Non-Obstetric Vulvar/Paravaginal Hematoma in an Adolescent Girl with Scleroderma: An Opportunity for Intimate Partner Violence Intervention.

Description A 15-year-old female presented to the emergency department with swelling and pain in her left labial region as well as urinary retention after intercourse. This was the patient's first time having sexual intercourse and the patient stated that her boyfriend "kneed" her in the labia. A CT scan of the pelvis revealed a large vulvar/external hematoma measuring 6 × 10 × 7 cm which extended into the vaginal vault. This case is the first of a vulvar hematoma reported in a pediatric patient with scleroderma. This case was complicated by the fact that our patient claimed her boyfriend intentionally "kneed" her in the labia, thereby calling sexual abuse into question. Discerning between childhood connective tissue disorders and abuse injuries can be difficult, especially in genital trauma. The treatment team suspected early on that this was a case of intimate partner assault based on the severity of the injury alone and continued when she presented again to the emergency department with concerns for abuse. Sexual violence should be high on the differential in children with connective tissue disorders who present with vulvar or paravaginal hematomas. In our opinion, these injuries warrant a thorough investigation by a child abuse specialist, child protective services and law enforcement.

Community distress predicts youth gun violence.

BACKGROUND: The purpose of this study was to investigate our institution's experience with pediatric firearm events. We sought to determine the relationship between a community's level of socioeconomic distress and the incidence of youth gun violence. METHODS: We performed a retrospective review of children <18 years involved in firearm events. Using visual cluster analysis, we portrayed all firearm events and violent firearm events (assaults + homicides). Distressed community indices (DCIs) were obtained from an interface that uses US Census Bureau data. Incident rate ratios (IRRs) were calculated for firearm circumstances (i.e. assault, homicide, suicide) using a DCI. Significant IRRs were analyzed to discern which DCI metrics contributed most to gun violence. RESULTS: There were 114 children involved in firearm events; 66 were county residents. The DCI of injury location significantly predicted total firearm events (IRR 1.02, 95% CI 1.01-1.03), assaults (IRR 1.02, 95% CI 1.01-1.05), and violent firearm events (IRR 1.03, 95% CI 1.01-1.05). The proportion of adults without a high school diploma, poverty rate, median income ratio, and housing vacancy rate were highly predictive of gun violence (VIP >1). CONCLUSION: Community distress significantly predicts pediatric firearm violence. Local interventions should target neighborhoods with high levels of distress to prevent further youth gun violence. LEVEL OF EVIDENCE: Retrospective study, IV.

Structural and Mechanical Properties of Cocoons of Antherina suraka (Saturniidae, Lepidoptera), an Endemic Species Used for Silk Production in Madagascar.

Antherina suraka Boisduval (Saturniidae, Lepidoptera) produces a silken cocoon that has been the focus of efforts to create a commercial wild silk industry in Madagascar. In this study, structural and mechanical properties of the cocoon of A. suraka from two sites were measured and compared to the cocoon of Bombyx mori L. (Bombycidae, Lepidoptera) the world's most common source for silk. Results of environmental scanning electron microscopy and mechanical testing showed that the silk sheet of A. suraka cocoon is less compact, with greater thickness and lower tensile strength and stiffness than that of B. mori Confirming these results, stiffness and cell and thread density were found to be negatively correlated with thickness, and the cell and thread volumes were positively correlated with thickness. Antherina suraka showed no major differences between silk sheets from Kirindy and Isalo sites in either structural or mechanical properties, except for mean cell volume, which was greater in cocoons from Kirindy. Comparison between the two layers forming the cocoon showed that the inner layer has greater elastic modulus, denser silk distribution and lower porosity. Cocoons from both Kirindy and Isalo are suitable for sericulture. Although the inner layer of cocoon silk is of higher quality than the outer layer, the fact that both layers are of great but lower tensile strength than B. mori silk suggests that the current practice of sewing the two layers together for making one single layer fabric should be continued in efforts to produce a commercially viable product.

Synthesis and Characterization of Fatty Acid Conjugates of Niacin and Salicylic Acid.

This report describes the synthesis and preliminary biological characterization of novel fatty acid niacin conjugates and fatty acid salicylate conjugates. These molecular entities were created by covalently linking two bioactive molecules, either niacin or salicylic acid, to an omega-3 fatty acid. This methodology allows the simultaneous intracellular delivery of two bioactives in order to elicit a pharmacological response that could not be replicated by administering the bioactives individually or in combination. The fatty acid niacin conjugate 5 has been shown to be an inhibitor of the sterol regulatory element binding protein (SREBP), a key regulator of cholesterol metabolism proteins such as PCSK9, HMG-CoA reductase, ATP citrate lyase, and NPC1L1. On the other hand, the fatty acid salicylate conjugate 11 has been shown to have a unique anti-inflammatory profile based on its ability to modulate the NF-κB pathway through the intracellular release of the two bioactives.

Discovery of 2,4-bis-arylamino-1,3-pyrimidines as insulin-like growth factor-1 receptor (IGF-1R) inhibitors.

The insulin-like growth factor-1 receptor (IGF-1R) plays an important role in the regulation of cell growth and differentiation, and in protection from apoptosis. IGF-1R has been shown to be an appealing target for the treatment of human cancer. Herein, we report the synthesis, structure-activity relationships (SAR), X-ray cocrystal structure and in vivo tumor study results for a series of 2,4-bis-arylamino-1,3-pyrimidines.

SIRT1 activation by small molecules: kinetic and biophysical evidence for direct interaction of enzyme and activator.

SIRT1 is a protein deacetylase that has emerged as a therapeutic target for the development of activators to treat diseases of aging. SIRT1-activating compounds (STACs) have been developed that produce biological effects consistent with direct SIRT1 activation. At the molecular level, the mechanism by which STACs activate SIRT1 remains elusive. In the studies reported herein, the mechanism of SIRT1 activation is examined using representative compounds chosen from a collection of STACs. These studies reveal that activation of SIRT1 by STACs is strongly dependent on structural features of the peptide substrate. Significantly, and in contrast to studies reporting that peptides must bear a fluorophore for their deacetylation to be accelerated, we find that some STACs can accelerate the SIRT1-catalyzed deacetylation of specific unlabeled peptides composed only of natural amino acids. These results, together with others of this study, are at odds with a recent claim that complex formation between STACs and fluorophore-labeled peptides plays a role in the activation of SIRT1 (Pacholec, M., Chrunyk, B., Cunningham, D., Flynn, D., Griffith, D., Griffor, M., Loulakis, P., Pabst, B., Qiu, X., Stockman, B., Thanabal, V., Varghese, A., Ward, J., Withka, J., and Ahn, K. (2010) J. Biol. Chem. 285, 8340-8351). Rather, the data suggest that STACs interact directly with SIRT1 and activate SIRT1-catalyzed deacetylation through an allosteric mechanism.

Pulmonary contusion in the pediatric population.

Pulmonary contusion in the adult population is an independent risk factor for respiratory failure, ventilator associated pneumonia, and acute respiratory distress syndrome. Pilot studies in adults note an increased risk when volume of pulmonary contusion exceeds 20 per cent of total lung volume. The purpose of this study was to determine if children with pulmonary contusion suffer the same morbidity as adults. From January 2005 to May 2007, all trauma patients ages 3 to 18-years-old were assessed for CT evidence of pulmonary contusion. Children were excluded if injury included confounding variables, which could result in respiratory failure independent of contusion status. CT images were reviewed and pulmonary contusion was calculated as a percentage of total lung volume. Outcomes including need for invasive ventilation, pneumonia, and development of oxygenation problems were recorded. Data collected included patient age, Injury Severity Score, arterial blood gas findings, and number of rib fractures. Twenty-six patients met criteria for the study with a mean age of 13.35 years and mean Injury Severity Score of 24. The mean percentage of pulmonary contusion was 19.81 per cent. No patients required intubation. Pediatric pulmonary contusion does not carry the same morbidity as noted in the adult population. Invasive airway management is rarely required.

Pegylated interferon and ribavirin promote early evolution of nonstructural 5A protein in individuals with hepatitis C who demonstrate a response to treatment.

BACKGROUND: Hepatitis C virus (HCV) quasispecies diversity is more likely to affect early viral decline during treatment of hepatitis C than is having human immunodeficiency virus (HIV) infection. We evaluated the influence of HCV therapy on changes in the nonstructural 5A (NS5A) protein. METHODS: Fifteen patients with HCV genotype 1 infection with or without HIV infection were recruited for the present study, and the decrease in the HCV RNA level was measured at early time points. The evolution of HCV NS5A quasispecies within the first week was analyzed by comparing the clones observed at later times in the study with the baseline consensus sequence of individual patients. The response to therapy was defined as an early response (ER; ie, an HCV RNA level <615 IU/mL at week 4) or a slow response (SR; ie, a detectable HCV RNA level at week 4). RESULTS: HIV infection did not affect early viral kinetics. At baseline, lower diversity was seen in NS5A and in the amino and carboxyl termini of patients with an ER, compared with those with an SR. Rapid evolution of the NS5A genetic region occurred in patients with an ER (P = .01) but not in those with an SR (P = .73). The evolution was the result of an increase in the number of amino acid substitutions in the carboxyl region (P = .02) in patients with an ER. CONCLUSIONS: Selective pressure appears to result in more-marked changes in individuals with an ER than in those with an SR. The carboxyl terminus was subject to the most change and may be an important determinant of phenotypic resistance to interferon-based therapy.

Bicyclic cyanothiazolidines as novel dipeptidyl peptidase 4 inhibitors.

The synthesis and biochemical evaluation of novel cyanothiazolidine inhibitors of dipeptidyl peptidase 4 (DPP4) is described. Their main structural feature is a constrained bicyclic core that prevents the intramolecular formation of inactive cyclic species. The inhibitors show good to moderate biochemical potency against DPP4 and display distinct selectivity profiles towards DPP7, DPP8 and DPP9 depending on their substitution.

Discovery of oxazolo[4,5-b]pyridines and related heterocyclic analogs as novel SIRT1 activators.

SIRT1 is an NAD(+)-dependent protein deacetylase that appears to produce beneficial effects on metabolic parameters such as glucose and insulin homeostasis. Activation of SIRT1 by resveratrol (1) has been shown to modulate insulin resistance, increase mitochondrial content and prolong survival in lower organisms and in mice on a high fat diet. Herein, we describe the identification and SAR of a series of oxazolo[4,5-b]pyridines as novel small molecule activators of SIRT1 which are structurally unrelated to and more potent than resveratrol.

Small molecule activators of SIRT1 replicate signaling pathways triggered by calorie restriction in vivo.

BACKGROUND: Calorie restriction (CR) produces a number of health benefits and ameliorates diseases of aging such as type 2 diabetes. The components of the pathways downstream of CR may provide intervention points for developing therapeutics for treating diseases of aging. The NAD+-dependent protein deacetylase SIRT1 has been implicated as one of the key downstream regulators of CR in yeast, rodents, and humans. Small molecule activators of SIRT1 have been identified that exhibit efficacy in animal models of diseases typically associated with aging including type 2 diabetes. To identify molecular processes induced in the liver of mice treated with two structurally distinct SIRT1 activators, SIRT501 (formulated resveratrol) and SRT1720, for three days, we utilized a systems biology approach and applied Causal Network Modeling (CNM) on gene expression data to elucidate downstream effects of SIRT1 activation. RESULTS: Here we demonstrate that SIRT1 activators recapitulate many of the molecular events downstream of CR in vivo, such as enhancing mitochondrial biogenesis, improving metabolic signaling pathways, and blunting pro-inflammatory pathways in mice fed a high fat, high calorie diet. CONCLUSION: CNM of gene expression data from mice treated with SRT501 or SRT1720 in combination with supporting in vitro and in vivo data demonstrates that SRT501 and SRT1720 produce a signaling profile that mirrors CR, improves glucose and insulin homeostasis, and acts via SIRT1 activation in vivo. Taken together these results are encouraging regarding the use of small molecule activators of SIRT1 for therapeutic intervention into type 2 diabetes, a strategy which is currently being investigated in multiple clinical trials.

Discovery of benzothiazole derivatives as efficacious and enterocyte-specific MTP inhibitors.

A series of triamide derivatives bearing a benzothiazole core is shown to be potent microsomal triglyceride transfer protein (MTP) inhibitors. In order to minimize liver toxicity, these compounds have been optimized to have activity only in the enterocytes and have limited systemic bioavailability. Upon oral administration, selected analogs within this series have been further demonstrated to reduce food intake along with body weight and thereby improve glucose homeostasis and insulin sensitivity in a 28-day mice diet-induced obesity (DIO) model.

Discovery of imidazo[1,2-b]thiazole derivatives as novel SIRT1 activators.

A series of imidazo[1,2-b]thiazole derivatives is shown to activate the NAD(+)-dependent deacetylase SIRT1, a potential new therapeutic target to treat various metabolic disorders. This series of compounds was derived from a high throughput screening hit bearing an oxazolopyridine core. Water-solubilizing groups could be installed conveniently at either the C-2 or C-3 position of the imidazo[1,2-b]thiazole ring. The SIRT1 enzyme activity could be adjusted by modifying the amide portion of these imidazo[1,2-b]thiazole derivatives. The most potent analogue within this series, namely, compound 29, has demonstrated oral antidiabetic activity in the ob/ob mouse model, the diet-induced obesity (DIO) mouse model, and the Zucker fa/fa rat model.

Biochemical characterization, localization, and tissue distribution of the longer form of mouse SIRT3.

SIRT3 is a key mitochondrial protein deacetylase proposed to play key roles in regulating mitochondrial metabolism but there has been considerable debate about its actual size, the sequences required for activity, and its subcellular localization. A previously cloned mouse SIRT3 has high sequence similarity with the C-terminus of human SIRT3 but lacks an N-terminal mitochondrial targeting sequence and has no detectable deacetylation activity in vitro. Using 5' rapid amplification of cDNA ends, we cloned the entire sequence of mouse SIRT3, as well as rat and rabbit SIRT3. Importantly, we find that full-length SIRT3 protein localizes exclusively to the mitochondria, in contrast to reports of SIRT3 localization to the nucleus. We demonstrate that SIRT3 has no deacetylation activity in vitro unless the protein is truncated, consistent with human SIRT3. In addition, we determined the inhibition constants and mechanism of action for nicotinamide and a small molecule SIRT3 inhibitor against active mouse SIRT3 and show that the mechanisms are different for the two compounds with respect to peptide substrate and NAD(+). Thus, identification and characterization of the actual SIRT3 sequence should help resolve the debate about the nature of mouse SIRT3 and identify new mechanisms to modulate enzymatic activity.

Successful treatment of earlobe keloids in the pediatric population.

BACKGROUND: Keloid scars present a difficult treatment challenge. Recently, intralesional steroid injection has become a common treatment modality [Akoz et al. Aesthetic Plast Surg. 2002;6:184-188; Studdiford et al. JABFM. 2008;21:149-152]. Although this has become a proven treatment technique, there is no standard injection protocol to which treating physicians commonly adhere. We hypothesize that timing of steroid injection may improve outcomes using this treatment technique in combination with lesion excision. METHODS: Fifteen patients with 16 earlobe keloids were treated using a standard steroid injection protocol with Kenalog (Bristol-Myers Squibb, New York, NY), in combination with lesion excision. Strict follow-up was enforced, with repeat injections as needed at any sign of abnormal scar formation postoperatively. RESULTS: Of 16 lesions, 15 (94%) were treated successfully with no sign of lesion recurrence at 6 months of follow-up. A single lesion was lost to follow-up and presented 18 months postoperatively with recurrence. This lesion was subsequently retreated successfully. CONCLUSIONS: Kenalog injection in combination with excision is a well-tolerated and effective treatment of earlobe keloids in the pediatric population. We feel that timing of injection and adherence to a strict follow-up regimen is crucial to success.

Thyroid involvement with Langerhans cell histiocytosis in a 3-year-old male.

We report on the thyroid involvement with Langerhans cell histiocytosis (LCH) in a 3-year-old male. The patient presented with goiter and primary hypothyroidism. His goiter caused life-threatening airway obstruction. He developed locally invasive disease 4 years after his response to LCH therapy. LCH should be suspected as a cause of goiter and thyroidectomy is recommended.

Small molecule activators of SIRT1 as therapeutics for the treatment of type 2 diabetes.

Calorie restriction extends lifespan and produces a metabolic profile desirable for treating diseases of ageing such as type 2 diabetes. SIRT1, an NAD+-dependent deacetylase, is a principal modulator of pathways downstream of calorie restriction that produce beneficial effects on glucose homeostasis and insulin sensitivity. Resveratrol, a polyphenolic SIRT1 activator, mimics the anti-ageing effects of calorie restriction in lower organisms and in mice fed a high-fat diet ameliorates insulin resistance, increases mitochondrial content, and prolongs survival. Here we describe the identification and characterization of small molecule activators of SIRT1 that are structurally unrelated to, and 1,000-fold more potent than, resveratrol. These compounds bind to the SIRT1 enzyme-peptide substrate complex at an allosteric site amino-terminal to the catalytic domain and lower the Michaelis constant for acetylated substrates. In diet-induced obese and genetically obese mice, these compounds improve insulin sensitivity, lower plasma glucose, and increase mitochondrial capacity. In Zucker fa/fa rats, hyperinsulinaemic-euglycaemic clamp studies demonstrate that SIRT1 activators improve whole-body glucose homeostasis and insulin sensitivity in adipose tissue, skeletal muscle and liver. Thus, SIRT1 activation is a promising new therapeutic approach for treating diseases of ageing such as type 2 diabetes.

Using pressure-volume curves to set proper PEEP in acute lung injury.

The evolution of respiratory care on patients with acute respiratory distress syndrome (ARDS) has been focused on preventing the deleterious effects of mechanical ventilation, termed ventilator-induced lung injury (VILI). Currently, reduced tidal volume is the standard of ventilatory care for patients with ARDS. The current focus, however, has shifted to the proper setting of positive end-expiratory pressure (PEEP). The whole lung pressure-volume (P/V) curve has been used to individualize setting proper PEEP in patients with ARDS, although the physiologic interpretation of the curve remains under debate. The purpose of this review is to present the pros and cons of using P/V curves to set PEEP in patients with ARDS. A systematic analysis of recent and relevant literature was conducted. It has been hypothesized that proper PEEP can be determined by identifying P/V curve inflection points. Acquiring a dynamic curve presents the key to the curve's bedside application. The lower inflection point of the inflation limb has been shown to be the point of massive alveolar recruitment and therefore an option for setting PEEP. However, it is becoming widely accepted that the upper inflection point (UIP) of the deflation limb of the P/V curve represents the point of optimal PEEP. New methods used to identify optimal PEEP, including tomography and active compliance measurements, are currently being investigated. In conclusion, we believe that the most promising method for determining proper PEEP settings is use of the UIP of the deflation limb. However, tomography and dynamic compliance may offer superior bedside availability.