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Background. There are no high-quality data to guide long-term mycophenolate mofetil (MMF) dosing in kidney transplant recipients (KTRs) to balance the long-term risks of allograft rejection with that of infections and malignancy. At our center, KTRs are managed with either a “preemptive” dose reduction strategy, where the MMF dose is reduced after the first year before the development of adverse events, or with a “reactive” dosing strategy, where they are maintained on the same MMF dose and only reduced if they develop an adverse event. We hypothesized that a preemptive MMF dosing strategy after the first year of transplantation is associated with decreased infections without increasing alloimmune complications. Methods. We conducted a retrospective cohort study of all KTRs receiving MMF from January 1, 2015, to December 31, 2020. The primary outcome was the incidence of infections requiring hospitalization. Results. One hundred forty-two KTRs met the inclusion criteria, of whom 44 (31%) were in the preemptive group and 98 (69%) were in the reactive group. The median follow-up was 4 y (interquartile range, 3.8–4.0). Multivariable analysis showed that a preemptive MMF dose reduction strategy was associated with a lower risk of infections requiring hospitalization (adjusted hazard ratio = 0.39; 95% confidence interval, 0.16-0.92). There was no difference in graft loss, rejection, or estimated glomerular filtration rate slope. Conclusions. Preemptive MMF dose reduction in KTRs may be an effective strategy to prevent infections without increasing the risk of allograft rejection. Randomized clinical trials are needed to confirm these findings.

Background. Compared with calcineurin inhibitor–based immunosuppression, belatacept (BELA)-based treatment has been associated with better renal function but higher acute rejection rates. This phase 2 study (NCT02137239) compared the antirejection efficacy of BELA plus everolimus (EVL) with tacrolimus (TAC) plus mycophenolate mofetil (MMF), each following lymphocyte-depleting induction and rapid corticosteroid withdrawal. Methods. Patients who were de novo renal transplant recipients seropositive for Epstein-Barr virus were randomized to receive BELA+EVL or TAC+MMF maintenance therapy after rabbit antithymocyte globulin induction and up to 7 d of corticosteroids. The primary endpoint was the rate of biopsy-proven acute rejection at month 6. Results. Because of an unanticipated BELA supply constraint, enrollment was prematurely terminated at 68 patients, of whom 58 were randomized and transplanted (intention-to-treat [ITT] population: n = 26, BELA+EVL; n = 32, TAC+MMF). However, 25 patients received BELA+EVL‚ and 33 received TAC+MMF (modified ITT population). In the ITT population, the 6-mo biopsy-proven acute rejection rates were 7.7% versus 9.4% in the BELA+EVL versus TAC+MMF group. The corresponding 24-mo biopsy-proven acute rejection rates were 19.2% versus 12.5% in the ITT population and 16.0% versus 15.2% in the mITT population; all events were Banff severity grade ≤IIA and similar between groups. One patient in each group experienced graft loss unrelated to acute rejection. The 24-mo mean unadjusted estimated glomerular filtration rates were 71.8 versus 68.7 mL/min/1.73 m2 in the BELA+EVL versus TAC+MMF groups. Posttransplant lymphoproliferative disorder was reported for 1 patient in each group. No deaths or unexpected adverse events were observed. Conclusions. A steroid-free maintenance regimen of BELA+EVL may be associated with biopsy-proven acute rejection rates comparable to TAC+MMF.

Background Referral to palliative medicine (PM) has been shown to improve quality of life, reduce hospitalizations, and improve survival. Limited data exist about PM utilization among racial minorities with gynecologic malignancies. Our objective was to assess differences in palliative medicine referrals and end of life interventions (within the last 30 days of life) by race and ethnicity in a diverse population of gynecologic oncology patients. Methods A retrospective cohort study of patients receiving gynecologic oncologic care at a tertiary referral center between 2017 – 2019 was conducted. Patients had either metastatic disease at the time of diagnosis or recurrence. Demographic and clinical data were abstracted. Exploratory analyses were done using chi-square and rank sum tests. Tests were two-sided with significance set at P < .05. Results A total of 186 patients were included. Of those, 82 (44.1%) were referred to palliative medicine. Underrepresented minorities accounted for 47.3% of patients. English was identified as the primary language for 69.9% of the patients and Spanish in 24.2%. Over 90% of patients had insurance coverage. Ovarian cancer (37.6%) and uterine cancer (32.8%) were the most common sites of origin. Most patients (75%) had advanced stage at the time of diagnosis. Race and language spoken were not associated with referral to PM. Black patients were more likely to have been prescribed appetite stimulants compared to White patients (41% vs 24%, P = .038). Black patients also had a higher number of emergency department visits compared to White patients during the study timeframe. Chemotherapy in the last 30 days of life was also more likely to be given to Black patients compared to White ( P = .019). Conclusions Race was associated with variation in interventions and healthcare utilization near end-of-life. Understanding the etiologies of these differences is crucial to inform interventions for care optimization as it relates specifically to the health of minority patients.

Purpose: Undergraduate medical education is facing an increasing need to bridge the longstanding gap between basic nutrition knowledge and its application to patient care. In an effort to improve upon knowledge and confidence in this area, the University of Minnesota Medical School Duluth Campus implemented a pilot curriculum to increase content and exposure in the dimensions of food, food systems, nutrition, and clinical application. Methods: Two classes of outgoing second-year medical students at the University of Minnesota Duluth Campus were surveyed about personal health, knowledge of nutritional topics, and confidence in implementing these topics in patient care. The control group consisted of outgoing second-year medical students (MS2s) during the 2019-2020 academic year (n=28) prior to pilot nutrition curriculum inception. The cohort group (n=29) consisted of outgoing MS2s from the 2020-2021 academic year who received the new pilot curriculum. Findings: Survey findings did not yield statistically significant differences in control versus cohort responses in students' personal health and knowledge of nutritional concepts. However, over 90% of the cohort group, versus 54% of control, agreed that they were able to discuss and recommend healthy dietary modifications to a patient with a chronic disease. The cohort group also reported higher confidence in talking with patients about dietary patterns (69% vs 39%), whole-food plant-rich diets (90% vs 50%), as well as working inter-professionally with other members of the healthcare team around issues of food and nutrition (97% vs 71%). Conclusion: Results demonstrate that the pilot curriculum increased medical student confidence in evaluating the multidimensionality of food, food systems, and nutrition content as well as the application of this content to patient care. This pilot curriculum may have relevance to other medical schools who are also wishing to bridge this long-standing gap in medical education.

ABSTRACT: Background: Despite regulations currently in place, the incidence of lawnmower injuries in children has not decreased for several decades in the United States. In fact, studies in several countries show that the incidence of riding lawnmower injuries are actually on the rise worldwide. Those injuries tend to be devastating and limb-threatening. The purpose of this study was to evaluate a pediatric trauma center's experience with those injuries over the past 25 years. Methods: All patients who presented to a level I pediatric trauma center with injuries from lawnmowers between 1994 and 2019 were reviewed. Date of birth, gender, date of injury, mechanism of injury, type of lawnmower, and type of injury (including whether an open fracture, soft tissue defect, and/or amputation were present) were recorded. Results: A total of 142 pediatric patients were treated over the study period. The average age was 7.5 years. The three most common mechanisms of injury were being hit by a riding lawnmower moving forward, falling off a riding lawnmower, and being hit by a riding lawnmower moving backward. Of all patients, 68.3% sustained an open fracture and 38% required an amputation. Riding lawnmowers resulted in more operative procedures, longer hospital stays, and more soft tissue defects that require reconstruction than push mowers. Younger patients were at a higher risk to sustain proximal amputations (wrist/ankle or proximal) than older patients. Conclusion: Lawnmower injuries are devastating and largely avoidable. There are currently recommendations and regulations in the United States, which if followed, would prevent the vast majority of pediatric lawnmower injuries. Unfortunately, the incidence of these injuries has not decreased despite the current regulations. Broader public education is essential to decrease the incidence of serious lawnmower injuries in children.Level of Evidence: IV

Background:. Lichen sclerosus (LS) and lichen planus (LP) are inflammatory diseases that demonstrate genital and extra-genital manifestations. Genital involvement may result in pruritus, sexual dysfunction, pain, and irritation. It is intuitive that the severity of symptoms may result in functional impairment and emotional distress, leading to a reduction in quality of life (QoL). Objective:. Investigate the current literature on the impact of genital LS and LP on QoL. Methods:. A literature review was performed using PubMed and results were summarized. Articles published between 1994 and 2020 were screened and reviewed by both the authors. Results:. These diseases have been assessed with dermatological assessments, such as the Skindex-29 and the Dermatology Life Quality Index, general health surveys such as the Short Form-12 questionnaire, and mental health instruments including the Beck Depression Inventory, and others; these instruments consistently demonstrate impaired QoL. It follows that treatment may reduce these symptoms. Interventions, such as photodynamic therapy, have demonstrated improvement in the depressive symptoms that impact QoL. Although both females and males experience a reduction in QoL related to these diseases, they experience the symptomatology differently. Through interviewing, male patients were more likely to report no symptoms compared with female patients, while female patients were also more likely to report worse QoL in the work-school domain of the Dermatology Life Quality Index as compared with male patients. Limitations:. Few studies have addressed the effect of disease severity or treatment on QoL. Conclusions:. Understanding how genital LS and LP contribute to reduced QoL for patients is critical for health care providers to better prioritize treatment strategies. Future prospective studies should investigate how QoL correlates with disease severity and response to treatment.

Objective: To assess demographic characteristics and perceptions of female physicians in attendance at a medical conference for women with content focused on growth, resilience, inspiration, and tenacity to better understand major barriers women in medicine face and to find solutions to these barriers. Patients and Methods: A Likert survey was administered to female physicians attending the conference (September 20 to 22, 2018). The survey consisted of demographic data and 4 dimensions that are conducive to women’s success in academic medicine: equal access, work-life balance, freedom from gender biases, and supportive leadership. Results: All of the 228 female physicians surveyed during the conference completed the surveys. There were 70 participants (31.5%) who were in practice for less than 10 years (early career), 111 (50%) who were in practice for 11 to 20 years (midcareer), and 41 (18.5%) who had more than 20 years of practice (late career). Whereas participants reported positive support from their supervisors (mean, 0.4 [SD 0.9]; P

Background Individuals from low-income groups report disproportionate rates of cigarette use, secondhand smoke (SHS) exposure with increased morbidity and mortality. Smoking bans in public housing have been enacted in attempt to reduce tobacco use and SHS exposure among lower income individuals. This study investigated the support needs of tobacco users living in two public housing complexes in Detroit, Michigan (USA), including their perspectives on smoking, resources and barriers for smoking cessation, and the impact of policy changes. Methods This is a mixed-methods study, using a qualitative focus groups approach and a short survey, public housing residents interview data was analyzed to explore themes related to smoking-related issues. Specifically, six themes were assessed across four focus groups: (1) Quitting Smoking, (2) Current Smoking Cessation Resources, (3) Legal Mandates, (4) Education and Perceptions of Smoking, (5) Community Needs and Barriers, and (6) Medical Experiences. Results There were 59 participants; the majority (39/42, 93%) of smokers reported at least one quit attempt. During the focus groups, several participants indicated a desire to quit smoking but reported barriers to smoking cessation, such as lack of access to medications, social triggers to continue smoking, and socioeconomic stressors. A number of suggestions were provided to improve smoking cessation resources, including support groups, graphic images of smoking-related diseased tissue, and better communication with health care providers. Conclusions These findings demonstrate smoking bans in two public housing complexes can be effective yet are dependent upon a complex set of issues, including numerous barriers to care.

Background:. The second victim phenomenon is the distress felt by healthcare providers after a medical error. Although the phenomenon is a significant risk factor for burnout, little has been written about it in surgery, especially among residents. Methods:. After institutional review board approval, a 27-question anonymous online survey was sent to plastic surgery residents throughout the United States, and to residents from all surgical specialties at our institution, for a total of 435 residents. Residents were asked to describe any adverse events they had experienced, and subsequent emotional sequelae. Results:. The survey was returned by 125 residents (response rate 28.7%), of whom 53 were plastic surgery residents (42.4%) and 72 were from other surgical specialties (57.6%). In total, 110 (88%) described having been part of a medical error. An estimated 74 residents (34 from plastic surgery, 40 from other surgical specialties) provided a detailed description of the event. Sixty-four of them (86.5%) had subsequent emotional sequelae, most commonly guilt, anxiety, and insomnia. Only 24.3% of residents received emotional support. They rated other residents as the most important source of support, followed by faculty members and then family/friends. Conclusions:. The second victim phenomenon seems to be common among surgical residents. The most important source of support for affected residents in our cohort was other residents. Given these findings, institutions should focus on fostering camaraderie among residents, building effective second victim response teams and training peer support specialists.

OBJECTIVES:. To investigate the association between plasma sodium concentrations and 6-month neurologic outcome in critically ill patients with aneurysmal subarachnoid hemorrhage. DESIGN:. Prospective cohort study. SETTING:. Eleven ICUs in Australia and New Zealand. PARTICIPANTS:. Three-hundred fifty-six aneurysmal subarachnoid hemorrhage patients admitted to ICU between March 2016 and June 2018. The exposure variable was daily measured plasma sodium. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Six-month neurologic outcome as measured by the modified Rankin Scale. A poor outcome was defined as a modified Rankin Scale greater than or equal to 4. The mean age was 57 years (± 12.6 yr), 68% were female, and 32% (n = 113) had a poor outcome. In multivariable analysis, including age, illness severity, and process of care measures as covariates, higher mean sodium concentrations (odds ratio, 1.17; 95% CI, 1.05–1.29), and greater overall variability—as measured by the sd (odds ratio, 1.53; 95% CI, 1.17–1.99)—were associated with a greater likelihood of a poor outcome. Multivariable generalized additive modeling demonstrated, specifically, that a high initial sodium concentration, followed by a gradual decline from day 3 onwards, was also associated with a poor outcome. Finally, greater variability in sodium concentrations was associated with a longer ICU and hospital length of stay: mean ICU length of stay ratio (1.13; 95% CI, 1.07–1.20) and mean hospital length of stay ratio (1.08; 95% CI, 1.01–1.15). CONCLUSIONS:. In critically ill aneurysmal subarachnoid hemorrhage patients, higher mean sodium concentrations and greater variability were associated with worse neurologic outcomes at 6 months, despite adjustment for known confounders. Interventional studies would be required to demonstrate a causal relationship.

Summary:. Vascularized omentum lymphatic transplant is frequently used for the treatment of lymphedema due to demonstrated efficacy, a reduced complication profile, and, in particular, negligible risk of donor site lymphedema. Historically harvested by open laparotomy, more recent techniques involve laparoscopic omental harvest. Although effective and reproducible, laparoscopy may be limited by reduced visualization, minimal tactile feedback, multiple port sites, and imprecise instrumentation. Therefore, we employed the da Vinci Single-Port (SP) surgical robot system for vascularized omentum lymphatic transplant. A 52-year-old man with a 3-year history of progressive left lower extremity swelling and lymphoscintigraphy and magnetic resonance lymphangiogram consistent with lymphedema of unknown etiology underwent vascularized omentum lymphatic transplant to the left groin. A 2.5-cm infraumbilical incision was used for placement of the primary trocar, through which the camera and operating instruments were passed. Following robotic harvest, the omental lymph node flap was transferred to the left groin for microsurgical anastomosis. The procedure was uneventful, and the patient was discharged on postoperative day 1. At 6 weeks, there were no complications. Here, we show for the first time the safety and feasibility of robotic omental lymph node flap harvest for extremity lymphedema using the da Vinci Single-Port robotic system. The benefits of this technology include a minimally-invasive approach that allows for flap dissection and removal through a single 2.5-cm incision. Further investigation is necessary to characterize the indications and limitations of this technique in plastic surgery.

Category: Midfoot/Forefoot Introduction/Purpose: Although the first metatarsophalangeal joint sesamoids have biomechanical value in the foot, pathologic conditions of these sesamoids are a source of disabling pain for patients, particularly during toe-off. Underlying causes include acute fracture, acute separation of bipartite sesamoids, sesamoiditis caused by repetitive trauma, infection, chondromalacia, osteochondritis dissecans, and osteoarthritis. Nonoperative treatment is the initial standard of care and has satisfactory outcomes overall, but operative management may be indicated in cases of pain refractory to conservative management. Surgical management includes tendo-Achilles or gastrocnemius lengthening, dorsiflexion osteotomy at the base of first metatarsal, corrective osteotomies, fusions for fixed pes cavus foot. Sesamoidectomy is a relatively uncommon procedure but should be considered if 6- 12 months of conservative managements fail or if the patient experiences ongoing debilitating symptoms. Methods: A retrospective chart review was conducted at our institution from 2009-2018. Twelve patients diagnosed with fibular sesamoiditis were treated with sesamoidectomy. Baseline patient demographics as well as postoperative outcomes were recorded. All patients were initially treated for an extended period conservatively with orthotics, anti-inflammatory medications, physical therapy, limitation of activity and a trial of non-weight bearing. Despite these measures, symptoms persisted for these twelve patients - all of who then underwent fibular sesamoidectomy for their symptoms. The fibular sesamoidectomy was performed by one of the three fellowship trained foot and ankle surgeons. All surgeons used plantar approach with a longitudinal incision on the lateral edge of the first metatarsal fat pad. Postoperatively, patients were kept non–weight bearing for 2 weeks and in a post-op walking shoe for 6 weeks. Results: Average age of the patients was 38 years. Ten of twelve patients (83%) were female. Majority of the patients (10) had no history of trauma, only two referred forefoot injury in the past. Average follow-up was 35 months. Two patients had both hallux valgus and hallux rigidus. One had preexisting rheumatoid arthritis with involvement of the first MTP. MRI showed 5 of 12 (42%) of patients had avascular necrosis of the sesamoid based on magnetic resonance imaging. None of the patients developed cock-up deformity of the lesser toes or hallux varus deformity, clinically or radiologically. Two patients experienced transient neuritis, one developed a superficial infection, and one had painful postoperative scarring. Hallux varus deformity was not observed in any patients. None underwent reoperation. Conclusion: Our study contradicts earlier studies which associate sesamoidectomy with high incidence of complications, particularly hallux varus. But, most of these earlier reports focus on combinations of medial, lateral, and paired excision, rather than lateral excision alone, unlike our study. Hence, fibular sesamoidectomy can be a safe, viable procedure for patients who fail conservative measures for sesamoiditis. The plantar lateral approach allows for adequate exposure of the fibular sesamoid, repair of the plantar plate, and preservation of flexor hallucis brevis, and is beneficial in preventing the occurrence of hallux varus deformity.

Background. The surgical Apgar score (SAS) is a 10-point scale using the lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL) during surgery to predict postoperative outcomes. The SAS has not yet been validated in liver transplantation patients, because typical blood loss usually exceeds the highest EBL category. Our primary aim was to develop a modified SAS for liver transplant (SAS-LT) by replacing the EBL parameter with volume of red cells transfused. We hypothesized that the SAS-LT would predict death or severe complication within 30 days of transplant with similar accuracy to current scoring systems. Methods. A retrospective cohort of consecutive liver transplantations from July 2007 to November 2013 was used to develop the SAS-LT. The predictive ability of SAS-LT for early postoperative outcomes was compared with Model for End-stage Liver Disease, Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation III scores using multivariable logistic regression and receiver operating characteristic analysis. Results. Of 628 transplants, death or serious perioperative morbidity occurred in 105 (16.7%). The SAS-LT (receiver operating characteristic area under the curve [AUC], 0.57) had similar predictive ability to Acute Physiology and Chronic Health Evaluation III, model for end-stage liver disease, and Sequential Organ Failure Assessment scores (0.57, 0.56, and 0.61, respectively). Seventy-nine (12.6%) patients were discharged from the ICU in 24 hours or less. These patients’ SAS-LT scores were significantly higher than those with a longer stay (7.0 vs 6.2, P < 0.01). The AUC on multivariable modeling remained predictive of early ICU discharge (AUC, 0.67). Conclusions. The SAS-LT utilized simple intraoperative metrics to predict early morbidity and mortality after liver transplant with similar accuracy to other scoring systems at an earlier postoperative time point.

Many modern crop varieties contain patented biotechnology traits, and an increasing number of these crops have multiple (stacked) traits. Fast and accurate determination of transgene levels is advantageous for a variety of use cases across the food, feed and fuel value chain. With the growing number of new transgenic crops, any technology used to quantify them should have robust assays that are simple to design and optimize, thereby facilitating the addition of new traits to an assay. Here we describe a PCR-based method that is simple to design, starts from whole seeds, and can be run to end-point in less than 5 minutes. Subsequent relative quantification (trait vs. non-trait) using capillary electrophoresis performed in 5% increments across the 0-100% range showed a mean absolute error of 1.9% (s.d. = 1.1%). We also show that the PCR assay can be coupled to non-optical solid-state nanopore sensors to give seed-to-trait quantification results with a mean absolute error of 2.3% (s.d. = 1.6%). In concert, the fast PCR and nanopore sensing stages demonstrated here can be fully integrated to produce seed-to-trait quantification results in less than 10 minutes, with high accuracy across the full dynamic range., Competing Interests: WD, MP, LN, YZ, WM, and TM are employed by Ontera. Additionally, there are three patents related to the work 1. Pearson M, Morin TJ. U.S. Patent Application No. 62/815,763, 2019 Mar. This application is currently unpublished, while all details provided in the manuscript and supporting material are sufficient to reproduce the reported results. 2. Zhao Y, MckennaW, Dunbar WB. “Fractional abundance of polynucleotide sequences in a sample.” International patent no. WO2018081178A1. 2018 May. This application is published, and cited in the paper. 3. McGrath DA, Shropshire TD, Smith AM. PCT Application No. PCT/US2019/050087, 2018 Sept. This application is currently unpublished, while all details provided in the manuscript and supporting material are sufficient to reproduce the reported results. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

This article proposes an integrative model of lesbian identity development that places cis and trans women together as equal contributors. Two of the most influential current models of female sexuality are reviewed, and we use their commonalities to build the foundation of our integrative model. We also use Tate's model of lesbian identity as a scaffolding to integrate trans women's experiences alongside cis women's. Finally, we provide the outline of the Inclusive Model of Female Sexuality and discuss the convergences and divergences that exist between cis women and trans women in the formation of lesbian identity.

Background: The continued advance of antibiotic resistance threatens the treatment and control of many infectious diseases. This is exemplified by the largest global outbreak of extensively drug-resistant (XDR) tuberculosis (TB) identified in Tugela Ferry, KwaZulu-Natal, South Africa, in 2005 that continues today. It is unclear whether the emergence of XDR-TB in KwaZulu-Natal was due to recent inadequacies in TB control in conjunction with HIV or other factors. Understanding the origins of drug resistance in this fatal outbreak of XDR will inform the control and prevention of drug-resistant TB in other settings. In this study, we used whole genome sequencing and dating analysis to determine if XDR-TB had emerged recently or had ancient antecedents., Methods and Findings: We performed whole genome sequencing and drug susceptibility testing on 337 clinical isolates of Mycobacterium tuberculosis collected in KwaZulu-Natal from 2008 to 2013, in addition to three historical isolates, collected from patients in the same province and including an isolate from the 2005 Tugela Ferry XDR outbreak, a multidrug-resistant (MDR) isolate from 1994, and a pansusceptible isolate from 1995. We utilized an array of whole genome comparative techniques to assess the relatedness among strains, to establish the order of acquisition of drug resistance mutations, including the timing of acquisitions leading to XDR-TB in the LAM4 spoligotype, and to calculate the number of independent evolutionary emergences of MDR and XDR. Our sequencing and analysis revealed a 50-member clone of XDR M. tuberculosis that was highly related to the Tugela Ferry XDR outbreak strain. We estimated that mutations conferring isoniazid and streptomycin resistance in this clone were acquired 50 y prior to the Tugela Ferry outbreak (katG S315T [isoniazid]; gidB 130 bp deletion [streptomycin]; 1957 [95% highest posterior density (HPD): 1937-1971]), with the subsequent emergence of MDR and XDR occurring 20 y (rpoB L452P [rifampicin]; pncA 1 bp insertion [pyrazinamide]; 1984 [95% HPD: 1974-1992]) and 10 y (rpoB D435G [rifampicin]; rrs 1400 [kanamycin]; gyrA A90V [ofloxacin]; 1995 [95% HPD: 1988-1999]) prior to the outbreak, respectively. We observed frequent de novo evolution of MDR and XDR, with 56 and nine independent evolutionary events, respectively. Isoniazid resistance evolved before rifampicin resistance 46 times, whereas rifampicin resistance evolved prior to isoniazid only twice. We identified additional putative compensatory mutations to rifampicin in this dataset. One major limitation of this study is that the conclusions with respect to ordering and timing of acquisition of mutations may not represent universal patterns of drug resistance emergence in other areas of the globe., Conclusions: In the first whole genome-based analysis of the emergence of drug resistance among clinical isolates of M. tuberculosis, we show that the ancestral precursor of the LAM4 XDR outbreak strain in Tugela Ferry gained mutations to first-line drugs at the beginning of the antibiotic era. Subsequent accumulation of stepwise resistance mutations, occurring over decades and prior to the explosion of HIV in this region, yielded MDR and XDR, permitting the emergence of compensatory mutations. Our results suggest that drug-resistant strains circulating today reflect not only vulnerabilities of current TB control efforts but also those that date back 50 y. In drug-resistant TB, isoniazid resistance was overwhelmingly the initial resistance mutation to be acquired, which would not be detected by current rapid molecular diagnostics employed in South Africa that assess only rifampicin resistance.

Trimethylguanosine Synthase catalyses transfer of two methyl groups to the m(7)G cap of RNA polymerase II transcribed snRNAs, snoRNAs, and telomerase RNA TLC1 to form a 2,2,7-trimethylguanosine cap. While in vitro studies indicate that Tgs1 functions as a monomer and the dimethylation of m(7)G caps is not a processive reaction, partially methylated sn(o)RNAs are typically not detected in living cells. Here we show that both yeast and human Tgs1p possess a conserved self-association property located at the N-terminus. A disruption of Tgs1 self-association led to a strong reduction of sn(o)RNA trimethylation as well as reduced nucleolar enrichment of Tgs1. Self-association of Tgs1p and its catalytic activity were also prerequisite to bypass the requirement for its accessory factor Swm2p for efficient pre-rRNA processing and snRNA trimethylation. The ability to self-associate might enable Tgs1 to efficiently dimethylate the caps of the targeted RNAs in vivo.

Background: Intraoperative neuromonitoring (IONM) has become standard practice in thyroid surgery for many surgeons. It reduces the risk of vocal cord palsy in high-risk patients and has led to two-stage operations to prevent bilateral palsies. The specificity of detecting nerve injuries is not 100 %, leading to patients with vocal cord dysfunction (VCD) despite regular neuromonitoring (false-negative IONM). We aimed to evaluate possible risk factors for this phenomenon and its importance regarding bilateral palsies., Methods: We performed a retrospective analysis of all patients with false-negative IONM., Results: A total of 2152 patients (3426 nerves at risk) underwent surgery for benign disease between January 2008 and October 2010. Sensitivity for predicting VCD was 85.4 % and specificity 99.0 %. The positive predictive value was 68.0 % and the negative predictive value 99.6 %. We were not able to identify risk factors for false-negative IONM. We found four patients with delayed occurrence of VCD after regular IONM (1-8 weeks). We registered two patients with bilateral VCD after false negative IONM on the first side of bilateral resections (2/7) and four patients with bilateral palsy after correct IONM (4/1256). The relative risk for bilateral VCD between patients with false-negative IONM on the primary resection side and patients with correct IONM was 89.7., Conclusions: Although seldom, false-negative IONM is of clinical importance as it bears a high risk of bilateral VCD if it occurs on the first side of a bilateral resection. It can also have a latent occurrence after surgery.

The Planococcaceae are extreme survivors, having been cultured from environments such as deep sea sediments, marine solar salterns, glaciers, permafrost, Antarctic deserts, and sea ice brine. The family contains both sporulating and nonsporulating genera. Here we present the unclosed, draft genome sequence of Planococcus donghaensis strain MPA1U2, a nonsporulating psychrotrophic bacterium isolated from surface coastal water of the Pacific Ocean.

Fungal genome annotation is the starting point for analysis of genome content. This generally involves the application of diverse methods to identify features on a genome assembly such as protein-coding and non-coding genes, repeats and transposable elements, and pseudogenes. Here we describe tools and methods leveraged for eukaryotic genome annotation with a focus on the annotation of fungal nuclear and mitochondrial genomes. We highlight the application of the latest technologies and tools to improve the quality of predicted gene sets. The Broad Institute eukaryotic genome annotation pipeline is described as one example of how such methods and tools are integrated into a sequencing center's production genome annotation environment.

Unlabelled: Human temporal bones in teaching ear surgery are rare. The lamb's temporal bone might be a possible alternative., Material and Methods: Temporal bones of the lamb were dissected with a typical temporal bone lab drilling program. We included a mastoidectomy, endaural approaches, but also analyzed the outer appearance, the external ear canal and the hypotympanon. Some steps differed from preparation done in humans. The morphometric results were compared to the known anatomy of human in order to verify the lambs' temporal bone for suitability in otosurgic training., Results: The lambs' temporal bone appears smaller than the human one. We found a bullous extended hypotympanon located under the external ear canal. The tympanic membrane is very similar to the human one. The external ear canal is smaller and shorter. The ossicular chain shows analogies to human one., Discussion: This study shows, that especially the middle ear, the tympanic membrane and the external ear canal are morphologically equal to the structures found in human temporal bones. The lamb seems feasible for teaching the anatomy of the ear. The smaller scales of some structures, especially the outer components of the temporal bone are a disadvantage., Conclusions: The lamb seems to be an alternative in teaching ear surgery.

Culex quinquefasciatus (the southern house mosquito) is an important mosquito vector of viruses such as West Nile virus and St. Louis encephalitis virus, as well as of nematodes that cause lymphatic filariasis. C. quinquefasciatus is one species within the Culex pipiens species complex and can be found throughout tropical and temperate climates of the world. The ability of C. quinquefasciatus to take blood meals from birds, livestock, and humans contributes to its ability to vector pathogens between species. Here, we describe the genomic sequence of C. quinquefasciatus: Its repertoire of 18,883 protein-coding genes is 22% larger than that of Aedes aegypti and 52% larger than that of Anopheles gambiae with multiple gene-family expansions, including olfactory and gustatory receptors, salivary gland genes, and genes associated with xenobiotic detoxification.

Antimicrobial proteins like human beta-defensins 1-4 (hBD1-4) protect the surface of organs against different bacteria. Little is still known about these proteins within an abscess formation. The purpose of this study was to analyse and describe the distribution of the antimicrobial proteins hBD 1-4 within the peritonsillar abscess. A total of 17 peritonsillar abscesses were analysed. Immunohistochemical stainings were performed, characteristic pictures were taken, and the mean colour intensity was measured using a specific imaging software. A statistical analysis compared the areas of interest of the specific protein staining with the one of the control staining. A total of 4,573 areas of interests were measured. A significantly stronger expression was detected for hBD1 in the surface epithelium, crypt, epithelium of the crypt, lymphocytic cap, and abscess formation in the hBD1 staining in comparison to the control samples. But there was no significance in the specific hBD1-protein expression in comparison to the control samples in the lymphoid follicle and in the germinal centre. There was a significantly stronger hBD2, hBD3, and hBD4 expression in all areas of interest for the specifics stainings in comparison to the control samples. In conclusion, we developed different scenarios which could lead to a peritonsillar abscess formation.

Background: Variations in transcript splicing can reveal how eukaryotes recognize intronic splice sites. Retained introns (RIs) commonly appear when the intron definition (ID) mechanism of splice site recognition inconsistently identifies intron-exon boundaries, and cassette exons (CEs) are often caused by variable recognition of splice junctions by the exon definition (ED) mechanism. We have performed a comprehensive survey of alternative splicing across 42 eukaryotes to gain insight into how spliceosomal introns are recognized., Results: All eukaryotes we studied exhibit RIs, which appear more frequently than previously thought. CEs are also present in all kingdoms and most of the organisms in our analysis. We observe that the ratio of CEs to RIs varies substantially among kingdoms, while the ratio of competing 3' acceptor and competing 5' donor sites remains nearly constant. In addition, we find the ratio of CEs to RIs in each organism correlates with the length of its introns. In all 14 fungi we examined, as well as in most of the 9 protists, RIs far outnumber CEs. This differs from the trend seen in 13 multicellular animals, where CEs occur much more frequently than RIs. The six plants we analyzed exhibit intermediate proportions of CEs and RIs., Conclusion: Our results suggest that most extant eukaryotes are capable of recognizing splice sites via both ID and ED, although ED is most common in multicellular animals and ID predominates in fungi and most protists.

A steady decline in androgen levels occurs in males as they age. Evidence suggests that this decline may be at least partially responsible for a variety of physical and mental changes associated with the aging process. For instance, abnormally low levels of androgens can lead to profound changes in bone density, body composition, as well as sexual and cognitive function. Testosterone replacement has been shown to produce improvements in many of these areas. However, this practice is not without risks, both proven and theoretic. Also, the diagnosis of androgen deficiency and the decision to treat is not always straightforward. The purpose of this article is to familiarize the clinician with issues associated with androgen deficiency in the aging male. The clinical symptoms of androgen deficiency as well as the risks and benefits of androgen replacement will be discussed. This should help clinicians better identify those patients in whom testosterone replacement therapy should be considered.

Introduction: Regarding the satisfaction of patients efficiency and outcome of surgery on the nasal septum and the turbinates regularly is the topic of controversial discussion and occasionally some health authorities doubt there is an indication for these procedures in general. Subjective and objective evaluation of surgical outcome do not necessarily match in all cases., Methods: A standardized questionnaire was sent to patients having undergone surgery on the nasal septum and the turbinates 33-45 months ago at a university hospital and a non-university hospital. Topics (10 all together) were e. g.: nasal aeration, sense of smell, rhinorrhea, snoring, general condition. Statistic significance of each parameter was verified., Results: 138 questionnaires were reviewed. 82% of the candidates reported better aeration of the nose after surgery. 71% stated to have benefited from the operation. A relevant positive effect on snoring, rhinorrhea, headache and sense of smell could not be proved. The results did no different whether surgery was performed at a university hospital or at a non-university-hospital. Older patients seem to profit more from the procedure than younger ones., Discussion: The survey clearly shows, that surgery on the nasal septum with turbinoplasty has a positive effect on the nasal aeration and the general condition. Therefore its performance is well justified when after careful verification of the pre-conditions the indication for surgery is given.

We present Conrad, the first comparative gene predictor based on semi-Markov conditional random fields (SMCRFs). Unlike the best standalone gene predictors, which are based on generalized hidden Markov models (GHMMs) and trained by maximum likelihood, Conrad is discriminatively trained to maximize annotation accuracy. In addition, unlike the best annotation pipelines, which rely on heuristic and ad hoc decision rules to combine standalone gene predictors with additional information such as ESTs and protein homology, Conrad encodes all sources of information as features and treats all features equally in the training and inference algorithms. Conrad outperforms the best standalone gene predictors in cross-validation and whole chromosome testing on two fungi with vastly different gene structures. The performance improvement arises from the SMCRF's discriminative training methods and their ability to easily incorporate diverse types of information by encoding them as feature functions. On Cryptococcus neoformans, configuring Conrad to reproduce the predictions of a two-species phylo-GHMM closely matches the performance of Twinscan. Enabling discriminative training increases performance, and adding new feature functions further increases performance, achieving a level of accuracy that is unprecedented for this organism. Similar results are obtained on Aspergillus nidulans comparing Conrad versus Fgenesh. SMCRFs are a promising framework for gene prediction because of their highly modular nature, simplifying the process of designing and testing potential indicators of gene structure. Conrad's implementation of SMCRFs advances the state of the art in gene prediction in fungi and provides a robust platform for both current application and future research.

Background: Intrapulmonary shunting (IPS) is a well-described phenomenon in chronic liver disease but its significance is not known., Hypothesis: The study was undertaken to enhance our understanding of the characteristics and prevalence of IPS., Methods: We retrospectively studied 204 consecutive patients with end-stage chronic liver disease who underwent a dobutamine stress echocardiogram, along with a saline contrast bubble study, as part of their pretransplant evaluation., Results: Intrapulmonary shunting of any degree was present in 56.4% of patients. Patients with IPS were more likely to report alcohol use and less likely to have diabetes mellitus. Patients in Child-Pugh classification C were more likely to have IPS than those with classification A or B. The resting room air PaO2 levels were significantly lower in patients with grade 3-4 IPS than in those with grade 1-2. Elevated estimated pulmonary systolic pressure on echocardiography was more prevalent in patients with than in those without IPS., Conclusions: A majority of patients with end-stage chronic liver disease undergoing transplant evaluation have IPS. There are important baseline differences between patients with and without IPS. The presence of IPS is associated with increased severity of chronic liver disease. Further study is required to define the prognostic significance of IPS and its impact on future liver transplantation.