Exposure to the troubles in Northern Ireland, memory functioning, and social activity engagement: results from NICOLA

We investigated the potential impact of a cohort traumatic exposure, the Troubles in Northern Ireland, on memory functioning in later life, and the potential moderating effect of social activity engagement. Using data from 6571 participants aged 60 + in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA) cohort, we used a structural equation modelling framework to explore associations between traumatic exposure during the Troubles and memory functioning. As expected, social activity engagement was positively associated with memory functioning, β = .102. Traumatic exposure was also positively associated with memory functioning, β = .053. This association was stronger at low levels of social activity engagement; among those with higher levels, there was little association, interaction β = - 0.054. The positive association between traumatic exposure during the Troubles and memory functioning was not moderated by the age at which the exposures occurred (based on analysis of a subsample with available data), interaction β = - 0.015. We conclude that superior memory functioning was associated with higher levels of traumatic exposure during the Troubles, particularly among those with lower levels of social activity engagement, and regardless of the age at which the exposures occurred. Future longitudinal analyses are required to build on these results, which potentially have implications for life-course epidemiology, in relation to critical periods for traumatising experiences.

Building On The Gains Of The ACA: Federal Proposals To Improve Coverage And Affordability

The Affordable Care Act (ACA) significantly improved health insurance coverage in the US, but too many Americans remain under- or uninsured. This article examines federal strategies under consideration that build on the ACA to extend comprehensive coverage to all low-income Americans and increase coverage affordability for middle-income Americans. For low-income Americans these policy options include extending the enhanced match rate offered to states that expanded eligibility for Medicaid in the early years of the ACA to states that have not yet expanded Medicaid and increasing Marketplace cost-sharing subsidies. To address the issue of affordability for middle-income Americans, this article considers options for lowering premiums (for example, extending tax credits to people with incomes above the current eligibility threshold, increasing the generosity of tax credits for those currently eligible, and making reinsurance permanent), lowering cost sharing (such as tying premium tax credits to the second-lowest-cost gold plan rather than the equivalent silver plan and extending federal assistance for cost sharing to people with incomes above the current threshold), and establishing a public option.

Risk of tuberculosis reactivation during interleukin-17 inhibitor therapy for psoriasis: a systematic review

Immunosuppressive therapies, effective in treating inflammatory disorders such as psoriasis, increase the risk of serious infections, such as tuberculosis (TB). For example, tumour necrosis factor (TNF)-alpha inhibitors significantly increase the risk of TB reactivation in patients with latent TB infection (LTBI), which has led clinicians to routinely test for TB prior to initiation of these medications. This protocol has since extended to other, newer immunomodulatory therapies for psoriasis, such as interleukin (IL)-17 inhibitors, including secukinumab, ixekizumab and brodalumab. We conducted a systematic review to examine whether there is any evidence that IL-17 inhibitor therapy for psoriasis increases the risk of TB reactivation. Using PubMed and EMBASE, our literature search resulted in 139 total articles. After manually reviewing each article for the discussion of IL-17 inhibitors for psoriasis, with data originating from clinical trials, and assessment for incidence of TB reactivation, 23 articles met the full inclusion criteria for our review. Overall, we found no cases of TB reactivation in patients treated with IL-17 inhibitors for psoriasis. This suggests that IL-17 inhibitors may be safely used in psoriasis patients with LTBI who receive appropriate LTBI treatment. However, long-term real-world studies are warranted to further evaluate this risk.

Pan-TRK Immunohistochemistry: A Useful Diagnostic Adjunct For Secretory Carcinoma of the Breast

Secretory carcinoma is a special-type breast carcinoma underpinned by a recurrent t(12;15)(p13;q25) translocation resulting in ETV6-NTRK3 gene fusion. Immunohistochemistry (IHC) using a pan-TRK antibody has been recently shown to help identify NTRK rearrangements in other tumor types. The purpose of this study was to assess the diagnostic utility of pan-TRK IHC in secretory carcinoma of the breast. Pan-TRK IHC was performed using a rabbit monoclonal antibody on whole sections of 24 breast secretory carcinomas and tissue microarray sections of other breast carcinoma types (n=203) and histologic mimics (n=15). Cases were assessed for staining intensity and localization. The 24 patients with secretory carcinoma had a median age of 44 years and a median tumor size of 1.0 cm. ETV6 fluorescence in situ hybridization was positive in all cases tested (n=20). Twenty-three cases (95.8%) showed staining with pan-TRK, which was exclusively nuclear in 19, primarily nuclear with weak cytoplasmic staining in 3, and primarily cytoplasmic with focal nuclear staining in 1. The nuclear staining was diffuse in 17 and at least focally strong in 17. The only pan-TRK negative case was a core biopsy with limited tumor. Among the 203 nonsecretory carcinomas, 21 (10.3%) showed focal, weak nuclear staining in <5% of tumor cells and 1 (0.5%) showed focal membranous staining. All histologic mimics were negative. In conclusion, diffuse and/or at least focally strong nuclear pan-TRK staining is a sensitive and specific marker for secretory carcinoma of the breast.

Promoting lifestyle behaviour change and well-being in hospital patients: a pilot study of an evidence-based psychological intervention

BACKGROUND

Lifestyle risk behaviours show an inverse social gradient, clustering in vulnerable groups. We designed and piloted an intervention to address barriers to lifestyle behaviour change among hospital patients.

METHODS

We designed our intervention using effective components of behaviour change interventions informed by psychological theory. Delivered by a health psychologist based at the Royal Free London NHS Foundation Trust, the 4-week intervention included detailed baseline assessment, personalized goal setting, psychological skills development, motivation support and referral to community services. Primary outcomes were feasibility and patient acceptability. We also evaluated changes to health and well-being.

RESULTS

From 1 July 2013 to 31 September 2014, 686 patients were referred, 338 (49.3%) attended a first appointment and 172 (25.1%) completed follow-up. Furthermore, 72.1% of attenders were female with the median age 55 years and poor self-reported baseline health. After 4 weeks, self-efficacy, health and well-being scores significantly improved: 63% of lifestyle goals and 89% of health management goals were fully achieved; 58% of referrals to community lifestyle behaviour change services and 79% of referrals to other services (e.g. Citizen's Advice Bureau) were accepted; 99% were satisfied/very satisfied with the service.

CONCLUSIONS

Our hospital-based intervention was feasible, acceptable and showed preliminary health and well-being gains.

Frequency of abnormal fecal biomarkers in irritable bowel syndrome

PRIMARY STUDY OBJECTIVE

Determine the frequency of abnormal fecal biomarker test results in patients with 13 irritable bowel syndrome (IBS)-related ICD-9 (International Statistical Classification of Diseases and Related Health Problems) codes.

STUDY DESIGN

Quantitative review of de-identified records from patients in whom IBS was a possible diagnosis.

METHODS

Records were selected for analysis if they included any of 13 IBS-related diagnostic codes and laboratory test results of fecal testing for all biomarkers of interest. Data collection was restricted to one 12-month period. Frequency distributions were calculated to identify rates of abnormal results for each biomarker within the total number of tests conducted in the eligible population.

RESULTS

Two thousand, two hundred fifty-six records were included in the study, of which 1867 (82.8%) included at least one abnormal value. Quantitative stool culture for beneficial bacteria (Lactobacillus and Bifidobacterium) indicated low growth suggestive of intestinal dysbiosis in 73.1% of records, followed by abnormally elevated eosinophil protein X (suggestive of food allergy) in 14.3%, elevated calprotectin (suggestive of inflammation) in 12.1%, detection of parasites in 7.5%, and low pancreatic elastase (suggestive of exocrine pancreatic insufficiency) in 7.1%.

CONCLUSIONS

Abnormal fecal biomarkers are prevalent in patients with diagnoses suggestive of IBS. Abnormal fecal biomarker testing, if confirmed in additional independent clinical trials, could substantially reduce the economic costs associated with diagnosis and management of IBS.

Novel Testing Enhances Irritable Bowel Syndrome Medical Management: The IMMINENT Study

Primary Study Objective:

To evaluate the economic utility of a fecal biomarker panel structured to suggest alternative, treatable diagnoses in patients with symptoms of irritable bowel syndrome (IBS) by quantifying, comparing, and contrasting health service costs between tested and non-tested patients.

Study Design:

Retrospective, matched cohort study comparing direct medical costs for IBS patients undergoing fecal biomarker testing with those of matched control subjects.

Methods:

We examined de-identified medical and pharmacy claims of a large American pharmacy benefit manager to identify plan members who underwent panel testing, were eligible for covered benefits for at least 180 days prior to the test date, and had data available for 30, 90, and 365 days after that date. We used propensity score matching to develop population-based control cohorts for each tested cohort, comprised of records with IBS-related diagnoses but for which panel testing was not performed. Primary outcome measures were diagnostic and medical services costs as determined from claims data.

Results:

Two hundred nine records from tested subjects met inclusion criteria. The only significant baseline differences between groups were laboratory costs, which were significantly higher in each tested cohort. At each follow-up time point, total medical and gastrointestinal procedural costs were significantly higher in non-tested cohorts. Within tested cohorts, costs declined significantly from baseline, while costs rose significantly in non-tested control cohorts; these differences were also significant between groups at each time point.

Conclusions:

Structured fecal biomarker panel testing was associated with significantly lower medical and gastrointestinal procedural costs in this study of patients with IBS symptoms.

Workshop on predictive science of the immunogenicity aspects of particles in biopharmaceutical products

Particles in protein therapeutics and concerns for a potential correlation with product immunogenicity are increasingly becoming the focus of recent publications and scientific forums. The consensus of academic, industrial, and regulatory scientists is that this area is not well understood and will require in-depth research because of the potential impact on the product safety and efficacy. This commentary presents a summary of the 1-day workshop entitled "Predictive Science of the Immunogenicity Aspects of Particles in Biopharmaceutical Products," which discussed the current state of analytical resources for quantitation and characterization of protein aggregates and potential paths for developing predictive preclinical tools.

Abstract 2111: Characterization of current and novel biomarkers of bladder cancer

Bladder cancer is one of the most common cancers in industrialized countries. It is reported that 3.51 billion dollars are spent each year on bladder cancer treatment making it the most expensive cancer to treat on a per patient basis. Approximately 80% of bladder cancer patients have at least one reported recurrence thereby prompting meticulous lifetime screening and surveillance by health care professionals. Therefore, careful evaluation of our institution's current fluorescent in situ hybridization surveillance tools in addition to investigation of novel biomarkers is imperative. Our investigation of novel biomarkers focused on apoptosis regulating genes which are often unbalanced in cancerous tissues. Our institution recently adopted BioView, an automated FISH capture/analysis system, to replace the manual protocol. Validation and assessment of the automated system for fluorescent in situ hybridization (FISH) interpretation to detect urothelial cancer was determined using patient cases to evaluate concordance, overall positivity, interpretative time spent, sensitivity, and specificity. To evaluate novel biomarkers, mRNA from patient samples was reversed transcribed to cDNA then utilized for biomarker quantification by RT-PCR. In addition, immunohistochemistry was performed on the most promising gene to further confirm its clinical usefulness. The automated BioView capture/ detection system does prove to be more time efficient and accurate when addressing all parameters described. In evaluation of novel biomarkers, API5, BIRC3, BIRC4, SURVIVIN, and BFAR provided the most promising data with sensitivity and specificity percentages all ranging from 83% to 97%. From this study of bladder cancer markers, we focused on API5 and its role in bladder cancer initiation and progression. API5 is strongly expressed early in tumorigenesis. Our data confirm that the automated FISH capture/detection system improves laboratory efficiency and accuracy. Furthermore, our data indicate that apoptotic regulators are promising biomarkers for clinical use. In addition, API5 is expressed early in tumorigenesis, which makes it an ideal early diagnostic marker. We have noticed increase in the level of API5 protein associated with tumor grade and stage which also suggest that API5 might be a potential prognostic marker for bladder cancer. In conclusion, detection of apoptosis regulating genes is a promising diagnostic and prognostic approach to aid our screening and surveillance tools.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2111. doi:1538-7445.AM2012-2111

Abstract 159: Prognostic and diagnostic significance of microRNA in bladder cancer

Purpose: Recently the role of microRNA (miRNA) in the development and progression of cancer including genitourinary tumors, and lymphomas to name a few have illustrated specific miRNA's to be dysregulated. Consequently miRNA's are currently being investigated as potential diagnostic and prognostic markers in neoplastic diseases. Because miRNA's are highly conserved they are promising as a potential biomarker that may be acquired by non-invasive means. This study investigated the presence of miR-21, miR-17-5p, miR-155, miR-26, miR-126, and miR-182 in bladder cancer tumor and tumor normal tissue specimens. We further investigated the presence of miR-21, miR-17-5p and miR-155 in urine sediment of bladder cancer patients.

Materials and Methods: quantitative Real time (RT-PCR) analysis was utilized for the detection of the precursors of miR-21, miR-17-5p, miR-155, miR-26, miR-126, and miR-182 in 23 RNA samples obtained from with bladder cancer tissue specimens. The relative expression values were compared to pooled matched non-tumor tissue. The presence of precursors of miRNA miR-21, miR-17-5p and miR-155 were also tested in 104 urine specimens from patients with active disease following positive cystoscopy (n=57) and patients previously diagnosed and treated for bladder cancer (n=34) with negative cystoscopic examination, patients with non-bladder cancer urological disease (n=6) and 7 healthy volunteers.

Results: The precursors of the oncogenic miRNA miR-21, miR-155, and miR-26 were up-regulated in the early grades and stages of the disease and the levels of expression are maintained in high grades and late disease stage. Interestingly, high levels of miR-17-5p were detected in higher grades and stages of bladder cancer and correlated with poor long term survival. Our data also indicated that the miR-126 is down-regulated in bladder cancer specimens compared to the non-tumor tissues. Our preliminary data have also shown that high levels of the precursors of miR-21, miR-17-5p and miR-155 can be detected in urine sediment collected from patients with active disease in higher levels compared to cytoscopy negative patients, patients with non-malignant urological diseases and healthy controls.

Conclusion: Our data have shown that miRNA detection in tissue and urine specimens in patients with bladder cancer has a promising prognostic and diagnostic significance and this preliminary data warranting further investigation to look at miRNA's as potential biomarkers. Illustrating the presence of miRNA in urine sediment of bladder cancer patients may prove useful in noninvasive evaluation of bladder cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 159. doi:10.1158/1538-7445.AM2011-159

An inactivated cell-culture vaccine against yellow fever

BACKGROUND

Yellow fever is a lethal viral hemorrhagic fever occurring in Africa and South America. A highly effective live vaccine (17D) is widely used for travelers to and residents of areas in which yellow fever is endemic, but the vaccine can cause serious adverse events, including viscerotropic disease, which is associated with a high rate of death. A safer, nonreplicating vaccine is needed.

METHODS

In a double-blind, placebo-controlled, dose-escalation, phase 1 study of 60 healthy subjects between 18 and 49 years of age, we investigated the safety and immunogenicity of XRX-001 purified whole-virus, β-propiolactone-inactivated yellow fever vaccine produced in Vero cell cultures and adsorbed to aluminum hydroxide (alum) adjuvant. On two visits 21 days apart, subjects received intramuscular injections of vaccine that contained 0.48 μg or 4.8 μg of antigen. Levels of neutralizing antibodies were measured at baseline and on days 21, 31, and 42.

RESULTS

The vaccine induced the development of neutralizing antibodies in 100% of subjects receiving 4.8 μg of antigen in each injection and in 88% of subjects receiving 0.48 μg of antigen in each injection. Antibody levels increased by day 10 after the second injection, at which time levels were significantly higher with the 4.8-μg formulation than with the 0.48-μg formulation (geometric mean titer, 146 vs. 39; P<0.001). Three adverse events occurred at a higher incidence in the two vaccine groups than in the placebo group: mild pain, tenderness, and (much less frequently) itching at the injection site. One case of urticaria was observed on day 3 after the second dose of 4.8 μg of vaccine.

CONCLUSIONS

A two-dose regimen of the XRX-001 vaccine, containing inactivated yellow fever antigen with an alum adjuvant, induced neutralizing antibodies in a high percentage of subjects. XRX-001 has the potential to be a safer alternative to live attenuated 17D vaccine. (Funded by Xcellerex; ClinicalTrials.gov number, NCT00995865.).

Removal of N-terminal blocking groups from proteins

Two enzymatic methods commonly used in N-terminal sequence analysis of blocked proteins are presented: one uses pyroglutamate aminopeptidase for N(α)-pyrrolidone carboxyl-proteins in solution or blotted onto a membrane, and the other uses acylaminoacyl-peptide hydrolase for N(α)-acyl-proteins blocked with other acyl groups. A Support Protocol describes a colorimetric assay for pyroglutamate aminopeptidase activity. Sequencing with acylaminoacyl-peptide hydrolase must include fragmentation of the protein before unblocking, so procedures are provided for chemically blocking newly generated peptides with either succinic anhydride or phenylisothiocyanate/performic acid. The hydrolase is then applied to the total mixture of peptides, only one of which, the acylated N-terminal peptide, should be a substrate for hydrolase. After incubation, the mixture of peptides is subjected to sequence analysis.

The Drosophila protein palmitoylome: characterizing palmitoyl-thioesterases and DHHC palmitoyl-transferases

Palmitoylation is the post-translational addition of a palmitate moiety to a cysteine residue through a covalent thioester bond. The addition and removal of this modification is controlled by both palmitoyl acyl-transferases and thioesterases. Using bioinformatic analysis, we identified 22 DHHC family palmitoyl acyl-transferase homologs in the Drosophila genome. We used in situ hybridization,RT-PCR, and published FlyAtlas microarray data to characterize the expression patterns of all 22 fly homologs. Our results indicate that all are expressed genes, but several, including CG1407, CG4676, CG5620, CG6017/dHIP14, CG6618, CG6627 and CG17257 appear to be enriched in neural tissues suggesting that they are important for neural function. Furthermore, we have found that several may be expressed in a sex-specific manner with adult male specific expression of CG4483 and CG17195. Using tagged versions of the DHHC genes, we demonstrate that fly DHHC proteins are primarily located in either the Golgi Apparatus or Endoplasmic Reticulum in S2 cells, except for CG1407, which was found on the plasma membrane. We also characterized the subcellular localization and expression of the three known thioesterases: Palmitoyl-protein Thioesterase 1 (Ppt1), Palmitoyl-protein Thioesterase 2 (Ppt2)and Acyl-protein Thioesterase 1 (APT1). Our results indicate that Ppt1 and Ppt2 are the major lysosomal thioesterases while APT1 is the likely cytoplasmic thioesterase. Finally, in vivo rescue experiments show that Ppt2 expression cannot rescue the neural inclusion phenotypes associated with loss of Ppt1, further supporting distinct functions and substrates for these two thioesterases. These results will serve as the basis for a more complete understanding of the protein palmitoylome's normal cellular functions in the fly and will lead to further insights into the molecular etiology of diseases associated with the mis-regulation of palmitoylation.

Inactivated yellow fever 17D vaccine: development and nonclinical safety, immunogenicity and protective activity

In the last 10 years new concerns have arisen about safety of the live, attenuated yellow fever (YF) 17D vaccine, in particular viscerotropic adverse events, which have a case-fatality rate of 64%. A non-replicating cell culture-based vaccine would not cause these adverse events, and potentially could be used in persons with precautions or contraindications to use of the live vaccine, including age <9 months and >60 years, egg allergy, immune suppression, and pregnancy. We developed a whole virion vaccine from the 17D strain inactivated with beta-propiolactone, and adsorbed to aluminum hydroxide. The inactivated vaccine was highly immunogenic in mice, hamsters, and cynomolgus macaques. After a single dose in hamsters and macaques, neutralizing antibody titers were similar to those elicited by the live 17D vaccine (YF-VAX, Sanofi Pasteur). After two doses of inactivated vaccine, neutralizing antibody titers in hamsters were significantly higher than after a single dose of YF-VAX [geometric mean titer (GMT) 20,480 vs. 1940, respectively (P<0.001, ANOVA)]. Hamsters given a single dose or two doses of inactivated vaccine or a single dose of YF-VAX were fully protected against hepatitis, viremia, weight loss and death after challenge with YF virus (Jimenez strain). A clinical trial of the inactivated vaccine (XRX-001) has been initiated.

C-terminal sequence analysis

Carboxy-terminal (C-terminal) sequence analysis is used for direct confirmation of the C-terminal sequence of native and expressed proteins, for detection and characterization of protein processing at the C-terminus, for identification of post-translational proteolytic cleavages, and for obtaining partial sequence information on N-terminally blocked protein samples in order to facilitate design of oligonucleotide probes for gene cloning. This unit describes an automated chemical method and a manual enzymatic (carboxypeptidase digestion) method for determining C-terminal sequence information. Carboxypeptidase digestion requires only a standard amino acid analysis method.

Removal of N-terminal blocking groups from proteins

Two enzymatic methods commonly used in N-terminal sequence analysis of blocked proteins are presented in this unit; one uses pyroglutamate aminopeptidase for N(alpha)-pyrrolidone carboxyl-proteins in solution or blotted onto a membrane, and the other uses acylaminoacyl-peptide hydrolase for N(alpha)-acyl-proteins blocked with other acyl groups. A Support Protocol describes a colorimetric assay for pyroglutamate aminopeptidase activity. Sequencing with acylaminoacyl-peptide hydrolase must include fragmentation of the protein before unblocking can be carried out, so procedures are provided for chemically blocking newly generated peptides with either succinic anhydride or phenylisothiocyanate/performic acid. The hydrolase is then applied to the total mixture of peptides, only one of which, the acylated N-terminal peptide, should be a substrate for hydrolase. After incubation, the mixture of peptides is subjected to sequence analysis. Protocols are also provided for unblocking N-terminally blocked proteins using acid-catalyzed hydrolysis or methanolysis, hydrazinolysis, and beta-elimination after acid-catalyzed N-O shift. Alternate protocols describe chemical removal of acetyl and longer-chain alkanoyl groups, as well as formyl groups to open the cyclic imide of pyrrolidone carboxylate.

Tumor necrosis factor-alpha haplotype is strongly associated with bone mineral density in patients with Crohn's disease

BACKGROUND AND AIM

There is limited consensus on the major variables that determine bone integrity and bone loss in patients with Crohn's disease. Twin and family studies in the general population indicate that up to 85% of variance in bone mineral density is inherited. The aim was to determine the prevalence of bone loss and both molecular and clinical risk factors for bone loss in a large Crohn's disease population.

METHODS

This was a cross-sectional study of 304 patients with Crohn's disease attending the Inflammatory Bowel Disease unit at Royal Brisbane and Women's Hospital, Queensland. The results of bone density testing were ascertained directly and by a mailed questionnaire. Bone mineral density data were combined with clinical information and correlated with single nucleotide polymorphisms within the tumor necrosis factor-alpha (TNF-alpha), interleukin-10, and NOD2/CARD15 genes.

RESULTS

Of 304 Crohn's disease patients, 101 had undergone previous bone density testing. Forty-five patients (45%) had been diagnosed with osteopenia and 18 (18%) were osteoporotic. After multivariate analysis, both the TNF-alpha GT haplotype and the -857 CC genotype showed strong associations with bone mineral density overall (P = 0.003 and P = 0.002, respectively). Body mass index (P = 0.01) and previous bowel resection in female patients (P = 0.03) were predictive of a higher spine bone density, while body mass index (P = 0.003) and the effect of years since first bowel resection (P = 0.02) remained independent predictors of proximal femur bone mineral density. There were no other significant associations observed.

CONCLUSIONS

This study has identified a novel protective association between a TNF-alpha haplotype and bone mineral density in Crohn's disease. It confirms the important influence of body mass index and intestinal resection on bone loss in this population.

A systematic literature review to investigate if we identify those patients who can cope with anterior cruciate ligament deficiency

Rupture of the anterior cruciate ligament (ACL) results in increased tibiofemoral laxity in the knee, thereby ultimately resulting in knee instability and dysfunction. However, ACL rupture does not automatically infer functional impairment and instability as confirmed by the ACL deficient (ACLD) coper, who can resume pre-morbid activity levels. Alternatively, an authentic ACLD non-coper is unable to return to pre-injury levels of activity due to repeated incidents of giving-way. Little is known as to the contributory factors, which allows copers dynamic stability and render non-copers functionally impaired. This systematic literature review aims to examine the evidence presented by relevant trials in order to identify measurement tools, which could differentiate ACLD copers and non-copers. A literature search found nine trials; four adhered to the inclusion criteria of this review. Consensus was achieved within the studies that laxity measurements and IKDC ratings are incapable of distinguishing the functional status of the ACLD patient. Alternatively, Lysholm, KOS-Sport, KOS-ADL and Global Knee Function Rating Scores were regarded as capable of discriminating between ACLD copers and non-copers. Disagreement existed as to the efficacy of the Quadriceps Index and the single leg hop in categorising the ACLD patient according to function level. It was concluded that no single measurement tool is sufficient in determining the functional status of the ACLD individual. Consequently, a collaboration of tests is recommended, specifically incorporating the KOS-Sport, Global Knee Function Rating, hop tests and Quadriceps Index.

High diversity and rapid changeover of expressed var genes during the acute phase of Plasmodium falciparum infections in human volunteers

Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) proteins expressed on the surface of P. falciparum-infected erythrocytes undergo antigenic variation by switching the gene expressed within a repertoire of approximately 50 var genes per haploid genome. The switching of PfEMP1 plays an important role in the survival and pathogenesis of the parasite. To understand how a parasite switches its var gene expression in human infections, we investigated the composition and change of var gene transcripts during the acute phase of well-defined laboratory-induced P. falciparum infections in naive human hosts. Multiple var transcripts, with the same dominant transcript, were identified in samples collected after three to four asexual-parasite cycles in two volunteers infected with cloned 3D7 P. falciparum via mosquito bites. A major change in composition and frequency of var gene transcripts was observed between the culture used to infect the mosquitoes and the parasites recovered from the infected volunteers. A further change was seen when infected blood from a mosquito-infected volunteer was either passaged to other volunteers or cultured in vitro. The diversity of var transcripts did not increase with time. The results suggest that the switch of var gene expression is reinitiated after mosquito transmission and that var genes may rapidly switch from the first gene expressed after liver stage, but subsequent switching occurs at a much lower rate.