Report of an international workshop to standardize response criteria for non-Hodgkin's lymphomas. NCI Sponsored International Working Group

Standardized guidelines for response assessment are needed to ensure comparability among clinical trials in non-Hodgkin's lymphomas (NHL). To achieve this, two meetings were convened among United States and international lymphoma experts representing medical hematology/oncology, radiology, radiation oncology, and pathology to review currently used response definitions and to develop a uniform set of criteria for assessing response in clinical trials. The criteria that were developed include anatomic definitions of response, with normal lymph node size after treatment of 1.5 cm in the longest transverse diameter by computer-assisted tomography scan. A designation of complete response/unconfirmed was adopted to include patients with a greater than 75% reduction in tumor size after therapy but with a residual mass, to include patients-especially those with large-cell NHL-who may not have residual disease. Single-photon emission computed tomography gallium scans are encouraged as a valuable adjunct to assessment of patients with large-cell NHL, but such scans require appropriate expertise. Flow cytometric, cytogenetic, and molecular studies are not currently included in response definitions. Response rates may be the most important objective in phase II trials where the activity of a new agent is important and may provide support for approval by regulatory agencies. However, the goals of most phase III trials are to identify therapies that will prolong the progression-free survival, if not the overall survival, of the treated patients. We hope that these guidelines will serve to improve communication among investigators and comparability among clinical trials until clinically relevant laboratory and imaging studies are identified and become more widely available.

Evaluating clinical accuracy of systems for self-monitoring of blood glucose

Although the scientific literature contains numerous reports of the statistical accuracy of systems for self-monitoring of blood glucose (SMBG), most of these studies determine accuracy in ways that may not be clinically useful. We have developed an error grid analysis (EGA), which describes the clinical accuracy of SMBG systems over the entire range of blood glucose values, taking into account 1) the absolute value of the system-generated glucose value, 2) the absolute value of the reference blood glucose value, 3) the relative difference between these two values, and 4) the clinical significance of this difference. The EGA of accuracy of five different reflectance meters (Eyetone, Dextrometer, Glucometer I, Glucometer II, Memory Glucometer II), a visually interpretable glucose reagent strip (Glucostix), and filter-paper spot glucose determinations is presented. In addition, reanalyses of a laboratory comparison of three reflectance meters (Accucheck II, Glucometer II, Glucoscan 9000) and of two previously published studies comparing the accuracy of five different reflectance meters with EGA is described. EGA provides the practitioner and the researcher with a clinically meaningful method for evaluating the accuracy of blood glucose values generated with various monitoring systems and for analyzing the clinical implications of previously published data.

Symptomatic depression in elderly medical outpatients. I. Prevalence, demography, and health service utilization

The authors assessed the prevalence and demography of depressive symptoms, their association with specific chronic diseases, and their influence on health service use in a large sample of elderly men seen in a primary care setting. Twenty-four percent of respondents reported clinically significant depressive symptoms; the prevalence of major depressive disorders was estimated at 10%, but only 1% reported receiving mental health treatment by a specialist. Self-reported marital separation or divorce and physical disability affecting employment were strongly associated with high depression scores, whereas the normative stresses of aging (widowhood, retirement, social isolation) were not. Only chronic lung disease was differentially associated with high depression scores, and this effect was weak. The authors discuss the implications of these findings for the design of comprehensive health services for the elderly with chronic disease.

The SOCS box of suppressor of cytokine signaling-1 is important for inhibition of cytokine action in vivo

Suppressor of Cytokine Signaling-1 (SOCS-1) is an essential physiological inhibitor of IFN-gamma signaling. Mice lacking this gene die in the early postnatal period from a disease characterized by hyperresponsiveness to endogenous IFN-gamma. The SOCS box is a C-terminal domain shared with over 30 other proteins that links SOCS proteins to an E3 ubiquitin ligase activity and the proteasome, but whether it contributes to inhibition of cytokine signaling is currently disputed. We have deleted only the SOCS box of the SOCS-1 gene in mice and show that such mice have an increased responsiveness to IFN-gamma and slowly develop a fatal inflammatory disease. These results demonstrate that deletion of the SOCS box leads to a partial loss of function of SOCS-1.

A comparison study of body dysmorphic disorder and obsessive-compulsive disorder

BACKGROUND

Body dysmorphic disorder, a preoccupation with an imagined or slight defect in appearance, is classified as a somatoform disorder, but has been hypothesized to be related to obsessive-compulsive disorder. A reflection of this hypothesis, body dysmorphic disorder is included in the Yale-Brown Obsessive Compulsive Scale symptom checklist, and its transfer to the anxiety disorders' section was considered for DSM-IV. However, the similarities and differences between body dysmorphic disorder and obsessive-compulsive disorder have received little investigation.

METHOD

We compared patients with DSM-IV body dysmorphic disorder (N = 53), obsessive-compulsive disorder (N = 53), or both disorders (N = 33) in terms of demographic features, clinical features, comorbidity, and family history. We also assessed the rate of body dysmorphic disorder among 62 of these subjects initially diagnosed with obsessive-compulsive disorder.

RESULTS

14.5% (9 of 62) of subjects initially diagnosed with obsessive-compulsive disorder had comorbid body dysmorphic disorder. The 2 disorders did not differ significantly in terms of sex ratio; most other demographic, course, and impairment variables; illness severity; or lifetime frequency of most associated disorders in probands or first-degree relatives. However, subjects with body dysmorphic disorder were less likely to be married and more likely to have had suicidal ideation or made a suicide attempt because of their disorder. They also had an earlier onset of major depression and higher lifetime rates of major depression, social phobia, and psychotic disorder diagnoses, as well as higher rates of substance use disorders in first-degree relatives.

CONCLUSION

Body dysmorphic disorder appears to be relatively common among patients with obsessive-compulsive disorder. While the 2 disorders have many similarities, they also have some differences and should be differentiated in clinical and research settings.

Novel ITGB4 mutations in lethal and nonlethal variants of epidermolysis bullosa with pyloric atresia: missense versus nonsense

Epidermolysis bullosa with pyloric atresia (EB-PA), an autosomal recessive genodermatosis, manifests with neonatal cutaneous blistering associated with congenital pyloric atresia. The disease is frequently lethal, but nonlethal cases have also been reported. Expression of the alpha6 beta4 integrin is altered at the dermal-epidermal basement-membrane zone; recently, mutations in the corresponding genes (ITGA6 and ITGB4) have been disclosed in a limited number of patients, premature termination codons in both alleles being characteristic of lethal variants. In this study, we have examined the molecular basis of EB-PA in five families, two of them with lethal and three of them with nonlethal variants of the disease. Mutation analysis disclosed novel lesions in both ITGB4 alleles of each proband. One of the patients with lethal EB-PA was a compound heterozygote for premature termination-codon mutations (C738X/4791delCA), whereas the other patient with a lethal variant was homozygous for a missense mutation involving a cysteine residue (C61Y). The three nonlethal cases had missense mutations in both alleles (C562R/C562R, R1281W/R252C, and R1281W/R1281W). Immunofluorescence staining of skin in two of the nonlethal patients and in one of the lethal cases was positive, yet attenuated, for alpha6 and beta4 integrins. These results confirm that ITGB4 mutations underlie EB-PA and show that missense mutations may lead to nonlethal phenotypes.

Purification of a ligand for the EPH-like receptor HEK using a biosensor-based affinity detection approach

Advances in screening technologies allowing the identification of growth factor receptors solely by virtue of DNA or protein sequence comparison call for novel methods to isolate corresponding ligand growth factors. The EPH-like receptor tyrosine kinase (RTK) HEK (human EPH-like kinase) was identified previously as a membrane antigen on the LK63 human pre-B-cell line and overexpression in leukemic specimens and cell lines suggested a role in oncogenesis. We developed a biosensor-based approach using the immobilized HEK receptor exodomain to detect and monitor purification of the HEK ligand. A protein purification protocol, which included HEK affinity chromatography, achieved a 1.8 X 10(6)-fold purification of an approximately 23-kDa protein from human placental conditioned medium. Analysis of specific sHEK (soluble extracellular domain of HEK) ligand interactions in the first and final purification steps suggested a ligand concentration of 40 pM in the source material and a Kd of 2-3 nM. Since the purified ligand was N-terminally blocked, we generated tryptic peptides and N-terminal amino acid sequence analysis of 7 tryptic fragments of the S-pyridylethylated protein unequivocally matched the sequence for AL-1, a recently reported ligand for the related EPH-like RTK REK7 (Winslow, J.W., Moran, P., Valverde, J., Shih, A., Yuan, J.Q., Wong, S.C., Tsai, S.P., Goddard, A., Henzel, W.J., Hefti, F., Beck, K.D., & Caras, I.W. (1995) Neuron 14, 973-981). Our findings demonstrate the application of biosensor technology in ligand purification and show that AL-1, as has been found for other ligands of the EPH-like RTK family, binds more than one receptor.

Lay person use of automatic external defibrillation

The ability of lay persons to learn and retain defibrillation skills using an automatic external defibrillator (AED) was assessed. Thirty-four family members of cardiac arrest survivors were trained in CPR techniques and defibrillation, and evaluated for performance of skills immediately following training and at six-week and three-month follow-ups. All but two were successfully trained to complete three cycles of CPR interspersed with three defibrillatory shocks in an average of four minutes with the first shock delivered in an average of two minutes. Although there were decrements in the speed and quality of performance at each follow-up period (P less than .01), we conclude that most lay persons can learn to operate an AED safely and under simulated conditions provide defibrillatory shocks an average of eight minutes faster than typical response times of emergency medical technicians. These results suggest that AEDs can be placed in many homes of patients at high risk for cardiac arrest.

Introduction of information during the initial medical visit: consequences for patient follow-through with physician recommendations for medication

While negotiation of treatment decisions in the medical visit has long been recognized as an important interviewing skill, limited work has been done to investigate how doctors and patients negotiate what information is relevant in understanding the patient's problem. In this research we tested how the introduction of information reflecting both the patient's and physician's perspective is related to the patient's adherence to physician recommendations for medication. Introduction of information was defined as bi-directional if patients independently offered information or behavior as frequently as they provided the information or exhibited behavior that physicians requested. Thirty random samples of audiotaped dialogue were used to construct estimates of introduction of information during the history, examination, and consultation phases of initial ambulatory care visits of 45 older male patients. The data demonstrate that bi-directional introduction of information during the examination segment explains more than half of the variance in patient adherence to physician recommendations for new medication. These findings support the idea that physician willingness to allow patients to contribute input may contribute to the partnership's arrival at treatment decisions that have meaning for both.

Alcohol consumption patterns and HIV viral suppression among persons receiving HIV care in Florida: an observational study

Background

Alcohol consumption has been associated with poor antiretroviral therapy (ART) adherence but less is known about its relationship to HIV viral suppression, or whether certain drinking patterns have a stronger association than others. The objectives of this study were to determine the association of different patterns of alcohol consumption to HIV viral suppression and ART adherence, and to determine whether any associations of alcohol with HIV viral suppression were mediated by poor ART adherence.

Methods

This observational study used baseline data from 619 HIV+ participants, recruited across 8 clinical and community settings across Florida as part of the Florida Cohort from 2014 to 2016. Alcohol consumption was measured by self-report, and grouped into four categories: heavy drinking (>7/week for women or >14 drinks/week for men); binge, but not heavy drinking (≥4 or >5 drinks/occasion for women and men, respectively), low level drinking (neither heavy nor binge), and abstinence. Serum HIV RNA measurements were obtained from statewide HIV surveillance data, and durable viral suppression was defined as achieving HIV viral suppression (<200 copies/ml) at every assessment in the past 12 months.

Results

The majority of the 619 participants were male (63%) and aged 45 or greater (65%). The proportion of participants with heavy, binge, low-level drinking and abstinence was 9, 25, 37 and 30%, respectively. Optimal ART adherence (≥95%) was reported by 68%, and 60% achieved durable viral suppression. In multivariable analysis controlling for demographic factors, drug use, and homelessness, heavy drinking (compared to abstinence) was associated with increased odds of failing to achieve durable viral suppression (OR 2.16, 95% CI 1.08–4.32) whereas binge drinking alone was not significantly associated with this outcome (OR 1.04, 95% CI 0.64–1.70). Both heavy drinking and binge drinking were significantly associated with suboptimal ART adherence. Mediation analyses suggested that only a small proportion of the relationship between heavy drinking and suboptimal viral suppression was due to poor ART adherence.

Conclusions

Exceeding weekly recommended levels of alcohol consumption (heavy drinking) was significantly associated with poor HIV viral suppression and ART non-adherence, while binge drinking was associated with suboptimal ART adherence in this sample. Clinicians should attempt to address heavy drinking in their patients with HIV.

The effect of soft cervical collars on persistent neck pain in patients with whiplash injury

OBJECTIVE

To assess the efficacy of soft cervical collars in the early management of whiplash-injury-related pain.

METHODS

A controlled, clinical trial was conducted in an urban ED. Adults with neck pain following automobile crashes indicated their initial degrees of pain on a visual analog scale. Patients with cervical spine fractures or subluxation, focal neurologic deficits, or other major distracting injuries were excluded. Patients were assigned to receive a soft cervical collar or no collar based on their medical record numbers. Pain at > or = 6 weeks postinjury was coded as none, better, same, or worse, and analyzed as 3 dichotomous outcomes: recovered (pain = none); improved (pain = none or better); and deteriorated (pain = worse).

RESULTS

Of 250 patients enrolled, 196 (78%) were available for follow-up. Of these patients, 104 (53%) were assigned to the soft cervical collar group, and 92 (47%) to the control group. These groups were similar in age, gender, seat position in the car, seat belt use, and initial pain score. Pain persisted at > or = 6 weeks in 122 (62%) patients. The groups showed no difference in follow-up pain category (p = 0.59). There was no significant difference between the 2 groups in complete recovery (p = 0.34), improvement (p = 0.34), or deterioration (p = 0.60). The study had a power of 80% to detect an absolute difference of at least 20% in recovery, 17% in improvement, and 7% in deterioration (2-tailed, alpha = 0.05).

CONCLUSIONS

Most patients with whiplash injuries have persistent pain for at least 6 weeks. Soft cervical collars do not influence the duration or degree of persistent pain.

Failure to validate a predictive model for refusal of care to emergency-department patients

OBJECTIVE

To determine whether previously developed triage criteria for refusal of care to patients presenting to an emergency department (ED) with nonurgent problems could be validated for an independent patient population.

METHODS

A convenience sample of 534 adults presenting to a municipal hospital ED between July 1, 1992, and October 15, 1992, who met preestablished criteria for refusal of care were entered into a prospective, observational, cohort study. The single target outcome variable was hospitalization. In order to optimize the criteria's performance, both the triage nurse and the physician caring for the patient had to agree that all criteria for "refusal of care" were specifically met. No patient was refused care, nor was a patient's management or disposition interfered with in any way by the investigators. All patients were followed until hospital admission or release from the ED.

RESULTS

Six (1.1%) of 534 patients (95% CI 0.4-2.4) who met the criteria for refusal of care were hospitalized. This represents a greater than 50-fold difference in incidence of hospitalization when compared with that found by other investigators, who reported that only 0.02% (95% CI 0.0004-0.04) of those patients who were refused care subsequently required hospitalization (p < 10 (-7)).

CONCLUSION

The authors were unable to validate a previously developed predictive model for refusal of care to patients presenting to an ED. Refusal of care to selected ED patients based on current guidelines is not a viable solution to overcrowding. Alternative strategies must be sought.

A refined genome-scale reconstruction of Chlamydomonas metabolism provides a platform for systems-level analyses

Microalgae have reemerged as organisms of prime biotechnological interest due to their ability to synthesize a suite of valuable chemicals. To harness the capabilities of these organisms, we need a comprehensive systems-level understanding of their metabolism, which can be fundamentally achieved through large-scale mechanistic models of metabolism. In this study, we present a revised and significantly improved genome-scale metabolic model for the widely-studied microalga, Chlamydomonas reinhardtii. The model, iCre1355, represents a major advance over previous models, both in content and predictive power. iCre1355 encompasses a broad range of metabolic functions encoded across the nuclear, chloroplast and mitochondrial genomes accounting for 1355 genes (1460 transcripts), 2394 and 1133 metabolites. We found improved performance over the previous metabolic model based on comparisons of predictive accuracy across 306 phenotypes (from 81 mutants), lipid yield analysis and growth rates derived from chemostat-grown cells (under three conditions). Measurement of macronutrient uptake revealed carbon and phosphate to be good predictors of growth rate, while nitrogen consumption appeared to be in excess. We analyzed high-resolution time series transcriptomics data using iCre1355 to uncover dynamic pathway-level changes that occur in response to nitrogen starvation and changes in light intensity. This approach enabled accurate prediction of growth rates, the cessation of growth and accumulation of triacylglycerols during nitrogen starvation, and the temporal response of different growth-associated pathways to increased light intensity. Thus, iCre1355 represents an experimentally validated genome-scale reconstruction of C. reinhardtii metabolism that should serve as a useful resource for studying the metabolic processes of this and related microalgae.

Bolous versus steady-state infusion for determination of CSF outflow resistance

For rapid changes in cerebrospinal fluid volume an exponential relationship was demonstrated between CSF pressure and CSF volume in 15 cats. This relationship was valid over a CSF pressure range from 7 to 50 mm Hg and for acute increases of up to 9% to total CSF volume (approximately 13 ml for humans). Our data agree well with previous reports for the cat. A similar relationship has been shown in the dog and in humans. It has been claimed that, given the equations for CSF bulk flow and the exponential relationship between CSF pressure and CSF volume, one can calculate CSF outflow resistance by observing the decay of CSF pressure after a bolus injection into the CSF space. This claim was evaluated in an additional 18 cats. In these animals CSF outflow resistance calculated by the bolus method was compared with resistance calculated by a steady-state infusion method over the CSF outflow resistance range of 74 to 293 mm Hg/ml min-1. Resistance calculated by the bolus method underestimated resistance calculated by the steady-state method, and this underestimate grew larger with increasing resistance. The bolus technique is therefore not a valid method for determining CSF outflow resistance. The explanation offered for these results is that the decay of CSF pressure after a bolus injection into the CSF space occurs not only because of runoff of the injected volume of CSF but also because of "pressure relaxation" of the brain parenchyma around the CSF space. The phenomenon of pressure relaxation was not considered in developing the equation for calculation of CSF outflow resistance by the bolus technique. The time dependency of pressure relaxation allows for a fundamental element of hysteresis within the CSF space. A method of quantifying this element of hysteresis is suggested.

Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease

STUDY OBJECTIVE

To validate previously developed guidelines for the selective use of chest radiography in adults admitted for exacerbation of obstructive airway disease.

DESIGN

Prospective, observational cohort study using criteria developed in a previous retrospective study.

PARTICIPANTS

Unselected convenience sample of 128 adults with obstructive airway disease who did not respond to standard emergency department treatment and required admission.

SETTING

Municipal hospital ED and inpatient medical service.

INTERVENTIONS

Patients were categorized as "complicated" or "uncomplicated" according to previously developed criteria. Management was recorded as altered if the patient's physician answered the question, "Did the chest radiography alter your management of this patient?" affirmatively.

RESULTS

Of 27 patients whose management was altered by the chest radiography, 26 were classified as complicated, for a sensitivity of 96% (95% confidence interval [CI], 81, 100). One of 44 admissions classified as uncomplicated had management altered by the chest radiography (negative predictive value, 98%, 95% CI, 88, 100). This chest radiography was later reread as normal. Classification as an uncomplicated patient with obstructive airway disease was strongly associated with either a normal chest radiography or a radiographic finding that was clinically unimportant (P = .0002).

CONCLUSION

Patients with acute exacerbation of obstructive airway disease who are otherwise uncomplicated do not benefit from routine admission chest radiography. The use of this simple clinical strategy would safely reduce the number of chest radiographs by about one-third in this and similar patient populations, decreasing both health care costs and exposure to ionizing radiation.

Antibodies to different members of the beta 1 (CD29) integrins induce homotypic and heterotypic cellular aggregation

Members of the beta 1 (CD29) integrin family are involved in cellular adhesion to extracellular matrix. However, there have been several reports of CD29 integrin participation in intercellular adhesion. For example, the treatment of the human T cell line Jurkat with antibodies to alpha 4 (CD49d) causes homotypic aggregation. The present report describes the induction of aggregation of Jurkat cells by antibodies to alpha 5 (CD49e) and to a lesser extent by antibodies to the common beta 1/CD29 chain of these integrins. The metabolic requirements for these aggregations are compared with that of the CD49d-induced process. The possible involvement of fibronectin in the cytoadhesion appears to be unlikely as (1) the aggregates form in the absence of plasma fibronectin; (2) antibodies to fibronectin do not inhibit the cell adhesion; and (3) exogenous fibronectin does not influence the process. One of the cognate partners involved in the CD49e-induced aggregation appears to be present on non-antibody-treated Jurkat cells as the cells are coincorporated into aggregates of anti-CD49e-stimulated cells. The adhesion does not appear to involve members of the CD2, CD3, CD4, or CD18 receptor groups. These results indicate that interaction with alpha 4, alpha 5 chain or the beta 1 chain of the CD29 integrins leads to the induction of intercellular adhesion. The possible biological significance of this process is discussed.

Identification of cardiac arrest by emergency dispatchers

Prompt identification of cardiac arrest by emergency dispatchers can save valuable time and increase the likelihood of successful resuscitation. The authors reviewed 516 cardiac and 146 non-cardiac calls to identify features of a probable cardiac arrest call. The results indicate that information about sex, location, and activity is of little use in the identification of cardiac arrest. When the patient is over 50 years old and the caller is emotional, the possibility of cardiac arrest is high, suggesting that questions about consciousness and breathing should be asked immediately. Additional information can be obtained or telephone cardiopulmonary resuscitation (CPR) instructions can be given after dispatch of an emergency vehicle.

Suppressor of cytokine signalling 1 (SOCS1) is a physiological regulator of the asthma response

BACKGROUND

The molecular determinants of the severity and persistence of allergic asthma remain poorly understood. Suppressor of cytokine signalling 1 (SOCS1) is a negative regulator of IL-4-dependent pathways in vitro and might therefore control T-helper type 2 (Th2) immunity associated traits, such as IgE levels, mucin production, IL-5 and IL-13 induction, and eosinophilic mucosal inflammation, which are implicated in allergic asthma.

OBJECTIVE

To investigate the role of SOCS1 in regulating Th2-associated disease traits in a murine sub-chronic aeroallergen-driven asthma model.

METHODS

Following sensitization and challenge with ovalbumin (OVA), bronchoalveolar lavage and serum were collected from mice lacking the Socs1 gene on an IFN-gamma null background (Socs1(-/-)Ifngamma(-/-)). The composition of infiltrating cells in the lung, serum IgE and IgG1 levels and cytokine levels were analysed.

RESULTS

Serum IgE levels and infiltrating eosinophils were considerably increased in the lungs of OVA-treated Socs1(-/-)Ifngamma(-/-) mice compared with Ifngamma(-/-) and C57BL/6 controls. Expression of the Th2 cytokines, IL-4, IL-5 and IL-13 was increased in CD4+ cells and lung tissue from OVA-treated Socs1(-/-)Ifngamma(-/-) mice. IgE, IL-5 levels and infiltrating eosinophils were also elevated in saline-treated Socs1(-/-)Ifngamma(-/-) mice, suggesting that in the absence of SOCS1, mice are already biased towards a Th2 response. It is at present unclear whether the elevated cytokine levels are sufficient to result in the exacerbated Th2 response to OVA challenge or whether enhanced intra-cellular signalling also contributes. Surprisingly, of the various IL-4/IL-13 responsive genes tested, only Arginase I appeared to be modestly up-regulated in the lungs of OVA-treated Socs1(-/-)Ifngamma(-/-) mice, suggesting that regulation by SOCS1 occurs primarily in haematopoietic cells and not in the airway epithelium.

CONCLUSIONS

Together these results indicate that SOCS1 is an important regulator of the Th2 response.

Development and pilot testing of an online intervention to support young couples' coping and adjustment to breast cancer

Couplelinks is an original, professionally facilitated online intervention tailored to the unique challenges facing young women with breast cancer and their male partners. The purpose of this evaluation was to determine the feasibility and acceptability of the intervention and areas for improvement. Sixteen couples were sequentially enrolled over an 18-month period. Couples provided feedback via a treatment satisfaction survey, and post-treatment interviews with a sub-group of participants. Qualitative information was analysed for themes relevant to the program's acceptability, perceived benefits and limitations, and directions for improvement. Of the 16 couples who enrolled, six completed four modules or less, and 10 completed the entire program. Completers reported satisfaction with the program overall, as well as with the website useability and professional facilitation. Reported benefits were: enhanced communication and self-other knowledge; creation of opportunities for meaningful, cancer-related discussion; affirmation of relationship strengths; and a greater sense of closeness between partners. The main reported limitation was how program participation disrupted the couple's usual routine. Themes related to non-completion suggest that partners with particularly elevated relational or illness-related distress, or with differential levels of motivation, are less likely to finish. These findings have led to targeted improvements to the website and intervention protocol.

Transcriptional program for nitrogen starvation-induced lipid accumulation in Chlamydomonas reinhardtii

BACKGROUND

Algae accumulate lipids to endure different kinds of environmental stresses including macronutrient starvation. Although this response has been extensively studied, an in depth understanding of the transcriptional regulatory network (TRN) that controls the transition into lipid accumulation remains elusive. In this study, we used a systems biology approach to elucidate the transcriptional program that coordinates the nitrogen starvation-induced metabolic readjustments that drive lipid accumulation in Chlamydomonas reinhardtii.

RESULTS

We demonstrate that nitrogen starvation triggered differential regulation of 2147 transcripts, which were co-regulated in 215 distinct modules and temporally ordered as 31 transcriptional waves. An early-stage response was triggered within 12 min that initiated growth arrest through activation of key signaling pathways, while simultaneously preparing the intracellular environment for later stages by modulating transport processes and ubiquitin-mediated protein degradation. Subsequently, central metabolism and carbon fixation were remodeled to trigger the accumulation of triacylglycerols. Further analysis revealed that these waves of genome-wide transcriptional events were coordinated by a regulatory program orchestrated by at least 17 transcriptional regulators, many of which had not been previously implicated in this process. We demonstrate that the TRN coordinates transcriptional downregulation of 57 metabolic enzymes across a period of nearly 4 h to drive an increase in lipid content per unit biomass. Notably, this TRN appears to also drive lipid accumulation during sulfur starvation, while phosphorus starvation induces a different regulatory program. The TRN model described here is available as a community-wide web-resource at http://networks.systemsbiology.net/chlamy-portal.

CONCLUSIONS

In this work, we have uncovered a comprehensive mechanistic model of the TRN controlling the transition from N starvation to lipid accumulation. The program coordinates sequentially ordered transcriptional waves that simultaneously arrest growth and lead to lipid accumulation. This study has generated predictive tools that will aid in devising strategies for the rational manipulation of regulatory and metabolic networks for better biofuel and biomass production.

Aneurysm of an aberrant right subclavian artery: case report and review of the literature

In this article, we describe a case of a surgically treated aneurysm of an aberrant right subclavian artery. The historical literature to date is summarized, as are the key concepts relative to the anatomy, embryology, diagnosis, and treatment of this uncommonly occurring entity. Although the topic might be expected to be of concern to only a few specialists, all physicians should be aware that a patient with an enlarging aneurysm of an aberrant subclavian artery may experience dyspnea, dysphagia, or sudden collapse from rupture as the initial manifestations. An asymptomatic patient may have a mediastinal mass detected by roentgenography. The diagnosis may be confirmed with computed tomography or magnetic resonance imaging. As with most aneurysms, surgical treatment is recommended, and the benefit-to-risk analysis depends on individual case factors.