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Nonhuman primates (NHPs) represent one of the most important models for preclinical studies of novel biomedical interventions. In contrast with small animal models, however, widespread utilization of NHPs is restricted by cost, logistics, and availability. Therefore, we sought to develop a translational primatized mouse model, akin to a humanized mouse, to allow for high-throughput in vivo experimentation leveraged to inform large animal immunology-based studies. We found that adult rhesus macaque mobilized blood (AMb) CD34+-enriched hematopoietic stem and progenitor cells (HSPCs) engrafted at low but persistent levels in immune-deficient mice harboring transgenes for human (NHP cross-reactive) GM-CSF and IL3, but did not in mice with wild-type murine cytokines lacking NHP cross-reactivity. To enhance engraftment, fetal liver-derived HSPCs were selected as the infusion product based on an increased CD34hi fraction compared with AMb and bone marrow. Coupled with cotransplantation of rhesus fetal thymic fragments beneath the mouse kidney capsule, fetal liver-derived HSPC infusion in cytokine-transgenic mice yielded robust multilineage lymphohematopoietic engraftment. The emergent immune system recapitulated that of the fetal monkey, with similar relative frequencies of lymphocyte, granulocyte, and monocyte subsets within the thymic, secondary lymphoid, and peripheral compartments. Importantly, while exhibiting a predominantly naïve phenotype, in vitro functional assays demonstrated robust cellular activation in response to nonspecific and allogenic stimuli. This primatized mouse represents a viable and translatable model for the study of hematopoietic stem cell physiology, immune development, and functional immunology in NHPs. Summary Sentence : Engraftment of rhesus macaque hematopoietic tissues in immune-deficient mice yields a robust BLT/NeoThy-type primatized mouse model for studying nonhuman primate hematopoiesis and immune function in vivo.

Co-stimulation serves as a critical checkpoint for T cell development and activation, and several genetic variants affecting co-stimulatory pathways confer risk for autoimmune diseases. A single nucleotide polymorphism in CD226 (rs763361; G307S) has been shown to increase susceptibility to type 1 diabetes, multiple sclerosis, and rheumatoid arthritis. CD226 competes with the co-inhibitory receptor TIGIT (T cell immunoreceptor with Ig and ITIM domains) to bind CD155 to amplify TCR signaling. We previously found that Cd226 knockout protected non-obese diabetic (NOD) mice from disease, but the impact of CD226 signaling on individual immune subsets remained unclear. We focused on regulatory T cells (Tregs) as a population of interest, as prior reports demonstrated that human CD226+ Tregs exhibit reduced FOXP3+Helios+ purity and suppressive function following expansion. Hence, we hypothesized that global deletion of Cd226 would increase Treg stability and accordingly, Treg-specific Cd226 deletion would inhibit diabetes in NOD mice. Indeed, crossing the NOD.Cd226-/- and NOD.Foxp3-GFP-Cre.R26-loxP-STOP-loxP-YFP Treg-fate tracking strains resulted in increased Treg induction and decreased FoxP3-deficient “ex-Tregs” in the pancreatic lymph nodes. We generated a Treg-conditional knockout (TregΔCd226) strain and found that female TregΔCd226 mice had decreased insulitis and diabetes incidence compared to TregWT mice. Additionally, we observed increased TIGIT expression on Tregs and conventional CD4+ T cells within the pancreas of TregΔCd226 versus TregWT mice. These findings demonstrate that an imbalance of CD226/TIGIT signaling may contribute to Treg destabilization in the NOD mouse and highlight the potential for therapeutic targeting of this pathway to prevent or reverse autoimmunity.

IL-2 has been proposed to restore tolerance via regulatory T cell (Treg) expansion in autoimmunity, yet off-target effects necessitate identification of a combinatorial approach. We recently reported reduced levels of immunoregulatory insulin-like growth factor-1 (IGF1) during type 1 diabetes (T1D) progression. Thus, we hypothesized that IGF1 would synergize with IL-2 to expand Tregs. We observed IGF1R was elevated on murine memory and human naïve Treg subsets. IL-2 and IGF1 promoted murine PI3K/Akt and human STAT5 signaling in Tregs. IL-2 and IGF1 treatment expanded Tregs beyond either agent alone in NOD mice. Incubation of naïve human CD4+T cells with IL-2 and IGF1 enhanced Treg proliferationin vitro, without the need for T cell receptor ligation. This synergism was attributed to increased high-affinity IL-2Rα expression on naïve Tregs, in contrast to intermediate-affinity IL-2Rβ and IL-2Rγ subunit enhancement on naïve conventional T cells (Tconv). We then demonstrated that IGF1 and IL-2 or the IL2Rγ-chain-dependent cytokine, IL-7, can be used to induce proliferation of genetically-engineered naïve Treg or Tconv cells, respectively. These data support the potential use of IGF1 in combination with common γ-chain cytokines to drive T cell expansions bothin vitroandin vivofor cellular therapeutics and genetic modifications.

Regulatory T cell (Treg) adoptive cell therapy (ACT) represents an emerging strategy for restoring immune tolerance in autoimmune diseases. Tregs are commonly purified using a CD4

Summary: Contractile to synthetic phenotypic switching of smooth muscle cells (SMCs) contributes to stenosis in vascular disease and vascular transplants. To generate more contractile SMCs, we performed a high-throughput differentiation screen using a MYH11-NLuc-tdTomato human embryonic stem cell reporter cell line. We identified RepSox as a factor that promotes differentiation of MYH11-positive cells by promoting NOTCH signaling. RepSox induces SMCs to exhibit a more contractile phenotype than SMCs generated using PDGF-BB and TGF-β1, two factors previously used for SMC differentiation but which also cause intimal hyperplasia. In addition, RepSox inhibited intimal hyperplasia caused by contractile to synthetic phenotypic switching of SMCs in a rat balloon injury model. Thus, in addition to providing more contractile SMCs that could prove useful for constructing artificial blood vessels, this study suggests a strategy for identifying drugs for inhibiting intimal hyperplasia that act by driving contractile differentiation rather than inhibiting proliferation non-specifically. : Thomson, Zhang, and colleagues report a high-throughput screen that can be used for optimization of the fully defined differentiation of contractile smooth muscle cells and identification of intimal hyperplasia inhibitors. Both in vitro and in vivo evidence revealed that RepSox is better than PDGF-BB and TGF-β1 in inducing contractile phenotype of smooth muscle cells and reducing the risk of intimal hyperplasia. Keywords: pluripotent stem cells, contractile smooth muscle cells, differentiation, maturation, RepSox, NOTCH, intima hyperplasia, MYH11-NLuc-tdTomato reporter cell line, high-throughput screen, restenosis

Human regulatory T cells (Tregs) are essential for the suppression of autoimmunity and adoptive cell therapy has been proposed as a means for restoring durable immune tolerance in T1D. The rare nature of this subset requires the isolation and in vitro expansion of thymic-derived Tregs (tTregs) for adoptive cell therapies to attenuate autoimmunity or islet transplant rejection. Current approaches involve the isolation of a subset with the marker profile of CD4+CD25+CD127-/lo. This strategy yields a population of Tregs that contains both naïve and peripheral Tregs (pTregs), with peripheral Tregs tending to lose lineage stability over time. Here, a novel gating strategy is presented for obtaining tTregs with high purity and extended lineage stability involving the elimination of the effector costimulatory molecule CD226. Tregs were obtained by fluorescence-activated cell sorting (FACS). This allows for the isolation of CD4+CD25+CD226- Tregs for comparison to classically sorted CD4+CD25+CD127-/lo Tregs over a 28-day culture period. Throughout the expansion, assessment of the lineage’s canonical transcription factors (FOXP3 and Helios), along with functional characteristics and epigenetic markers of the lineage occurred. Isolation of CD226- Tregs as compared to CD127- Tregs yields a Treg population with a higher proportion of tTregs (9.35%, p=0.0016), increased expression of CD25 (1.13-fold, p=0.0023), Helios (1.21-fold, p=0.0419), and CD45RA (1.24-fold, p=0.0017), equally low expression of CD127, and decreased expression of CD226 (2.27-fold, p=0.0001). Overall, this study suggests CD226- Tregs possess an increased therapeutic potential for adoptive transfer immunotherapies, including a more naïve phenotype and increased suppressive capabilities - both of which are critical factors for suppressing autoimmune destruction in vivo. Disclosure M. E. Brown: None. S. R. Hanbali: None. L. Gomez rodriguez: None. J. M. Arnoletti: None. E. B. Carpenter: None. T. M. Brusko: Consultant; Self; OneVax, LLC. Funding National Institutes of Health (1R01DK106191-01A1, UG3DK122638)

New human pluripotent stem cell (hPSC)-derived therapies are advancing to clinical trials at an increasingly rapid pace. In addition to ensuring that the therapies function properly, there is a critical need to investigate the human immune response to these cell products. A robust allogeneic (or autologous) immune response could swiftly eliminate an otherwise promising cell therapy, even in immunosuppressed patients. In coming years, researchers in the regenerative medicine field will need to utilize a number of in vitro and in vivo assays and models to evaluate and better understand hPSC immunogenicity. Humanized mouse models-mice engrafted with functional human immune cell types-are an important research tool for investigating the mechanisms of the adaptive immune response to hPSC therapies. This article provides an overview of humanized mouse models relevant to the study of hPSC immunogenicity and explores central considerations for investigators seeking to utilize these powerful models in their research. © 2020 Wiley Periodicals LLC.

Translation of wound healing research is limited by the lack of an appropriate animal model, due to the anatomic and wound healing differences in animals and humans. Here, we characterize healing of grafted, full-thickness human skin in an in vivo model of wound healing. Full-thickness human skin, obtained from reconstructive operations, was grafted onto the dorsal flank of NOD.Cg-Kit(W41J) Tyr + Prkdc(scid) Il2rg(tm1Wjl)/ThomJ mice. The xenografts were harvested 1 to 12 weeks after grafting, and histologic analyses were completed for viability, neovascularization, and hypoxia. Visual inspection of the xenograft shows drying and sloughing of the epidermis starting at week four. By week 12, the xenograft appears healed but has lost 63.05 ± 0.24% of the initial graft size. There is histologic evidence of epidermolysis as early as 2 weeks, which progresses until week 4, when new epidermis appears from the wound edges. Epidermal regeneration is complete by week 12, although the epidermis appears hypertrophied. An initial increase of infiltrating immune mouse cells into the xenograft normalizes to baseline 6 months after grafting. Neovascularization, as evidenced by positive staining for the proteins human CD31 and alpha smooth muscle actin, is present as early as 2 weeks after grafting at the interface between the xenograft and the mouse tissue. CD31 and alpha smooth muscle actin staining increased throughout the xenograft over the 12 weeks, leading to greater viability of the tissue. Likewise, there is increased Hypoxia Inducible Factor 1-alpha expression at the interface of viable and nonviable tissue, which suggest a hypoxia-driven process causing early graft loss. These findings illustrate human skin wound healing in an ischemic environment, providing a timeline for use of full thickness human skin after grafting in a murine model to study mechanisms underlying human skin wound healing.

Extracellular matrix (ECM) plays an important developmental role by regulating cell behaviour through structural and biochemical stimulation. Tissue-specific ECM, attained through decellularization, has been proposed in several strategies for tissue and organ replacement. Decellularization of animal pancreata has been reported, but the same methods applied to human pancreas are less effective due to higher lipid content. Moreover, ECM-derived hydrogels can be obtained from many decellularized tissues, but methods have not been reported to obtain human pancreas-derived hydrogel. Using novel decellularization methods with human pancreas we produced an acellular, 3D biological scaffold (hP-ECM) and hydrogel (hP-HG) amenable to tissue culture, transplantation and proteomic applications. The inclusion of a homogenization step in the decellularization protocol significantly improved lipid removal and gelation capability of the resulting ECM, which was capable of gelation at 37 °C in vitro and in vivo, and is cytocompatible with a variety of cell types and islet-like tissues in vitro. Overall, this study demonstrates the characterisation of a novel protocol for the decellularization and delipidization of human pancreatic tissue for the production of acellular ECM and ECM hydrogel suitable for cell culture and transplantation applications. We also report a list of 120 proteins present within the human pancreatic matrisome.

T helper 17 (Th17)-dependent autoimmune responses can develop after heart or lung transplantation and are associated with fibro-obliterative forms of chronic rejection; however, the specific self-antigens involved are typically different from those associated with autoimmune disease. To investigate the basis of these responses, we investigated whether removal of regulatory T cells or blockade of function reveals a similar autoantigen bias. We found that Th17 cells specific for collagen type V (Col V), kα1-tubulin, and vimentin were present in healthy adult peripheral blood mononuclear cells, cord blood, and fetal thymus. Using synthetic peptides and recombinant fragments of the Col V triple helical region (α1[V]), we compared Th17 cells from healthy donors with Th17 cells from Col V-reactive heart and lung patients. Although the latter responded well to α1(V) fragments and peptides in an HLA-DR-restricted fashion, Th17 cells from healthy persons responded in an HLA-DR-restricted fashion to fragments but not to peptides. Col V, kα1-tubulin, and vimentin are preferred targets of a highly conserved, hitherto unknown, preexisting Th17 response that is MHC class II restricted. These data suggest that autoimmunity after heart and lung transplantation may result from dysregulation of an intrinsic mechanism controlling airway and vascular homeostasis.

Discussion on exhaustion/senescence marker profiles on human T cells in BRGSF-A2 humanized mice and how they resemble those in human samples; describes how this model fits into the humanized-mouse research field.

Human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) exhibit a fetal phenotype that limits in vitro and therapeutic applications. Strategies to promote cardiomyocyte maturation have focused interventions on differentiated hPSC-CMs, but this study tests priming of early cardiac progenitor cells (CPCs) with polyinosinic-polycytidylic acid (pIC) to accelerate cardiomyocyte maturation. CPCs were differentiated from hPSCs using a monolayer differentiation protocol with defined small molecule Wnt temporal modulation, and pIC was added during the formation of early CPCs. pIC priming did not alter the expression of cell surface markers for CPCs (>80% KDR+/PDGFRα+), expression of common cardiac transcription factors, or final purity of differentiated hPSC-CMs (∼90%). However, CPC differentiation in basal medium revealed that pIC priming resulted in hPSC-CMs with enhanced maturity manifested by increased cell size, greater contractility, faster electrical upstrokes, increased oxidative metabolism, and more mature sarcomeric structure and composition. To investigate the mechanisms of CPC priming, RNAseq revealed that cardiac progenitor-stage pIC modulated early Notch signaling and cardiomyogenic transcriptional programs. Chromatin immunoprecipitation of CPCs showed that pIC treatment increased deposition of the H3K9ac activating epigenetic mark at core promoters of cardiac myofilament genes and the Notch ligand, JAG1. Inhibition of Notch signaling blocked the effects of pIC on differentiation and cardiomyocyte maturation. Furthermore, primed CPCs showed more robust formation of hPSC-CMs grafts when transplanted to the NSGW mouse kidney capsule. Overall, epigenetic modulation of CPCs with pIC accelerates cardiomyocyte maturation enabling basic research applications and potential therapeutic uses. Stem Cells 2019;37:910–923

Summary In this study, we demonstrate a newly derived mouse model that supports engraftment of human hematopoietic stem cells (HSCs) in the absence of irradiation. We cross the NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ (NSG) strain with the C57BL/6J-KitW-41J/J (C57BL/6.KitW41) strain and engraft, without irradiation, the resulting NBSGW strain with human cord blood CD34+ cells. At 12-weeks postengraftment in NBSGW mice, we observe human cell chimerism in marrow (97% ± 0.4%), peripheral blood (61% ± 2%), and spleen (94% ± 2%) at levels observed with irradiation in NSG mice. We also detected a significant number of glycophorin-A-positive expressing cells in the developing NBSGW marrow. Further, the observed levels of human hematopoietic chimerism mimic those reported for both irradiated NSG and NSG-transgenic strains. This mouse model permits HSC engraftment while avoiding the complicating hematopoietic, gastrointestinal, and neurological side effects associated with irradiation and allows investigators without access to radiation to pursue engraftment studies with human HSCs., Highlights • In engraftment experiments, nonirradiated NBSGW mice show enhanced humanization • Similar levels of human chimerism are observed between both irNSG and NBSGW mice • NBSGW mice are conducive to serial transplantation without irradiation • NBSGW mice harbor a mutant KitW41 allele, aiding Gly-A+ development in the marrow, In a newly generated murine strain, Thomson et al. demonstrate enhanced engraftment of human hematopoietic stem cells in the absence of irradiation. Maintained as a homozygous line, a mutant Kit (W41) allele, combined with Prkdcscid, Il2rγ−, and NOD.Sirpa, yields humanized grafts comparable to those observed in irradiated strains. This advancement allows researchers to humanize hosts without ionizing radiation.

Summary Here, we describe the NeoThy humanized mouse model created using non-fetal human tissue sources, cryopreserved neonatal thymus and umbilical cord blood hematopoietic stem cells (HSCs). Conventional humanized mouse models are made by engrafting human fetal thymus and HSCs into immunocompromised mice. These mice harbor functional human T cells that have matured in the presence of human self-peptides and human leukocyte antigen molecules. Neonatal thymus tissue is more abundant and developmentally mature and allows for creation of up to ∼50-fold more mice per donor compared with fetal tissue models. The NeoThy has equivalent frequencies of engrafted human immune cells compared with fetal tissue humanized mice and exhibits T cell function in assays of ex vivo cell proliferation, interferon γ secretion, and in vivo graft infiltration. The NeoThy model may provide significant advantages for induced pluripotent stem cell immunogenicity studies, while bypassing the requirement for fetal tissue., Highlights • Neonatal tissue is a viable alternative to fetal for mouse humanization • Over 1,000 NeoThy mice can be made from one neonatal thymus donor • The NeoThy enables robust pre-clinical immunogenicity studies of iPSC therapies, Corresponding author William Burlingham and colleagues created a humanized mouse model called the NeoThy. The NeoThy uses human neonatal, rather than fetal, tissue sources for generating a human immune system within immunocompromised mouse hosts. NeoThy mice are an attractive alternative to conventional humanized mouse models, as they enable robust and reproducible iPSC immunogenicity experiments in vivo.

Significance Generating fully functional arterial endothelial cells is a critical problem for vascular development and disease research. Currently, the arterial endothelial cells derived from human pluripotent stem cells lack the range of arterial-specific functions in vitro and the protective function for ischemic tissues in vivo. Here, we combine single-cell RNA sequencing and CRISPR-Cas9 technology to identify pathways for regulating arterial endothelial cell differentiation. We then manipulate these pathways and generate arterial endothelial cells that demonstrate unprecedented arterial-specific functions as well as improve survival of myocardial infarction. These findings facilitate the understanding of vascular development and disease and provide a source of cells that have broad applications for vascular disease modeling and regenerative medicine.

Immunocompromised mice are an essential tool for human xenotransplantation studies, including human haematopoietic stem cell (HSC) biology research. Over the past 35 years, there have been many advances in the development of these mouse models, offering researchers increasingly sophisticated options for creating clinically relevant mouse-human chimeras. This addendum article will focus on our recent development of the "NSGW" mouse, which, among other beneficial traits, is genetically modified to obviate the need for myeloablative irradiation of the animals. Thus, the complicating haematopoietic, gastrointestinal, and neurological side effects associated with irradiation are avoided and investigators without access to radiation sources are enabled to pursue engraftment studies with human HSCs. We will also discuss the topics of transgenics, knock-ins, and other mutants with an overarching goal of enhancing chimerism in these animal models.

The carcinoembryonic antigen (CEA)-derived peptide CAP1 and heteroclitic peptide CAP1-6D are stimulators of HLA-A*A0201 restricted CEA-specific T cells in vivo and in vitro. The goal of this study was to evaluate differences in T cell responses to peptide and modified peptide antigens from CEA. The heterogeneity of responses among individuals is potentially important for the design of future CEA-directed immunotherapy trials. Peripheral blood mononuclear cells from blood donors were stimulated with peptide, IL-2, and IL-7. Weekly, microcultures were restimulated with irradiated, autologous peptide-loaded peripheral blood mononuclear cells and expanded in IL-2. Established T cell lines were tested by cytokine release assays using peptide-loaded T2 targets. T cell avidity was measured by cytokine release using targets expressing diminishing concentrations of peptide. Fine specificities were measured using targets loaded with alanine-substituted CAP1 peptide. Tumor recognition was measured using HLA-A*A0201/CAP1-transduced COS tumor targets. Varied responses to CAP1 and CAP1-6D were seen among individuals. The immunogenicity of CAP1 or CAP1-6D was donor dependent. Many T cells recognized one peptide but did not cross-recognize the altered peptide. The avidities of T cell lines were moderate to low, and fine specificities were consistent with a narrow antigen-specific repertoire. CAP1-6D-based immune therapy may not be optimal in some patients with CAP1-specific precursors. The T cell repertoire may be a central contributor to the limited responses seen with CEA-directed immunotherapy to date. Treatment strategies designed to alter or expand the T cell repertoire against CEA should be considered for trials.

Patients with voice impairment caused by advanced vocal fold (VF) fibrosis or tissue loss have few treatment options. A transplantable, bioengineered VF mucosa would address the individual and societal costs of voice-related communication loss. Such a tissue must be biomechanically capable of aerodynamic-to-acoustic energy transfer and high-frequency vibration and physiologically capable of maintaining a barrier against the airway lumen. We isolated primary human VF fibroblasts and epithelial cells and cocultured them under organotypic conditions. The resulting engineered mucosae showed morphologic features of native tissue, proteome-level evidence of mucosal morphogenesis and emerging extracellular matrix complexity, and rudimentary barrier function in vitro. When grafted into canine larynges ex vivo, the mucosae generated vibratory behavior and acoustic output that were indistinguishable from those of native VF tissue. When grafted into humanized mice in vivo, the mucosae survived and were well tolerated by the human adaptive immune system. This tissue engineering approach has the potential to restore voice function in patients with otherwise untreatable VF mucosal disease.

Tissues derived from induced pluripotent stem cells (iPSCs) are a promising source of cells for building various regenerative medicine therapies; from simply transplanting cells to reseeding decellularized organs to reconstructing multicellular tissues. Although reprogramming strategies for producing iPSCs have improved, the clinical use of iPSCs is limited by the presence of unique human leukocyte antigen (HLA) genes, the main immunologic barrier to transplantation. In order to overcome the immunological hurdles associated with allogeneic tissues and organs, the generation of patient-histocompatible iPSCs (autologous or HLA-matched cells) provides an attractive platform for personalized medicine. However, concerns have been raised as to the fitness, safety and immunogenicity of iPSC derivatives because of variable differentiation potential of different lines and the identification of genetic and epigenetic aberrations that can occur during the reprogramming process. In addition, significant cost and regulatory barriers may deter commercialization of patient specific therapies in the short-term. Nonetheless, recent studies provide some evidence of immunological benefit for using autologous iPSCs. Yet, more studies are needed to evaluate the immunogenicity of various autologous and allogeneic human iPSC-derived cell types as well as test various methods to abrogate rejection. Here, we present perspectives of using allogeneic vs. autologous iPSCs for transplantation therapies and the advantages and disadvantages of each related to differentiation potential, immunogenicity, genetic stability and tumorigenicity. We also review the current literature on the immunogenicity of syngeneic iPSCs and discuss evidence that questions the feasibility of HLA-matched iPSC banks. Finally, we will discuss emerging methods of abrogating or reducing host immune responses to PSC derivatives.

A 0.6-V 2-2 cascaded audio delta-sigma ADC is described. It uses a resistor-based sampling technique which achieves high linearity and low-voltage operation without subjecting the devices to large terminal voltages. A low-distortion feed-forward topology combined with nonlinear local feedback results in enhanced linearity by reducing the sensitivity to opamp distortion, and allows increased input amplitude, resulting in higher SNDR. The modulator achieves 82-dB dynamic range and 81-dB peak SNDR in the A-weighted audio signal bandwidth with an OSR of 64. The total power consumption of the modulator is 1 mW from a 0.6-V supply. The prototype occupies 2.9 mm/sup 2/ using a 0.35-/spl mu/m CMOS technology.

I. INTRODUCTION Consider a mother of two who works full-time as a secretary in order to provide for her family. For several months in early 2000, she had excruciating lower back pain-the consequences, she believed, of playing high-school and college field-hockey. At work, she was unable to stand up from her chair without tremendous pain; at home, she was unable to sleep soundly. After visiting several physicians and undergoing a battery of diagnostic tests, the need for surgery became apparent. She consulted an orthopedic surgeon and was impressed with his qualifications. After informing her employer and seeking the advice of her family and friends, she consented to surgery. What the mother of two did not know, however, was that she had entrusted her life and livelihood to a surgeon who, in the ten years preceding her surgery, had settled twelve medical malpractice claims for an average of just under $300,000 per claim.1 Nearly every new parent faces a more common situation. Imagine that you just welcomed a beautiful baby girl into your life, and must now begin looking for a pediatrician. No one short of the most outstanding pediatrician will suffice. Your friend recommends Doctor Mary, who recently finished her residency and moved to your state. She has impeccable credentials and her office is only a ten-minute drive from your home. She has been practicing there for two years. You met Doctor Mary and believe that she is very friendly, caring, and well qualified. Before entrusting her to treat your baby girl, would you like to know that in her two years of practice she has settled two malpractice claims, one for $74,000, and the other for $71,000? Beginning in 1986, the Health Care Quality Improvement Act required that all physicians' medical malpractice settlements be reported to, and housed in, a National Practitioner Data Bank (NPDB).2 The information in the NPDB is not, and has never been, publicly accessible.3 In 1996, after several failed legislative attempts to open the NPDB to public inspection, states began implementing publicly accessible "physician profiles" to provide comparable physician malpractice settlement information.4 Despite nearly ten years of physician profile proliferation, there remain several fundamental flaws in states' efforts. First, advocates' public policy arguments to publicly disseminate physicians' malpractice settlement histories are unpersuasive. Second, many consumers lack the requisite background to understand how the dynamic between insurers, physicians, plaintiffs, their attorneys, and the expense of litigation affects reported malpractice information. Third, many studies concerning the correlation between malpractice settlements and future medical negligence have reached conflicting conclusions, such that there may be no predictive value to settlement reporting, and therefore the premise for allowing public access may itself be flawed.5 Finally, because many physician profile statutes-particularly as they relate to malpractice settlement information-reflect a compromise between advocates and opponents of settlement disclosure, disclosure mechanisms are often complicated and may hinder consumers from properly using settlement information in their physician selection processes.6 By way of example, every state provides publicly accessible physician profiles via the Internet. Of these states, fourteen currently provide medical malpractice settlement information available through the Internet.7 Of these fourteen states, however, only seven would disclose the settlement information of Doctor Mary, the new pediatrician, and the presentation of the settlement information would vary greatly between states.8 The remaining seven states' websites would provide no settlement information under Doctor Mary's profile. Although a determinative assessment of the public policy behind medical malpractice settlement disclosure webpages is significantly beyond the scope of this article, it is my aim to identify the shortcomings in rationales proffered by advocates and legislators, and illustrate that the public policy behind disclosing malpractice settlement histories, at the very least, should be reconsidered. …

A 2-2 MASH ADC consumes 1mW from a 0.6V supply. It utilizes a local feedback loop for large input range, and switched-RC integrators to achieve high linearity without clock boosting or bootstrapping. The prototype IC is fabricated in a 0.35/spl mu/m CMOS process. It provides 82dB DR over the A-weighted audio band, and 103dB SFDR at -3dBFS input.

We report a case of a 53-year-old female with a retained uterine fundus, presenting 2 years following a vaginal hysterectomy. It is important for imagers to be aware that morcellation techniques can result in retained portions of the uterus following vaginal hysterectomy.