Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Congenital cytomegalovirus infection and neonatal auditory screening

Auditory screening of newborn infants has been recommended on the basis of the presence of risk criteria, including congenital infection. We assessed the ability of risk criteria-based neonatal auditory brain stem response to identify infants with hearing loss resulting from congenital cytomegalovirus (CMV) infection. Data from 6 1/2 years of risk criteria-based neonatal auditory screening were compared with the results of screening of all newborn infants for congenital CMV infection. Infants with congenital CMV infection received follow-up hearing evaluations. Congenital CMV infection was found in 167 (1.3%) of 12,371 infants; 134 had follow-up hearing evaluations, and 14 (10.4%) had confirmed sensorineural hearing loss. The rate of sensorineural hearing loss resulting from congenital CMV infection was 14 per 12,371 infants, of 1.1 per 1000 live births; the rate of bilateral loss > or = 50 dB was 0.6 per 1000. Although 2036 infants received auditory screening because of risk criteria, only 34 (20%) of 167 infants with congenital CMV infection were included. Only 2 (14%) of 14 children with sensorineural hearing loss caused by CMV were identified by risk criteria-based screening. We conclude that congenital CMV infection is an important cause of hearing impairment. Neonatal auditory screening based on the presence of risk criteria will fail to identify the majority of cases of sensorineural hearing loss caused by congenital CMV infection.

Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian earthquake

On 12 January 2010, a 7.0-magnitude earthquake devastated the island nation of Haiti, leading to the world's largest humanitarian effort in over 6 decades. The catastrophe caused massive destruction of homes and buildings and overwhelmed the Haitian health care system. The United States responded immediately with a massive relief effort, sending U.S. military forces and civilian volunteers to Haiti's aid and providing a tertiary care medical center aboard the USNS COMFORT hospital ship. The COMFORT offered sophisticated medical care to a geographically isolated population and helped to transfer resource-intensive patients from other treatment facilities. Working collaboratively with the surgical staff, ancillary services, and nursing staff, internists aboard the COMFORT were integral to supporting the mission of the hospital ship and provided high-level care to the casualties. This article provides the perspective of the U.S. Navy internists who participated in the initial response to the Haitian earthquake disaster onboard the COMFORT.

Factors influencing fluid intake behavior among kidney stone formers

PURPOSE

We determined factors influencing the behavior of patients with kidney stones in the prevention of recurrent stones.

MATERIALS AND METHODS

Patients with stones from an academic and a community practice were recruited for key informant interviews and focus groups. Groups were guided based on the framework of the health belief model. Content analysis was done on transcriptions using qualitative data analysis software.

RESULTS

Key informant interviews were completed with 16 patients and with a total of 29 subjects in 5 focus groups. Content analysis revealed that patients were highly motivated to prevent stones. The minimum level of perceived benefit for adopting the behavior change varied among patients and the behaviors proposed. An important strategy to increase fluid intake was insuring availability with containers. Patients were more consistently confident in the ability to increase fluid, in contrast to ingesting medicine or changing the diet. While barriers to increasing fluid were multifactorial among individuals, the barriers aligned into 3 progressive stages that were associated with distinct patient characteristics. Stage 1 barriers included not knowing the benefits of fluid or not remembering to drink. Stage 2 barriers included disliking the taste of water, lack of thirst and lack of availability. Stage 3 barriers included the need to void frequently and related workplace disruptions.

CONCLUSIONS

Patients with kidney stones are highly motivated to prevent recurrence and were more amenable to fluid intake change than to another dietary or pharmaceutical intervention. Barriers preventing fluid intake success aligned into 3 progressive stages. Tailoring fluid intake counseling based on patient stage may improve fluid intake behavior.

Fucosidases from the human gut symbiont Ruminococcus gnavus

The availability and repartition of fucosylated glycans within the gastrointestinal tract contributes to the adaptation of gut bacteria species to ecological niches. To access this source of nutrients, gut bacteria encode α-l-fucosidases (fucosidases) which catalyze the hydrolysis of terminal α-l-fucosidic linkages. We determined the substrate and linkage specificities of fucosidases from the human gut symbiont Ruminococcus gnavus. Sequence similarity network identified strain-specific fucosidases in R. gnavus ATCC 29149 and E1 strains that were further validated enzymatically against a range of defined oligosaccharides and glycoconjugates. Using a combination of glycan microarrays, mass spectrometry, isothermal titration calorimetry, crystallographic and saturation transfer difference NMR approaches, we identified a fucosidase with the capacity to recognize sialic acid-terminated fucosylated glycans (sialyl Lewis X/A epitopes) and hydrolyze α1–3/4 fucosyl linkages in these substrates without the need to remove sialic acid. Molecular dynamics simulation and docking showed that 3′-Sialyl Lewis X (sLeX) could be accommodated within the binding site of the enzyme. This specificity may contribute to the adaptation of R. gnavus strains to the infant and adult gut and has potential applications in diagnostic glycomic assays for diabetes and certain cancers.

The influence of secretin on ion transport in the human jejunum

Using a triple-lumen tube perfusion technique in normal human subjects secretin (2U/kg/hour intravenously) was shown to reduce the absorption of sodium, potassium, and chloride in the most proximal 30 cm of jejunum but it had no effect on bicarbonate absorption. This effect was not due to an artefact produced by the entry of secretin-stimulated, bicarbonate-rich, pancreatic juice into the test segment. Absorption of sodium chloride and water was stimulated rather than inhibited by higher bicarbonate concentrations and the effect of secretin was obvious even when this factor was controlled by adjusting the bicarbonate concentrations of the test fluids. Secretin did not influence ion transport in the mid-jejunum. It is suggested that the effects described may indicate a physiological role for secretin in the intestine where it could prevent the too rapid dehydration of upper jejunal contents which might interfere with adequate mixing and digestion.

Assessing transfer probabilities in a Bayesian interpretation of forensic glass evidence

When someone breaks glass a number of tiny fragments may be transferred to that person. If the glass is broken in the commission of a crime then these fragments may be used as evidence. A Bayesian interpretation of this evidence relies on the forensic scientist's ability to assess the probability of transfer. This paper examines the problem of assessing this probability and suggests some solutions.

FUT8-Directed Core Fucosylation of N-glycans Is Regulated by the Glycan Structure and Protein Environment

FUT8 is an essential α-1,6-fucosyltransferase that fucosylates the innermost GlcNAc of N-glycans, a process called core fucosylation. In vitro, FUT8 exhibits substrate preference for the biantennary complex N-glycan oligosaccharide (G0), but the role of the underlying protein/peptide to which N-glycans are attached remains unclear. Here, we explored the FUT8 enzyme with a series of N-glycan oligosaccharides, N-glycopeptides, and an Asn-linked oligosaccharide. We found that the underlying peptide plays a role in fucosylation of paucimannose (low mannose) and high-mannose N-glycans but not for complex-type N-glycans. Using saturation transfer difference (STD) NMR spectroscopy, we demonstrate that FUT8 recognizes all sugar units of the G0 N-glycan and most of the amino acid residues (Asn-X-Thr) that serve as a recognition sequon for the oligosaccharyltransferase (OST). The largest STD signals were observed in the presence of GDP, suggesting that prior FUT8 binding to GDP-β-l-fucose (GDP-Fuc) is required for an optimal recognition of N-glycans. We applied genetic engineering of glycosylation capacities in CHO cells to evaluate FUT8 core fucosylation of high-mannose and complex-type N-glycans in cells with a panel of well-characterized therapeutic N-glycoproteins. This confirmed that core fucosylation mainly occurs on complex-type N-glycans, although clearly only at selected glycosites. Eliminating the capacity for complex-type glycosylation in cells (KO mgat1) revealed that glycosites with complex-type N-glycans when converted to high mannose lost the core Fuc. Interestingly, however, for erythropoietin that is uncommon among the tested glycoproteins in efficiently acquiring tetra-antennary N-glycans, two out of three N-glycosites obtained Fuc on the high-mannose N-glycans. An examination of the N-glycosylation sites of several protein crystal structures indicates that core fucosylation is mostly affected by the accessibility and nature of the N-glycan and not by the nature of the underlying peptide sequence. These data have further elucidated the different FUT8 acceptor substrate specificities both in vitro and in vivo in cells, revealing different mechanisms for promoting core fucosylation.

The classification and discrimination of glass fragments using non destructive energy dispersive X-ray μfluorescence

Frequency of analytical characteristics is best estimated on glass recovered at random. However, as such data were not available to us, we decided to use control windows for this estimation. In order to use such a database, one has to establish that the recovered fragment comes from a window. Therefore, elemental analysis was used both for classification and discrimination of glass fragments. Several articles have been published on the subject, but most methods alter the glass sample. The use of non destructive energy dispersive X-ray microfluorescence (microXRF) for the analysis of small glass fragments has been evaluated in this context. The refractive index (RI) has also been measured in order to evaluate the complementarity of techniques. Classification of fragments has been achieved using Fisher's linear discriminant analysis (LDA) and neural networks (NN). Discrimination was based on Hotelling's T2 test. Only pairs that were not differentiated by RI followed by the Welch test were studied. The results show that neural network and linear discriminant analysis using qualitative and semi-quantitative data establishes a classification of glass specimens with a high degree of reliability. For discrimination, 119 windows collected from crime scene were compared: using RI it was possible to distinguish 6892 pairs. Out of 129 remaining pairs, 112 were distinguished by microXRF.

Large-scale automated machine reading discovers new cancer-driving mechanisms

PubMed, a repository and search engine for biomedical literature, now indexes >1 million articles each year. This exceeds the processing capacity of human domain experts, limiting our ability to truly understand many diseases. We present Reach, a system for automated, large-scale machine reading of biomedical papers that can extract mechanistic descriptions of biological processes with relatively high precision at high throughput. We demonstrate that combining the extracted pathway fragments with existing biological data analysis algorithms that rely on curated models helps identify and explain a large number of previously unidentified mutually exclusive altered signaling pathways in seven different cancer types. This work shows that combining human-curated ‘big mechanisms’ with extracted ‘big data’ can lead to a causal, predictive understanding of cellular processes and unlock important downstream applications.

Extracellular pH, transmembrane distribution and cytotoxicity of chlorambucil

The effects of extracellular pH (6.2 to 7.3) on uptake and cytotoxicity of the weak acid anti-tumor drug chlorambucil were investigated. Decreasing extracellular pH from 7.3 to 6.5 had a negligible effect on the intracellular pH of Chinese hamster V79 fibroblasts, thus resulting in the formation of a transmembrane pH gradient (intracellular alkaline). Addition of high concentrations of acetate or bicarbonate partially collapsed the pH gradient. Chlorambucil (pKa = 5.8) behaved as a weak acid with enhanced accumulation and cytotoxicity at extracellular pH less than 7.0. As predicted for a weak acid, partial collapse of the transmembrane pH gradient decreased both uptake and cell killing. Since the interstitial pH of micrometastases and solid tumors of many cancers is low relative to normal tissues, these results have potential implications for both in vitro drug testing and in vivo therapy.

Prevalence of amyotrophic lateral sclerosis (ALS), United States, 2016

Objective: To estimate the prevalence of amyotrophic lateral sclerosis (ALS) in the United States for 2016 using data from the National ALS Registry (Registry). Established in 2009, the Registry collects data on ALS patients in the U.S. to better describe the epidemiology of ALS, examine risk factors such as environmental and occupational exposures, and characterize the demographics of those living with the disease. Methods: To identify adult prevalent cases of ALS, the Registry compiles data from three national administrative databases (maintained by the Centers for Medicare and Medicaid Services, the Veterans Health Administration, and the Veterans Benefits Administration). To ascertain cases not necessarily included in these databases and to better understand risk-factors associated with ALS and disease progression, the Registry also includes data collected from patients who voluntarily enroll via a web portal to complete online surveys. Results: In 2016, the Registry conservatively identified 16,424 adult persons who met the Registry definition of ALS for an age-adjusted prevalence rate of 5.2 per 100,000 U.S. population. The pattern of patient characteristics (e.g., age, sex, and race/ethnicity) has not changed from previous Registry reports. Overall, ALS was more common among whites, males, and persons aged 60-69 years. The age groups with the lowest number of ALS cases were persons aged 18-39 years. Males had a higher prevalence rate of ALS than females overall and across all data sources. Conclusions: Data collected by the National ALS Registry are being used to better describe the epidemiology and demographics of ALS in the U.S.

Cognitive behaviour therapy for specific phobia of vomiting (Emetophobia): A pilot randomized controlled trial

This is the first randomised controlled trial to evaluate a protocol for cognitive behaviour therapy (CBT) for a Specific Phobia of Vomiting (SPOV) compared with a wait list and to use assessment scales that are specific for a SPOV.

METHOD

24 participants (23 women and 1 man) were randomly allocated to either 12 sessions of CBT or a wait list.

RESULTS

At the end of the treatment, CBT was significantly more efficacious than the wait list with a large effect size (Cohen's d=1.53) on the Specific Phobia of Vomiting Inventory between the two groups after 12 sessions. Six (50%) of the participants receiving CBT achieved clinically significant change compared to 2 (16%) participants in the wait list group. Eight (58.3%) participants receiving CBT achieved reliable improvement compared to 2 (16%) participants in the wait list group.

CONCLUSIONS

A SPOV is a condition treatable by CBT but further developments are required to increase efficacy.

Use of DNA profiles for investigation using a simulated national DNA database: Part I. Partial SGM Plus profiles

In traditional criminal investigation, uncertainties are often dealt with using a combination of common sense, practical considerations and experience, but rarely with tailored statistical models. For example, in some countries, in order to search for a given profile in the national DNA database, it must have allelic information for six or more of the ten SGM Plus loci for a simple trace. If the profile does not have this amount of information then it cannot be searched in the national DNA database (NDNAD). This requirement (of a result at six or more loci) is not based on a statistical approach, but rather on the feeling that six or more would be sufficient. A statistical approach, however, could be more rigorous and objective and would take into consideration factors such as the probability of adventitious matches relative to the actual database size and/or investigator's requirements in a sensible way. Therefore, this research was undertaken to establish scientific foundations pertaining to the use of partial SGM Plus loci profiles (or similar) for investigation.

The human gut symbiont Ruminococcus gnavus shows specificity to blood group A antigen during mucin glycan foraging: Implication for niche colonisation in the gastrointestinal tract

The human gut symbiont Ruminococcus gnavus displays strain-specific repertoires of glycoside hydrolases (GHs) contributing to its spatial location in the gut. Sequence similarity network analysis identified strain-specific differences in blood-group endo-β-1,4-galactosidase belonging to the GH98 family. We determined the substrate and linkage specificities of GH98 from R. gnavus ATCC 29149, RgGH98, against a range of defined oligosaccharides and glycoconjugates including mucin. We showed by HPAEC-PAD and LC-FD-MS/MS that RgGH98 is specific for blood group A tetrasaccharide type II (BgA II). Isothermal titration calorimetry (ITC) and saturation transfer difference (STD) NMR confirmed RgGH98 affinity for blood group A over blood group B and H antigens. The molecular basis of RgGH98 strict specificity was further investigated using a combination of glycan microarrays, site-directed mutagenesis, and X-ray crystallography. The crystal structures of RgGH98 in complex with BgA trisaccharide (BgAtri) and of RgGH98 E411A with BgA II revealed a dedicated hydrogen network of residues, which were shown by site-directed mutagenesis to be critical to the recognition of the BgA epitope. We demonstrated experimentally that RgGH98 is part of an operon of 10 genes that is overexpresssed in vitro when R. gnavus ATCC 29149 is grown on mucin as sole carbon source as shown by RNAseq analysis and RT-qPCR confirmed RgGH98 expression on BgA II growth. Using MALDI-ToF MS, we showed that RgGH98 releases BgAtri from mucin and that pretreatment of mucin with RgGH98 confered R. gnavus E1 the ability to grow, by enabling the E1 strain to metabolise BgAtri and access the underlying mucin glycan chain. These data further support that the GH repertoire of R. gnavus strains enable them to colonise different nutritional niches in the human gut and has potential applications in diagnostic and therapeutics against infection.

Procedures used by North Carolina dairies for vitamins A and D fortification of milk

New research findings have documented fortification errors in fortified milk products all across the US milk industry. Also, the consumption of overfortified bovine milk has led the public to question whether vitamin fortification is safe. Therefore, North Carolina dairies were surveyed to determine vitamin fortification procedures used and to determine differences among these procedures. Of the parameters surveyed, the general conditions under which vitamin preparations were stored, the method used to add vitamin preparations to milk, and the point during processing at which vitamin preparations were added to milk were different among dairies. Forty-six percent of the dairies stored vitamin preparations under refrigerated conditions, and 54% stored vitamin preparations at ambient temperatures. The addition of vitamin preparations to bovine milk was accomplished by metered injection at 64% of the dairies and batch addition techniques at 36%. Vitamin preparations were added before fat content standardization and separation by 23% of the dairy processors; 77% added the vitamin preparations after this point. When dairies were asked at what point they added their vitamin preparations to the milk, nine different answers were given. Although other sources of error could also contribute to inconsistent concentrations of vitamin fortification, differences in fortification procedures may have a large impact upon the problem. The diversity of vitamin fortification practices used in North Carolina may be an indication of nationwide trends.

Root cause analysis applied to the investigation of serious untoward incidents in mental health services

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.