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Introduction: Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. Methods: The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. Results: Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. Discussion: Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal.

Introduction: Pragmatic trials in comparative effectiveness research assess the effects of different treatment, therapeutic, or healthcare options in clinical practice. They are characterized by broad eligibility criteria and large sample sizes, which can lead to an unmanageable number of participants, increasing the risk of bias and affecting the integrity of the trial. We describe the development of a sampling strategy tool and its use in the PREPARE trial to circumvent the challenge of unmanageable work flow. Methods: Given the broad eligibility criteria and high fracture volume at participating clinical sites in the PREPARE trial, a pragmatic sampling strategy was needed. Using data from PREPARE, descriptive statistics were used to describe the use of the sampling strategy across clinical sites. A Chi-square test was performed to explore whether use of the sampling strategy was associated with a reduction in the number of missed eligible patients. Results: 7 of 20 clinical sites (35%) elected to adopt a sampling strategy. There were 1539 patients excluded due to the use of the sampling strategy, which represents 30% of all excluded patients and 20% of all patients screened for participation. Use of the sampling strategy was associated with lower odds of missed eligible patients (297/4545 (6.5%) versus 341/3200 (10.7%) p

Introduction: Anticoagulant-related nephropathy (ARN) is an increasingly recognized cause of acute kidney injury (AKI), initially associated with warfarin use. Supratherapeutic warfarin levels were implicated in kidney toxicity. With the widespread adoption of direct oral anticoagulants (DOACs), it becomes imperative to understand their potential risk for ARN and its clinical presentation., Case Presentation: We report a case of a 64-year-old male prescribed DOAC for paroxysmal atrial fibrillation management, presenting with heart failure and worsening AKI. Hematuria and mild proteinuria were also observed. Despite management attempts, AKI persisted, prompting a kidney biopsy. Histopathological examination revealed acute tubular injury with numerous intratubular red blood cell casts consistent with ARN. Additionally, findings indicative of IgA nephropathy (IgAN), including mesangial hypercellularity and IgA dominant deposition, were noted., Conclusion: This case underscores the emerging risk of ARN associated with DOACs and emphasizes the potential exacerbation of ARN in the presence of underlying glomerular diseases such as IgAN. Clinicians should maintain a high index of suspicion for ARN in patients on anticoagulation therapy, particularly DOACs, who present with AKI and urinary abnormalities, as early recognition and intervention are crucial in preventing further renal damage., Competing Interests: In compliance with the ICMJE uniform disclosure form, all authors declare that there are no conflicts of interest or competing interests associated with this work., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Peripheral artery disease (PAD), a condition where there is reduced blood flow due to narrowing or blockage of the arteries of the peripheral vasculature, is an epidemic that currently affects eight million people in the United States alone and is a major risk equivalent to having active coronary artery disease (CAD). However, it is commonly underdiagnosed in the general population. Hypertension is a common cardiovascular condition characterized by elevated blood pressure levels. There are several mitigating risk factors that can reduce the risk of complications of PAD, with hypertension playing a major role. This literature review aims to explore the relationship between hypertension and PAD, including their shared risk factors, pathophysiological mechanisms, and management strategies. In addition, we will analyze how this impacts major cardiovascular outcomes, such as critical limb ischemia, vascular amputation, myocardial infarction (MI), ischemic stroke, and cardiovascular-related death by examining relevant studies, current guidelines, and evidence. This literature review is intended to guide practitioners on ideal blood pressure parameters and evidence-based anti-hypertensives that provide overall cardiovascular benefit in both the primary care and hospital-based setting. By understanding the association between hypertension and PAD and the underlying pathophysiological mechanisms, healthcare professionals can improve diagnosis, treatment, and management strategies for affected individuals., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Abraham et al.)

"Toddler's fractures" are common in the pediatric population. Traditional treatment recommends casting these fractures, although with their inherent stability, may be unnecessary. This study evaluated if toddler's fractures can be treated with observation alone as opposed to casts. A prospective pilot study was performed with randomization and observational arms. Children were placed in short casts or observed without immobilization. A 21-day log was given to families to record walking. Follow up with radiographs occurred at 3 and 12 weeks. Twenty-one patients enrolled, three randomized and 18 chose their treatment. Thirteen patients were casted, and eight went without immobilization. Ambulation time was similar between groups (p = 0.260). Three without immobilization returned early but none converted to cast. All fractures healed uneventfully. There were no cast complications. Toddler's fractures treated with or without cast immobilization appears to be safe and effective but should be a shared decision between physician and parents. (Journal of Surgical Orthopaedic Advances 32(3):207-211, 2023).

Global health delivery is a complex initiative requiring dedicated personnel to achieve a successful program. To be most beneficial, global health delivery should focus on cultural competence, bidirectional education, and capacity building through direct and purposeful means. The authors present the expansion of their global health delivery program in Ecuador focusing on the evolution of the program from a medical mission trip to a multilayered program that helps foster engagement, education, and learning while helping children who might not otherwise have access to care, along with future directions and potential methods to decrease the need for such initiatives in Ecuador., Competing Interests: Disclosure The authors all report no commercial or financial conflicts of interest or any funding sources pertinent or related to this work., (Copyright © 2020 Elsevier Inc. All rights reserved.)

High-dimensional mass cytometry data potentially enable a comprehensive characterization of immune cells. In order to positively affect clinical trials and translational clinical research, this advanced technology needs to demonstrate a high reproducibility of results across multiple sites for both peripheral blood mononuclear cells (PBMC) and whole blood preparations. A dry 30-marker broad immunophenotyping panel and customized automated analysis software were recently engineered and are commercially available as the Fluidigm® Maxpar® Direct™ Immune Profiling Assay™. In this study, seven sites received whole blood and six sites received PBMC samples from single donors over a 2-week interval. Each site labeled replicate samples and acquired data on Helios™ instruments using an assay-specific acquisition template. All acquired sample files were then automatically analyzed by Maxpar Pathsetter™ software. A cleanup step eliminated debris, dead cells, aggregates, and normalization beads. The second step automatically enumerated 37 immune cell populations and performed label intensity assessments on all 30 markers. The inter-site reproducibility of the 37 quantified cell populations had consistent population frequencies, with an average %CV of 14.4% for whole blood and 17.7% for PBMC. The dry reagent coupled with automated data analysis is not only convenient but also provides a high degree of reproducibility within and among multiple test sites resulting in a comprehensive yet practical solution for deep immune phenotyping., (© 2019 International Clinical Cytometry Society.)

Mass cytometry is an emerging technology capable of 40 or more correlated measurements on a single cell. The complexity and volume of data generated by this platform have accelerated the creation of novel methods for high-dimensional data analysis and visualization. A key step in any high-level data analysis is the removal of unwanted events, a process often referred to as data cleanup. Data cleanup as applied to mass cytometry typically focuses on elimination of dead cells, debris, normalization beads, true aggregates, and coincident ion clouds from raw data. We describe a probability state modeling (PSM) method that automatically identifies and removes these elements, resulting in FCS files that contain mostly live and intact events. This approach not only leverages QC measurements such as DNA, live/dead, and event length but also four additional pulse-processing parameters that are available on Fluidigm Helios™ and CyTOF® (Fluidigm, Markham, Canada) 2 instruments with software versions of 6.3 or higher. These extra Gaussian-derived parameters are valuable for detecting well-formed pulses and eliminating coincident positive ion clouds. The automated nature of this new routine avoids the subjectivity of other gating methods and results in unbiased elimination of unwanted events. © 2019 International Society for Advancement of Cytometry., (© 2019 International Society for Advancement of Cytometry.)

Objectives: The aim of this study was to assess the role of hepatitis B (HepB) infection in the causation of pancreatic cancer and the predictors of pancreatic cancer and mortality., Methods: We identified pancreatic cancer patients 11 to 70 years of age from the 2013-2014 National Inpatient Sample. Pearson χ test and Student's t-test were used for categorical and continuous variables, respectively. We assessed the association of HepB and pancreatic cancer and the independent mortality predictors by multivariate analyses., Results: Of 69,210 pancreatic cancer patients, 175 patients with a history of HepB and 69,035 patients without a history of HepB were identified. Compared with the pancreatic cancer-non-HepB group, the pancreatic cancer-HepB group consisted more of younger (mean, 60.4 [standard deviation, 7.4] years vs 68.2 [standard deviation, 12.1] years), male, black, and Asian patients with low household income and nonelective admissions. The odds of developing pancreatic cancer among the HepB patients were significantly higher (adjusted odds ratio, 1.24; 95% confidence interval, 1.056-1.449; P = 0.008). Black race, age ≥ 65 years, and male sex demonstrated greater odds of mortality., Conclusions: This study concluded up to a 24% increased likelihood of pancreatic cancer among the HepB patients. Blacks showed greater odds of pancreatic cancer and related mortality.

Background: Despite the problem of inadequate recruitment to randomised trials, there is little evidence to guide researchers on decisions about how people are effectively recruited to take part in trials. The PRioRiTy study aimed to identify and prioritise important unanswered trial recruitment questions for research. The PRioRiTy study - Priority Setting Partnership (PSP) included members of the public approached to take part in a randomised trial or who have represented participants on randomised trial steering committees, health professionals and research staff with experience of recruiting to randomised trials, people who have designed, conducted, analysed or reported on randomised trials and people with experience of randomised trials methodology., Methods: This partnership was aided by the James Lind Alliance and involved eight stages: (i) identifying a unique, relevant prioritisation area within trial methodology; (ii) establishing a steering group (iii) identifying and engaging with partners and stakeholders; (iv) formulating an initial list of uncertainties; (v) collating the uncertainties into research questions; (vi) confirming that the questions for research are a current recruitment challenge; (vii) shortlisting questions and (viii) final prioritisation through a face-to-face workshop., Results: A total of 790 survey respondents yielded 1693 open-text answers to 6 questions, from which 1880 potential questions for research were identified. After merging duplicates, the number of questions was reduced to 496. Questions were combined further, and those that were submitted by fewer than 15 people and/or fewer than 6 of the 7 stakeholder groups were excluded from the next round of prioritisation resulting in 31 unique questions for research. All 31 questions were confirmed as being unanswered after checking relevant, up-to-date research evidence. The 10 highest priority questions were ranked at a face-to-face workshop. The number 1 ranked question was "How can randomised trials become part of routine care and best utilise current clinical care pathways?" The top 10 research questions can be viewed at www.priorityresearch.ie ., Conclusion: The prioritised questions call for a collective focus on normalising trials as part of clinical care, enhancing communication, addressing barriers, enablers and motivators around participation and exploring greater public involvement in the research process.

Background: The costs of medical research are a concern. Clinical Trials Units (CTUs) need to better understand variations in the costs of their activities., Methods: Representatives of ten CTUs and two grant-awarding bodies pooled their experiences in discussions over 1.5 years. Five of the CTUs provided estimates of, and written justification for, costs associated with CTU activities required to implement an identical protocol. The protocol described a 5.5-year, nonpharmacological randomized controlled trial (RCT) conducted at 20 centres. Direct and indirect costs, the number of full time equivalents (FTEs) and the FTEs attracting overheads were compared and qualitative methods (unstructured interviews and thematic analysis) were used to interpret the results. Four members of the group (funding-body representatives or award panel members) reviewed the justification statements for transparency and information content. Separately, 163 activities common to trials were assigned to roles used by nine CTUs; the consistency of role delineation was assessed by Cohen's κ., Results: Median full economic cost of CTU activities was £769,637 (range: £661,112 to £1,383,323). Indirect costs varied considerably, accounting for between 15% and 59% (median 35%) of the full economic cost of the grant. Excluding one CTU, which used external statisticians, the total number of FTEs ranged from 2.0 to 3.0; total FTEs attracting overheads ranged from 0.3 to 2.0. Variation in directly incurred staff costs depended on whether CTUs: supported particular roles from core funding rather than grants; opted not to cost certain activities into the grant; assigned clerical or data management tasks to research or administrative staff; employed extensive on-site monitoring strategies (also the main source of variation in non-staff costs). Funders preferred written justifications of costs that described both FTEs and indicative tasks for funded roles, with itemised non-staff costs. Consistency in role delineation was fair (κ = 0.21-0.40) for statisticians/data managers and poor for other roles (κ < 0.20)., Conclusions: Some variation in costs is due to factors outside the control of CTUs such as access to core funding and levels of indirect costs levied by host institutions. Research is needed on strategies to control costs appropriately, especially the implementation of risk-based monitoring strategies.

Colorectal cancer (CRC) continues to be one of the most commonly diagnosed cancers and contributes significantly to many cancer-related deaths despite sustained progress in diagnostic and treatment options. Many forms of CRC can be prevented through early and routine screening, when precancerous lesions may be detected and removed before they undergo malignant transformation or metastasis. Despite widespread efforts to improve CRC screening rates, at least 40% of age-eligible adults do not adhere to screening guidelines. A new generation of noninvasive, molecular-based diagnostic tests with high sensitivities and specificities has the potential to improve screening rates through optimal risk stratification of patients who may benefit from more invasive screening techniques. This review presents various guidelines and methods that are currently available for CRC screening, summarizes the rationale behind utilization of novel molecular-based diagnostic tests for CRC screening and prevention, and discusses appropriate screening techniques and intervals in populations of varying risk.

Introduction: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are widely used laboratory markers of systemic inflammation., Objective: A thorough understanding of the similarities and differences between these two serological markers, including factors that affect measurements, is necessary for the proper utilization and interpretation of ESR and CRP., Methods: This review summarizes the current published literature (searched on MEDLINE through February 2016) surrounding the history and utilization of ESR and CRP, and examines factors that affect ESR and CRP measurements and discordance amongst these two inflammatory markers., Results: As ESR and CRP lack sensitivity or specificity, these tests should be used only in combination with clinical history and physical exam for diagnosis and monitoring of pathological conditions. The clinical application of these tests in diagnosis is best applied to conditions in which there is high or low clinical probability of disease. Importantly, discrepancies between ESR and CRP measurements commonly have been reported in both inpatient and outpatient settings and this problem may be particularly prevalent in chronic inflammatory diseases. Numerous physiological factors, including noninfectious conditions and resolution of inflammation can contribute to abnormally high ESR/low CRP readings or vice versa., Conclusions: Although discordance may be encountered in certain settings, proper utilization of ESR and CRP measurements continues to play an important role in clinical management of many inflammatory and other conditions.

Background: This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation., Methods: Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold., Results: Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score., Conclusions: After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery., Level of Evidence: Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Kirsten rat sarcoma virus (KRAS) wild-type status determined using a locked nucleic acid (LNA)-mediated quantitative polymerase chain reaction (qPCR) clamping assay (LNA assay) predicted response to therapy in the CRYSTAL (Cetuximab Combined With Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer) study. A companion KRAS diagnostic tool has been developed for routine clinical use (QIAGEN therascreen kit) (QIAGEN Manchester Ltd, Manchester, UK). We wanted to assess the concordance between the validated US Food and Drug Administration (FDA)-approved therascreen assay and the LNA assay in determining the KRAS status of a subset of patients enrolled in the CRYSTAL study., Patients and Methods: DNA extracted from paraffin-embedded tumor sections was tested for KRAS status using the therascreen assay. Efficacy data from the CRYSTAL study were assessed to determine if the overall survival (OS) hazard ratio for cetuximab in patients identified as having KRAS wild-type status using the therascreen assay was equivalent to that in patients identified as KRAS wild-type using the LNA assay. This was determined by assessing if the concordance between the therascreen assay and the LNA assay met the minimum threshold (prespecified as 0.8) to achieve a significant difference in the OS hazard ratio in favor of the cetuximab + FOLFIRI (5-fluorouracil, leucovorin [folinic acid], irinotecan) arm in the KRAS wild-type population as identified using the therascreen assay., Results: Of the 148 samples determined to be KRAS wild-type (therascreen assay), 141 (95.3%) samples were also KRAS wild-type (LNA assay) and 7 samples (4.7%) were KRAS mutant (LNA assay). The prespecified primary concordance measure p was 141/148 = 0.953 (95% confidence interval [CI], 0.905-0.981). The concordance was statistically significantly higher than the prespecified threshold of 0.8 for concordance between the therascreen assay and the LNA assay. Consistent with the concordance exceeding the prespecified threshold, the OS hazard ratio (cetuximab + FOLFIRI arm vs. FOLFIRI arm) in the KRAS wild-type population, determined by the therascreen assay, supported a significant benefit for cetuximab (ie, the 95% CI excluded 1) and was comparable to the OS hazard ratio observed in the CRYSTAL study KRAS wild-type population (LNA assay) even after adjustment for potentially confounding baseline variables., Conclusion: These results support the utility of the therascreen assay for identifying patients who may benefit from cetuximab therapy for metastatic colorectal cancer., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Soluble N-ethylmaleimide-sensitive fusion protein attachment protein receptors (SNAREs) mediate vesicle fusion with the plasma membrane on activation by calcium binding to synaptotagmin. In the present study, we used fluorescence resonance energy transfer (FRET) and fluorescence lifetime imaging microscopy between fluorescently labeled SNARE proteins expressed in cultured rat hippocampal neurons to detect resting SNARE complexes, their conformational rearrangement on exocytosis, their disassembly before endocytosis of vesicular proteins, and SNARE assembly at newly docked vesicles. Assembled SNAREs are not only present in docked vesicles; unexpected residual "orphan SNARE complexes" also reside in para-active zone regions. Real-time changes in FRET between N-terminally labeled SNAP-25 and VAMP reported a reorientation of the SNARE motif upon exocytosis, SNARE disassembly in the active zone periphery, and SNARE reassembly in newly docked vesicles. With VAMP labeled C-terminally, decreased fluorescence in C-terminally labeled syntaxin (extracellular) reported trans-cis-conformational changes in SNAREs on vesicle fusion. After fusion SNAP-25 and syntaxin disperse along with VAMP, as well as the FRET signal itself, indicating diffusion of intact SNAREs after vesicle fusion but before their peripheral disassembly. Our measurements of spatiotemporal dynamics of SNARE conformational changes and movements refine models of SNARE function. Technical advances required to detect tiny changes in fluorescence in small fractions of labeled proteins in presynaptic boutons on a time scale of seconds permit the detection of rapid intermolecular interactions between small proportions of protein partners in cellular subcompartments.

Background: Surgeons and software developers recognize that apps can improve patient care by replicating the function of existing medical devices. However, the incorporation of new tools requires that the clinical data being recorded is accurate and valid. This study attempts to validate a new iPhone app to measure scoliotic rotation. The objective of this study was to validate the scoliogauge iPhone application by comparing the results to simultaneous readings from a standard Scoliometer., Methods: Four orthopaedic medical providers (attending surgeon, fellow, resident, and nurse practitioner) each read a standard scoliometer at 60 randomly selected angular measurements between -30 and 30 degrees, whereas a blinded observer simultaneously recorded the angular measurement derived from the scoligauge app. The correlation between the 2 measurements were calculated using a Pearson correlation coefficient with a P-value set to < 0.05 for significance., Results: The Pearson correlation values ranged from 0.9994 to 0.9996 for all providers and all P-values < 0.001. There was no increase in time associated with using the app compared with the standard device., Conclusions: The scoligauge app is a convenient novel tool that replicates the function of a standard clinical scoliometer but with a potentially decreased financial cost and greater convenience for providers., Clinical Relevance: Validation of this new device demonstrates the potential to increase the distribution of cost-effective scoliosis screening tools to a broad population of medical providers.

The UK DNA Banking Network (UDBN) undertakes biobanking for genetic epidemiology research projects. A task assigned to it is the addition of scientific value to the resources under its management. This task is implemented by enabling appropriate access to the resources. We reasoned that access requires not only a fair access policy but also a quality policy implemented via a Quality Management System (QMS). UDBN decided to achieve consistency in sample management by identifying and implementing a suitable QMS with external certification. UDBN selected ISO9001 as a QMS. It was soon recognized that the QMS needed to encompass not only UDBN but also the academic department in which UDBN sits. An external certification body was selected and a post was dedicated to the role of QMS-Management Representative. Specialized software was acquired. A Quality Manual, individual training files and Standard Operating Procedures (SOPs) were prepared. QMS training was provided. These actions led to the approval of the ISO9001:2000 standard. This is the first report of an academic genetic epidemiology research laboratory receiving approval of the ISO9001 standard to validate the consistency of its operations. ISO9001 was selected because of its greater breadth of scope compared with other QMSs. We found that while laboratory protocols are transferable between labs, QMS SOPs are not transferable. This has consequences for efforts to ensure consistency across a biobank network: joint adoption of one multiparty QMS is probably required. We found that it was not possible to implement a QMS for biobanking in isolation: its host university department needed to be included. We have found that ISO9001 helps enable longitudinal accrual of data on the use of biobanking methods. Thus ISO9001 is not only a management tool to improve access to a biobanking research infrastructure but also a research tool for research infrastructure development.

Background: Lowering LDL cholesterol with statin regimens reduces the risk of myocardial infarction, ischaemic stroke, and the need for coronary revascularisation in people without kidney disease, but its effects in people with moderate-to-severe kidney disease are uncertain. The SHARP trial aimed to assess the efficacy and safety of the combination of simvastatin plus ezetimibe in such patients., Methods: This randomised double-blind trial included 9270 patients with chronic kidney disease (3023 on dialysis and 6247 not) with no known history of myocardial infarction or coronary revascularisation. Patients were randomly assigned to simvastatin 20 mg plus ezetimibe 10 mg daily versus matching placebo. The key prespecified outcome was first major atherosclerotic event (non-fatal myocardial infarction or coronary death, non-haemorrhagic stroke, or any arterial revascularisation procedure). All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00125593, and ISRCTN54137607., Findings: 4650 patients were assigned to receive simvastatin plus ezetimibe and 4620 to placebo. Allocation to simvastatin plus ezetimibe yielded an average LDL cholesterol difference of 0·85 mmol/L (SE 0·02; with about two-thirds compliance) during a median follow-up of 4·9 years and produced a 17% proportional reduction in major atherosclerotic events (526 [11·3%] simvastatin plus ezetimibe vs 619 [13·4%] placebo; rate ratio [RR] 0·83, 95% CI 0·74-0·94; log-rank p=0·0021). Non-significantly fewer patients allocated to simvastatin plus ezetimibe had a non-fatal myocardial infarction or died from coronary heart disease (213 [4·6%] vs 230 [5·0%]; RR 0·92, 95% CI 0·76-1·11; p=0·37) and there were significant reductions in non-haemorrhagic stroke (131 [2·8%] vs 174 [3·8%]; RR 0·75, 95% CI 0·60-0·94; p=0·01) and arterial revascularisation procedures (284 [6·1%] vs 352 [7·6%]; RR 0·79, 95% CI 0·68-0·93; p=0·0036). After weighting for subgroup-specific reductions in LDL cholesterol, there was no good evidence that the proportional effects on major atherosclerotic events differed from the summary rate ratio in any subgroup examined, and, in particular, they were similar in patients on dialysis and those who were not. The excess risk of myopathy was only two per 10,000 patients per year of treatment with this combination (9 [0·2%] vs 5 [0·1%]). There was no evidence of excess risks of hepatitis (21 [0·5%] vs 18 [0·4%]), gallstones (106 [2·3%] vs 106 [2·3%]), or cancer (438 [9·4%] vs 439 [9·5%], p=0·89) and there was no significant excess of death from any non-vascular cause (668 [14·4%] vs 612 [13·2%], p=0·13)., Interpretation: Reduction of LDL cholesterol with simvastatin 20 mg plus ezetimibe 10 mg daily safely reduced the incidence of major atherosclerotic events in a wide range of patients with advanced chronic kidney disease., Funding: Merck/Schering-Plough Pharmaceuticals; Australian National Health and Medical Research Council; British Heart Foundation; UK Medical Research Council., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

In this study we investigate the role of the CHRNA7 subunit (also known as the alpha7 subunit) of the nicotinic acetylcholine receptor in mouse sperm function. We confirm by reverse-transcription-polymerase chain reaction the expression in adult mouse testis of Chrna7 mRNA and demonstrate the subunit's presence in mouse sperm by immunoblot. Alpha-bungarotoxin binds a range of nicotinic acetylcholine receptor subunits, including the CHRNA7 subunit. Localization studies using a fluorescent alpha-bungarotoxin-tetramethyl-rhodamine conjugate revealed specific binding sites on the midpiece of mouse sperm with fainter alpha-bungarotoxin binding on the remainder of the flagellum. Mice engineered with a double-null disruption of the Chrna7 gene displayed only faint fluorescence on the midpiece, suggesting that the CHRNA7 contributed the majority of the observed alpha-bungarotoxin binding sites. The location of alpha-bungarotoxin binding suggested that nicotinic acetylcholine receptors may play an ionotropic role in sperm motility. Sperm from Chrna7(-/-) mice display no difference in number, morphology, viability or spontaneous acrosome reaction rate compared with Chrna7(+/+) sperm. Studies using computer-assisted sperm analysis indicate the motility of Chrna7(-/-) sperm is significantly impaired. This impairment is characterized by significantly reduced swimming velocities, failure to maintain vigorous swimming, and lower levels of hyperactivated swimming patterns in Chrna7(-/-) sperm compared with Chrna7(+/+) sperm. This is the first genetic evidence that sperm nicotinic acetylcholine receptors are important for maintenance of normal sperm motility.

Despite normal levels of erythropoiesis in PU.1(-/-) embryos, PU.1(-/-) fetal hematopoietic progenitors are unable to establish sustained erythropoiesis in the adult bone marrow. This study demonstrates that PU.1(-/-) fetal erythroid progenitors are synergistically expanded by TPO plus SCF, but not combinations of EPO plus SCF, IL-3 or GM-CSF. The EPO defect is not corrected by a constitutively active variant of EPOR. Microarray analysis identified several candidate PU.1 target genes known to affect cytokine signaling and gene regulation in the erythroid lineage. These data suggest that PU.1 plays an important role in regulating the proliferation of immature erythroid progenitors.

One of the essential steps in mammalian fertilization is the acrosome reaction (AR), a modified exocytotic event in the sperm head that occurs upon contact with the glycoprotein matrix of the zona pellucida (ZP) surrounding the oocyte. Acetylcholine (ACh) at concentrations of 10-250 micro M and nicotine at 10-250 nM significantly initiate the AR of capacitated human sperm. Preincubation with three antagonists of the nicotinic acetylcholine receptor (nAChR), alpha-bungarotoxin (alpha-BTX, 100 nM), alpha-conotoxin IMI (alpha-CTX IMI, 250 nM and 25 nM), and methyllycaconitine (MLA, 100 nM and 10 nM), significantly blocked AR initiation by ACh. alpha-BTX is an anatagonist of several nAChRs, including the alpha7 nAChR, and alpha-CTX IMI and MLA are highly specific antagonists of alpha7 subunit-containing AChRs. The sperm nAChR plays a role in the AR initiated in vitro by a purified recombinant human ZP protein (rhZP3). Previously, rhZP3 was able to stimulate the AR by mechanisms similar to those seen with native ZP. Preincubation of human sperm with alpha-BTX (from 10 micro M to 100 nM), alpha-CTX IMI (250 and 100 nM), or MLA (100 nM and 10 nM) caused a significant inhibition in the rhZP3-initated AR. The inhibition of the ACh-initiated and rhZP3-initiated AR by these nAChR antagonists strongly suggests the involvement of an alpha7 subunit-containing nAChR in the AR initiated by both ligands. AR initiation by progesterone was not inhibited by MLA or alpha-BTX, suggesting that this particularnAChR is not involved in the AR initiated by that ligand. In vitro results show for the first time that ACh can initiate the human sperm AR and strongly suggest that a human sperm alpha7 subunit-containing nAChR plays a role in the rhZP3-initiated AR. This nAChR ligand-gated ion channel may be important to the signal transduction events of ZP-initiated AR in vivo.

Previously, we have demonstrated an essential role for the neuronal glycine receptor (GlyR) in the acrosome reaction (AR) of mouse and porcine sperm initiated by the egg zona pellucida (ZP). In the present study, we have demonstrated presence of the GlyR in human sperm by immunoprecipitation and Western blot analysis, investigated the potential of a recombinant human ZP3 (rhZP3) preparation as an alternative research tool to solubilized human ZP, and shown that the human sperm GlyR is essential to the human AR initiated by rhZP3. Additionally, we have been able to demonstrate that rhZP3 possesses biological activity, because it is able to rapidly stimulate the AR in capacitated human sperm and its action is blocked by the addition of pertussis toxin. Moreover, spectrofluorometric studies using fura-2-loaded human sperm have shown that rhZP3 triggers a peak-and-plateau rise in intracellular Ca(2+) levels similar to that seen with solubilized mammalian ZP. These results suggest that the actions of rhZP3 and solubilized ZP are elicited via the same signal transduction pathways. Furthermore, incubation of human sperm with an antibody directed against the alpha1 subunit of the human spinal cord GlyR or with 50 nM strychnine caused significant inhibition in the rhZP3-initated AR. Finally, studies using fura-2-loaded human sperm showed that 50 nM strychnine was also able to inhibit the Ca(2+) influx associated with addition of rhZP3. These results further support the view that rhZP3 and the ZP work through the same mechanisms, show that the GlyR is involved in rhZP3-initiated AR, and suggest that the GlyR may also play a role in the early signal transduction cascades associated with ZP-initiated AR in vivo.