.82, P = 0.65) between groups., Conclusion: Inguinal herniorrhaphy under local anesthesia is a safe operation with a high success rate in the elderly. Patients with significant comorbidities are not at higher risk of complications or recurrences.

Foot-and-mouth disease virus (FMDV) causes a highly contagious infection in cloven-hoofed animals. Current inactivated FMDV vaccines generate short-term, serotype-specific protection, mainly through neutralizing antibody. An improved understanding of the mechanisms of protective immunity would aid design of more effective vaccines. We have previously reported the presence of virus-specific CD8(+) T cells in FMDV-vaccinated and -infected cattle. In the current study, we aimed to identify CD8(+) T cell epitopes in FMDV recognized by cattle vaccinated with inactivated FMDV serotype O. Analysis of gamma interferon (IFN-γ)-producing CD8(+) T cells responding to stimulation with FMDV-derived peptides revealed one putative CD8(+) T cell epitope present within the structural protein P1D, comprising residues 795 to 803 of FMDV serotype O UKG/2001. The restricting major histocompatibility complex (MHC) class I allele was N*02201, expressed by the A31 haplotype. This epitope induced IFN-γ release, proliferation, and target cell killing by αβ CD8(+) T cells, but not CD4(+) T cells. A protein alignment of representative samples from each of the 7 FMDV serotypes showed that the putative epitope is highly conserved. CD8(+) T cells from FMDV serotype O-vaccinated A31(+) cattle recognized antigen-presenting cells (APCs) loaded with peptides derived from all 7 FMDV serotypes, suggesting that CD8(+) T cells recognizing the defined epitope are cross-reactive to equivalent peptides derived from all of the other FMDV serotypes.

Asthma and chronic obstructive pulmonary disease occur commonly and may overlap among older adults. Smoking, air pollution, and bronchial hyperresponsiveness are the main risk factors. The treatment of these diseases in older adults does not differ from the available guidelines but may be complicated by the presence of comorbidities. Smoking cessation is essential for smokers, and pulmonary rehabilitation must be considered regardless of the age of the patient., (Copyright © 2010 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.)

Major histocompatibility complex (MHC) class I chain-related (MIC) genes encode molecules that are expressed in response to stress, signalling immune system cells primarily via the activating receptor NKG2D. We investigated the expression of receptors for MIC in lymphocyte subsets found in peripheral blood, lymph node and gut in cattle and demonstrated their presence on natural killer (NK) cells, gammadelta T cells and CD8(+) T cells. Recognition of MIC by NKG2D was formally demonstrated using recombinant protein and an ELISA. Staining with a cross-reactive monoclonal antibody recognising both human and cattle MIC showed that MIC is constitutively expressed within cattle intestinal epithelium. A functional response to soluble MIC was observed in receptor-bearing cells in blood, lymph node and gut, the latter requiring relatively high levels of MIC to trigger a response. Results suggest that NKG2D is a functionally important activating receptor in cattle., (Copyright 2010 Elsevier B.V. All rights reserved.)

Papillary carcinoma of the breast represents approximately 0.5% of all newly diagnosed cases of breast cancer. The prevalence of both invasive and in situ papillary carcinoma seems to be greater in older postmenopausal women and, in relative terms, in males. Histologic features of the tumor include cellular proliferations surrounding fibrovascular cores, with or without invasion. In this review, characteristics of both in situ and invasive disease are outlined. Immunohistochemical analyses of papillary carcinoma suggest the utility of markers such as smooth muscle myosin heavy chain, calponin, p63, and high molecular weight keratins, which can characterize the myoepithelial cell layer. With respect to radiographic evaluation of papillary carcinoma, ultrasonography is the most extensively studied imaging modality, though magnetic resonance mammography has potential utility. Available data suggest improved outcome for papillary carcinoma as compared to invasive ductal carcinoma. Treatment-related information for patients with papillary carcinoma is limited, and patterns noted in available series suggest a variable approach to this disease. The scarcity of information underscores the need for further treatment- and outcome-related studies in papillary carcinoma of the breast.

Background: The frequency of combined obstruction and restriction identified in pulmonary function tests has not been well described. Moreover, although the causes of combined-obstruction-and-restriction patterns are known, the frequency of the various etiologies has received little attention., Methods: We retrospectively reviewed medical records and surveyed pulmonologists., Results: 43,212 PFT sessions were evaluated, which yielded 130 patients who satisfied our criteria for spirometry evidence of combined obstruction and restriction. Their demographic features were: mean +/- SD age 54 +/- 14 y, 51% male, mean +/- SD body mass index 28.8 +/- 6.7 kg/m(2), mean +/- SD height 174 +/- 9 cm (men) and 162 +/- 7 cm (women). The causes of combined obstruction and restriction were classified as either a pulmonary parenchymal disorder (Group A, n = 49, 38%) or a combination of pulmonary parenchymal and non-pulmonary diseases (Group B, n = 63, 48%). In 18 patients (14%) no clear etiology of combined obstruction and restriction could be determined. The most common pulmonary disease was chronic obstructive pulmonary disease (45/130, 35%), and the most common non-parenchymal disease was congestive heart failure (27/130, 21%). We electronically sent a survey to 55 pulmonary physicians, of whom 30 (55%) responded. The respondents estimated that combined obstruction and restriction occurs in approximately 20% of all the pulmonary function tests performed in their practices and that pulmonary parenchymal diseases were responsible for 35% of all instances of combined obstruction and restriction., Conclusions: Combined obstruction and restriction occurs infrequently and is more commonly caused by a combination of pulmonary parenchymal and non-pulmonary disorders. Pulmonologists' impressions regarding the frequency and causes are generally discordant with the observed frequencies.

Purpose: During retinal development, post-mitotic neural progenitor cells must activate thousands of genes to complete synaptogenesis and terminal maturation. While many of these genes are known, others remain beyond the sensitivity of expression microarray analysis. Some of these elusive gene activation events can be detected by mapping changes in RNA polymerase-II (Pol-II) association around transcription start sites., Methods: High-resolution (35 bp) chromatin immunoprecipitation (ChIP)-on-chip was used to map changes in Pol-II binding surrounding 26,000 gene transcription start sites during photoreceptor maturation of the mouse neural retina, comparing postnatal age 25 (P25) to P2. Coverage was 10-12 kb per transcription start site, including 2.5 kb downstream. Pol-II-active regions were mapped to the mouse genomic DNA sequence by using computational methods (Tiling Analysis Software-TAS program), and the ratio of maximum Pol-II binding (P25/P2) was calculated for each gene. A validation set of 36 genes (3%), representing a full range of Pol-II signal ratios (P25/P2), were examined with quantitative ChIP assays for transcriptionally active Pol-II. Gene expression assays were also performed for 19 genes of the validation set, again on independent samples. FLT-3 Interacting Zinc-finger-1 (FIZ1), a zinc-finger protein that associates with active promoter complexes of photoreceptor-specific genes, provided an additional ChIP marker to highlight genes activated in the mature neural retina. To demonstrate the use of ChIP-on-chip predictions to find novel gene activation events, four additional genes were selected for quantitative PCR analysis (qRT-PCR analysis); these four genes have human homologs located in unidentified retinal disease regions: Solute carrier family 25 member 33 (Slc25a33), Lysophosphatidylcholine acyltransferase 1 (Lpcat1), Coiled-coil domain-containing 126 (Ccdc126), and ADP-ribosylation factor-like 4D (Arl4d)., Results: ChIP-on-chip Pol-II peak signal ratios >1.8 predicted increased amounts of transcribing Pol-II and increased expression with an estimated 97% accuracy, based on analysis of the validation gene set. Using this threshold ratio, 1,101 genes were predicted to experience increased binding of Pol-II in their promoter regions during terminal maturation of the neural retina. Over 800 of these gene activations were additional to those previously reported by microarray analysis. Slc25a33, Lpcat1, Ccdc126, and Arl4d increased expression significantly (p<0.001) during photoreceptor maturation. Expression of all four genes was diminished in adult retinas lacking rod photoreceptors (Rd1 mice) compared to normal retinas (90% loss for Ccdc126 and Arl4d). For rhodopsin (Rho), a marker of photoreceptor maturation, two regions of maximum Pol-II signal corresponded to the upstream rhodopsin enhancer region and the rhodopsin proximal promoter region., Conclusions: High-resolution maps of Pol-II binding around transcription start sites were generated for the postnatal mouse retina; which can predict activation increases for a specific gene of interest. Novel gene activation predictions are enriched for biologic functions relevant to vision, neural function, and chromatin regulation. Use of the data set to detect novel activation increases was demonstrated by expression analysis for several genes that have human homologs located within unidentified retinal disease regions: Slc25a33, Lpcat1, Ccdc126, and Arl4d. Analysis of photoreceptor-deficient retinas indicated that all four genes are expressed in photoreceptors. Genome-wide maps of Pol-II binding were developed for visual access in the University of California, Santa Cruz (UCSC) Genome Browser and its eye-centric version EyeBrowse (National Eye Institute-NEI). Single promoter resolution of Pol-II distribution patterns suggest the Rho enhancer region and the Rho proximal promoter region become closely associated with the activated gene's promoter complex.

Background: Drug hypersensitivity is responsible for substantial mortality and morbidity, and increased health costs. However, epidemiological data on drug hypersensitivity in general or specific populations are scarce., Methods: We performed a cross-sectional survey of 1015 university students, using a self-reported questionnaire., Results: The prevalence of self-reported drug hypersensitivity was 12,11% (123/1015). The most frequently implicated drugs were non-steroidal anti-inflammatory drugs (45,9%) and beta-lactam and sulfonamide antibiotics (25,40%). The majority of the patients reported dermatological manifestations (99), followed by respiratory (40), digestive (23) and other (19). Forty-five patients had an immediate type reaction, and 76,72% (89) had the drug by oral route., Conclusion: The results showed that drug hypersensitivity is highly prevalent in university students, and that nonsteroidal anti-inflammatory drug and antibiotics (beta-lactams and sulfonamide) are the most frequently concerned drugs.

Background: Methohexital has been used for procedural sedation in the emergency department, but its use for endotracheal intubation in intensive care units has not been studied., Objective: To compare methohexital with etomidate with respect to their effectiveness and safety of use for endotracheal intubation in the intensive care unit., Methods: Retrospective, observational, single-center cohort study of consecutive patients admitted between December 2006 and August 2007 to a medical intensive care unit in a tertiary-care hospital., Results: Twenty-three patients who received methohexital and 23 who received etomidate for endotracheal intubation were included. The 2 groups differed in age (mean [SD], 55 [13] vs 64 [13] years, P = .03) but not in baseline demographics or illness severity scores. Mean (SD) doses given were 1 (0.2) mg/kg for methohexital and 0.2 (0.1) mg/kg for etomidate. Use of midazolam, fentanyl, and succinylcholine was similar between the groups. Rates of successful intubation after 1 attempt (78% vs 83%), time to successful intubation (mean, 5.9 vs 4 minutes), and number of intubation attempts (mean, 1.5 vs 1.2) also were similar. Change in hemodynamics (delta systolic blood pressure), vasopressor requirements, and amount of fluid resuscitation (normal saline) did not differ significantly between the groups., Conclusions: Rates of successful intubation are similar with etomidate and methohexital. Methohexital provides adequate sedation and could be an alternative to etomidate, although both agents were often associated with development of hypotension. Prospective studies are needed to establish the safety of methohexital use in intensive care patients.

Background: The lack of biomarkers that are predictive of safety is a critical gap in the development of microbicides. The present experiments were designed to evaluate the predictive value of in vitro models of microbicide safety., Methods: Changes in the epithelial barrier were evaluated by measuring transepithelial electrical resistance (TER) after exposure of human epithelial cells to candidate microbicides in a dual-chamber system. The significance of observed changes was addressed by challenging cultures with human immunodeficiency virus (HIV) and measuring the ability of virus to cross the epithelium and infect target T cells cultured in the lower chamber., Results: Exposure to nonoxynol-9 (N-9) or cellulose sulfate (CS), but not 9-[2-(phosphonomethoxy)propyl]adenine (also referred to as tenofovir) or PRO2000, resulted in a rapid and sustained reduction in TER and a marked increase in HIV infection of T cells cultured in the lower chamber. Moreover, CS triggered nuclear factor kappaB activation in peripheral blood mononuclear cells and increased HIV replication in chronically infected U1 cells., Conclusions: Epithelial barrier disruption and enhanced viral replication may have contributed to the increased risk of HIV acquisition observed in phase 3 trials of N-9 and CS. Expansion of in vitro safety testing to include these models would provide a more stringent preclinical assessment of microbicide safety and may prove to be more predictive of clinical outcomes.

Newer ventilators can be set to modes other than the pressure-control and volume-control modes of older machines. In this paper, the authors review several of these alternative modes (adaptive pressure control, adaptive support ventilation, proportional assist ventilation, airway pressure-release ventilation, biphasic positive airway pressure, and high-frequency oscillatory ventilation), explaining how they work and contrasting their theoretical benefits and the actual evidence of benefit.

Background: Central nervous system is a common site of metastasis in NSCLC and confers worse prognosis and quality of life. The aim of this prospective study was to evaluate the prognostic significance of clinical-pathological factors (CPF), serum CEA levels, and EGFR and HER2 tissue-expression in brain metastasis (BM) and overall survival (OS) in patients with advanced NSCLC., Methods: In a prospective manner, we studied 293 patients with NSCLC in IIIB-IV clinical stage. They received standard chemotherapy. CEA was measured prior to treatment; EGFR and HER2 were evaluated by immunohistochemistry. BM development was confirmed by MRI in symptomatic patients., Results: BM developed in 27, and 32% of patients at 1 and 2 years of diagnosis with adenocarcinoma (RR 5.2; 95% CI, 1.002-29; p = 0.05) and CEA > or = 40 ng/mL (RR 11.4; 95% CI, 1.7-74; p < 0.01) as independent associated factors. EGFR and HER2 were not statistically significant. Masculine gender (RR 1.4; 95% CI, 1.002-1.9; p = 0.048), poor performance status (RR 1.8; 95% CI, 1.5-2.3; p = 0.002), advanced clinical stage (RR 1.44; 95% CI, 1.02-2; p = 0.04), CEA > or = 40 ng/mL (RR 1.5; 95% CI, 1.09-2.2; p = 0.014) and EGFR expression (RR 1.6; 95% CI, 1.4-1.9; p = 0.012) were independent associated factors to worse OS., Conclusion: High CEA serum level is a risk factor for BM development and is associated with poor prognosis in patients with advanced NSCLC. Surface expression of CEA in tumor cells could be the physiopathological mechanism for invasion to CNS.

Objective: We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis., Study Design: Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment., Results: There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each., Conclusion: TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Background: Metalloproteinase inhibitors can protect mice against experimental autoimmune encephalomyelitis (EAE), an animal model for multiple sclerosis (MS). Matrix metalloproteinase-9 (MMP-9) has been implicated, but it is not clear if other MMPs are also involved, including matrilysin/MMP-7 - an enzyme capable of cleaving proteins that are essential for blood brain barrier integrity and immune suppression., Results: Here we report that MMP-7-deficient (mmp7-/-) mice on the C57Bl/6 background are resistant to EAE induced by myelin oligodendrocyte glycoprotein (MOG). Brain sections from MOG-primed mmp7-/-mice did not show signs of immune cell infiltration of the CNS, but MOG-primed wild-type mice showed extensive vascular cuffing and mononuclear cell infiltration 15 days after vaccination. At the peak of EAE wild-type mice had MMP-7 immuno-reactive cells in vascular cuffs that also expressed the macrophage markers Iba-1 and Gr-1, as well as tomato lectin. MOG-specific proliferation of splenocytes, lymphocytes, CD4+ and CD8+ cells were reduced in cells isolated from MOG-primed mmp7-/- mice, compared with MOG-primed wild-type mice. However, the adoptive transfer of splenocytes and lymphocytes from MOG-primed mmp7-/- mice induced EAE in naïve wild-type recipients, but not naïve mmp7-/- recipients. Finally, we found that recombinant MMP-7 increased permeability between endothelial cells in an in vitro blood-brain barrier model., Conclusion: Our findings suggest that MMP-7 may facilitate immune cell access or re-stimulation in perivascular areas, which are critical events in EAE and multiple sclerosis, and provide a new therapeutic target to treat this disorder.

Background: Patients with pulmonary hypertension (PH) are considered to be at risk for complications associated with flexible bronchoscopy (FB). Although previous reports suggest that transbronchial biopsies increase the risk for hemorrhage in this population, data are limited to survey analyses and isolated reports., Objectives: It was the aim of this study to describe our experience with FB and to determine if bronchoscopic procedures are associated with adverse events in this population., Methods: We conducted a retrospective review of patients with diagnosis of PH who underwent FB at the Cleveland Clinic between 2002 and 2005. Patients without PH who underwent FB by the same pulmonary physician were used as controls., Results: A total of 90 patients, PH (n = 45) versus controls (n = 45), were included. The mean systolic pulmonary artery pressure in patients with PH was 58 +/- 7 mm Hg. Patients with PH had higher oxygen requirements at baseline (FiO(2) 0.42 vs. 0.3%; p = 0.01). The total number of procedures was similar between the groups (95 vs. 102). Procedures performed were bronchoalveolar lavage (21 vs. 13), transbronchial biopsies (24 vs. 32) and transbronchial needle aspiration (7 vs. 6). There were no hemodynamic complications or episodes of respiratory failure associated with the procedures. None of the patients had significant hemorrhage and only 2 developed mild bleeding which resolved spontaneously. Similarly, none required hospitalization or transfer to an intensive care unit., Conclusions: FB can be performed safely in patients with mild to moderate PH. Transbronchial biopsies are not associated with worsening hypoxemia or an increased risk of hemorrhage. Prospective studies with hemodynamic measurements are necessary to confirm these findings., (Copyright 2009 S. Karger AG, Basel.)

Objective: To examine the natural history of cervical length shortening in women who had experienced at least one prior spontaneous preterm birth at between 17+0 and 33+6 weeks' gestation., Methods: This was an analysis of prerandomization data from the multicenter Vaginal Ultrasound Cerclage Trial. Serial cervical length was measured by transvaginal sonography in 1014 high-risk women at 16+0 to 22+6 weeks. We performed survival analyses in which the outcome was cervical length shortening<25 mm and data were censored if this did not occur before 22+6 weeks' gestation. The incidence of cervical length shortening and the time to shortening were compared for women whose earliest prior preterm birth was in the mid-trimester, defined as <24 weeks, vs. those at weeks 24-33. Similar comparisons were performed based on each patient's most recent birth history., Results: Time to cervical length shortening by survival analysis was significantly shorter (hazard ratio (HR)=2.2, P<0.0001) and the relative risk (RR) of shortening significantly higher (RR=1.8, P<0.0001) for women whose earliest prior spontaneous preterm birth was at <24 weeks. A larger effect was observed for women whose most recent birth was at <24 weeks (HR=2.8, P<0.0001; RR=2.1, P<0.0001). The observed hazard ratios remained significant after adjusting for confounders in a multivariable Cox proportional hazards model., Conclusion: Women with a prior spontaneous preterm birth at <24 weeks are at a higher risk of cervical shortening, and do so at a higher rate and at an earlier gestational age, than do women with a later preterm birth history., (Copyright (c) 2008 ISUOG.)

Purpose: First-time pass rates on the American Board of Surgery Certifying Examination (ABSCE) have now become one of the standards of excellence to evaluate residency programs. Our residency program started monthly simulated and critiqued (verbal, written, and video) oral examinations (MSCE) in 2003. The current study explores the outcomes of this intervention., Methods: We evaluated ABSCE performance of 48 residents who graduated from a large academic/community program between the years 2001 and 2006 though a prospective study with historical controls. Residents were divided into 2 groups: The intervention group comprised the 2003 to 2006 classes, which underwent MSCE; the historical control group spanned the 2001 and 2002 classes, which did not undergo MSCE. Results in the ABSCE were compared between groups using the Fisher exact test. In addition, the intervention group was queried in relation to the most important aspects of the MSCE as a learning experience through a structured questionnaire., Results: A statistically significant improvement (p = 0.038) in ABSCE first-time pass rates was noted in the intervention group. Examinees unanimously asserted they had been helped by the MSCE. Improvements in clinical reasoning and promotion of self-study were the most often cited benefits of the MSCE., Conclusion: Monthly simulated and critiqued oral examinations improved the first-time pass rate of the American Board of Surgery Certifying Examination. Additional perceived benefits of this intervention included improvements in clinical reasoning and promotion of self-study.

Unlabelled: To display the experience of vascular lesions in the upper digestive tract in 2007-2008 at Daniel Alcides Carrión Hospital., Methodology: Transverse study. All endoscopies performed in the indicated period were reviewed. Vascular lesions found were record. The OMED classification for vascular lesions was used in this research., Results: 1.979 examinations were reviewed. 26 vascular injuries were found (prevalence = 13.13/1000 endoscopies). The most frequent location was in stomach (65.4%). The most common type of injury was vascular angiectasia(57.7%)., Conclusion: Vascular lesions in the upper digestive tract were rare; these lesions were more common in the stomach. Vascular angiectasias were the most frequently reported.

Pulmonary hypertension is an uncommon complication of sarcoidosis, but in severe pulmonary disease it occurs frequently. It is an important cause of cryptogenic dyspnea in sarcoidosis patients and can occur despite the absence of pulmonary fibrosis. The true prevalence is unknown. With the advent of specific therapies for pulmonary hypertension, there has been a resurgence of interest in the pathophysiology, diagnosis, and treatment of sarcoidosis-associated pulmonary hypertension. This article reviews the status of the current epidemiologic, pathophysiologic, and therapeutic knowledge regarding this entity.

Atrial fibrillation occurs frequently after lung transplantation and is commonly treated with amiodarone. Pulmonary toxicity may result from amiodarone exposure and is characterized by non-specific respiratory manifestations. To our knowledge, there are no reports of this complication occurring after lung transplantation. We present a patient who developed radiologic evidence of amiodarone deposition in the lungs after bilateral lung transplantation.

The initiation of chromosomal replication occurs only once during the prokaryote cell cycle. Some origins of replication have been experimentally determined and have led to the development of in silico approaches to find the origin of replication among other prokaryotes. DNA base composition asymmetry is the basis of numerous in silico methods used to detect the origin and terminus of replication in prokaryotes. However, the composition asymmetry does not allow us to locate precisely the positions of the origin and terminus. Since DNA replication is a key step in the cell cycle it is important to determine properly the origin and terminus regions. Therefore, we have reviewed here the methods, tools, and databases for predicting the origins and terminuses of replication, and we have proposed some complementary analyses to reinforce these predictions. These analyses include finding the dnaA gene and its binding sites; making BLAST analyses of the intergenic sequences compared to related species; studying the gene order around the origin sequence; and studying the distribution of the genes encoded in the leading versus the lagging strand.

Introduction: Erlotinib, a tyrosine kinase inhibitor, has improved survival and quality of life in patients with non-small cell lung cancer (NSCLC) after first- or second-line chemotherapy. Asian origin, adenocarcinoma histology, female gender, lack of tobacco use, and expression of epidermal growth factor receptor are significant independent predictors of response to Erlotinib. Although tobacco use is considered a major cause of NSCLC, other risk factors such as wood-smoke exposure (WSE) are associated. Almost 3 billion people worldwide rely on solid fuels as their primary source of domestic energy for cooking and heating., Methods: In this study, 150 consecutive unselected patients with histologically proven NSCLC with progression after prior first- or second-line chemotherapy and/or poor performance status were treated with Erlotinib 150 mg/d. Clinical and pathologic characteristics were associated with response., Results: Overall response to Erlotinib was observed in 51 patients [34%; 95% confidence interval {95% CI}, 29.9-37.6]. In multivariate analysis, clinical features associated with response to Erlotinib were adenocarcinoma (35 versus 20%; p = 0.05) and WSE (83 versus 13%; p < 0.001). Factors associated with longer progression-free survival in Cox analysis included adenocarcinoma (7.9 versus 2.3 months; p = 0.009), female gender (8.4 versus 5.3 months; p = 0.04), and WSE (17.6 versus 5.3 months; p = 0.006)., Conclusions: WSE is associated with better response to Erlotinib and improved progression-free survival in patients with NSCLC. Additional studies in epidermal growth factor receptor signaling pathway in WSE-associated NSCLC are warranted.

Major histocompatibility complex (MHC) class I chain-related (MIC) genes have been previously identified and characterised in human. They encode polymorphic class I-like molecules that are stress-inducible, and constitute one of the ligands of the activating natural killer cell receptor NKG2D. We have identified three MIC genes within the cattle genome, located close to three non-classical MHC class I genes. The genomic position relative to other genes is very similar to the arrangement reported in the pig MHC region. Analysis of MIC cDNA sequences derived from a range of cattle cell lines suggest there may be four MIC genes in total. We have investigated the presence of the genes in distinct and well-defined MHC haplotypes, and show that one gene is consistently present, while configuration of the other three genes appears variable.

The increase of proinflammatory cytokines in vaginal secretions may serve as a surrogate marker of unwanted inflammatory reaction to microbicide products topically applied for the prevention of sexually transmitted diseases, including HIV-1. Interleukin (IL)-1beta and IL-6 have been proposed as indicators of inflammation and increased risk of HIV-1 transmission; however, the lack of information regarding detection platforms optimal for vaginal fluids and interlaboratory variation limit their use for microbicide evaluation and other clinical applications. This study examines fluid matrix variants relevant to vaginal sampling techniques and proposes a model for interlaboratory comparisons across current cytokine detection technologies. IL-1beta and IL-6 standards were measured by 12 laboratories in four countries, using 14 immunoassays and four detection platforms based on absorbance, chemiluminescence, electrochemiluminescence, and fluorescence. International reference preparations of cytokines with defined biological activity were spiked into (1) a defined medium simulating the composition of human vaginal fluid at pH 4.5 and 7.2, (2) physiologic salt solutions (phosphate-buffered saline and saline) commonly used for vaginal lavage sampling in clinical studies of cytokines, and (3) human blood serum. Assays were assessed for reproducibility, linearity, accuracy, and significantly detectable fold difference in cytokine level. Factors with significant impact on cytokine recovery were determined by Kruskal-Wallis analysis of variance with Dunn's multiple comparison test and multiple regression models. All assays showed acceptable intra-assay reproducibility; however, most were associated with significant interlaboratory variation. The smallest reliably detectable cytokine differences ( P < 0.05) derived from pooled interlaboratory data varied from 1.5- to 26-fold depending on assay, cytokine, and matrix type. IL-6 but not IL-1beta determinations were lower in both saline and phosphate-buffered saline as compared to vaginal fluid matrix, with no significant effect of pH. The (electro)chemiluminescence-based assays were most discriminative and consistently detected <2-fold differences within each matrix type. The Luminex-based assays were less discriminative with lower reproducibility between laboratories. These results suggest the need for uniform vaginal sampling techniques and a better understanding of immunoassay platform differences and cross-validation before the biological significance of cytokine variations can be validated in clinical trials. This investigation provides the first standardized analytic approach for assessing differences in mucosal cytokine levels and may improve strategies for monitoring immune responses at the vaginal mucosal interface.

The cattle major histocompatibility complex (MHC) region contains a variable number of classical class I genes encoding polymorphic, ubiquitously expressed molecules with a role in antigen presentation. Class I cDNA sequences have previously been reported that are thought to derive from putative nonclassical class I genes. We have located four nonclassical class I genes within the cattle genome; three are close to the MIC genes, and one is close to the classical class I genes. The genomic position relative to anchor genes is very similar to the arrangement reported in the pig MHC region. We have designed gene-specific oligonucleotide primers with which to investigate the presence of these genes in distinct and well-defined MHC haplotypes and to assess transcription in different cell types. Analysis and comparison of all sequences allows an assessment of allelic variation in each case. Partial characterisation gives an indication of the possible role and likely importance of each of these genes.

Background: Long-term follow-up after transition to oral agents from parenteral prostanoid therapy has not been well characterized., Methods: We reviewed our long-term experience after oral transitioning in patients with pulmonary hypertension. Patients were weaned off parenteral therapy based on a pre-determined outpatient protocol. Data were collected retrospectively after transition had taken place., Results: Twenty-one transitioned patients were identified. Fifteen patients (71.4%) were successfully transitioned (ST): 7 to bosentan, 5 to bosentan and sildenafil, and 3 to sildenafil. Six patients failed transition (FT). None of the patients in the FT group received sildenafil. Prior to transition attempt, patients in the ST group were treated with parenteral agents for a mean of 26 months vs. 16 months in the FT group (p=0.12). Maximal epoprostenol dose was low in both groups (ST 17.8 ng/kg/min vs. FT 14.5 ng/kg/min). Mean duration of oral therapy prior to transition was 11 months. After a mean follow-up of 24 months, most patients on both groups were able to maintain stable 6 min walk distance and hemodynamics. FT was not associated with short- or long-term adverse events., Conclusions: Oral transition from parenteral prostanoid agents can be safely done in a selected group of patients. Most patients are able to maintain stable functional class and hemodynamics at long follow up regardless of success of transition attempt. Combination therapy with sildenafil appears to be associated with higher likelihood of successful transitioning.