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Endovascular mechanical thrombectomy has significantly improved recovery in acute ischemic stroke (AIS). While traditional patient selection has relied on factors such as last known well and penumbra volume, emerging research highlights the importance of collateral circulation in influencing thrombectomy success. However, current methods to assess collateral circulation are often unreliable and lack standardization, limiting their integration into clinical decision-making and prompting the need for innovative approaches. This study introduces trans-clot manometry as a promising approach for quantitatively assessing collateral blood flow before thrombectomy. Two patients were included in this study: a 64-year-old female with a left M1 near-complete occlusion and an 81-year-old male with a left P1 occlusion. After receiving intravenous tenecteplase, each patient underwent emergent thrombectomy where intraoperative trans-clot manometry revealed significant trans-clot mean arterial pressure (MAP) gradients (66.7% for Patient 1 and 96.9% for Patient 2). Both patients had successful first-pass thrombectomy (Patient 1: TICI 3; Patient 2: TICI 3), with substantial clinical improvement (Patient 1: NIHSS 11 to 1; Patient 2: NIHSS 19 to 8). Intraoperative trans-clot manometry offers a simple yet powerful, objective, and generalizable measure of collateral circulation, applicable to a wide range of AIS cases regardless of clot location or vessel size. In addition, real-time correlations with heart-rate variability and radial artery pressures provide an intrinsic quality control, ensuring proper execution of the technique and accuracy of the resulting MAP gradient. Future research will focus on validating this approach, determining its generalizability, and establishing MAP gradient thresholds to enhance device selection and predict first-pass success., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Recent studies have reported that reduced excretion of urinary uromodulin is associated with renal tubular function and risks of progressive kidney disease. Gouty nephropathy is usually seen in patients with gout. Patients with chronic gouty nephropathy are characterized by the deposition of monosodium urate crystals primarily involving the collecting ducts in the medulla. We postulated that this correlation may be specific to gout and may serve as a useful biomarker for chronic kidney disease (CKD)., Materials and Methods: A total of 114 Taiwanese patients diagnosed with gout (n = 72), CKD (n = 26), or healthy volunteers (n = 16) were prospectively enrolled for this study from the Rheumatology and Nephrology Outpatient Clinics of our institution. We obtained urine and blood samples on patient visits to the outpatient clinics. Demographic data were obtained from medical records., Results: In patients with gout, the spot urinary uromodulin/creatinine ratio (uUMCR; mg/g) in patients with CKD was significantly lower than that in those without CKD (CKD group: 2.2; non-CKD group: 5.6, p = 0.005). Multivariate analysis revealed that patients with CKD and gout had a lower uUMCR than those with gout alone (p = 0.028). A significant association was not observed in our non-gout cohort., Conclusion: The association of decreased uUMCR with CKD status was identified only in patients with gout in the present study. We believe that uUMCR might serve as an indicator of differential CKD in patients with gout., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

Background: Comprehensive data regarding the epidemiology of chronic urticaria (CU) in general populations are scant., Objectives: To investigate the prevalence, incidence, and comorbidities of CU in general population., Methods: The data were sourced from the National Health Insurance Research Database (NHIRD) for 2009-2012. Patients who had a primary/secondary ICD-9-CM diagnosis code of 708.1, 708.8, or 708.9 during the year with at least two outpatient visits and an antihistamine prescription, were identified as the cases of CU for each year. The incidence, persistence and comorbidities of CU were examined., Results: The prevalence of CU ranged from 0.69% to 0.79% for each year from 2009 to 2012, and the incidence was around 0.50% per year from 2010 to 2012. Comparing to the Standard Population, the standardized prevalence ratios (SPRs) for the rheumatic diseases, thyroid disorders, inflammatory diseases, and psychiatric disorders among CU patients were 2.74, 1.81, 1.57 and 1.87, respectively., Conclusion: The prevalence of CU in Taiwan is about 0.69-0.79%. CU is associated with a significantly increased risk of psychiatric disorders, inflammatory diseases, thyroid disorders, and rheumatic diseases. Except for thyroid disorders, the prevalence of these comorbidities tends to increase the longer CU persists., (Copyright © 2017. Published by Elsevier B.V.)

Background: Cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS-HIPEC) prolongs survival in patients with metastatic peritoneal disease. We look at the incidence of acute kidney injury (AKI) in patients who have received cisplatin during CRS-HIPEC in the treatment of peritoneal carcinomatosis from an ovarian primary, and identify possible peri-operative risk factors., Methods: Between 2005 and 2013, we performed CRS-HIPEC on 47 patients with ovarian primaries and peritoneal metastasis. Retrospective data were collected on the patient's demographics, treatment details and outcomes. Renal impairment was graded according to the NCI-CTCAE 3.0 criteria., Results: There were 47 patients, with a median age of 50 (24-74) years. The median baseline creatinine was 53 μmol/L (23-102) and median baseline albumin of 39 g/L (13-45). All underwent pre-operative chemotherapy for a median of six cycles (0-22) with a median of 15 days between chemotherapy and surgery. They received intra-operative cisplatin at a temperature of 40 °C for 60 min at a median dose of 90 mg/kg. 19 (40.4%) experienced post-operative AKI, of which 5 (8.5%) developed grade 3 and 4 impairment. Two (4.3%) required long-term dialysis. Univariate analysis showed that risk factors for AKI included age, baseline creatinine, baseline estimated glomerular filtration rate, pre-operative albumin, number of cycles of pre-operative carboplatin, time interval between pre-operative chemotherapy and CRS-HIPEC and volume of blood transfusions., Conclusions: Identification of risk factors for AKI post-CRS-HIPEC helps improve pre-operative patient selection and optimisation, facilitate tailoring of chemotherapy, and foster closer peri-operative monitoring and fluid management in at-risk patients.

Postsynaptic density protein 95 (PSD95) and synapse-associated protein 97 (SAP97) are homologous scaffold proteins with different N-terminal domains, possessing either a palmitoylation site (PSD95) or an L27 domain (SAP97). Here, we measured PSD95 and SAP97 conformation in vitro and in postsynaptic densities (PSDs) using FRET and EM, and examined how conformation regulated interactions with AMPA-type and NMDA-type glutamate receptors (AMPARs/NMDARs). Palmitoylation of PSD95 changed its conformation from a compact to an extended configuration. PSD95 associated with AMPARs (via transmembrane AMPAR regulatory protein subunits) or NMDARs [via glutamate ionotropic receptor NMDA-type subunit 2B (GluN2B) subunits] only in its palmitoylated and extended conformation. In contrast, in its extended conformation, SAP97 associates with NMDARs, but not with AMPARs. Within PSDs, PSD95 and SAP97 were largely in the extended conformation, but had different orientations. PSD95 oriented perpendicular to the PSD membrane, with its palmitoylated, N-terminal domain at the membrane. SAP97 oriented parallel to the PSD membrane, likely as a dimer through interactions of its N-terminal L27 domain. Changing PSD95 palmitoylation in PSDs altered PSD95 and AMPAR levels but did not affect NMDAR levels. These results indicate that in PSDs, PSD95 palmitoylation, conformation, and its interactions are dynamic when associated with AMPARs and more stable when associated with NMDARs. Altogether, our results are consistent with differential regulation of PSD95 palmitoylation in PSDs resulting from the clustering of palmitoylating and depalmitoylating enzymes into AMPAR nanodomains segregated away from NMDAR nanodomains., Competing Interests: The authors declare no conflict of interest.

Malignant transformation of the epithelial component of phyllodes tumours (PT) is rare and only reported in literature as sporadic cases of carcinoma associated with PTs. We report the clinicopathological characteristics of in situ and invasive carcinoma coexisting with PT in 10 patients treated in our institution over an 11-year period from 1992 to 2012. Ten patients with coexisting PT and in situ or invasive carcinoma were identified from our records. Six had carcinoma found within the PT. All were female with a median age of 47 (43-72) years. One patient had a history of PT in the same breast while another had a history of PT in the same breast as well as invasive ductal carcinoma in the contralateral breast. The rest did not have any risk factors of breast cancer. Five patients had a preoperative core needle biopsy performed with the report of a fibroepithelial lesion. The rest of the patients had surgery upfront for their breast masses. Two patients who had ER/PR positive invasive carcinoma received adjuvant hormonal therapy. Patients were followed up for a mean of 3.6 years (9 months-10 years) and all patients were alive and recurrence free. PT associated with carcinoma is rare, and we present a series of cases that add to the limited current literature. It is often difficult to detect the presence of the carcinomatous component preoperatively. Hence, close examination of resected PT specimens must be carried out to allow prompt detection of any associated carcinomas, however rare, such that adequate treatment can be given., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: We describe an unusual case of 2 intra-parenchymal breast melanomas with a concomitant subcutaneous melanoma in the ipsilateral upper limb and no definite primary lesion., Case Report: Our patient is a 40-year-old Chinese female who presented with a breast lump in her left breast for which excision biopsy showed melanoma. A PET-CT revealed a second lesion in her breast. A left upper arm nodule with no overlying skin changes was also noted. She underwent a mastectomy and excision biopsy of the upper arm nodule. Histology showed that the second breast lesion was also a melanoma, while the arm nodule contained melanoma cells within a fibrous capsule., Conclusion: The presence of a melanoma in the breast should prompt a close and meticulous search for a primary lesion and potential signs of metastasis. Encapsulated subcutaneous nodules can be attributed to replaced lymph nodes or subcutaneous melanoma which can be either primary dermal melanoma or metastasis from an unknown primary., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Microsatellite instability (MSI) is caused by defective mismatch repair in 15-20% of colorectal cancers (CRCs). Higher mutation loads in tumors with mismatch repair deficiency can predict response to pembrolizumab, an anti-programmed death 1 (PD-1) immune checkpoint inhibitor. We analyzed the mutations in 113 CRCs without MSI (MSS) and 29 CRCs with MSI-High (MSI-H) using the 50-gene AmpliSeq cancer panel. Overall, MSI-H CRCs showed significantly higher mutations than MSS CRCs, including insertion/deletion mutations at repeat regions. MSI-H CRCs showed higher incidences of mutations in the BRAF, PIK3CA, and PTEN genes as well as mutations in the receptor tyrosine kinase families. While the increased mutations in BRAF and PTEN in MSI-H CRCs are well accepted, we also support findings of mutations in the mTOR pathway and receptor tyrosine kinase family genes. MSS CRCs showed higher incidences of mutations in the APC, KRAS and TP53 genes, confirming previous findings. NGS assays may be designed to detect driver mutations for targeted therapeutics and to identify tumors with high mutation loads for potential treatment with immune checkpoint blockade therapies. Further studies may be warranted to elucidate potential targeted therapeutics against mutations in the mTOR pathway and the receptor tyrosine kinase family in MSI-H CRCs as well as the benefit of anti-PD-1 immunotherapy in hypermutated MSS CRCs or other cancers.

Introduction: There is strong evidence that epidural analgesia provides good postoperative pain relief in adults, but its use in infants is less established. In this retrospective study, we present our experience with managing infant epidural analgesia for abdominal surgeries in a tertiary paediatric institution., Methods: The records of 54 infants who had received a thoracic or lumbar epidural as perioperative analgesia for abdominal surgeries were included. The mean age of the infants was 6.1 (standard deviation [SD] 3.8) months and their mean weight was 6.8 kg (SD 1.8). Most (63%) had an ASA (American Society of Anesthesiologists) status of 2 and all underwent elective gastrointestinal, urogenital, hepatobiliary or retroperitoneal surgeries. 20 catheters (37.0%) were inserted in the thoracic region and 33 (61.1%) in the lumbar region., Results: A total of 52 (96.3%) catheters provided adequate intraoperative analgesia and 36 (66.7%) provided effective analgesia for the postoperative period. Active management of epidural analgesia, such as through epidural top-ups and infusion rate adjustment, was necessary to optimise analgesia in 22 (44%) of the 50 patients postoperatively. Reasons for premature catheter removal were mainly technical issues such as catheter disconnection, leakage and blockage., Conclusion: Our data suggests that in experienced hands, specialised settings and active management, the success rate of epidural analgesia in infants undergoing major abdominal surgeries is high and without major incident.

Primary cerebral neuroblastoma is a rare malignant tumor encountered most commonly in children. The radiological features of this entity are variable and rarely reported. The diffusion-weighted imaging (DWI) findings have not previously reported. We describe serial DWI and conventional MRI in a case of primary cerebral neuroblastoma to assess the imaging features and the role of DWI for monitoring chemoradiotherapy response.

Context: DNA sequencing is critical to identifying many human genetic disorders caused by DNA mutations, including cancer. Pyrosequencing is less complex, involves fewer steps, and has a superior limit of detection compared with Sanger sequencing. The fundamental basis of pyrosequencing is that pyrophosphate is released when a deoxyribonucleotide triphosphate is added to the end of a nascent strand of DNA. Because deoxyribonucleotide triphosphates are sequentially added to the reaction and because the pyrophosphate concentration is continuously monitored, the DNA sequence can be determined., Objective: To demonstrate the fundamental principles of pyrosequencing., Data Sources: Salient features of pyrosequencing are demonstrated using the free software program Pyromaker ( http://pyromaker.pathology.jhmi.edu ), through which users can input DNA sequences and other pyrosequencing parameters to generate the expected pyrosequencing results., Conclusions: We demonstrate how mutant and wild-type DNA sequences result in different pyrograms. Using pyrograms of established mutations in tumors, we explain how to analyze the pyrogram peaks generated by different dispensation sequences. Further, we demonstrate some limitations of pyrosequencing, including how some complex mutations can be indistinguishable from single base mutations. Pyrosequencing is the basis of the Roche 454 next-generation sequencer and many of the same principles also apply to the Ion Torrent hydrogen ion-based next-generation sequencers.

SAP97 interacts with AMPA receptors (AMPARs) and NMDA receptors (NMDARs) during sorting and trafficking to synapses. Here we addressed how SAP97 distinguishes between AMPARs and NMDARs and what role the adaptor/scaffold protein, CASK, plays in the process. Using intramolecular SAP97 Förster resonance energy transfer sensors, we demonstrated that SAP97 is in "extended" or "compact" conformations in vivo. SAP97 conformation was regulated by a direct interaction between SAP97 and CASK through L27 protein-interaction domains on each protein. Unbound SAP97 was mostly in the compact conformation, while CASK binding stabilized it in an extended conformation. In HEK cells and rat hippocampal neurons, SAP97 in the compact conformation preferentially associated and colocalized with GluA1-containing AMPARs, and in the extended conformation colocalized with GluN2B-containing NMDARs. Altogether, our findings suggest a molecular mechanism by which CASK binding regulates SAP97 conformation and its subsequent sorting and synaptic targeting of AMPARs and NMDARs during trafficking to synapses.

Introduction: Phantom limb sensations (PLS), phantom limb pain (PLP) and stump pain (SP) are well-recognised postamputation phenomena. However, there is a dearth of related epidemiological data in Asian populations. This study was conducted to fill the information gap., Methods: Telephone interviews were conducted with patients who underwent lower limb amputations at a tertiary hospital in Singapore. Information was obtained on phantom limb characteristics, perioperative pain and functional assessment., Results: A total of 159 patients underwent amputations over a 31-month period. At the time of the interview, 47 patients had died and 66 were contactable, of whom 49 patients were interviewed. Of these, 31 (63%) patients experienced PLS. 22 patients had postoperative pain, with 9 having both PLP and SP, 3 having PLP alone and 10 having SP alone. Among the 12 patients with PLP, at least 6 (50%) experienced constant or daily pain and 7 (58%) scored their pain as moderate-to-severe. Among those with PLP and/or SP (n = 22), 5 were distressed by the pain, 11 were on analgesics and 3 received medical follow-up. 7 (32%) patients reported functional limitations secondary to PLP or SP. Altogether, 28 (57%) patients were wheelchair or bed bound., Conclusion: The incidence of PLP was 25% in our cohort. Although this is lower than that reported in other studies, it remains significant, as some patients suffered moderate-to-severe pain. The difference in incidence may be due to differences in the ethnic composition and/or indications for amputation in our group. Follow-up and care could improve the outcomes in these patients.

Nonnative peptide aggregation underlies many diseases and is a major problem in the development of peptide-based therapeutics. Efforts in the past decade have revealed remarkable correlations between aggregation rates or propensities and very simple sequence metrics like hydrophobicity and charge. Here, we investigate the extent to which a molecular picture of peptide folding bears out similar relationships. Using replica exchange molecular dynamics folding simulations, we compute equilibrium conformational ensembles of 142 hexa- and decapeptide systems, of which about half readily form amyloid fibrils and half do not. The simulations are used to compute a variety of ensemble-based properties, and we investigate the extent to which these metrics provide molecular clues about fibril formation. To assess whether multiple metrics together are useful in understanding aggregation, we also develop a number of logistic regression models, some of which predict fibril formers with 70-80% accuracy and identify aggregation-prone regions in larger proteins. Importantly, these models quantify the importance of different molecular properties in aggregation driving forces; notably, they suggest that hydrophobic interactions play a dominant role.

Synaptic plasticity is dependent on the differential sorting, delivery and retention of neurotransmitter receptors, but the mechanisms underlying these processes are poorly understood. We found that differential sorting of glutamate receptor subtypes began in the endoplasmic reticulum of rat hippocampal neurons. As AMPA receptors (AMPARs) were trafficked to the plasma membrane via the conventional somatic Golgi network, NMDA receptors (NMDARs) were diverted from the somatic endoplasmic reticulum into a specialized endoplasmic reticulum subcompartment that bypasses somatic Golgi, merging instead with dendritic Golgi outposts. This endoplasmic reticulum subcompartment was composed of highly mobile vesicles containing the NMDAR subunits NR1 and NR2B, the microtubule-dependent motor protein KIF17, and the postsynaptic adaptor proteins CASK and SAP97. Our data demonstrate that the retention and trafficking of NMDARs in this endoplasmic reticulum subcompartment requires both CASK and SAP97. These findings indicate that NMDARs are sorted away from AMPARs via a non-conventional secretory pathway that utilizes dendritic Golgi outposts.