Impact of Prior Drug Allergies on the Risk, Clinical Features, and Outcomes of Idiosyncratic Drug-Induced Liver Injury in Adults

BACKGROUND

Prior drug allergies are common and may increase susceptibility to adverse medication effects. The aim of this study was to compare the frequency, clinical features, and outcomes of DILI among patients with and without a history of prior drug allergy.

METHODS

The EMR at a large liver referral center was searched for all DILI encounters using ICD-10 T-codes for drug poisoning/toxicity and K-71 codes for toxic liver injury between 10/1/2015 and 9/30/2019. Clinically significant liver injury was identified using predefined laboratory criteria, and cases were adjudicated using a 5-point expert opinion scale: 1/2/3 = probable DILI and 4/5 = non-DILI. Drug allergy was defined as a history of anaphylaxis, hives, rash, or pruritus after drug exposure.

RESULTS

Among 766,930 patient encounters, 127 unique patients met inclusion criteria with 72 (56.7%) cases adjudicated as probable DILI and 55 (43.3%) as non-DILI. In the probable DILI group, the most frequent suspect drug classes were: antimicrobials (41.9%), herbal and dietary supplements (9.5%), and antineoplastics (8.1%). Twenty-three of the 72 DILI patients (31.9%) had a history of drug allergy before the DILI episode compared to 16 (29.1%) of the 55 non-DILI cases (p = 0.89). However, none of the allergy drugs and suspect DILI drugs were the same although many were in the same drug class. DILI patients with a prior drug allergy were more likely to be female (73.9% vs. 44.9%, p = 0.04) and have lower serum bilirubin (4.0 vs. 7.8, p = 0.08) and INR (1.1 vs. 1.6, p = 0.043) levels at presentation. The likelihood of death or liver transplantation among probable DILI cases with prior drug allergy was lower than those without prior drug allergy (0% vs. 8.2%, p = 0.35). The suspect drug was subsequently documented in the "Drug Allergy" section of the EMR in only 23 (31.9%) of the 72 probable DILI patients, and these patients were more likely to present with a rash (7% vs. 2%, p = 0.006) and higher serum bilirubin levels (10.5 vs. 4.7, p = 0.008) compared to those in whom the suspect drug was not listed as "drug allergy."

CONCLUSION

A prior drug allergy history was not associated with a greater likelihood of developing DILI compared to other causes of acute liver injury. However, the probable DILI patients with a history of prior drug allergy tended to have less severe liver injury and clinical outcomes. The low rate of suspect drug documentation in the "Drug Allergy" section of EMR after a DILI episode is of concern and could lead to avoidable harm from inadvertent suspect drug re-challenge.

Smoking Is Associated With Microbial Translocation in the Miami Adult Studies on HIV (MASH) Cohort

Objectives

The prevalence of cigarette smoking is 2 to 3 times greater among people living with HIV (PLWH) than in the HIV uninfected population. Smoking has also been associated with deleterious effects on the gut leading to potential microbial translocation. Thus, we sought to use CD14 (sCD14) as a surrogate marker of microbial translocation to determine if smoking was associated with changes in microbial translocation.

Methods

A cross-sectional analysis was completed with participants from the Miami Adult Studies on HIV (MASH) cohort. Demographic characteristics and cigarette smoking status were self-reported. Levels of sCD14 were analyzed using ELISA kits in Dr. Sherman's laboratory. HIV serostatus and viral load (VL) were abstracted from medical records with the participants’ consent. Statistical analyses included descriptive statistics, T-test, linear regression for sCD14 levels, and logistic regression to calculate the odds of having an sCD14 level above the sample median (1064.3 ng/mL). All analyses were conducted on SPSS 26.

Results

A total of 470 participants were included in the analysis. The mean age was 53 ± 8 years, 42.8% were females and 64.5% were Black. PLWH accounted for 76.8% of participants and 85.1% had a suppressed VL (<50 copies/mL). Smokers had significantly higher mean sCD14 levels than non-smokers (1025.8 ± 429.0 vs. 1183.4 ± 465.7, respectively; P = 0.002). This relationship remained significant after adjusting for sex, age, BMI, and HIV status (β = 166.70, SE = 52.36, P = 0.002). Also, smoking tended to be associated with 1.6 times the odds of having high sCD14 levels, adjusted for BMI, age, sex, and HIV status (β = 1.6, 95% CI = 1.0–2.6, P = 0.051).

Conclusions

Cigarette smoking appears to contribute to immune activation regards of HIV status which may contribute to microbial translocation, regardless of HIV status. The findings provide further evidence of the deleterious effect of cigarette smoking on physiological functions, including gut health. Further research is needed to determine the long-term effects of smoking on immune activation and microbial translocation.

Funding Sources

Supported by the National Institute on Drug Abuse.

Predictors of Insulin Resistance and Liver Steatosis in the Miami Adult Studies on HIV (MASH) Cohort

Objectives

Immune activation is central to developing insulin resistance and is implicated in the pathophysiology of liver steatosis. People living with HIV (PLWH) have elevated biomarkers of immune activation, which may play a role in faster development of insulin resistance and liver steatosis. The objective of this study was to examine if HIV status and immune activation are related to insulin resistance and liver steatosis.

Methods

Demographic and anthropometric data on MASH cohort participants were obtained. Insulin resistance was estimated using the triglyceride-glucose (TyG) index from fasting blood. HIV status was abstracted from participants’ medical records. Immune activation biomarkers soluble CD163 (sCD163), sCD27, sCD14, and monocyte chemoattractant protein (MCP-1) measured with multiplex flow cytometry in Dr. Sherman's laboratory. High sensitivity C-Reactive Protein (hsCRP), measure of inflammation, was determined by LabCorp. Liver steatosis was defined as liver fat &gt;3.5% obtained with magnetic resonance elastography scans. Statistics included descriptive analysis, Mann-Whitney tests, multivariate linear, and logistic regressions, controlled for age, sex, and BMI.

Results

Of the 712 participants (age 54.24 ± 7.48 years), 336 were PLWH with suppressed viral load, and 376 were uninfected healthy participants. PLWH had higher levels of sCD27 (P = 0.003) and MCP-1 (P = 0.034) than uninfected participants. Multiple linear regressions showed HIV status and sCD163 were independently associated with higher insulin resistance (HIV status b = 0.130, P = 0.014, sCD163 Multiple logistic regressions showed higher levels of sCD163 (OR = 1.097, 95% CI: 1.01–1.19, P = 0.032) and insulin resistance (OR = 7.126, 95% CI: 2.59–19.58, P &lt; 0.001) were significant predictors of liver steatosis. HIV status, sCD14, sCD27, hsCRP, or MCP-1 were not related to liver steatosis.

Conclusions

These results indicate that HIV infection and sCD163, a marker of immune activation, are independent predictors of insulin resistance, and sCD163 was associated with greater odds of liver steatosis. Lifestyle interventions and anti-inflammatory agents aimed at reducing insulin resistance and immune activation in PLWH may help to reduce the risk of liver steatosis and other co-morbidities.

Funding Sources

Grant Number: U01DA040381.

Sex Differences, Cocaine Use, and Liver Fibrosis Among African Americans in the Miami Adult Studies on HIV Cohort

Background: HIV infection disproportionally affects African Americans. Liver disease is a major cause of non-HIV morbidity and mortality in this population. Substance abuse accelerates HIV disease and may facilitate progression of liver disease. This study investigated the relationship between sex differences and cocaine use with liver injury, characterized as hepatic fibrosis. Materials and Methods: A cross-sectional study was conducted on 544 African Americans [369 people living with HIV (PLWH) and 175 HIV seronegative] from the Miami Adult Studies on HIV (MASH) cohort. Cocaine use was determined with a validated self-reported questionnaire and confirmed with urine screen. Fasting blood was used to estimate liver fibrosis using the noninvasive fibrosis-4 (FIB-4) index. Results: Men living with HIV had 1.79 times higher odds for liver fibrosis than women living with HIV (p = 0.038). African American women had higher CD4 count (p = 0.001) and lower HIV viral load (p = 0.011) compared to African American men. Fewer women (PLWH and HIV seronegative) smoked cigarettes (p = 0.002), and fewer had hazardous or harmful alcohol use (p < 0.001) than men. Women also had higher body mass index (kg/m²) (p < 0.001) compared to men. No significant association was noted among HIV seronegative participants for liver fibrosis by sex differences or cocaine use. Among African Americans living with HIV, cocaine users were 1.68 times more likely to have liver fibrosis than cocaine nonusers (p = 0.044). Conclusions: Sex differences and cocaine use appear to affect liver disease among African Americans living with HIV pointing to the importance of identifying at-risk individuals to improve outcomes of liver disease.

359. TLR7 Gene Polymorphisms Influence Development of Hepatic Fibrosis in HCV/HIV Coinfection

Background

Hepatic fibrosis in individuals with HCV/HIV coinfection or HCV mono-infection may be modulated by a variety of host factors. In this study, we investigated the role of gene polymorphisms of putative genes that might influence fibrosis progression including MICA (rs2596542), interferon-stimulated gene OAS2 (rs1293762) and the pathogen recognition receptors TLR7 (rs179009) and TLR9 (rs187084). Effect on a cytokine panel was evaluated.

Methods

Longitudinal samples were obtained from subjects enrolled in the NCI Multicenter Hemophilia Cohort Study. Within the cohort, a subset of subjects were included based upon presence or absence of the CCR5 delta-32 mutation which was previously shown to influence the rate of fibrosis progression. Hepatic fibrosis change was determined using the serum-derived Enhanced Liver Fibrosis (ELF) Index. Four putative genes with polymorphisms that have been previously associated with the development or progression of hepatic fibrosis were evaluated using Taqman SNP genotyping assays. Cytokine assays were performed using Luminex chipsets. Samples were analyzed using Statistix 10.0 using ANOVA and least square regression models.

Results

58 unique subjects were evaluated. The mean age was 38 years, and all were male. 74% were HIV infected and 97% were HCV infected (76.8% coinfection). Controlling for the effect of CCR5, only the TLR7 A -> G polymorphism was predictive of change in the ELF Index. There was no statistically significant predictive difference between genotypes in the other three polymorphisms. Subjects with the TLR7 A allele (n = 47) had an average increase in ELF of 0.79 units, while the G allele (n = 11) had an increase in ELF of 2.1 units (P = 0.008). A regression model identified TLR7 as a key factor in ELF change, as well as HCV/HIV coinfection. Interferon alfa-2 levels were highly associated (increased, P = 0.0007) with the TLR7 A -> G polymorphism, while RANTES levels were inversely associated (decreased, P = 0.0443) with it.

Conclusion

Of the gene polymorphisms investigated, only TLR7 (rs179009) is an independent predictor of development of hepatic fibrosis in HCV/HIV coinfected subjects. The mechanism may involve modulation of inflammatory response pathways.

Disclosures

All authors: No reported disclosures.

285. Fibrosis Progression and Clinical Outcomes in HCV/HBV Coinfected Persons in the ERCHIVES Cohort

Background

Progression of liver disease and clinical outcomes in HCV/HBV coinfected persons and how they differ from HCV monoinfected persons and HCV infected persons with resolved HBV infection are not well characterized. We compared incidence of cirrhosis, hepatic decompensation and overall mortality in these three groups.

Methods

Using the Electronically Retrieved Cohort of HCV-infected Veterans (ERCHIVES), we identified those with HCV infection only, HCV/HBV coinfection (HbsAg or HBV DNA or both positive) or HCV with resolved HBV (HbcAb+ in absence of HbsAg or HBV DNA positivity). We excluded those with HIV coinfection or hepatocellular carcinoma at or before baseline, and those who received any HCV or HBV treatment. Incident rates (95% CI) were determined for cirrhosis, first hepatic decompensation event and overall mortality in the three groups.

Results

We identified 60,368 HCV monoinfected (Gp A), 151 HCV/HBV coinfected (Gp B) and 19,802 HCV infected with resolved HBV infection (Gp C). Mean age was 61.0, 60.9, and 63.0 years in the three groups and 96.5%, 96.0%, and 97.9% were males. Median baseline FIB-4 index was 2.0, 2.2, and 2.1, respectively. Incident cirrhosis (among those without cirrhosis at baseline) was increased 2- to 2.5-fold in HCV/HBV coinfected persons with baseline FIB-4 of 1.46–3.25. Hepatic decompensation and mortality were also increased several-fold in the HCV/HBV coinfected who had minimal or mild/moderate fibrosis at baseline. However, among those with cirrhosis at baseline, the difference was small among HCV/HBV coinfected and the other groups.

Conclusion

HCV/HBV coinfected persons with minimal or mild/moderate fibrosis at baseline have a much higher risk of developing cirrhosis, hepatic decompensation and mortality. However, once cirrhosis has is established, the difference is diminished. This underscores the need to intervene early when HCV/HBV coinfected persons still have minimal or mild/moderate fibrosis.

Disclosures

All authors: No reported disclosures.

294. Hepatitis C Virologic Response in Hepatitis B and C Coinfected Persons Treated with Directly Acting Antiviral Agents: Results from ERCHIVES

Background

Methods

Results

Conclusion

Disclosures

A text message intervention to support women's physical and mental health after breast cancer treatments (EMPOWER-SMS): a randomised controlled trial protocol

Background

Breast cancer is the most common cancer diagnosed in women worldwide. In developed countries, 80–90% of women will survive five years after diagnosis but the transition from hospital-based care to health self-management and self-efficacy can be difficult. Text messaging programs offer a simple and proven way to provide support to people with chronic diseases. This study aims to test the effectiveness of a text message support program at improving women’s health self-efficacy, and physical and mental health outcomes after breast cancer treatments compared to usual care at 6-months and to understand the barriers and enablers to widespread implementation.

Methods

Single-blind randomised control trial (RCT; N = 160) comparing a text message support intervention to usual care in women with breast cancer (recruited from a large tertiary referral hospital in Sydney, Australia). The intervention group will receive a six-month text message support program, which consists of semi-personalised, supportive, lifestyle-focused text messages (4 messages/week) in addition to usual care. The control group will receive usual care without the text message program. Outcomes will be assessed at 6-months. The primary outcome is change in self-efficacy for managing chronic disease. Secondary outcomes include change in clinical outcomes (body mass index), lifestyle outcomes (physical activity levels, dietary behaviours), mood (depression and anxiety scales), quality of life, satisfaction with, and usefulness of the intervention. Analyses will be performed on the principle of intention-to-treat to examine differences between intervention and control groups.

Discussion

This study will test if a scalable and cost-effective text-messaging intervention is effective at improving women’s health self-efficacy, as well as physical and mental health outcomes. Moreover, this study will provide essential preliminary data to bolster a large multicentre RCT to helpsupport breast cancer survivors throughout recovery and beyond.

Trial registration

Australia New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12618002020268, 17 December 2018

Association of TIMP1 Levels and Liver Disease Progression Among HIV/HCV Co-infected, HIV Mono-, HCV Mono-infected, and Healthy Groups from the MASH Cohort (FS09-07-19)

Objectives

Antiretroviral therapy has increased life expectancy for HIV infected patients; however, this population is developing chronic illnesses associated with aging. Liver disease is a major cause of non-AIDS mortality, characterized by progressive fibrosis. Infection with HIV and with Hepatitis C Virus (HCV) promotes liver fibrogenesis. Tissue inhibitor of metalloproteinase-1 (TIMP1), inhibits fibrosis regression and is profibrogenic. Association between TIMP1 and liver disease progression in an aging population of HIV/HCV co-infected, HIV mono-infected, HCV mono-infected, and healthy groups from the Miami Adult Studies on HIV (MASH) cohort in Miami, Florida, was investigated.

Methods

Serum TIMP1 levels were determined by ELISA. A non-invasive estimate of liver fibrosis, FIB-4 score was calculated. Liver fibrosis was defined as FIB-4: Low <1.45, intermediate 1.45 < = FIB-4 < = 3.25, High >3.25. ANOVA with Tukey's test assessed the mean differences of FIB-4 score and TIMP1 level between groups, TIMP1 levels between 3 FIB-4 categories, and the effect of age on FIB-4 and TIMP1. Linear regression predicted the association of FIB-4 score and TIMP-1 level.

Results

Mean age of the cohort was 54.3 ± 8.1 years with no difference between groups. Mean FIB-4 for HIV/HCV co-infected group was the highest among the 4 groups (P < 0.05). Mean TIMP1 for HIV/HCV co-infected group was also the highest among the 4 groups (P < 0.05). FIB-4 and TIMP1 were associated and remained so (β = 0.01, SE = 0.002, P < 0.001) after adjusting for age. Mean TIMP1 for the high FIB-4 category was the highest among the 3 FIB-4 categories (P < 0.05). There was a direct effect of TIMP1 levels on FIB-4 category (P < 0.001). After adjusting for HIV/HCV co-infection (P < 0.001), HIV infection (P < 0.0001), HCV infection (P < 0.002), non-infection (P < 0.001) and age, the relationship between TIMP1 and FIB-4 remained significant. The adjusted TIMP1 mean for HIV/HCV co-infected group was significantly higher compared to HIV infected (P < 0.0001), HCV infected (P < 0.002), and healthy groups (P < 0.0001), regardless of age.

Conclusions

Age is a significant factor of liver diseases progression. Our findings of the highest levels of TIMP1 in HIV/HCV co-infected group, which had the highest liver fibrosis regardless of age, supports the role of TIMP1 as a regulator in the progression of hepatic fibrosis.

Funding Sources

National Institutes on Drug Abuse #5UO1DA040381.

Accelerated warming and emergent trends in fisheries biomass yields of the world's large marine ecosystems

Information on the effects of global climate change on trends in global fisheries biomass yields has been limited in spatial and temporal scale. Results are presented of a global study of the impact of sea surface temperature (SST) changes over the last 25 years on the fisheries yields of 63 large marine ecosystems (LMEs) that annually produce 80% of the world's marine fisheries catches. Warming trends were observed in 61 LMEs around the globe. In 18 of the LMEs, rates of SST warming were two to four times faster during the past 25 years than the globally averaged rates of SST warming reported by the Intergovernmental Panel on Climate Change in 2007. Effects of warming on fisheries biomass yields were greatest in the fast-warming northern Northeast Atlantic LMEs, where increasing trends in fisheries biomass yields were related to zooplankton biomass increases. In contrast, fisheries biomass yields of LMEs in the fast-warming, more southerly reaches of the Northeast Atlantic were declining in response to decreases in zooplankton abundance. The LMEs around the margins of the Indian Ocean, where SSTs were among the world's slowest warming, revealed a consistent pattern of fisheries biomass increases during the past 25 years, driven principally by human need for food security from fisheries resources. As a precautionary approach toward more sustainable fisheries utilization, management measures to limit the total allowable catch through a cap-and-sustain approach are suggested for the developing nations recently fishing heavily on resources of the Agulhas Current, Somali Current, Arabian Sea, and Bay of Bengal LMEs.

Smart tool for force measurements during knee arthroscopy: in vivo human study

This paper describes the magnitude and patterns of forces obtained by using a probe, equipped with a six-axis force torque sensor, in knee arthroscopy. The probe was used by orthopaedic surgeons and trainees, who performed 11 different tasks in 10 standard knee arthroscopies. The force magnitude and patterns generated are presented; which can support the development of virtual arthroscopy systems with realistic haptic feedback. The results were compared across both groups of surgeons. A difference in the force patterns generated by senior versus junior surgeons was noted which can aid in the development of an objective assessment system for arthroscopy skills. The results could potentially be useful to assess future performance in real arthroscopy.

Computer assisted orthopaedic surgical system for insertion of distal locking screws in intra-medullary nails: a valid and reliable navigation system

The insertion of distal locking screws is a difficult task in intra-medullary (IM) nailing operations of long bones and contributes a significant proportion to the overall operating time. The current technique to insert these screws uses numerous fluoroscopic images and depends on the skills and expertise of the surgeon. The Computer Assisted Orthopaedic Surgical System (CAOSS) was developed to assist orthopaedic surgeons in these operations. The laboratory based test results for insertion of distal locking screws in IM nailing procedures are presented and discussed in terms of accuracy and as part of the validation process to introduce new CAOS procedures into clinical use. This study shows that CAOSS in IM nailing is robust and reliable. Positional accuracy was shown to be within 0.3 mm and angular accuracy within 0.2 degrees with femoral IM nail. CAOSS was also shown to be very reliable and accurate at different angles of distal screws in fluoroscopic image space.

Maintenance therapy with a probiotic in antibiotic-dependent pouchitis: experience in clinical practice

BACKGROUND

Management of antibiotic-dependent pouchitis is often challenging. Oral bacteriotherapy with probiotics (such as VSL #3) as maintenance treatment has been shown to be effective in relapsing pouchitis in European trials. However, this agent has not been studied in the US, and its applicability in routine clinical practice has not been evaluated.

AIM

To determine compliance and efficacy of probiotic treatment in patients with antibiotic-dependent pouchitis.

METHODS

Thirty-one patients with antibiotic-dependent pouchitis were studied. VSL #3 is a patented probiotic preparation of live freeze-dried bacteria. All patients received 2 weeks of ciprofloxacin 500 mg b.d. followed by VSL #3 6 g/day for 8 months. Baseline Pouchitis Disease Activity Index scores were calculated. Patients' symptoms were reassessed at week 3 when VSL #3 therapy was initiated and at the end of the 8-month trial. Some patients underwent repeat pouch endoscopy at the end of the trial.

RESULTS

All 31 patients responded to the 2-week ciprofloxacin trial with resolution of symptoms and they were subsequently treated with VSL #3. The mean duration of follow-up was 14.5+/-5.3 months (range: 8-26 months). At the 8-month follow-up, six patients were still on VSL #3 therapy, and the remaining 25 patients had discontinued the therapy due to either recurrence of symptoms while on treatment or development of adverse effects. All six patients who completed the 8-month course with a mean treatment period of 14.3+/-7.2 months (range: 8-26 months) had repeat clinical and endoscopic evaluation as out-patients. At the end of 8 months, these six patients had a mean Pouchitis Disease Activity Index symptom score of 0.33+/-0.52 and a mean Pouchitis Disease Activity Index endoscopy score of 1.83+/-1.72, which was not statistically different from the baseline Pouchitis Disease Activity Index endoscopy score of 2.83+/-1.17 (P=0.27).

CONCLUSION

This study was conducted to evaluate bacteriotherapy in routine care. The use of probiotics has been adopted as part of our routine clinical practice with only anecdotal evidence of efficacy. Our review of patient outcome from the treatment placebo showed that only a minority of patients with antibiotic-dependent pouchitis remained on the probiotic therapy and in symptomatic remission after 8 months.

Absence of cyclic citrullinated peptide antibody in nonarthritic patients with chronic hepatitis C infection

OBJECTIVE

The increased prevalence of rheumatoid factor (RF) in patients with chronic hepatitis C virus (HCV) infection markedly diminishes the diagnostic specificity of serum rheumatoid factor (RF) for rheumatoid arthritis (RA) in patients with HCV. Cyclic citrullinated peptide (CCP) antibody, a highly specific biomarker for RA in the general population, may have better diagnostic utility for RA in the HCV population. To investigate if CCP antibody retains its specificity for RA in HCV infection, we determined the prevalence of CCP antibodies and examined the relationship between RF production and CCP antibody levels in a population of nonarthritic patients with chronic HCV infection.

METHODS

CCP antibody and IgM, IgG, and IgA RF isotypes were determined by ELISA in serum from nonarthritic patients with chronic HCV infection.

RESULTS

In a series of 50 HCV patients, IgG-RF, IgM-RF, and IgA-RF were detectable in 52%, 26%, and 14%, respectively, with a total seropositivity rate of 54%. Marginally elevated CCP antibody was detected in a single patient (2%). By regression analysis, serum levels of CCP antibodies did not correlate with RF levels.

CONCLUSION

In contrast to RF, CCP antibody is not increased in HCV infection. CCP antibody may have improved utility for the diagnosis of RA in this patient population.

Antiapoptotic role of the p38 mitogen-activated protein kinase-myocyte enhancer factor 2 transcription factor pathway during neuronal differentiation

Myocyte enhancer factor 2 (MEF2) is in the MADS (MCM1agamous-deficiens-serum response factor) family of transcription factors. Although MEF2 is known as a myogenic factor, the expression pattern of the MEF2 family of genes (MEF2A-D) in developing brain also suggests a role in neurogenesis. Here we show that transfection with MEF2C, the predominant form in mammalian cerebral cortex, induces a mixed neuronal/myogenic phenotype in undifferentiated P19 precursor cells. During retinoic acid-induced neurogenesis of these cells, a dominant negative form of MEF2 enhances apoptosis but does not affect cell division. The mitogen-activated protein kinase p38alpha activates MEF2C. Dominant negative p38alpha also enhances apoptotic death of differentiating neurons, but these cells can be rescued from apoptosis by coexpression of constitutively active MEF2C. These findings suggest that the p38alpha/MEF2 pathway prevents cell death during neuronal differentiation.

Absence of binding activity of neuron-restrictive silencer factor is necessary, but not sufficient for transcription of NMDA receptor subunit type 1 in neuronal cells

Neuron-restrictive silencer factor (NRSF, also termed REST) has been proposed to restrict expression of a set of genes to neurons by blocking their transcription in nonneuronal cells. The N-methyl-D-aspartate (NMDA) receptor subunit type I (NR1) gene contains a consensus sequence for the NRSF/REST binding site (NRSE/RE1). In this study, we evaluated the contribution of NRSF/REST to neuronal specificity of the NR1 gene. NR1 mRNA expression correlates with the absence of NRSF/REST binding activity, rather than expression of NRSF/REST protein, in several cell lines, suggesting that the absence of NRSF/REST-binding activity is necessary for the expression of the NR1 gene. HeLa cells, which do not express the NR1 gene, have NRSF/REST binding activity to the NR1 NRSE/RE1, resulting in inhibition of NR1 promoter activity. However, we also found that two nonneuronal cell lines (C6 glioma and P19 embryonal carcinoma) that lack NRSF/REST-binding activity, manifest only small amounts of NR1 mRNA compared to neuronal cell lines (PC12 pheochromocytoma and neuronally differentiated P19 cells). The enhancement of NR1 mRNA levels during neuronal differentiation of P19 cells is accompanied by an increase in NR1 promoter activity in an NRSF/REST-binding independent manner. Our results suggest therefore that the absence of NRSF/REST-binding activity is necessary but not sufficient for robust NR1 transcription in neuronal cells.

Zhong Yi acupuncture and low-back pain: traditional Chinese medical acupuncture differential diagnoses and treatments for chronic lumbar pain

Little attention has been given to selecting treatments in clinical trials of acupuncture. Yet in order to perform objective tests of this procedure, it is crucial that the selected treatments are considered representative of the style of practice being tested. We examined 16 traditional Chinese medicine (TCM) acupuncture texts or treatment articles to determine the consistency of diagnosis and recommended treatment for chronic low-back pain. Although 24 diagnostic patterns were described by 1 or more texts, only 4 patterns were described by at least half of the texts. Most texts (12/16) described only 3 or 4 patterns. These could be categorized into 3 broad types: cold, damp, wind, heat channel obstruction patterns; kidney vacuity patterns (sometimes differentiated into yang and yin patterns); and blood (or blood and qi) stasis patterns. Several acupuncture points were recommended by most texts regardless of the diagnosis, whereas other acupoints were recommended for specific diagnostic patterns. There was, however, substantial variation between texts in recommended acupoints, with less than 20% of all acupoints recommended by half or more of the texts. This varibility will make it difficult to select TCM treatments for clinical trials of chronic low-back pain that have wide applicability. We believe that examining treatment patterns in actual clinical practice is crucial in this situation. We suggest that this method of selecting treatments should be part of the process used when selecting treatments for all clinical trials of acupuncture, regardless of the style of practice.

Structure-function analysis of the trypanosomatid spliced leader RNA

In trypanosomes, all mRNAs possess a spliced leader (SL) at their 5' end. SL is added to pre-mRNA via trans -splicing from a small RNA, the SL RNA. To examine structure-function aspects of the trypanosomatid SL RNA, an in vivo system was developed in the monogenetic trypanosomatid Leptomonas collosoma to analyze the function of chimeric and site-directed SL RNA mutants in trans -splicing. Stable cell lines expressing chimeric and mutated SL RNA from the authentic SL RNA regulatory unit were obtained. The chimeric RNA was expressed and assembled into an SL RNP particle, but could not serve as a substrate in splicing. Mutations in loop II and III of L.collosoma SL RNA formed the Y structure intermediate. In addition, a double SL RNA mutant in loop II, and positions 7 and 8 of the intron, also formed the Y structure intermediate, suggesting that these intron positions, although proposed to participate in the interaction of SL RNA with U5, may not be crucial for the first step of the trans -splicing reaction. A mutation in the exon located in loop I was not utilized in splicing, suggesting the importance of exon sequences for trans -splicing in trypanosomes. However, a double SL RNA mutant in loop II and exon position 31 was utilized in both steps of splicing; the mutant thus provides a model molecule for further analysis of positions essential for the function of the SL RNA.

Recruiting nurses based on competencies needed in the restructured environment

Although the market seems to be flooded with them, you may very well be facing a shortage of nurses. It has never been more critical to the survival of your organization to have the "right" nurses in place. By using a careful and intentional process of defining successful characteristics while your new care model is being designed, you should be able to avoid the pitfalls of recruiting during a period of urgent need. To hire the right nurses to support the restructured environment, you need to avoid the approach of hiring "all-at-once" just to fill vacancies.

Evidence for a global scanpath strategy in viewing abstract compared with realistic images

Scanpaths, the repetitive sequences of saccadic eye movements, occurred when subjects viewed slide projections of both realistic and abstract art. Variance analysis demonstrated that global/local eye movement indices were lower for local scanning by professional art viewers who relied on more global viewing, particularly in abstract images. Non-professional, unsophisticated subjects carried their local scanpath patterns from realistic images on to abstract images. The blink rate of professional subjects viewing abstract images was also significantly lower, indicating increased visual effort. Non-professional viewers showed no difference in blink rates.