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PURPOSE: Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue and not scheduled within 2 weeks of their first requested date. METHODS: We conducted a series of structured, interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration to critically review the scheduling process utilizing Lean Kaizen quality improvement methods. A new workflow was developed in which clinic staff scheduled CT scans before clinic discharge. Three months after our initial meeting, the new workflow was launched. We set a target of decreasing the percentage of overdue scans to below 20%. RESULTS: At baseline, 87% (65 of 75) of CT scans awaiting scheduling were overdue. Data were gathered at 5 and 10 weeks after implementation of our workflow. The percentage of CT scans overdue for scheduling was 17% (9 of 53) at 5 weeks and 0.97% (1 of 103) at 10 weeks after implementation. Clinic visit durations were not affected. CONCLUSION: The Lean Kaizen QI model was successful in decreasing the rate of oncology patients overdue for CT scan scheduling with minimal effects on clinic visit durations. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other outpatient clinics within our institution.

Aim: The Combining Mechanisms for Better Outcomes randomized controlled trial assessed the effectiveness of various spinal cord stimulation (SCS) modalities for chronic pain. Specifically, combination therapy (simultaneous use of customized sub-perception field and paresthesia-based SCS) versus monotherapy (paresthesia-based SCS) was evaluated. Methods: Participants were prospectively enrolled (key inclusion criterion: chronic pain for ≥6 months). Primary end point was the proportion with ≥50% pain reduction without increased opioids at the 3 month follow-up. Patients were followed for 2 years. Results: The primary end point was met (n = 89; p Clinical Trial Registration: NCT03689920 ( ClinicalTrials.gov ), Combining Mechanisms for Better Outcomes (COMBO)

Jennifer M Lee,1 David Lee,2 Sandy Christiansen,3 Jonathan M Hagedorn,4 Zheyan Chen,3 Timothy Deer5 1Department of Sports & Spine, EvergreenHealth Medical Group, Kirkland, WA, USA; 2Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA; 3Department of Anesthesiology & Perioperative Medicine, Oregon Health Sciences University, Portland, OR, USA; 4iSpine Pain Physicians, Maple Grove, MN, USA; 5The Spine and Nerve Center of the Virginias, Charleston, WV, USACorrespondence: Jennifer M Lee, Email jelee@evergreenhealthcare.orgAbstract: Chronic bleeding disorders, allergy to implants, and chronic infections are all complicating factors when considering neuromodulation therapies. The American Society of Pain and Neuroscience (ASPN) determined a need for clinical guidance in these special patient populations that have increased risk of complications, in order to ensure patient safety and optimal outcomes with device implantation. The purpose of this publication was to review the published literature and explore the unique clinical challenges encountered among several special patient populations with relation to spinal cord stimulation. The executive board of the ASPN appointed a diverse group of well-established physicians to develop best practice guidelines regarding spinal cord stimulation implantation in these special populations. The physicians used the United States Preventive Services Task Force (USPSTF) structured guidelines for grading and level of certainty to make evidence-based recommendations about clinical practice. Where sufficient evidence was lacking to justify a USPSTF ranking, the physicians queried experts in neuromodulation and achieved consensus. These best practices and interventional guideline found the evidence for the use of neuromodulation in specialized patient populations to be relatively modest.Keywords: guidelines, metallurgic allergy, epidural hematoma, epidural abscess

Apathy symptoms are common in healthy older adults and may manifest independently of depressive symptoms. Perceived social support is considered a protective factor against adverse health outcomes in aging. We investigated the differential associations of apathy and depressive symptoms with perceived social support in older adults.The sample (Fully adjusted multiple linear regression revealed that, when jointly modeled as predictors, both apathy (standardized β= -0.214We provide the first evidence that apathy and depressive symptoms have independent associations with perceived social support in older adults.

The first colloidal nanoparticle synthesis of the copper selenophosphate Cu3 PSe4 , a promising new material for photovoltaics, is reported. Because the formation of binary copper selenide impurities seemed to form more readily, two approaches were developed to install phosphorus bonds directly: 1) the synthesis of molecular P4 Se3 and subsequent reaction with a copper precursor, (P-Se)+Cu, and 2) the synthesis of copper phosphide, Cu3 P, nanoparticles and subsequent reaction with a selenium precursor, (Cu-P)+Se. The isolation and purification of Cu3 P nanoparticles and subsequent selenization yielded phase-pure Cu3 PSe4 . Solvent effects and Se precursor reactivities were elucidated and were key to understanding the final reaction conditions.

Summary Maximizing the personal, public, research, and clinical value of genomic information will require the reliable exchange of genetic variation data. We report here the Variation Representation Specification (VRS, pronounced “verse”), an extensible framework for the computable representation of variation that complements contemporary human-readable and flat file standards for genomic variation representation. VRS provides semantically precise representations of variation and leverages this design to enable federated identification of biomolecular variation with globally consistent and unique computed identifiers. The VRS framework includes a terminology and information model, machine-readable schema, data sharing conventions, and a reference implementation, each of which is intended to be broadly useful and freely available for community use. VRS was developed by a partnership among national information resource providers, public initiatives, and diagnostic testing laboratories under the auspices of the Global Alliance for Genomics and Health (GA4GH).

Although CA 19-9 is a commonly used tumor marker in the management of PBMs, the literature describing outcomes in patients with PBMs who have undetectable or low (hereinafter “low”) CA 19-9 levels remains scarce. In this study, we sought to compare clinical features and outcomes in patients with PBMs and low CA 19-9 levels to those with normal and elevated CA 19-9 levels. Methods: We retrospectively collected data on patients with biopsy-confirmed PBMs and stratified patients into categories based on their CA 19-9 level at diagnosis. Survival curves were estimated for patients in each of the three aforementioned CA 19-9 groups using the Kaplan–Meier method and compared using a Cox proportional hazards regression model. Results: Of the 283 patients identified, 23 (8.1%) had low, 70 (24.7%) had normal, and 190 (67.1%) had elevated CA 19-9 levels. After controlling for sex, age, BMI, the presence of metastases at the time of diagnosis, and treatment with curative intent, the hazard ratio for death in the elevated CA 19-9 group compared to the low CA 19-9 group was 1.993 (95% CI 1.089–3.648; p = 0.025). Conclusion: The elevated CA 19-9 level compared to the low CA 19-9 level and the presence of metastases were associated with an increased hazard of death, while treatment with curative intent was associated with a decreased hazard of death.

BACKGROUND Patient outcomes and experience during a Spinal Cord Stimulation (SCS) screening trial can have a significant effect on whether to proceed with long-term, permanent implantation of an SCS device for the treatment of chronic pain. Enhancing the ability to track and assess patients during this initial trial evaluation offers the potential for improved understanding regarding the suitability of permanent device implantation as well as identification of the SCS-based neurostimulative modalities and parameters that may provide substantial analgesia in a patient-specific manner. OBJECTIVE In this report, we aimed to describe a preliminary, real-world assessment of a new, real time tracking, smart, device-based digital app used by patients with chronic pain undergoing trial screening for SCS therapy. METHODS This is a real-world, retrospective evaluation of 13,331 patients diagnosed with chronic pain who used the new “mySCS” mobile app during an SCS screening trial. The app design is health insurance portability and accountability act (HIPAA)-compliant and compatible with most commercially available smartphones (eg, Apple, iPhone, and Android). The app enables tracking of user-inputted health-related responses (ie, pain relief, activity level, and sleep quality) in addition to personal trial goals and a summary of overall experience during the SCS trial. A deidentified, aggregate analysis of user engagement, user-submitted responses, and overall trial success was conducted. RESULTS When provided the opportunity, the percentage of users who engaged with the tracking app for ≥50% of the time during their trial was found to be 64.43% (n=8589). Among the 13,331 patients who used the app, 58.24% (n=7764) entered a trial goal. Most patients underwent SCS screening with a trial duration of at least 7 days (n=7739, 58.05%). Of those patients who undertook a 7-day SCS trial, 62.30% (n=3456) engaged the app for 4 days or more. In addition, among all who submitted descriptive responses using the app, health-related improvements were reported by 77.84% (n=10,377) of patients who reached day 3 of the screening phase assessment and by 83.04% (n=11,070) of those who reached trial completion. A trial success rate of 91% was determined for those who used the app (versus 85% success rate for nonusers). CONCLUSIONS Data from this initial, real-world examination of a mobile, digital-health–based tracking app (“mySCS”), as used during the SCS screening phase, demonstrate that substantial patient engagement can be achieved while also providing for the acquisition of more real time patient-outcome measures that may help facilitate improved SCS trial success.

Background Patient outcomes and experience during a Spinal Cord Stimulation (SCS) screening trial can have a significant effect on whether to proceed with long-term, permanent implantation of an SCS device for the treatment of chronic pain. Enhancing the ability to track and assess patients during this initial trial evaluation offers the potential for improved understanding regarding the suitability of permanent device implantation as well as identification of the SCS-based neurostimulative modalities and parameters that may provide substantial analgesia in a patient-specific manner. Objective In this report, we aimed to describe a preliminary, real-world assessment of a new, real time tracking, smart, device-based digital app used by patients with chronic pain undergoing trial screening for SCS therapy. Methods This is a real-world, retrospective evaluation of 13,331 patients diagnosed with chronic pain who used the new “mySCS” mobile app during an SCS screening trial. The app design is health insurance portability and accountability act (HIPAA)-compliant and compatible with most commercially available smartphones (eg, Apple, iPhone, and Android). The app enables tracking of user-inputted health-related responses (ie, pain relief, activity level, and sleep quality) in addition to personal trial goals and a summary of overall experience during the SCS trial. A deidentified, aggregate analysis of user engagement, user-submitted responses, and overall trial success was conducted. Results When provided the opportunity, the percentage of users who engaged with the tracking app for ≥50% of the time during their trial was found to be 64.43% (n=8589). Among the 13,331 patients who used the app, 58.24% (n=7764) entered a trial goal. Most patients underwent SCS screening with a trial duration of at least 7 days (n=7739, 58.05%). Of those patients who undertook a 7-day SCS trial, 62.30% (n=3456) engaged the app for 4 days or more. In addition, among all who submitted descriptive responses using the app, health-related improvements were reported by 77.84% (n=10,377) of patients who reached day 3 of the screening phase assessment and by 83.04% (n=11,070) of those who reached trial completion. A trial success rate of 91% was determined for those who used the app (versus 85% success rate for nonusers). Conclusions Data from this initial, real-world examination of a mobile, digital-health–based tracking app (“mySCS”), as used during the SCS screening phase, demonstrate that substantial patient engagement can be achieved while also providing for the acquisition of more real time patient-outcome measures that may help facilitate improved SCS trial success.

Objective Onasemnogene abeparvovec, a one-time intravenous gene replacement therapy, and nusinersen, an antisense oligonucleotide that requires ongoing intrathecal administration, have been evaluated as treatments for spinal muscular atrophy (SMA) type 1 in separate Phase III trials, but no head-to-head comparison studies have been conducted. Onasemnogene abeparvovec was compared with nusinersen using a matching-adjusted indirect comparison (MAIC) to estimate the treatment effect of onasemnogene abeparvovec relative to nusinersen for the treatment of symptomatic patients with SMA type 1 for up to 24 months of follow-up. Methods In the absence of studies for both onasemnogene abeparvovec and nusinersen with a common comparator, a Bayesian naive indirect treatment comparison (ITC) and MAIC between onasemnogene abeparvovec and nusinersen were conducted to compare efficacy and safety of onasemnogene abeparvovec with nusinersen. Outcomes of interest were event-free survival (EFS), overall survival (OS), and motor milestone achievements (independent sitting and independent walking). Relative treatment effects were expressed as relative risk (RR) and risk difference. Results Pooled and weighted patient-level data illustrated a favorable effect toward onasemnogene abeparvovec, suggesting longer EFS for patients compared with nusinersen (HR of onasemnogene abeparvovec vs. nusinersen: 0.19 [95% CI: 0.07-0.54; 99% CI: 0.05-0.74]). At 24 months of follow-up, patients receiving onasemnogene abeparvovec were statistically significantly more likely to achieve the motor milestone of sitting independently compared with patients treated with nusinersen. Although statistically significant differences were not observed at 6 to 18 months between treatment options, the likelihood of sitting independently at 12 and 18 months numerically favored onasemnogene abeparvovec. A numerically greater likelihood of walking by 18 and 24 months was also observed for patients treated with onasemnogene abeparvovec compared with nusinersen. Onasemnogene abeparvovec therapy was also associated with a favorable (but statistically nonsignificant) outcome for OS and may be associated with prolonged survival compared with nusinersen (HR of onasemnogene abeparvovec vs. nusinersen: 0.35 [95% CI: 0.09-1.32; 99% CI: 0.06-2.01]). Bayesian naive ITC results were similar to the MAIC analysis for EFS, OS, and motor milestone achievements. Small sample size limited covariate matching to baseline CHOP INTEND and nutritional support requirement, leading to wider CIs and statistically inconclusive outcomes for some of the results. Conclusions Despite limitations of the current MAIC analysis (mainly a small sample size for statistical testing, even for the pooled onasemnogene abeparvovec trials, and potential differences in prognostic and predictive factors between studies), the relative treatment effects in EFS, OS, and motor milestone achievement indicate that onasemnogene abeparvovec may offer continued benefit compared with nusinersen through 24 months of follow-up.

Be prepared to become enlightened and come to know what you may have thought that you knew but probably have no clue and know nothing at all. This is a comprehensive book that is packed full of his...

While the association of immune thrombocytopenic purpura (ITP) and inflammatory bowel disease (IBD) has been described in a few case reports, management of ITP as an extraintestinal manifestation of Crohn’s disease (CD) is less studied. There are approximately a dozen cases describing the management of patients dually diagnosed with CD/ITP. Previous reports postulated that the mechanism of ITP in CD was through the presence of circulating immune complexes in the serum and antigenic mimicry due to increased mucosal permeability in active colitis, versus increased mucosal production of TH1-type proinflammatory cytokines during CD flares, which may account for remission of ITP with surgery for CD. We present a case of a 27-year-old man who presented with medically refractory CD and ITP who responded to surgical management with colectomy and splenectomy, along with a systematic review of the literature. These cases suggest that colectomy should be considered in the treatment of medically refractory ITP among patients with concomitant CD.

This book serves multiple purposes in that it defines civic youth work and civic youth engagement theory in practical and empowering terms while providing alternate frameworks and utilizing the log...

As time elapses it is important to obtain and disseminate new information. Information that builds and expands upon the precedent of what we have previously learned. Especially in our current times...

ClinVar (https://www.ncbi.nlm.nih.gov/clinvar/) is a freely available, public archive of human genetic variants and interpretations of their significance to disease, maintained at the National Institutes of Health. Interpretations of the clinical significance of variants are submitted by clinical testing laboratories, research laboratories, expert panels and other groups. ClinVar aggregates data by variant-disease pairs, and by variant (or set of variants). Data aggregated by variant are accessible on the website, in an improved set of variant call format files and as a new comprehensive XML report. ClinVar recently started accepting submissions that are focused primarily on providing phenotypic information for individuals who have had genetic testing. Submissions may come from clinical providers providing their own interpretation of the variant (‘provider interpretation’) or from groups such as patient registries that primarily provide phenotypic information from patients (‘phenotyping only’). ClinVar continues to make improvements to its search and retrieval functions. Several new fields are now indexed for more precise searching, and filters allow the user to narrow down a large set of search results.

The first colloidal nanoparticle synthesis of the copper selenophosphate Cu

Factor X deficiency is a rare bleeding disorder that varies in the severity of its clinical manifestations. The symptoms of this disorder can occur at any age, although most severe cases appear in childhood. The rarity of this condition has not allowed for the establishment of evidence‐based management guidelines, and thus, individuals afflicted with factor X deficiency are treated based on limited literature and the opinions of clinicians with extensive experience. In this case report, we discuss a unique presentation of a 38-year-old male who was found to have cardiac tamponade as a result of his newly diagnosed inherited moderate factor X deficiency. This was discovered by obtaining a factor X activity assay and confirmed with genetic testing which demonstrated a missense variant on the factor X gene on chromosome 13. His management involved correction of his factor X deficiency with fresh frozen plasma, a pericardiocentesis, and placement of a pericardial window. He has been asymptomatic and without hemorrhagic episodes for the 10 months following his discharge.

Lung cancer remains the leading cause of cancer-related deaths worldwide, with an estimated 1.6 million deaths each year. Non-small cell lung cancer (NSCLC) is with 85% by far the most common subtype of lung cancer, comprising adenocarcinomas and lung squamous cell carcinoma. Mutations in Kirsten rat sarcoma viral oncogene homolog (KRAS), epidermal growth factor receptor (EGFR) and anaplastic lymphoma receptor tyrosine kinase (ALK) genes are common with the worst overall survival for KRAS mutant adenocarcinoma patients. We have established a murine model of lung cancer, wherein expression of oncogenic Kras can be controlled genetically, allowing activation of oncogenic KrasG12D (Kras*) to initiate tumor growth, tumor eradication upon Kras* depletion and re-activation as a means to model relapse. Oncogenic Kras depletion (deactivation) has previously been reported to result in tumor cell apoptosis even in the presence of tumor suppressor loss. However, the mechanisms of apoptosis, the role of the immune system on these changes, and the mechanisms allowing some tumor cells to escape apoptosis, which typically results in tumor relapse, are unknown. Here, we interrogated the immune response in mediating tumor regression and relapse using this genetically engineered models. Multiplex immunohistochemistry as well as CyTOF provided insight into the changes in immune contexture upon Kras* depletion in mice haploinsufficient for tumor suppressor p53 or mutant for p53 (R172H). Interestingly, total number of T cells including cytotoxic T cells (CTLs) was elevated in lung tumors from p53 mutant mice supporting findings of heightened immune activation and overall response to immune therapy with an increased mutational burden. Kras* inactivation and thus inhibition of MAPK signaling resulted in an overall decrease in abundance of CTLs and antigen presenting cells (APC) as well as engagement of CTL with tumor cells and APCs indicating a decrease in immune presence likely due to proceeding tumor cell kill and immune recruitment. However, intracellular distance of CTL with tumor cells indicated active tumor cell kill of the CTLs to eradicate remaining tumor cells. In summary, these findings support recent observation of increased immune activation in tumors with higher mutational load as well as changes mediated by inhibition of MAPK signaling which both maybe harnessed for enhancing future immunotherapies. Citation Format: Nina Steele, Kristena Y. Abdelmalak, Sarah F. Ferris, Jennifer M. Lee, Carlos Espinoza, Yaqing Zhang, Sundaresh Ram, Craig Galban, Nithya Ramnath, Timothy L. Frankel, Marina Pasca di Magliano, Stefanie Galbán. Oncogenic Kras-mediated regulation of the tumor microenvironment in lung cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3855.

Apathy syndrome is distinct from depression but apathy symptoms are present in both conditions. Moreover, apathy symptoms are also present in healthy older adults. Perceived social support is considered a protective factor against adverse health outcomes in the aging population. While numerous studies found depressive symptoms to be inversely associated with perceived social support, the relationship between apathy and perceived social support has not been reported. Hence, we investigated the associations of apathy and depressive symptoms with perceived social support in older adults. The sample included 295 community-dwelling healthy older adults (mean age=78.29yrs; % female=52.9%). Apathy was evaluated with the Apathy Evaluation Scale, depression with the Geriatric Depression Scale- 30, and perceived social support with the Medical Outcomes Study- Social Support Survey. In order to adjust for the apathy symptoms found in depression, four apathy/withdrawal items were excluded, based on prior literature, from the Geriatric Depression Scale. Hierarchical linear regression analysis adjusting for age, gender, education, cognition, and medical comorbidities revealed that, when apathy and depressive symptoms were jointly modeled as predictors, both had significant negative associations with perceived social support. We provided the first evidence that worse apathy symptoms were associated with lower perceived social support in older adults independently of depressive symptoms. These findings suggest that apathy may be a novel risk factor for diminished social support and a plausible candidate for interventions designed to enhance it.

Apomorphine (apo), an unspecific direct dopamine agonist, elicits an intense and lasting pecking bout in pigeons. Apo yielded orderly dose–response functions, and repeated administrations led to sensitization. Strain and individual differences in sensitivity to apo were at least partly due to genetic factors. However, a strong cage-context dependency of the sensitization, which is indicative of conditioning, occurred in both pigeon strains studied. Apo-induced pecking and sensitization also occurred in total darkness. Pigeons could be conditioned to discriminate between an apo state and a non-apo state. A small dose of apo was effective as a conditioned stimulus when paired with a high dose as an unconditioned stimulus. The conditioned response (CR) was strongly specific to the context in which the sensitization to apo took place. The resistance to extinction of the CR could be increased through an oversensitization treatment. The incremental responses arising during the sensitization treatment and the CRs shown afterward by individual pigeons correlated significantly. The sensitization to apo in pigeons is well accounted for by a conditioning schema in which an interoceptive drug state is a conditional conditioned stimulus for the full expression of the incremental response. Variants of the scheme might also account for the sensitization of rodents to psychostimulants. A neural model that embodies the characteristics of the conditioning scheme has been proposed.

Background: Cardiovascular changes of pregnancy are well-known; however, parameters for accurately assessing these changes have not been refined as measurement tools have advanced. We sought to examine the range of echocardiographic parameters during normal pregnancy using current echocardiographic imaging modalities. Methods: We performed a retrospective analysis of normal echocardiograms in 121 women (97 pregnant, 24 non-pregnant) without evidence of cardiovascular disease. Linear, area, and Doppler fl ow measurements were made of commonly reviewed cardiac structures. Height-indexed measurements were compared between pregnant women and controls and between trimesters of pregnancy. Results: Compared to non-pregnant patients, all four cardiac chambers showed significant enlargement in the pregnant patients. The left atrium was the first chamber to enlarge. LV mass also increased in the third trimester (134.5 ± 31 vs. 112.3 ± 28.2 g, P & lt; 0.01), with preservation of LV mass to volume ratio. LV ejection fraction was significantly larger (68% vs. 63%, P Conclusion: This study provides data on echocardiographic parameters during normal pregnancy and is one of the largest sample sizes in the literature. The results will contribute to the current literature by helping to distinguish between normal and abnormal echocardiograms during pregnancy. Key words: Chamber quantifi cations, echocardiography, pregnancy.

A new approach to prepare functional organic nanoparticles (ONPs) from linear polymers is described. The nanoparticles are obtained by ring-opening metathesis polymerisation (ROMP) of functionalised norbornene dicarboximides, side-chain amidation with tri-O-allyl-TRIS, and ring-closing metathesis (RCM). The synthesis is quite flexible and mild, allowing preparation of organic- and aqueous-soluble particles with narrow molecular weight (MW) distributions that are tunable, ranging from MW ≈ 10 to >100 kD with diameters between ca. 5 and 50 nm. The use of functional monomer(s) and/or chain-transfer agents (CTAs) leads to the fully controlled synthesis of nanoparticles containing single or multiple reactive functional groups. This non-toxic ONP scaffold can be readily used as a protective carrier for a broad range of groups using the appropriate monomers, such as a fluorescein-functionalised monomer that affords fluorescent ONPs with significantly enhanced photostability.

ClinVar is a freely accessible, public archive of reports of the relationships among genomic variants and phenotypes. To facilitate evaluation of the clinical significance of each variant, ClinVar aggregates submissions of the same variant, displays supporting data from each submission, and determines if the submitted clinical interpretations are conflicting or concordant. The unit describes how to (1) identify sequence and structural variants of interest in ClinVar with by multiple searching approaches, including Variation Viewer and (2) understand the display of submissions to ClinVar and the evidence supporting each interpretation. By following this protocol, ClinVar users will be able to learn how to incorporate the wealth of resources and knowledge in ClinVar into variant curation and interpretation.

The National Institutes of Health Genetic Testing Registry (GTR; available online at http://www.ncbi.nlm.nih.gov/gtr/) maintains comprehensive information about testing offered worldwide for disorders with a genetic basis. Information is voluntarily submitted by test providers. The database provides details of each test (e.g. its purpose, target populations, methods, what it measures, analytical validity, clinical validity, clinical utility, ordering information) and laboratory (e.g. location, contact information, certifications and licenses). Each test is assigned a stable identifier of the format GTR000000000, which is versioned when the submitter updates information. Data submitted by test providers are integrated with basic information maintained in National Center for Biotechnology Information's databases and presented on the web and through FTP (ftp.ncbi.nih.gov/pub/GTR/_README.html).

The master circadian clock located within the hypothalamic suprachiasmatic nucleus (SCN) is necessary for the circadian rhythm of glucocorticoid (GC) release. The pathways by which the SCN sustains rhythmic GC release remain unclear. We studied the circadian regulation of cortisol release in the behaviorally split golden hamster, in which the single bout of circadian locomotor activity splits into two bouts approximately12 h apart after exposing the animals to constant light conditions. We show that unsplit control hamsters present a single peak of cortisol release that is concomitant with a single peak of ACTH release. In contrast, split hamsters show two peaks of cortisol release that are approximately12 h appart and are appropriately phased to each locomotor activity bout but surprisingly do not rely on rhythmic release of ACTH. Our results are consistent with a model in which the circadian pacemaker within the SCN regulates the circadian release of GC via input to the hypothalamo-pituitary-adrenal axis and via a second regulatory pathway, which likely involves sympathetic innervation of the adrenal and can operate even in the absence of ACTH circadian rhythmic release. Furthermore, we show that although the overall 24-h cortisol output in split hamsters is lower than in unsplit controls, split hamsters release constant low levels of ACTH. This result suggests that the timing, rather than the absolute amount, of cortisol release is more critical for the induction of negative feedback effects that regulate the hypothalamo-pituitary-adrenal axis.

• An association genetics approach was used to examine individual genes and alleles at the loci responsible for complex traits controlling lignocellulosic biosynthesis in black cottonwood (Populus trichocarpa). Recent interest in poplars as a source of renewable energy, combined with the vast genomic resources available, has enabled further examination of their genetic diversity. • Forty candidate genes were resequenced in a panel of 15 unrelated individuals to identify single nucleotide polymorphisms (SNPs). Eight hundred and seventy-six SNPs were successfully genotyped in a clonally replicated population (448 clones). The association population (average of 2.4 ramets per clone) was phenotyped using pyrolysis molecular beam mass spectrometry. Both single-marker and haplotype-based association tests were implemented to identify associations for composite traits representing lignin content, syringyl : guaiacyl ratio and C6 sugars. • Twenty-seven highly significant, unique, single-marker associations (false discovery rate Q < 0.10) were identified across 40 candidate genes in three composite traits. Twenty-three significant haplotypes within 11 genes were discovered in two composite traits. • Given the rapid decay of within-gene linkage disequilibrium and the high coverage of amplicons across each gene, it is likely that the numerous polymorphisms identified are in close proximity to the causative SNPs and the haplotype associations reflect information present in the associations between markers.

Prolactin and leukemia inhibitory factor (LIF) have different roles in the adult mammary gland, which are mediated in part by the signal transducers and activators of transcription (STAT)5 and STAT3. In vivo studies have shown that STAT5 contributes to prolactin-dependent lobuloalveolar development and lactation whereas STAT3 mediates LIF-dependent epithelial apoptosis during postlactational involution. To understand the molecular basis of these STAT-dependent pathways, we demonstrate the ligand-independent effects of STAT5 and STAT3 in mammary epithelial cells in vitro and also identify the genes regulated by these related transcription factors. Thus, using conditionally active STAT3- or STAT5a-GyraseB fusion proteins, we observed that enforced and specific dimerization of STAT3 induced apoptosis whereas STAT5 induced differentiation of mammary epithelial cells. Furthermore, STAT5 attenuated apoptosis mediated by LIF, the physiological inducer of STAT3. Microarray analysis of STAT3- and STAT5-induced genes using this system demonstrated a marked specificity, which reflected their different physiological effects in vitro and in vivo. STAT5-specific gene targets included the milk protein genes alpha-casein and kallikrein-8 and the survival factors prosaposin and Grb10. STAT3-specific genes included the apoptosis regulators CCAAT enhancer binding protein-delta, phosphatidylinositol 3-kinase-regulatory subunits, purine nucleoside phosphorylase, and c-fos. These data illustrate that specific activation of STAT3 and STAT5 alone is sufficient to induce and suppress apoptosis, respectively, and that these transcription factors elicit their actions by inducing distinct subsets of target genes in mammary epithelial cells.

Best evidence from prospective studies with aggressive monitoring suggests that the incidence of needlestick injuries is significantly higher than reported through passive surveillance, ranging from 14 to 839 needlestick injuries per 1,000 health care workers per year. The economic cost of managing these injuries is substantial, ranging from dollars 51 to dollars 3,766 (2002 U.S. dollars). This amount excludes the cost of treating the long-term complications of needlestick injuries, such as HIV and hepatitis B and C infections, each of which can cost several hundreds of thousands of dollars to manage. In addition, health care workers experience significant fear, anxiety, and emotional distress following a needlestick injury, sometimes resulting in occupational and behavior changes. Despite the availability of engineered injury prevention devices, the implementation of these new technologies has been mixed in part because of the perception that these devices are costly and cost ineffective. However, widespread use of safety devices might be more easily justified on economic grounds when the full clinical and economic benefits of these new technologies are considered, especially within the context of injury prevention.

This literature review presents the economics of head and neck cancer (HNC), the world's sixth most common neoplasm. HNC economics is complicated by the involvement of multiple body sites, multiple medical specialties, and multiple treatment modalities. Economic analyses of HNC published in English between 1990 and 2002 were identified from electronic data sources. Additional studies were identified manually from bibliographies of retrieved articles. Study characteristics and findings were analyzed. We identified 51 studies that reported original cost data. Most were cost-identification or cost-comparison studies; only one evaluated cost-effectiveness. Few assessed the overall economic burden of HNC or cost effectiveness of current treatments, thus making appropriate comparisons impossible. Systematic measurement of the cost of HNC and its treatment in existing practice settings would be valuable. Inclusion of economic components in clinical trials and the conduct of retrospective or prospective observational studies, such as patient registries, would yield important new information.

Serum and synovial tissue expression of the matrix metalloproteinase (MMP)-2 and -9 and their molecular regulators, MMP-14 and TIMP-2 was examined in 28 patients with inflammatory early synovitis and 4 healthy volunteers and correlated with the presence of erosions in the patients. Immunohistological staining of MMP-2, MMP-14 and TIMP-2 localized to corresponding areas in the synovial lining layer and was almost absent in normal synovium. Patients with radiographic erosions had significantly higher levels of active MMP-2 than patients with no erosions, suggesting that activated MMP-2 levels in synovial tissue may be a marker for a more aggressive synovial lesion., Introduction: In cancer the gelatinases [matrix metalloproteinase (MMP)-2 and MMP-9] have been shown to be associated with tissue invasion and metastatic disease. In patients with inflammatory arthritis the gelatinases are expressed in the synovial membrane, and have been implicated in synovial tissue invasion into adjacent cartilage and bone. It is hypothesized that an imbalance between the activators and inhibitors of the gelatinases results in higher levels of activity, enhanced local proteolysis, and bone erosion. Objectives: To determine whether the expression and activity levels of MMP-2 and MMP-9, and their regulators MMP-14 and tissue inhibitor of metalloproteinase (TIMP), are associated with early erosion formation in patients with synovitis of recent onset. Patients and method: A subset of 66 patients was selected from a larger early synovitis cohort on the basis of tissue availability for the study of synovial tissue and serum gelatinase expression. Patients with peripheral joint synovitis of less than 1 years' duration were evaluated clinically and serologically on four visits over a period of 12 months. At the initial visit, patients underwent a synovial tissue biopsy of one swollen joint, and patients had radiographic evaluation of hands and feet initially and at 1year. Serum MMP-1, MMP-2, MMP-9, MMP-14, and TIMP-1 and TIMP-2 levels were determined, and synovial tissue was examined by immunohistology for the expression of MMP-2 and MMP-9, and their molecular regulators. Gelatinolytic activity for MMP-2 and MMP-9 was quantified using a sensitive, tissue-based gel zymography technique. Four healthy individuals underwent closed synovial biopsy and their synovial tissues were similarly analyzed. Results: Of the 66 patients studied, 45 fulfilled American College of Rheumatology criteria for rheumatoid arthritis (RA), with 32 (71%) being rheumatoid factor positive. Of the 21 non-RA patients, seven had a spondylarthropathy and 14 had undifferentiated arthritis. Radiographically, 12 of the RA patients had erosions at multiple sites by 1 year, whereas none of the non-RA patients had developed erosive disease of this extent. In the tissue, latent MMP-2 was widely expressed in the synovial lining layer and in areas of stromal proliferation in the sublining layer and stroma, whereas MMP-9 was expressed more sparsely and focally. MMP-14, TIMP-2, and MMP-2 were all detected in similar areas of the lining layer on consecutive histologic sections. Tissue expression of MMP-14, the activator for pro-MMP-2, was significantly higher in RA than in non-RA patients (8.4 ± 5 versus 3.7 ± 4 cells/high-power field; P = 0.009). In contrast, the expression of TIMP-2, an inhibitor of MMP-2, was lower in the RA than in the non-RA samples (25 ± 12 versus 39 ± 9 cells/high-power field; P = 0.01). Synovial tissue expressions of MMP-2, MMP-14, and TIMP-2 were virtually undetectable in normal synovial tissue samples. The synovial tissue samples of patients with erosive disease had significantly higher levels of active MMP-2 than did those of patients without erosions (Fig. 1). Tissue expression of MMP-2 and MMP-9, however, did not correlate with the serum levels of these enzymes. With the exception of serum MMP-2, which was not elevated over normal, serum levels of all of the other MMPs and TIMPs were elevated to varying degrees, and were not predictive of erosive disease. Interestingly, MMP-1 and C-reactive protein, both of which were associated with the presence of erosions, were positively correlated with each other (r = 0.42; P < 0.001). Discussion: MMP-2 and MMP-9 are thought to play an important role in the evolution of joint erosions in patients with an inflammatory arthritis. Most studies have concentrated on the contribution of MMP-9 to the synovitis, because synovial fluid and serum MMP-9 levels are markedly increased in inflammatory arthropathies. Previously reported serum levels of MMP-9 have varied widely. In the present sample of patients with synovitis of recent onset, serum MMP-9 levels were elevated in only 21%. Moreover, these elevations were not specific for RA, the tissue expression of MMP-9 was focal, and the levels of MMP-9 activity were not well correlated with early erosions. Although serum MMP-2 levels were not of prognostic value, high synovial tissue levels of MMP-2 activity were significantly correlated with the presence of early erosions. This may reflect augmented activation of MMP-2 by the relatively high levels of MMP-14 and low levels of TIMP-2 seen in these tissues. We were able to localize the components of this trimolecular complex to the synovial lining layer in consecutive tissue sections, a finding that is consistent with their colocalization. In conclusion, we have provided evidence that active MMP-2 complexes are detectable in the inflamed RA synovium and may be involved in the development of early bony erosions. These results suggest that strategies to inhibit the activation of MMP-2 may have the potential for retarding or preventing early erosions in patients with inflammatory arthritis.

Appressed pubescence genes in soybean cause hairs on the upper surface of leaves to lie flat, while pubescence remains erect elsewhere on the plant. For decades this trait was believed to be controlled in soybean by duplicated single genes, Pa1 and Pa2. However, reports in the literature conflicted as to which phenotype was dominant or recessive. Two populations were developed, each approximately 100 individuals, and each segregating for one of the appressed pubescence genes. A combination of SSRs (simple sequence repeats) and RFLPs (restriction fragment length polymorphisms) were used in each of these populations to map the independent genes. Two-point analysis weakly linked Pa1 and Pa2 to separate linkage groups. Lack of strong linkage suggested the trait may not be controlled by single genes. When QTL (quantitative trait loci) analysis was performed, one major locus and several minor loci were detected in each population. We report the mapping of the genes controlling appressed pubescence in soybean and their placement in homologous regions. Although appressed pubescence was originally reported to be single duplicate genes, we report that it is actually a more complex phenotype with major duplicated genes and minor modifying genes. These results offer interesting implications regarding the evolution of duplicate genetic factors and the definition of qualitative traits.Key words: homoeologous, Glycine, evolution, appressed pubescence, quantitative genetics.

The suprachiasmatic nuclei (SCN) contain the mammalian circadian clock whose rhythm of firing rate can be recorded in vitro for several days. Application of a protein kinase A (PKA) inhibitor onto the SCN at Zeitgeber time (ZT) 10 on the first day in vitro phase delayed the rhythm of firing rate expressed by SCN neurons on the subsequent day in vitro. Application of the inhibitor (Rp-cAMPS) at other circadian phases did not phase shift the rhythm. These results suggest that during approximately 1 h in the late subjective day the presence and activity of PKA plays a role in setting the phase of the mammalian circadian clock.

ClinVar (http://www.ncbi.nlm.nih.gov/clinvar/) provides a freely available archive of reports of relationships among medically important variants and phenotypes. ClinVar accessions submissions reporting human variation, interpretations of the relationship of that variation to human health and the evidence supporting each interpretation. The database is tightly coupled with dbSNP and dbVar, which maintain information about the location of variation on human assemblies. ClinVar is also based on the phenotypic descriptions maintained in MedGen (http://www.ncbi.nlm.nih.gov/medgen). Each ClinVar record represents the submitter, the variation and the phenotype, i.e. the unit that is assigned an accession of the format SCV000000000.0. The submitter can update the submission at any time, in which case a new version is assigned. To facilitate evaluation of the medical importance of each variant, ClinVar aggregates submissions with the same variation/phenotype combination, adds value from other NCBI databases, assigns a distinct accession of the format RCV000000000.0 and reports if there are conflicting clinical interpretations. Data in ClinVar are available in multiple formats, including html, download as XML, VCF or tab-delimited subsets. Data from ClinVar are provided as annotation tracks on genomic RefSeqs and are used in tools such as Variation Reporter (http://www.ncbi.nlm.nih.gov/variation/tools/reporter), which reports what is known about variation based on user-supplied locations.

A primary goal of evolutionary genetics is to discover and explain the genetic basis of fitness-related traits and how this genetic basis evolves within natural populations. Unprecedented technological advances have fueled the discovery of genetic variants associated with ecologically relevant phenotypes in many different life forms, as well as the ability to scan genomes for deviations from selectively neutral models of evolution. Theoretically, the degree of overlap between lists of genomic regions identified using each approach is related to the genetic architecture of fitness-related traits and the strength and type of natural selection molding variation at these traits within natural populations. Here we address for the first time in a plant the degree of overlap between these lists, using patterns of nucleotide diversity and divergence for >7000 unique amplicons described from the extensive expressed sequence tag libraries generated for loblolly pine (Pinus taeda L.) in combination with the >1000 published genetic associations. We show that loci associated with phenotypic traits are distinct with regard to neutral expectations. Phenotypes measured at the whole plant level (e.g., disease resistance) exhibit an approximately twofold increase in the proportion of adaptive nonsynonymous substitutions over the genome-wide average. As expected for polygenic traits, these signals were apparent only when loci were considered at the level of functional sets. The ramifications of this result are discussed in light of the continued efforts to dissect the genetic basis of quantitative traits.

e13120Background: Genetic testing of tumors and germlines has proliferated in oncology, as gauged by ASCO’s meeting topics and the medical literature. A quantitative appraisal of orderable genetic ...

Temporal and demographic aspects of the growth of Botrychium gallicomontanum and B. mormo were studied for 2 yr. A total of 219 B. gallicomontanum and 412 B. mormo plants were monitored in a prairie and maple-basswood forest, respectively. Growth events were divided into four stages: leaf emergence, leaf separation, spore release, and senescence. Botrychium gallicomontanum emerged in April, peaked during the first week of June, and declined rapidly. The largest plants were found in late June and early July with a mean peak trophophore size of 4.0 ± 1.8 cm. Botrychium mormo emerged in June, and the population size peaked in early July. The largest plants occurred late in August with a mean peak trophophore size of 3.0 ± 1.1 cm. The mean season span, or period of emergence aboveground annually, for B. gallicomontanum and B. mormo was 7.7 ± 2.4 and 11.9 ± 3.5 wk, respectively. Late-emerging plants produced spores in shorter periods. The separation stage was prolonged in B. gallicomontanum plants, whereas B. mormo plants had a much longer separation stage. Phenological differences are related to different habitat parameters of grassland and forest. Understanding the phenology of these rare species will help us more accurately predict the impact of management practices.