Impact of the introduction of minimally invasive treatments of the thyroid (MITT) for benign thyroid nodules in an Italian hospital: a cost-minimization analysis

BACKGROUND

Prevalence of thyroid nodules is high in the adult population, approaching 60% in women and older people. Most thyroid nodules are benign and asymptomatic. However, a not negligible part of them causes compressive symptoms and/or cosmetic concerns and need to be treated. In the last two decades, minimally-invasive treatments of the thyroid (MITT) have been proposed in routine clinical practice as a reliable cost-effective alternative to surgery in patients with symptomatic benign thyroid nodules (SBTNs).

AIM OF THE STUDY

To perform a cost-minimization analysis comparing direct, indirect and intangible costs of radiofrequency (RFA) and laser thermal ablation (LTA) with traditional surgery in patients with SBTNs.

METHODS

Data of patients treated by MITT for SBTNs from October 1st 2019 to September 30th 2022 in a single Italian tertiary Center were analyzed. Costs were compared to those of traditional surgery reported in the 2022 Associazione Medici Endocrinologi Guidelines on the Management of SBTNs.

RESULTS

In the study lapse, 157 MITT of SBTNs were performed in 148 patients, 114 females and 34 males (mean age: 59 yrs; median age: 57 yrs). Before MITT, the mean thyroid nodule volume was 19 ml; 1 year after MITT, volume reduction rate >50% and symptom relief were achieved in 89% and 93% of patients, respectively. No major complications occurred. Adding up pre-operative, operative and post-operative costs, total direct costs per single procedure are the following: 1361.43 € for LTA when using one optic fiber; 1761.43 € for LTA when using two optic fibers; 1968.53 € for RFA; 3338.39 € for hemithyroidectomy plus isthmectomy; 4034.99 € for total thyroidectomy. Surgery was impactful on direct-i.e., preoperative, operative and postoperative-costs, due to longer operating room occupation time and hospital stay. Overall, a total saving for the Italian National Health Service of 285,377.15 € has been obtained treating the 148 patients by MITT instead of surgery. Likewise, MITT was advantageous also for indirect costs-i.e., those related to "loss of productivity" caused by time off work due to hospital stay and recovery time-, for both the self-employed workers and the Government, the latter saving 53,838.50 € overall. Finally, intangible costs, related to patients' quality of life-e.g., residual surgical scar, stress related to general anesthesia, convalescence, and life-long intake of L-Thyroxine replacement therapy-were all in favor of MITT.

CONCLUSIONS

This real-life cost-minimization analysis demonstrates that LTA and RFA are safe and cost-effective procedures for the treatment of SBTNs. In our 3 years experience, adding the savings of 285,377.15 € for direct costs to those of 53.838,50 € for indirect costs, in total 339,215.65 € were saved. The saving concern patients, the National Health System and the Government.

Towards a global perspective for Salvia L.: Phylogeny, diversification and floral evolution

Salvia is the most species-rich genus in Lamiaceae, encompassing approximately 1000 species distributed all over the world. We sought a new evolutionary perspective for Salvia by employing macroevolutionary analyses to address the tempo and mode of diversification. To study the association of floral traits with speciation and extinction, we modelled and explored the evolution of corolla length and the lever-mechanism pollination system across our Salvia phylogeny. We reconstructed a multigene phylogeny for 366 species of Salvia in the broad sense including all major recognized lineages and 50 species from Iran, a region previously overlooked in studies of the genus. Our comprehensive sampling of Iranian species of Salvia provides higher phylogenetic resolution for southwestern Asian species than obtained in previous studies. Our phylogenetic data in combination with divergence time estimates were used to examine the evolution of corolla length, woody versus herbaceous habit, and presence versus absence of a lever mechanism. We investigated the timing and dependence of Salvia diversification related to corolla length evolution through a disparity test and BAMM analysis. A HiSSE model was used to evaluate the dependency of diversification on the lever-mechanism pollination system in Salvia. A medium corolla length (15-18 mm) was reconstructed as the ancestral state for Salvia with multiple shifts to shorter and longer corollas. Macroevolutionary model analyses indicate that corolla length disparity is high throughout Salvia evolution, significantly different from expectations under a Brownian motion model during the last 28 million years of evolution. Our analyses show evidence of a higher diversification rate of corolla length for some Andean species of Salvia compared to other members of the genus. Based on our tests of diversification models, we reject the hypothesis of a direct effect of the lever mechanism on Salvia diversification. Therefore, we suggest caution in considering the lever-mechanism pollination system as one of the main drivers of speciation in Salvia.

Does Aging Activate T-cells to Reduce Bone Mass and Quality?

PURPOSE OF REVIEW

Aging leads to decline in bone mass and quality starting at age 30 in humans. All mammals undergo a basal age-dependent decline in bone mass. Osteoporosis is characterized by low bone mass and changes in bone microarchitecture that increases the risk of fracture. About a third of men over the age of 50 years are osteoporotic because they have higher than basal bone loss. In women, there is an additional acute decrement in bone mass, atop the basal rate, associated with loss of ovarian function (menopause) causing osteoporosis in about half of the women. Both genetics and environmental factors such as smoking, chronic infections, diet, microbiome, and metabolic disease can modulate basal age-dependent bone loss and eventual osteoporosis. Here, we review recent studies on the etiology of age-dependent decline in bone mass and propose a mechanism that integrates both genetic and environmental factors.

RECENT FINDINGS

Recent findings support that aging and menopause dysregulate the immune system leading to sterile low-grade inflammation. Both animal models and human studies demonstrate that certain kinds of inflammation, in both men and women, mediate bone loss. Senolytics, meant to block a wide array of age-induced effects by preventing cellular senescence, have been shown to improve bone mass in aged mice. Based on a synthesis of the recent data, we propose that aging activates long-lived tissue resident memory T-cells to become senescent and proinflammatory, leading to bone loss. Targeting this population may represent a promising osteoporosis therapy. Emerging data indicates that there are several mechanisms that lead to sterile low-grade chronic inflammation, inflammaging, that cause age- and estrogen-loss dependent osteoporosis in men and women.

Pseudoaneurysm of the uterine artery with presentation of haematuria; a rare case report

Introduction

Pseudoaneurysm of the uterine artery is a condition in which extra luminal collection of blood with a turbulent flow that communicates with flowing blood of uterine artery through a defect in its arterial wall. As per literature uterine artery pseudoaneurysm is a very rare condition and its incidence is 2–3/1000 deliveries. Clinical diagnosis is very challenging and in the index case haematuria was the presenting complaint which in fact is the extremely rare presenting complaint. Angioembolization is the ideal treatment modality for such a rare condition.

Case presentation

A 25-year old female presented in a shock state with history of massive haematuria two months after delivering a baby. She was resuscitated with fluid, blood and blood products. A computed tomography angiogram was done which showed a large pseudoaneurysm of the left uterine artery so consequently angioembolization was done with n-butyl cyanoacrylate (NBCA) and lipoid mixture. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up.

Discussion

A post-partum massive haematuria could be due to pseudo aneurysm of uterine artery. The presentation of haematuria may occur due to communication of aneurysm with urinary bladder and which further get ruptured. Aggressive resuscitation and angioembolization of the pseudoaneurysm is employed to treat such patients.

Conclusion

Pseudoaneurysm of uterine artery is rare condition which may present as haematuria. Once clinical diagnosis is suspected it's better to first resuscitate and plan for angioembolization for better outcome.

•

Pseudoaneurysm of uterine artery presented with haematuria is the first case to be reported in the leterature.

•

Clinically the pseudoaneurysm of uterine artery should be considered in mind in patients with massive haematuria after caesarean/normal deliveries.

•

Aggressive resuscitation and definitive management with embolization is the ideal treatment for such cases.

Long time behavior and stable patterns in high-dimensional polarity models of asymmetric cell division

Asymmetric cell division is one of the fundamental processes to create cell diversity in the early stage of embryonic development. During this process, the polarity formation in the cell membrane has been considered as a key process by which the entire polarity formation in the cytosol is controlled, and it has been extensively studied in both experiments and mathematical models. Nonetheless, a mathematically rigorous analysis of the polarity formation in the asymmetric cell division has been little explored, particularly for bulk-surface models. In this article, we deal with polarity models proposed for describing the PAR polarity formation in the asymmetric cell division of a C. elegans embryo. Using a simpler but mathematically consistent model, we exhibit the long time behavior of the polarity formation of a bulk-surface cell. Moreover, we mathematically prove the existence of stable polarity solutions of the model equation in an arbitrary high-dimensional domain and analyse how the boundary position of polarity domain is determined. Our results propose that the existence and dynamics of the polarity in the asymmetric cell division can be understood universally in terms of basic mathematical structures.

Influence of technology usage on family communication patterns and functioning: A systematic review

The upsurge of technological advancement and the introduction of the internet has impacted face to face communication.

BACKGROUND

The advances in this field have gained much interest in implying increased technology usage on various psychosocial factors, mainly mental health and changing communication patterns in the family system.

METHODOLOGY

This paper provides a systematic review of the literature published between 1990-2020, examining the relationship between technology usage and its impact on family factors like communication and family relationships.

RESULTS

A database search was conducted using certain keywords, and in total, 20 papers were selected according to inclusion criteria. The results are categorized into domains of 1) technology use of the family, 2) family communication 3) family bonding 4) rules for technology use 5) boundaries maintained by the family members related to technology use.

CONCLUSION

The results indicate that technology usage in families is very high, and maximum daily communication happens through technology. Family leisure time, offline family bonding and communication is negatively affected due to technology use. A model was developed which has implications in the family psychiatry field and specifically in working with families having difficulties managing healthy use of technology.

Targeted Therapies for Follicular Lymphoma

Follicular lymphoma (FL) is the 2nd most common lymphoma in the USA/Western Europe. While incurable, the majority of patients are able to survive at least a decade with this disease. Response duration though varies, and subset of patients will relapse within 24 months of initial therapy (POD24). These patients have shortened survival compared to those who achieve more durable responses. Treatment interventions for patients are varied and include observation, radiation, or systemic therapies. Treatment outcomes have improved considerably over the last several decades with the introduction of new agents such as the CD 20 antibody rituximab and more recently with the advent of more targeted therapy. Most of the newer agents work differently from cytotoxic chemotherapy and either inhibit tumor-specific mutations, survival pathways, or harness the immune systems. While outcomes with traditional cytotoxic agents have been historically poor in certain subtypes such as POD24 and rituximab refractory disease, the reported outcomes with the newer agents have been encouraging as evident by several new drug approvals in FL. The biggest impact has been in the relapsed/refractory setting where we have approval of the immunomodulatory agent lenalidomide given in combination with rituximab. Based on the AUGMENT study, this agent has been approved for patients with R/R FL after one previous line of therapy. The EZH2 inhibitor, tazemetostat, was approved recently for patients with a known EZH2 mutation after one prior line of therapy or for FL patients who are deemed intolerant to other agents given the impressive safety profile in all patients. Finally, there is a plethora of agents that are designed to harness the immune system to combat this lymphoma. The data for these agents is still very early but nonetheless very impressive. In summary, FL is an incurable lymphoma without any standard of care options but has numerous treatments that have demonstrated some degree of efficacy. Recently we have made enormous strides in the understanding of some of the biological drivers of this disease which has allowed for refinement of treatment options. Moving forward, I would anticipate that we will continue to explore the use of agents that target specific mutations or utilize the immune system to hopefully one day achieve a cure.

Intrinsic stochasticity and the emergence of collective behaviours in insect swarms

Intrinsic stochasticity associated with finite population size is fundamental to the emergence of collective behaviours in insect swarms. It has been assumed that this intrinsic stochasticity is purely additive (position independent) in quiescent (unperturbed) swarms. Here, I identify the hallmarks of intrinsic multiplicative (position dependent) stochasticity and show that they are evident in quiescent laboratory swarms of the non-biting midge Chironomus riparius. In accordance with theoretical expectations, the smallest well-documented laboratory swarms (containing between 14 and 46 individuals) are found to have q-Gaussian density profiles with [Formula: see text] 1, whereas larger laboratory swarms have Gaussian ([Formula: see text]1) density profiles. I show that these newly identified states are analogous to interstellar clouds and thereby extend a long-standing analogy between insect swarms and self-gravitating systems. Smaller laboratory swarms have been observed and are predicted to be gas-like, filling the available space rather than occupying just a small proportion of it. The new results unify laboratory swarms with wild swarms. Unlike laboratory swarms, wild swarms must contend with environmental (extrinsic) noise and have density profiles that are accurately represented by q-Gaussians with [Formula: see text] 1. Finally, it is shown how intrinsic multiplicative noise allows for the nucleation of swarms away from prominent visual features (basins of attraction) known as swarm markers.

CT features of lung metastases from pancreatic adenocarcinoma: Correlation with histopathologic findings

PURPOSE

The purpose of this study was to evaluate the prevalence of an atypical, alveolar presentation of pulmonary metastases from pancreatic adenocarcinoma (PDAC) on computed tomography (CT) and to correlate CT features with those obtained at histopathologic analysis.

MATERIAL AND METHODS

A total of 76 patients with lung metastases from PDAC over a 10-year period (2009-2019) in a French university hospital were retrospectively included. There were 34 men and 42 women with a mean age of 67.6±11.3 (SD) years (range: 38-89 years). CT features of PDAC were classified according to their presentations as usual metastatic pattern or atypical alveolar pattern; the atypical alveolar pattern corresponding to either ground glass nodules or opacities, solid nodules with a halo sign, "air-space" nodules with air bronchogram, or parenchymal consolidation. Imaging-histopathologic correlation was performed when tissue samples were available.

RESULTS

Pulmonary metastases were synchronous in 36 patients (36/76; 47%) and metachronous in 40 patients (40/76; 53%). A predominant alveolar presentation on CT was observed in 17 patients (17/76, 22%). Nodules with halo sign were the predominant alveolar pattern in 7 patients (7/17; 41%), air-space nodules were predominant in 4 patients (4/17; 24%) whereas pure ground glass nodules and consolidations were observed as predominant features in 3 patients (3/17; 18%) each. For 5 patients who had histopathological confirmation, alveolar metastases of PDAC were characterized by columnar tumor cells lining the alveolar wall, which was not seen in other radiological presentations, whereas there were no differences regarding mucin secretion between pulmonary metastases with alveolar presentation and those with typical pattern.

CONCLUSIONS

Lung metastases from PDAC may present with a so-called "alveolar" pattern on CT. This misleading CT features is found in 22% of patients with lung metastases from PDAC and is due to lepidic growth of the metastatic cells.

Effectiveness of mindfulness by smartphone, for patients with chronic migraine and medication overuse during the Covid-19 emergency

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Heterologous Microcompartment Assembly in Bacillaceae: Establishing the Components Necessary for Scaffold Formation

Bacterial microcompartments (BMCs) are organelles that host specific biochemical reactions for both anabolic and catabolic functions. Engineered morphologically diverse BMCs bearing heterologous enzymatic pathways have shown enhanced productivity for commodity chemicals, which makes BMCs an important focus for metabolic engineering. Gaining control of BMC assembly and incorporation of a heterologous enzymatic cargo has yet to be achieved in thermophiles. Herein, we address this by first conducting a detailed bioinformatic analysis of the propanediol utilization (pdu) operon in the thermophile Parageobacillus thermoglucosidasius. We then demonstrated, in vivo, the ability to assemble the native BMCs at an elevated temperature of 60 °C. Heterologous expression of Pdu shell proteins from P. thermoglucosidasius in Bacillus subtilis resulted in the assembly of a single tubular BMC with an average length of 1.4 μm; BMCs assembled after a 20 min induction of expression of the shell operons. Moreover, we show that it is possible to target the monomeric superfolder GFP (msfGFP) to the interior of the compartment by fusion of an N-terminal sequence of the propanediol utilization protein (PduP) of at least 24 amino acids. This study establishes the feasibility of constructing cell factories for small molecules in industrially important Bacillus and Geobacillus spp. by heterologous cargo-carrying BMC production and assembly. Additionally, the study provides experimental confirmation that BMCs are produced in thermophilic bacteria, which opens a path for future research on repurposing the native organelles to provide new functionality at elevated temperatures.

Artemisinin and its derivatives; ancient tradition inspiring the latest therapeutic approaches against malaria

Artemisinin (ART) is an endoperoxide sesquiterpene lactone, commonly used in the treatment of malaria. Although it was isolated from Artemisia annua L., a plant widely applied in Chinese Traditional Medicine, its mechanism of action remains uncertain and its clinical use is still limited due to its low solubility, its poor bioavailability and short in vivo half-life. Over time, several studies have been aimed towards the discovery of potent ART derivatives that could overcome clinical drawbacks. In this review, we focus on the multifaced aspects of ART and on the efforts spent to improve its pharmacological profile that so far culminated in the discovery of more effective drugs. Lastly, we outline the new perspectives in the ART-derivatives scenario.

Effects of an Oil-Free Hydroethanolic Pumpkin Seed Extract on Symptom Frequency and Severity in Men with Benign Prostatic Hyperplasia: A Pilot Study in Humans

Majority of men are affected by symptomatic benign prostatic hyperplasia (BPH) from a certain age. Botanical extracts are frequently used in the early management of the symptoms. In a single-arm, mono-center pilot study, the effects of a proprietary oil-free hydroethanolic pumpkin seed extract on the symptoms of BPH were investigated. A total of 60 men (62.3 years [95% confidence interval (CI): 60.3–64.3 years]) with a total International Prostate Symptom Score (IPSS) of 14.8 (95% CI: 13.5–16.1) participated between January 2017 and October 2017 in the study by ingesting the oil-free hydroethanolic pumpkin seed extract once daily before going to bed during 3 months. Change in IPSS within treatment period was assessed. Frequency of nocturia was recorded by bladder diary, and postvoid residual urine volume was determined through ultrasound. Between baseline and after 12 weeks of supplementation, a significant symptom reduction of an average 30.1% (95% CI: 23.1–37.1) was seen for the total IPSS. Symptom alleviation had a high impact on quality of life (P < .0001) and was significant after 8 and 12 weeks of intervention (P < .001). Nocturia significantly decreased over time (P < .0001), as confirmed by IPSS questionnaire and bladder diary. Postvoid residual urine volume was significantly reduced at the end of intervention (baseline: 83.67 mL [95% CI: 58.02–109.3]; after 12 weeks: 63.11 mL [95% CI: 45.37–80.85]; P = .0394). These results indicate that the oil-free hydroethanolic pumpkin seed extract seems to be a very well tolerable, appropriate plant extract to support health benefits in a collective suffering from BPH related symptoms without the need of medical treatment.

Genotypic variability and stability of poplars and willows grown onnitrate-contaminated soils

Phyto-recurrent selection is an established method for selecting tree genotypes for phytoremediation. To identify promising Populus (poplar) and Salix (willow) genotypes for phytotechnologies, our objectives were to (1) evaluate the genotypic variability in survival, height, and diameter of poplar and willow clones established on soils heavily contaminated with nitrates; and (2) assess the genotypic stability in survival and diameter of selected poplar clones after one and eleven growing seasons. We tested 27 poplar and 10 willow clones planted as unrooted cuttings, along with 15 poplar genotypes planted as rooted cuttings. The trees were tested at an agricultural production facility in the Midwestern, United States. After 11 growing seasons, using phyto-recurrent selection, we surveyed survival and measured the diameter of 27 poplar clones (14 unrooted, 13 rooted) that were selected based on superior survival and growth throughout plantation development. Overall, willow exhibited the greatest survival, while poplar had the greatest height and diameter. At 11 years after planting, superior clones were identified that exhibited above-average diameter growth at the establishment- and rotation-age, most of which had stable genotypic performance over time. Selection of specific clones was favorable to genomic groups, based on the geographic location and soil conditions of the site.

The Borel map in locally integrable structures

Given a locally integrable structure V over a smooth manifold Ω and given p ∈ Ω we define the Borel map of V at p as the map which assigns to the germ of a smooth solution of V at p its formal Taylor power series at p. In this work we continue the study initiated in Barostichi et al. (Math. Nachr. 286(14-15):1439-1451, 2013), Della Sala and Lamel (Int J Math 24(11):1350091, 2013) and present new results regarding the Borel map. We prove a general necessary condition for the surjectivity of the Borel map to hold and also, after developing some new devices, we study some classes of CR structures for which its surjectivity is valid. In the final sections we show how the Borel map can be applied to the study of the algebra of germs of solutions of V at p.

Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial

Background

Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days.

Methods

Patients of 8 years and older undergoing appendectomy for acute complex appendicitis – defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess – are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed.

Discussion

This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly.

Trial registration

Dutch Trial Register, NTR6128. Registered on 20 December 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2629-0) contains supplementary material, which is available to authorized users.

The intracellular immune receptor Rx1 regulates the DNA-binding activity of a Golden2-like transcription factor

Plant nucleotide-binding leucine-rich repeat (NLR) proteins enable the immune system to recognize and respond to pathogen attack. An early consequence of immune activation is transcriptional reprogramming, and some NLRs have been shown to act in the nucleus and interact with transcription factors. The Rx1 NLR protein of potato is further able to bind and distort double-stranded DNA. However, Rx1 host targets that support a role for Rx1 in transcriptional reprogramming at DNA are unknown. Here, we report a functional interaction between Rx1 and NbGlk1, a Golden2-like transcription factor. Rx1 binds to NbGlk1 in vitro and in planta. NbGlk1 binds to known Golden2-like consensus DNA sequences. Rx1 reduces the binding affinity of NbGlk1 for DNA in vitro. NbGlk1 activates cellular responses to potato virus X, whereas Rx1 associates with NbGlk1 and prevents its assembly on DNA in planta unless activated by PVX. This study provides new mechanistic insight into how an NLR can coordinate an immune signaling response at DNA following pathogen perceptions.

Chest Radiograph Findings in Childhood Pneumonia Cases From the Multisite PERCH Study

Background.

Chest radiographs (CXRs) are frequently used to assess pneumonia cases. Variations in CXR appearances between epidemiological settings and their correlation with clinical signs are not well documented.

Methods.

The Pneumonia Etiology Research for Child Health project enrolled 4232 cases of hospitalized World Health Organization (WHO)–defined severe and very severe pneumonia from 9 sites in 7 countries (Bangladesh, the Gambia, Kenya, Mali, South Africa, Thailand, and Zambia). At admission, each case underwent a standardized assessment of clinical signs and pneumonia risk factors by trained health personnel, and a CXR was taken that was interpreted using the standardized WHO methodology. CXRs were categorized as abnormal (consolidation and/or other infiltrate), normal, or uninterpretable.

Results.

CXRs were interpretable in 3587 (85%) cases, of which 1935 (54%) were abnormal (site range, 35%–64%). Cases with abnormal CXRs were more likely than those with normal CXRs to have hypoxemia (45% vs 26%), crackles (69% vs 62%), tachypnea (85% vs 80%), or fever (20% vs 16%) and less likely to have wheeze (30% vs 38%; all P < .05). CXR consolidation was associated with a higher case fatality ratio at 30-day follow-up (13.5%) compared to other infiltrate (4.7%) or normal (4.9%) CXRs.

Conclusions.

Clinically diagnosed pneumonia cases with abnormal CXRs were more likely to have signs typically associated with pneumonia. However, CXR-normal cases were common, and clinical signs considered indicative of pneumonia were present in substantial proportions of these cases. CXR-consolidation cases represent a group with an increased likelihood of death at 30 days post-discharge.

Discordant Effects of Licensed Meningococcal Serogroup B Vaccination on Invasive Disease and Nasal Colonization in a Humanized Mouse Model

Background

The multicomponent meningococcal serogroup B vaccine (4CMenB) is an outer membrane vesicle and recombinant protein-based vaccine licensed to protect against serogroup B meningococcal disease. It remains unknown whether this vaccine will prevent carriage or transmission, key aspects in long-term vaccine success and disease eradication.

Methods

Using a "humanized" transgenic mouse model of nasal colonization, we took a systematic approach to estimate the potential for carriage prevention against antigenically diverse Neisseria meningitidis strains and to compare this protection to an invasive meningococcal disease challenge model.

Results

The 4CMenB vaccine prevented morbidity and mortality after lethal invasive doses of all meningococcal strains tested. Immunization effectively prevented carriage with only 1 of 4 single antigen-matched strains but reduced or prevented nasal colonization by all 4 isolates with multiple cross-reacting antigens. Each immunized mouse had substantial immunoglobulin G targeting the challenge strains, indicating that antibody correlates with protection against sepsis but not nasal carriage.

Conclusions

Immunization with the 4CMenB vaccine elicits a robust humoral response that correlates with protection against invasive challenge but not with prevention of asymptomatic colonization. This suggests that widespread use of this vaccine will reduce morbidity and mortality rates in immunized individuals, with the potential to contribute to herd protection against a subset of strains.

How Can Synergism of Traditional Medicines Benefit from Network Pharmacology?

Many prescriptions of traditional medicines (TMs), whose efficacy has been tested in clinical practice, have great therapeutic value and represent an excellent resource for drug discovery. Research into single compounds of TMs, such as artemisinin from Artemisia annua L., has achieved great success; however, it has become evident that a TM prescription (which frequently contains various herbs or other components) has a synergistic effect in effecting a cure or reducing toxicity. Network pharmacology targets biological networks and analyzes the links among drugs, targets, and diseases in those networks. Comprehensive, systematic research into network pharmacology is consistent with the perspective of holisticity, which is a main characteristic of many TMs. By means of network pharmacology, research has demonstrated that many a TM show a synergistic effect by acting at different levels on multiple targets and pathways. This approach effectively bridges the gap between modern medicine and TM, and it greatly facilitates studies into the synergistic actions of TMs. There are different kinds of synergistic effects with TMs, such as synergy among herbs, effective parts, and pure compounds; however, for various reasons, new drug discovery should at present focus on synergy among pure compounds.

Bayesian Estimation of Pneumonia Etiology: Epidemiologic Considerations and Applications to the Pneumonia Etiology Research for Child Health Study

In pneumonia, specimens are rarely obtained directly from the infection site, the lung, so the pathogen causing infection is determined indirectly from multiple tests on peripheral clinical specimens, which may have imperfect and uncertain sensitivity and specificity, so inference about the cause is complex. Analytic approaches have included expert review of case-only results, case-control logistic regression, latent class analysis, and attributable fraction, but each has serious limitations and none naturally integrate multiple test results. The Pneumonia Etiology Research for Child Health (PERCH) study required an analytic solution appropriate for a case-control design that could incorporate evidence from multiple specimens from cases and controls and that accounted for measurement error. We describe a Bayesian integrated approach we developed that combined and extended elements of attributable fraction and latent class analyses to meet some of these challenges and illustrate the advantage it confers regarding the challenges identified for other methods.

Psychological distress in informal caregivers of patients with dementia in primary care: course and determinants

BACKGROUND

The course of psychological distress in informal caregivers of patients with dementia has been investigated in longitudinal studies with conflicting outcomes.

OBJECTIVES

We investigated the course and determinants of psychological distress in informal caregivers of patients with dementia in primary care.

METHODS

In this prospective observational cohort study, data were collected at baseline, after 9 and 18 months. We assessed cognition and neuropsychiatric symptoms (NPS) of the patient (Mini-Mental State Examination and Neuropsychiatric Inventory) and psychological distress (Sense of Competence Questionnaire, Center for Epidemiological Studies Depression scale and General Health Questionnaire 12-tem version) of the informal caregivers. Determinants for the course of psychological distress were caregivers' age, gender and relationship with the patient, patients' cognition and NPS, participation in a care program and admission to long-term care facilities (LTCF). With linear mixed models, the course over time for psychological distress and its determinants were explored.

RESULTS

We included 117 informal caregivers, of whom 23.1% had a high risk for depression and 41.0% were identified to be likely to have mental problems at baseline. We found a stable pattern of psychological distress over time. Higher frequency of NPS, informal caregivers' age between 50 and 70 years and being female or spouse were associated with higher psychological distress. For patients who were admitted to a LTCF during the study psychological distress of the informal caregivers improved.

CONCLUSIONS

GPs should focus on NPS in patients with dementia and on caregivers' psychological distress and be aware of their risk for depression and mental problems, specifically to those who are spouse, female or between 50 and 70 years of age.

Flower development: the evolutionary history and functions of the AGL6 subfamily MADS-box genes

AGL6 is an ancient subfamily of MADS-box genes found in both gymnosperms and angiosperms. Its functions remained elusive despite the fact that the MADS-box genes and the ABC model have been studied for >20 years. Nevertheless, recent discoveries in petunia, rice, and maize support its involvement in the 'E' function of floral development, very similar to the closely related AGL2 (SEPALLATA) subfamily which has been well characterized. The known functions of AGL6 span from ancient conserved roles to new functions acquired in specific plant families. The AGL6 genes are involved in floral meristem regulation, in floral organs, and ovule (integument) and seed development, and have possible roles in both male and female germline and gametophyte development. In grasses, they are also important for the development of the first whorl of the flower, whereas in Arabidopsis they may play additional roles before floral meristem formation. This review covers these recent insights and some other aspects that are not yet fully elucidated, which deserve more studies in the future.

Developing a community matron service:a neighbourhood model

NHS Blackburn with Darwen Provider Services Unit has adopted an innovative team approach to improve patient access to its community matron service. This article reviews the national picture and local development of the community matrons role.

Combined cadmium and ozone treatments affect photosynthesis and ascorbate-dependent defences in sunflower

•  The combined effects of the two pollutants, cadmium and ozone, on sunflower (Helianthus annuus) metabolism are analysed here. •  Photosysnthetic processes and ascorbate metabolism were studied in sunflower plants grown for 15 d in the presence of cadmium and exposed to acute O₃ treatments. •  CO₂ assimilation rate was reduced in plants subjected to Cd(II) and/or O₃ treatments, but no alterations in stomatal conductance and F_v  : F_m ratio were observed. Rubisco activity was significantly reduced only in plants grown in the presence of cadmium indicating that the photosynthetic process is mainly altered by this factor. Photochemical quenching and the quantum efficiency of PSII in steady-state conditions were significantly depressed and nonphotochemical quenching increased in stressed plants. Cd(II) and O₃ also strongly affected ascorbate metabolism. •  The changes in ascorbate redox state and the increase in ascorbate-redox enzymes strongly supported an ascorbate over-utilization in Cd(II) and/or O₃ -treated plants. However, the increase in ascorbate-based detoxification mechanisms did not provide complete protection against the oxidative stress imposed by the two pollutants, since an increase in lipid peroxidation and protein oxidation accompanied a decrease in photosynthesis under pollutant exposure.