The Role of Imatinib in Pediatric Type 1 Diabetes

We report the first case of imatinib use in an adolescent with diabetes and suggest that it impacts the natural course of disease. A 14-year-old male patient presented in diabetic ketoacidosis (DKA) and was diagnosed with presumed autoantibody-negative type 1 diabetes (T1D) as well as myeloid neoplasm with platelet-derived growth factor receptor beta (PDGFRB) rearrangement. After starting exogenous insulin and imatinib, he experienced a 1.7-point reduction in glycated hemoglobin (HbA1c) and a 71% reduction in insulin requirement with sustained partial diabetes remission. Our case suggests imatinib as a potential therapeutic agent for pediatric T1D.

326 Resorbable Composite Materials for Fracture Fixation

Introduction

Titanium-based fracture fixation devices often necessitate removal in the maxillofacial region. Resorbable composite implants negate the need for a revision operation; however, concurrent devices either possess a prolonged degradation profile or bioactivity, resulting in undesirable bone deposition. To that end, a novel, fast-resorbing, non-bioactive composite material is proposed, which still possesses an osteoinductive potential, thereby aiding fracture healing.

Method

Three bioglasses were available (NCL1-3) as filler material. NCL2 was selected and different concentrations (5%; 20%) were added to reinforce medical grade poly(lactic-co- glycolide) (PLGA). The final compression moulded samples underwent material characterisation and an 8-week degradation assay.

Results

No significant difference was found between the cytotoxicity of the glasses and both the positive (apatite wollastonite) and negative (absence of glass) controls in relation to mesenchymal stem cells or osteoblasts. pH and weight change analyses showed an increased rate of degradation with an increase in glass concentration. Although reinforcement with NCL2 did not increase the mechanical properties of the polymer, no significant difference was present between the mechanical properties of the composites, and, as made, both 5% and 20% composites had flexural strengths of 13MPa±5, which did not decrease significantly during degradation.

Conclusions

NCL1-3 are non-toxic in the context of fracture healing. The PLGA/NCL2 composite is not suitable for fracture fixation as produced currently, due to increased polymer degradation and lower mechanical properties. However, 20% compositions are recommended for future research, as they would hypothetically provide a superior osteoinductive response without significantly lowering the mechanical properties of the composite.

The Need for Precision Medicine to be Applied to Diabetes

Precision medicine refers to the tailoring of medical treatment for an individual based on large amounts of biologic and extrinsic data. The fast advancing fields of molecular biology, gene sequencing, machine learning, and other technologies enable precision medicine to utilize this detailed information to enhance clinical management decision-making for an individual in the real time of the disease course. Traditional clinical decision making is based on reacting to a relatively limited number of phenotypes that are determined by history, physical examination, and conventional lab tests. Precision medicine depends on highly detailed profiling of the patient's genetic, morphologic, and metabolic makeup. The precision medicine approach can be applied to individuals with diabetes to select treatments most likely to offer benefit and least likely to cause side effects, offering prospects of improved clinical outcomes and economic costs savings over current empiric practices. As genetic, metabolomic, immunologic, and other sophisticated testing becomes less expensive and more widespread in the medical record, it is expected that precision medicine will become increasingly applied to diabetes care.

Fluoride removal from groundwater using Zirconium Impregnated Anion Exchange Resin

Drinking water containing excess fluoride is a major health concern across the globe. The present study reports the feasibility of zirconium impregnated hybrid anion exchange resin (HAIX-Zr) for treating fluoride contaminated groundwater. The HAIX-Zr resin was prepared by impregnating ZrO₂ nanoparticles on polymeric anion exchanger resin. Fluoride uptake by HAIX-Zr was quite rapid, 60% removal was obtained within 30 min. Kinetics of fluoride uptake by HAIX-Zr resin followed the pseudo-second-order kinetic model and adsorption data fitted best to Freundlich adsorption isotherm model. Maximum fluoride uptake capacity was observed as 12.0 mg/g. The defluoridation capacity of the resin decreases with increase in solution pH. The co-existing anions like chloride, phosphate, bicarbonate, nitrate, and sulphate at 100 mg/L concentration significantly affected fluoride removal and bicarbonate showed the highest interference. Continuous flow packed bed experiments were performed with real groundwater. To maintain a lower pH, weak acid cation exchange resin (INDION-236) was used before HAIX-Zr. It was observed that reducing the pH of the sample water to 4-4.5, increased the number of treated bed volumes fifteen times. Regeneration of fluoride-containing resin was done by passing 3% NaOH and 3% NaCl solution through an exhausted resin bed. The results revealed that HAIX-Zr can effectively remove fluoride from groundwater.

Identification of novel, clinically correlated autoantigens in the monogenic autoimmune syndrome APS1 by proteome-wide PhIP-Seq

The identification of autoantigens remains a critical challenge for understanding and treating autoimmune diseases. Autoimmune polyendocrine syndrome type 1 (APS1), a rare monogenic form of autoimmunity, presents as widespread autoimmunity with T and B cell responses to multiple organs. Importantly, autoantibody discovery in APS1 can illuminate fundamental disease pathogenesis, and many of the antigens found in APS1 extend to more common autoimmune diseases. Here, we performed proteome-wide programmable phage-display (PhIP-Seq) on sera from a cohort of people with APS1 and discovered multiple common antibody targets. These novel APS1 autoantigens exhibit tissue-restricted expression, including expression in enteroendocrine cells, pineal gland, and dental enamel. Using detailed clinical phenotyping, we find novel associations between autoantibodies and organ-restricted autoimmunity, including a link between anti-KHDC3L autoantibodies and premature ovarian insufficiency, and between anti-RFX6 autoantibodies and diarrheal-type intestinal dysfunction. Our study highlights the utility of PhIP-Seq for extensively interrogating antigenic repertoires in human autoimmunity and the importance of antigen discovery for improved understanding of disease mechanisms.

Ultrasonic cement removal in cement-in-cement revision total hip arthroplasty: What is the effect on the final cement-in-cement bond?

Objectives

Previous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. Commonly, the original cement mantle is reshaped, aiding accurate placement of the new stem. Ultrasonic devices selectively remove cement, preserve host bone, and have lower cortical perforation rates than other techniques. As far as the authors are aware, the impact of ultrasonic devices on final cement-in-cement bonds has not been investigated. This study assessed the impact of cement removal using the Orthosonics System for Cemented Arthroplasty Revision (OSCAR; Orthosonics) on final cement-in-cement bonds.

Methods

A total of 24 specimens were manufactured by pouring cement (Simplex P Bone Cement; Stryker) into stainless steel moulds, with a central rod polished to Stryker Exeter V40 specifications. After cement curing, the rods were removed and eight specimens were allocated to each of three internal surface preparation groups: 1) burr; 2) OSCAR; and 3) no treatment. Internal holes were recemented, and each specimen was cut into 5 mm discs. Shear testing of discs was completed by a technician blinded to the original grouping, recording ultimate shear strengths. Scanning electron microscopy (SEM) was completed, inspecting surfaces of shear-tested specimens.

Results

The mean shear strength for OSCAR-prepared specimens (33.6 MPa) was significantly lower than for the control (46.3 MPa) and burr (45.8 MPa) groups (p < 0.001; one-way analysis of variance (ANOVA) with Tukey’s post hoc analysis). There was no significant difference in shear strengths between control and burr groups (p = 0.57). Scanning electron microscopy of OSCAR specimens revealed evidence of porosity undiscovered in previous studies.

Conclusion

Results show that the cement removal technique impacts on final cement-in-cement bonds. This in vitro study demonstrates significantly weaker bonds when using OSCAR prior to recementation into an old cement mantle compared with cement prepared with a burr or no treatment. This infers that care must be taken in surgical decision-making regarding cement removal techniques used during cement-in-cement revision arthroplasty, suggesting that the risks and benefits of ultrasonic cement removal need consideration.

Cite this article: A. Liddle, M. Webb, N. Clement, S. Green, J. Liddle, M. German, J. Holland. Ultrasonic cement removal in cement-in-cement revision total hip arthroplasty: What is the effect on the final cement-in-cement bond? Bone Joint Res 2019;8:246–252. DOI: 10.1302/2046-3758.86.BJR-2018-0313.R1.

Aluminum-Cycle Ion Exchange Process for Hardness Removal: A New Approach for Sustainable Softening

From a sustainability viewpoint, sodium exchange softening, although used widely, is under scrutiny due to its production of excess Na-laden spent regenerant and subsequent discharge to the environment. Many arid regions are introducing regulations disallowing dumping of concentrated sodium salts, the residuals from popular Na-exchange softening. The sodium content of the softened water is, also, always higher than in the feed, which poses a dietary health concern when used for drinking or cooking. An efficient, easy-to-operate hardness removal process with reduced sodium in both the treated water and in the spent regenerant is an unmet global need. Use of a cation exchange resin in Al³⁺-form for hardness removal, that is, exchange of divalent Ca²⁺ or Mg²⁺ with trivalent Al³⁺, is counterintuitive, and this is particularly so, because the aluminum ion to be exchanged has higher affinity than calcium. Nevertheless, ion exchange accompanied by precipitation of aluminum hydroxide allows progress of the cation exchange reaction leading to hardness removal. Experimental results demonstrated that calcium can be consistently removed for multiple cycles using a stoichiometric amount of AlCl₃ as the regenerant. The process essentially operates at the maximum possible thermodynamic efficiency: removal of one equivalent of Ca²⁺ corresponds to use of one equivalent of Al³⁺ as a regenerant. During the Al-cycle process there is no increase in Na⁺ concentration and partial reduction in the total dissolved solids (TDS) of the treated water. It is noteworthy that the ion-exchange resin used, components of the fixed-bed column and operational protocol are nearly the same as traditional softening processes on Na-cycle. Thus, existing Na-cycle systems can be retrofitted into Al-cycle operation without major difficulty.

Mitigating arsenic crisis in the developing world: role of robust, reusable and selective hybrid anion exchanger (HAIX)

In trying to address the public health crisis from the lack of potable water, millions of tube wells have been installed across the world. From these tube wells, natural groundwater contamination from arsenic regularly puts at risk the health of over 100 million people in South and Southeast Asia. Although there have been many research projects, awards and publications, appropriate treatment technology has not been matched to ground level realities and water solutions have not scaled to reach millions of people. For thousands of people from Nepal to India to Cambodia, hybrid anion exchange (HAIX) resins have provided arsenic-safe water for up to nine years. Synthesis of HAIX resins has been commercialized and they are now available globally. Robust, reusable and arsenic-selective, HAIX has been in operation in rural communities over numerous cycles of exhaustion-regeneration. All necessary testing and system maintenance is organized by community-level water staff. Removed arsenic is safely stored in a scientifically and environmentally appropriate manner to prevent future hazards to animals or people. Recent installations have shown the profitability of HAIX-based arsenic treatment, with capital payback periods of only two years in ideal locations. With an appropriate implementation model, HAIX-based treatment can rapidly scale and provide arsenic-safe water to at-risk populations.

Hydrogen ion (H+) in waste acid as a driver for environmentally sustainable processes: opportunities and challenges

Acid-base neutralization reaction in the aqueous phase is thermodynamically favorable and kinetically fast. Waste acid neutralization is also the most common waste management practice globally. However, waste acid neutralization is yet to be used for any work/energy generation because of the low concentrations of the waste acid and the high heat capacity of aqueous solutions. In this paper, we address potential processes that can effectively take advantage of the high energy inherent in neutralization reactions, in accordance with the goal of sustainable development.

Oral synechia with epithelial cyst in neonate with cleft palate: a case report

Cleft palate with oral synechia is a rare congenital deformity that is represented in the literature by only a handful of cases. Midline synechia is less common than lateral. Failure to recognize and appropriately treat this condition has serious implications for neonatal airway management and feeding. We present a case of cleft palate with midline subglossopalatal synechia that was transferred from an outside institution after a prolonged period of nonsurgical management in which the patient ultimately required intubation for respiratory distress. Release of the synechia was performed without complications. We review the current literature and discuss diagnosis and surgical management of this rare condition.

Notch signaling as gatekeeper of rat acinar-to-beta-cell conversion in vitro

BACKGROUND & AIMS

Exocrine acinar cells in the pancreas are highly differentiated cells that retain a remarkable degree of plasticity. After isolation and an initial phase of dedifferentiation in vitro, rodent acinar cells can convert to endocrine beta-cells when cultured in the presence of appropriate factors. The mechanisms regulating this phenotypic conversion are largely unknown.

METHODS

Using rat acinar cell cultures, we studied the role of Notch signaling in a model of acinar-to-beta-cell conversion.

RESULTS

We report a novel lectin-based cell labeling method to demonstrate the acinar origin of newly formed insulin-expressing beta-cells. This method allows for specific tracing of the acinar cells. We demonstrate that growth factor-induced conversion of adult acinar cells to beta-cells is negatively regulated by Notch1 signaling. Activated Notch1 signaling prevents the reexpression of the proendocrine transcription factor Neurogenin-3, the key regulator of endocrine development in the embryonic pancreas. Interfering with Notch1 signaling allows modulating the acinar cell susceptibility to the differentiation-inducing factors. Its inhibition significantly improves beta-cell neoformation with approximately 30% of acinar cells that convert to beta-cells. The newly formed beta-cells mature when transplanted ectopically and are capable of restoring normal blood glycemia in diabetic recipients.

CONCLUSIONS

We report for the first time an efficient way to reprogram one third of the acinar cells to beta-cells by adult cell type conversion. This could find application in cell replacement therapy of type 1 diabetes, provided that it can be translated from rodent to human models.

Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks

BACKGROUND

Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization.

METHODS

A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak.

RESULTS

In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed.

CONCLUSION

Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.

Genotyping of Toxoplasma gondii strains from immunocompromised patients reveals high prevalence of type I strains

Toxoplasma gondii is an important food- and waterborne opportunistic pathogen that causes severe disease in immunocompromised patients. T. gondii has an unusual clonal population structure consisting of three widespread lineages known as I, II, and III. To establish the genotypes of strains of T. gondii associated with human toxoplasmosis, we have developed a set of four highly sensitive and polymorphic nested PCR markers. Multiplex nested PCR analysis was used to genotype parasites in cerebral spinal fluid samples from 8 of 10 human immunodeficiency virus-positive patients. Remarkably, a majority of these patients had infections with type I strains or strains containing type I alleles, despite the fact that this lineage is normally uncommon in humans and animals. Multiplex analysis of these four unlinked makers was able to distinguish all three common genotypes and also detected two strains with mixed genotypes. Further analysis based on sequencing of a polymorphic intron revealed that one of these recombinant strains was an exotic lineage distinct from the archetypal clonal lineages. The multiplex nested PCR analysis described here will be useful for analyzing the contribution of parasite genotype to toxoplasmosis.

Feeding behavior modulation in the leopard lizard (Gambelia wislizenii): Effects of noxious versus innocuous prey

Feeding, a fundamentally rhythmic behavior in many animals, is expected to exhibit modulation with respect to prey type. Using high-speed videography (200 frames(-1)) and kinematic analysis, we investigated prey-processing behavior in the long-nosed leopard lizard (Gambelia wislizenii). The effects of two prey types were examined, innocuous immature crickets (Acheta domesticus) and noxious stinging hymenopterans (honeybees [Apis mellifer] and yellow jackets [Vespula sp.]). Stinging hymenopterans are processed more extensively, with higher gape-cycling frequencies, and for a greater duration than are crickets. Generalized tetrapod feeding models were used as a framework to test the hypothesis that gape profile characteristics are modulated in response to prey noxiousness. Cricket processing generally fits the models, but hymenopteran processing departs from typical model parameters. In particular, the SO phase is absent to barely detectable during hymenopteran processing. This likely represents an effect of extrinsic neural input on a centrally directed rhythmic motor pattern, possibly to avoid being stung. Differences in the capture behavior of crickets versus hymenopterans indicate that G. wislizenii assesses prey noxiousness before physical contact with prey and modifies its capture behavior accordingly. These results add to the growing body of evidence that sensory information can play a critical role in shaping stereotyped rhythmic behaviors in non-mammalian tetrapods.

The production of hydrogen peroxide during early-stage protein aggregation: a common pathological mechanism in different neurodegenerative diseases?

By means of an ESR spin-trapping method, we have shown that Aβ (amyloid β), α-synuclein and various toxic forms of the prion protein all appear to generate H2O2in vitro. A fundamental molecular mechanism underlying the pathogenesis of cell death in several different neurodegenerative diseases could be the direct production of H2O2 during the early stages of protein aggregation.

The Nkx6.1 homeodomain transcription factor suppresses glucagon expression and regulates glucose-stimulated insulin secretion in islet beta cells

We have previously described rat insulinoma INS-1-derived cell lines with robust or poor glucose-stimulated insulin secretion (GSIS). In the current study, we have further resolved these lines into three classes: class 1, glucose-unresponsive/glucagon-expressing; class 2, glucose-unresponsive/glucagon-negative; and class 3, glucose-responsive/glucagon-negative. The transcription factor Nkx2.2 was expressed with relative abundance of 3.3, 1.0, and 1.0 in class 1, class 2, and class 3 cells, respectively, whereas Nkx6.1 expression had the opposite trend: 1.0, 2.6, and 6.4 in class 1, class 2, and class 3 cells, respectively. In class 1 cells, overexpressed Nkx6.1 suppressed glucagon expression but did not affect the levels of several other prominent beta cell transcription factors. RNA interference (RNAi)-mediated suppression of Nkx6.1 in class 3 cells resulted in a doubling of glucagon mRNA, with no effect on Pdx1 levels, whereas suppression of Pdx1 in class 3 cells caused a 12-fold increase in glucagon transcript levels, demonstrating independent effects of Nkx6.1 and Pdx1 on glucagon expression in beta cell lines. RNAi-mediated suppression of Nkx6.1 expression in class 3 cells also caused a decrease in GSIS from 13.9- to 3.7-fold, whereas suppression of Pdx1 reduced absolute amounts of insulin secretion without affecting fold response. Finally, RNAi-mediated suppression of Nkx6.1 mRNA in primary rat islets was accompanied by a significant decrease in GSIS relative to control cells. In sum, our studies have revealed roles for Nkx6.1 in suppression of glucagon expression and control of GSIS in islet beta cells.

Proendocrine genes coordinate the pancreatic islet differentiation program in vitro

In the developing pancreas, the basic helix-loop-helix (bHLH) protein Neurogenin3 (Ngn3) specifies which precursor cells ultimately will become endocrine cells and initiates the islet differentiation program. NeuroD1, a closely related bHLH protein and a downstream target of Ngn3, maintains the differentiation program initiated by Ngn3. We have developed an in vitro model of Ngn3-dependent differentiation by infecting pancreatic duct cell lines with an Ngn3-expressing adenovirus. We found that both Ngn3 and its downstream target NeuroD1 activated the islet differentiation program in these cells by inducing the expression of genes with early roles in the differentiation cascade, as well as genes characteristic of fully differentiated islet cells. Induction of these genes, as exemplified by the insulin1 gene, involved alteration of the local chromatin structure. Interestingly, the subsets of genes activated by Ngn3 and NeuroD1 were not completely overlapping, indicating that these two bHLH proteins serve specific functions in the development of the endocrine pancreas. In addition, microarray gene expression analysis identified a previously uncharacterized group of Ngn3-induced genes with potentially important roles in islet development and function. These studies demonstrate how Ngn3 initiates islet differentiation and provide us with a model for testing methods for producing islet cells for people with diabetes.

Progress in near-field photothermal infra-red microspectroscopy

Near-field photothermal Fourier transform infra-red microspectroscopy, which utilizes atomic force microscopy (AFM)-type temperature sensors, is being developed with the aim of achieving a spatial resolution higher than the diffraction limit. Here we report on a new implementation of the technique. Sensitivity of the technique is assessed by recording infra-red spectra from small quantities of analytes and thin films. A photothermomechanical approach, which utilizes conventional AFM probes as temperature sensors, is also discussed based on preliminary results. Early indication suggests that the photothermal approach is more sensitive than the thermomechanical one.

Region-specific and stage-dependent regulation of Olig gene expression and oligodendrogenesis by Nkx6.1 homeodomain transcription factor

During early neural development, the Nkx6.1 homeodomain neural progenitor gene is specifically expressed in the ventral neural tube, and its activity is required for motoneuron generation in the spinal cord. We report that Nkx6.1 also controls oligodendrocyte development in the developing spinal cord, possibly by regulating Olig gene expression in the ventral neuroepithelium. In Nkx6.1 mutant spinal cords, expression of Olig2 in the motoneuron progenitor domain is diminished, and the generation and differentiation of oligodendrocytes are significantly delayed and reduced. The regulation of Olig gene expression by Nkx6.1 is stage dependent, as ectopic expression of Nkx6.1 in embryonic chicken spinal cord results in an induction of Olig2 expression at early stages, but an inhibition at later stages. Moreover, the regulation of Olig gene expression and oligodendrogenesis by Nkx6.1 also appears to be region specific. In the hindbrain, unlike in the spinal cord, Olig1 and Olig2 can be expressed both inside and outside the Nkx6.1-expressing domains and oligodendrogenesis in this region is not dependent on Nkx6.1 activity.

The Gene Pill and its therapeutic applications

Gene delivery represents a revolutionary therapeutic approach with the potential for sustained protein production by the human body, leading to a convenient and effective method for systemic delivery of protein drugs. In this review, advantages of an orally administered DNA formulation, Gene Pill, are presented. Unlike previously described DNA delivery approaches, the Gene Pill enables DNA delivery in a non-invasive manner, leading to the secretion of therapeutic proteins into a patient's blood, supplanting the need for injection of therapeutic protein products. The Gene Pill also has potential for the development of oral DNA vaccination through expression of protein antigens in the gut lymphoid tissue. This approach limits the biodistribution of the delivered DNA to the gut and retains all of the safety advantages of non-viral gene delivery, including repeat dosing. Development of an oral DNA formulation involves overcoming several challenges, including depurination by low pH in the stomach, enzymatic degradation by DNases in the gut, crossing the physical barrier imposed by the mucus layer, cell entry, intracellular trafficking and nuclear uptake. The advantages of the Gene Pill technology, as well as challenges for its development, are presented in this review.

Neurogenin3 participates in gliogenesis in the developing vertebrate spinal cord

To study the role of basic helix-loop-helix (bHLH) transcription factors in gliogenesis, we examined whether bHLH transcription factors were expressed in glial precursor cells and participated in regulating oligodendrocyte and astrocyte development. As assessed by reverse transcription-polymerase chain reaction (RT-PCR), Neurogenin3 (Ngn3) was transiently expressed in bipotential glial cells fated to become either oligodendrocytes or astrocytes. Mice lacking Ngn3 displayed a loss of Nkx2.2 expression, a transcription factor required for proper oligodendrogliogenesis. Furthermore, a reduction in the expression of myelin basic protein (MBP), proteolipid protein (PLP), and glial fibrillary acidic protein (GFAP), markers for mature oligodendrocytes and astrocytes, was observed in the Ngn3 null mice. Overexpression of Ngn3 was sufficient to drive expression from the PLP promoter in transient cotransfection assays. Overall, the data suggest that Ngn3 may regulate glial differentiation at a developmental stage prior to the segregation of the oligodendrocyte and astrocyte lineage.

Homeobox gene Nkx6.1 lies downstream of Nkx2.2 in the major pathway of beta-cell formation in the pancreas

Most insulin-producing beta-cells in the fetal mouse pancreas arise during the secondary transition, a wave of differentiation starting at embryonic day 13. Here, we show that disruption of homeobox gene Nkx6.1 in mice leads to loss of beta-cell precursors and blocks beta-cell neogenesis specifically during the secondary transition. In contrast, islet development in Nkx6. 1/Nkx2.2 double mutant embryos is identical to Nkx2.2 single mutant islet development: beta-cell precursors survive but fail to differentiate into beta-cells throughout development. Together, these experiments reveal two independently controlled pathways for beta-cell differentiation, and place Nkx6.1 downstream of Nkx2.2 in the major pathway of beta-cell differentiation.

Ventral neural patterning by Nkx homeobox genes: Nkx6.1 controls somatic motor neuron and ventral interneuron fates

There is growing evidence that sonic hedgehog (Shh) signaling regulates ventral neuronal fate in the vertebrate central nervous system through Nkx-class homeodomain proteins. We have examined the patterns of neurogenesis in mice carrying a targeted mutation in Nkx6.1. These mutants show a dorsal-to-ventral switch in the identity of progenitors and in the fate of postmitotic neurons. At many axial levels there is a complete block in the generation of V2 interneurons and motor neurons and a compensatory ventral expansion in the domain of generation of V1 neurons, demonstrating the essential functions of Nkx6.1 in regional patterning and neuronal fate determination.

Regulation of insulin gene transcription

Recent studies of the insulin gene promoter and the transcription factors that regulate it have expanded our understanding of both how the production of insulin is restricted to the pancreatic beta -cell, and how that production is regulated by physiologic signals such as glucose. A picture is emerging in which an elaborate set of transcription factors binds to specific sequences along the promoter and recruits additional transcriptional co-activators to build a functional transcriptional activation complex that is unique to beta -cells. Surprisingly, however, genetic experiments in mice have demonstrated an unexpected degree of redundancy in the factors that control insulin gene expression, and have revealed the presence of a network of transcription factors that coordinate the expression of factors forming the insulin gene activation complex.

A pilot study of the management of uncomplicated candidemia with a standardized protocol of amphotericin B

We evaluated an amphotericin treatment strategy on the basis of duration of candidemia and clinical findings. Patients without neutropenia who had uncomplicated candidemia received 200 mg of amphotericin B over 5-7 days if they had had </=1 day of documented positive blood cultures (SC group) or a total of 500 mg of amphotericin B over 14-20 days if they had had >1 day of positive cultures (PC group). The clinical cure rate was 93% (95% confidence interval [CI], 77%-99%; n=29 episodes) in the SC group, with no relapses (median follow-up, 272 days). The clinical cure rate was 83% (95% CI, 64%-94%; n=29 episodes) in the PC group, with 1 relapse (4.2%). The results of this pilot study suggest that patients with candidemia may be stratified into risk groups on the basis of the duration of positive blood cultures and other clinical findings. Decisions about the duration of therapy can be made 4-7 days after initiation of treatment. Carefully selected patients with transient uncomplicated candidemia may be safely treated with a short course of amphotericin B. Further prospective validation of this concept should be undertaken particularly to evaluate the impact on low-frequency late complications (e.g., endophthalmitis).

Regulation of insulin preRNA splicing by glucose

Glucose tightly regulates the synthesis and secretion of insulin by beta cells in the pancreatic islets of Langerhans. To investigate whether glucose regulates insulin synthesis at the level of insulin RNA splicing, we developed a method to detect and quantify a small amount of RNA by using the branched DNA (bDNA) signal-amplification technique. This assay is both sensitive and highly specific: mouse insulin II mRNA can be detected from a single beta cell (betaTC3 cells or mouse islets), whereas 1 million non-insulin-producing alpha cells (alphaTC1.6 cells) give no signal. By using intron and exon sequences, oligonucleotide probes were designed to distinguish the various unspliced and partially spliced insulin preRNAs from mature insulin mRNA. Insulin RNA splicing rates were estimated from the rate of disappearance of insulin preRNA signal from beta cells treated with actinomycin D to block transcription. We found that the two introns in mouse insulin II are not spliced with the same efficiency. Intron 2 is spliced out more efficiently than intron 1. As a result, some mRNA retaining intron 1 enters the cytoplasm, making up approximately 2-10% of insulin mRNA in the cell. This partially spliced cytoplasmic mRNA is quite stable, with a half-life similar to the completely spliced form. When islets grown in high glucose are shifted to low glucose medium, the level of insulin preRNA and the rate of splicing fall significantly. We conclude that glucose stimulates insulin gene transcription and insulin preRNA splicing. Previous estimates of insulin transcription rates based on insulin preRNA levels that did not consider the rate of splicing may have underestimated the effect of glucose on insulin gene transcription.

The insulin gene promoter. A simplified nomenclature

The tools of molecular biology have rapidly expanded our knowledge of how β-cells regulate insulin gene expression. As this work has progressed in parallel in different laboratories, alternate nomenclature systems have been developed to describe the functionally important elements of the insulin gene. This jumble of names is confusing to those outside the field and intimidating to neophytes. Therefore, we have agreed to a simple, uniform set of names for the major insulin gene promoter elements.

Effective case management in managed mental health care: conditions, methods and outcomes

Case management methods were utilized after changing from a "provider network" to a "staff model" mental health center serving approximately 30,000 HMO enrollees. This change allowed for tighter systems and case management, interdisciplinary coordination, longitudinal evaluation of clients and measures of quality assurance, staff productivity and cost savings. Effective case management conditions and methods were implemented that ensured immediate accessibility, broad-ranging evaluation and triage, use of both psychiatric and operational diagnosis, proper matching of client with therapist, group, and setting; coordination of the roles of various support systems and use of proven treatment and case management methods. The change to this staff model case management system resulted in 38.8% cost savings while delivering high-quality, accessible service.

[Relationship between ultrastructure of various phages and protein-phage conjugates with their specific neutralization]

Back to our technique of phage sensitization by protein fixation with the aid of coupling reagents, and of their inactivation by the specific anti-protein antibodies, comparative studies were made on phages having a morphologically different tail. Here we report the results concerning the ultramicorscopic observation of four phages, the efficiency and the rate of their sensitization, and the possibility of their respective neutralization.