Differential interaction patterns of opioid analgesics with µ opioid receptors correlate with ligand-specific voltage sensitivity.

The µ opioid receptor (MOR) is the key target for analgesia, but the application of opioids is accompanied by several issues. There is a wide range of opioid analgesics, differing in their chemical structure and their properties of receptor activation and subsequent effects. A better understanding of ligand-receptor interactions and the resulting effects is important. Here, we calculated the respective binding poses for several opioids and analyzed interaction fingerprints between ligand and receptor. We further corroborated the interactions experimentally by cellular assays. As MOR was observed to display ligand-induced modulation of activity due to changes in membrane potential, we further analyzed the effects of voltage sensitivity on this receptor. Combining in silico and in vitro approaches, we defined discriminating interaction patterns responsible for ligand-specific voltage sensitivity and present new insights into their specific effects on activation of the MOR.

Voltage modulates the effect of µ-receptor activation in a ligand-dependent manner.

BACKGROUND AND PURPOSE: Various GPCRs have been described as being modulated in a voltage-dependent manner. Opioid analgesics act via activation of µ receptors in various neurons. As neurons are exposed to large changes in membrane potential, we were interested in studying the effects of depolarization on µ receptor signalling. EXPERIMENTAL APPROACH: We investigated potential voltage sensitivity of µ receptors in heterologous expression systems (HEK293T cells) using electrophysiology in combination with Förster resonance energy transfer-based assays. Depolarization-induced changes in signalling were also tested in physiological rat tissue containing locus coeruleus neurons. We applied depolarization steps across the physiological range of membrane potentials. KEY RESULTS: Studying µ receptor function and signalling in cells, we discovered that morphine-induced signalling was strongly dependent on the membrane potential (VM ). This became apparent at the level of G-protein activation, G-protein coupled inwardly rectifying potassium channel (Kir 3.X) currents and binding of GPCR kinases and arrestin3 to µ receptors by a robust increase in signalling upon membrane depolarization. The pronounced voltage sensitivity of morphine-induced µ receptor activation was also observed at the level of Kir 3.X currents in rat locus coeruleus neurons. The efficacy of peptide ligands to activate µ receptors was not (Met-enkephalin) or only moderately ([D-Ala2 , N-Me-Phe4 , Gly5 -ol]-enkephalin) enhanced upon depolarization. In contrast, depolarization reduced the ability of the analgesic fentanyl to activate µ receptors. CONCLUSION AND IMPLICATIONS: Our results indicate a strong ligand-dependent modulation of µ receptor activity by the membrane potential, suggesting preferential activity of morphine in neurons with high neuronal activity.

Interprofessional team management in pediatric critical care: some challenges and possible solutions.

BACKGROUND: Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous. METHODS: We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts. FINDINGS: The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted. CONCLUSION: Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

Variation in Current Management of Term and Late-preterm Neonates at Risk for Early-onset Sepsis: An International Survey and Review of Guidelines.

BACKGROUND: Uncertainty about the presence of infection results in unnecessary and prolonged empiric antibiotic treatment of newborns at risk for early-onset sepsis (EOS). This study evaluates the impact of this uncertainty on the diversity in management. METHODS: A web-based survey with questions addressing management of infection risk-adjusted scenarios was performed in Europe, North America, and Australia. Published national guidelines (n = 5) were reviewed and compared with the results of the survey. RESULTS: 439 Clinicians (68% were neonatologists) from 16 countries completed the survey. In the low-risk scenario, 29% would start antibiotic therapy and 26% would not, both groups without laboratory investigations; 45% would start if laboratory markers were abnormal. In the high-risk scenario, 99% would start antibiotic therapy. In the low-risk scenario, 89% would discontinue antibiotic therapy before 72 hours. In the high-risk scenario, 35% would discontinue therapy before 72 hours, 56% would continue therapy for 5-7 days, and 9% for more than 7 days. Laboratory investigations were used in 31% of scenarios for the decision to start, and in 72% for the decision to discontinue antibiotic treatment. National guidelines differ considerably regarding the decision to start in low-risk and regarding the decision to continue therapy in higher risk situations. CONCLUSIONS: There is a broad diversity of clinical practice in management of EOS and a lack of agreement between current guidelines. The results of the survey reflect the diversity of national guidelines. Prospective studies regarding management of neonates at risk of EOS with safety endpoints are needed.

[Management of atrial fibrillation in 2011]. / Prise en charge de la fibrillation auriculaire en 2011.

Some new guidelines have been published by European (2010) and American (2011) Societies of Cardiology regarding to the management of atrial fibrillation, the most frequent arrhythmia affecting from 1 to 2% of the global population. In this article we summarize and analyse the new aspects of these guidelines in which the different types of atrial fibrillation are redefined, as well as new criterias for the indication of oral anticoagulation and bleeding risk. New antiarrhythmic and anticoagulant molecules also appear in these guidelines, and there is growing evidence for the use of catheter ablation.

[Coronary artery aneurysm associated with fistula: two anatomically similar cases with different clinical presentation]. / Anévrysme coronaire associé à une fistule artérielle: deux cas anatomiquement similaires malgré une présentation clinique différente.

Coronary artery fistulas are rare anomalies and their association with a coronary aneurysm even more infrequent. We report two cases which are illustrative because of their different clinical presentations. In the first case the diagnosis was made after discovering fortuitously a heart murmur. In contrast in the second case the coronary artery fistula was demonstrated during a check-up for thoracic pain. In both cases the right coronary artery gave a fistulous communication to the right atrium.

Nephrogenic systemic fibrosis with a spectrum of clinical and histopathological presentation: a disorder of aberrant dermal remodeling.

BACKGROUND: Nephrogenic fibrosing dermopathy (NFD) has emerged as a clinicopathologic entity since 1997 and recently renamed as nephrogenic systemic fibrosis (NSF). The etiology and pathogenesis remain uncertain. Characteristic clinical presentation is described as diffuse thickening and hardening of the skin occurring in patients with renal insufficiency. Typical histological features include proliferation of CD34 positive fibrocytes, increased thick collagen bundles and mucin deposition, without significant inflammatory infiltrate. Variations in clinical presentations have been reported, including papular and plaque-like skin lesions, focal lesion only, as well as systemic involvement. Histological changes can be subtle and non-specific, overlapping with other disease processes and harboring features including calcification and osteoclast-like giant cells with osseous metaplasia. METHODS: We reviewed patients with NSF that presented to our dermatology clinic by chart review, clinical examination and histological examination. Skin biopsy specimens were obtained from all cases. Histopathology evaluations were carried out by three dermatopathologists (AD, BS and GK) independently and the features were compared among all the cases. Special stains and immunohistochemistry study were also performed to highlight the histological features. RESULTS: Seven cases of NSF presented with a spectrum of clinical manifestations, from classic diffuse hardening of the skin to localized linear plaques. On histological examination, proliferation of CD34-positive fibrocytes ranged from sparse to dense, collagen bundles ranged from thin to thick, and the interstitial dermal mucin accumulation ranged from scant-patchy to abundant. In addition, the lesion displayed various degrees of vascular proliferation, inflammatory infiltrates and intensities of CD68 and Factor XIIIa staining. Two cases showed extensive dermal calcification and ossification. CONCLUSION: NSF may present with a spectrum of clinical abnormalities, and exhibit overlapping histopathological features resembling cicatrix and other dermal reparative/regenerative processes. NSF may in fact to be a disorder of aberrant extracellular matrix remodeling in patients with renal insufficiency.

Naevus comedonicus: a spectrum of body involvement.

Naevus comedonicus (NC) is a rare developmental anomaly, with < 200 cases reported in the literature. It usually occurs on the face, neck or chest, appearing as groups of closely arranged dilated follicular openings with keratin plugs. Several associations have been made in the literature. We review the current literature, emphasizing the clinical features, associated conditions and therapeutic options.

Overcoming ethical barriers to childhood tuberculosis research in developing countries.

In 2002, an international Workshop on Tuberculosis in Children was held to determine priority areas for basic, clinical and programmatic research to improve paediatric TB practice. During the workshop, issues related to the ethical treatment of children as research subjects, particularly in resource-poor settings, were identified as major constraints to the goal of expanding paediatric TB research. Based on participation in the workshop discussions, this article proposes concrete activities that can begin to address the ethical barriers. The time and costs associated with creating collaborative scientific and ethical research projects between high and low-income countries should be supported in grants for paediatric TB research studies in developing countries. Paediatric TB researchers in developing countries should be given opportunities to participate in international programmes that develop bioethics expertise. Relevant case studies of paediatric research in developing countries can assist ethical review committees in industrialised countries in understanding the special issues related to paediatric research in resource-limited settings. Paediatricians in developing countries need to be included in childhood TB research studies and ethical review committees.

The neglected burden of Plasmodium vivax malaria.

We estimate that the global burden of malaria due to Plasmodium vivax is approximately 70-80 million cases annually. Probably approximately 10-20% of the world's cases of P. vivax infection occur in Africa, south of the Sahara. In eastern and southern Africa, P. vivax represents around 10% of malaria cases but < 1% of cases in western and central Africa. Outside of African, P. vivax accounts for > 50% of all malaria cases. About 80-90% of P. vivax outside of Africa occurs in the Middle East, Asia, and the Western Pacific, mainly in the most tropical regions, and 10-15% in Central and South America. Because malaria transmission rates are low in most regions where P. vivax is prevalent, the human populations affected achieve little immunity to this parasite; as a result, in these regions, P. vivax infections affect people of all ages. Although the effects of repeated attacks of P. vivax through childhood and adult life are only rarely directly lethal, they can have major deleterious effects on personal well-being, growth, and development, and on the economic performance at the individual, family, community, and national levels. Features of the transmission biology of P. vivax give this species greater resilience than the less robust Plasmodiumfalciparum in the face of conditions adverse to the transmission of the parasites. Therefore, as control measures become more effective, the residual malaria burden is likely increasingly to become that of P. vivax.

Effects of initial dose on eastern equine encephalomyelitis virus dependent mortality in intrathoracically inoculated Culiseta melanura (Diptera: Culicidae).

Viral growth characteristics that favor rapid and prodigious virion production may increase virus transmission but be detrimental to infected hosts. Several arboviruses, including eastern equine encephalomyelitis (EEE) virus, negatively affect the survival of their infected mosquito vectors. To test the hypothesis that the mosquito virulent properties of EEE virus are caused by the presence of intrinsic viral growth properties, we investigated the effects of infecting dose on the survival of intrathoracically inoculated Culiseta melanura (Coquillett). Daily survival of age-matched females inoculated with either a low initial dose of 10(1.5) plaque-forming units (PFUs) per mosquito or a high initial dose of 10(5.5) PFUs per mosquito was monitored for 8 wk. Compared with diluent inoculated controls, mosquitoes from both dosage groups displayed highly significant decreases in survival. No significant differences in daily survival were detected between the two infected groups. Virus production within inoculated mosquitoes was assessed by sampling mosquitoes every 12 h for 96 h after inoculation. Rapid virus amplification occurred in both dosage groups, and by 24 h after exposure the mean viral loads in mosquitoes inoculated with the low dose were comparable to those inoculated with the high dose. Likewise, although detectable virions appeared sooner in the saliva of high dosage mosquitoes, by 72 h after inoculation no significant differences in virus transmission were detected between the two exposure groups. These results indicate that the virulence of EEE virus for its enzootic North American mosquito vector is not dosage dependent and likely reflects the inherent growth properties of this virus within infected mosquitoes.

Laboratory and field evaluation of polymerase chain reaction-based forensic DNA profiling for use in identification of human blood meal sources of Aedes aegypti (Diptera: Culicidae).

We modified polymerase chain reaction (PCR)-based forensic DNA profiling for field studies on the feeding behavior of Aedes aegypti, the principal mosquito vector of dengue virus. Human DNA was extracted from oral swabs of human subjects and from blood-engorged mosquitoes, DNA was quantified by slot blot, and alleles at variable number tandem repeats and three short tandem repeats loci were amplified by PCR. Alleles were separated electrophoretically and then visualized by silver staining. A custom software program was written to match DNA fingerprints of potential human hosts to allelic profiles detected in engorged mosquitoes, and to calculate error rates for identification of human hosts of single and multiple-host blood meals. At 29 degrees C in the laboratory, human DNA recovered from mosquito blood meals declined an average of 67% 8 h after feeding and 90% after 24 h. We obtained complete allelic profiles from seven of 10 mosquitoes collected after 24 h. In a field trial, complete DNA profiles were obtained successfully for 43 people living in a rural village in south central Thailand and for 20 of 100 Ae. aegypti that contained blood and were collected in those peoples' homes. Blood imbibed from more than one person was detected in 45% (9 of 20) of the meals. Sixty-five percent of the meals contained blood from nonresidents of the house in which the mosquito was collected or from people who were not profiled; data consistent with the hypothesis that human movement is important for the spread of dengue virus within and among communities. When using alleles at four loci, all of the Thais and nine members spanning three generations of a Chinese-American family had unique allelic profiles. Error rates from classifying possible multiple-host meals as single-host meals were low (1-8%), with the highest error associated with closely related people. Results from our laboratory and field studies indicated that DNA profiling can be used to study the details and epidemiological implications of Ae. aegypti blood-feeding behavior.

Solitary mastocytoma arising at a hepatitis B vaccination site.

On the first day of life, a healthy infant was given a recombinant hepatitis B vaccine. Over the following year, a 3 by 4.5 cm, well-defined, erythematous patch with an overlying white, reticulated, smaller plaque gradually appeared on her thigh at the vaccination site. Darier's sign was elicited at the site. Examination of a biopsy specimen showed an upper dermal mast cell infiltrate. This is the first reported case of a solitary mastocytoma appearing in a vaccination site.

Plasmodium vivax: a monoclonal antibody recognizes a circumsporozoite protein precursor on the sporozoite surface.

The major surface circumsporozoite (CS) proteins are known to play a role in malaria sporozoite development and invasion of invertebrate and vertebrate host cells. Plasmodium vivax CS protein processing during mosquito midgut oocyst and salivary gland sporozoite development was studied using monoclonal antibodies which recognize different CS protein epitopes. Monoclonal antibodies which react with the CS amino acid repeat sequences by ELISA recognized a 50-kDa precursor protein in immature oocyst and additional 47- and 42-kDa proteins in older oocysts. A 42-kDa CS protein was detected after initial sporozoite invasion of mosquito salivary glands and an additional 50-kDa precursor CS protein observed later in infected salivary glands. These data confirm previous results with other Plasmodium species, in which more CS protein precursors were detected in oocysts than in salivary gland sporozoites. A monoclonal antibody (PvPCS) was characterized which reacts with an epitope found only in the 50-kDa precursor CS protein. PvPCS reacted with all P. vivax sporozoite strains tested by indirect immunofluorescent assay, homogeneously staining the sporozoite periphery with much lower intensity than that produced by anti-CS repeat antibodies. Immunoelectron microscopy using PvPCS showed that the CS protein precursor was associated with peripheral cytoplasmic vacuoles and membranes of sporoblast and budding sporozoites in development oocysts. In salivary gland sporozoites, the CS protein precursor was primarily associated with micronemes and sporozoite membranes. Our results suggest that the 50-kDa CS protein precursor is synthesized intracellularly and secreted on the membrane surface, where it is proteolytically processed to form the 42-kDa mature CS protein. These data indicate that differences in CS protein processing in oocyst and salivary gland sporozoites development may occur.

Metastatic inflammatory carcinoma of the rectum: tumor spread by three routes.

We report a case of a patient with adenocarcinoma of the rectum with inflammatory metastases to the skin who was treated with radiation therapy and subsequently developed lymphatic obstruction with resultant extensive lymphedema of the lower extremities. Histopathologic examination and immunohistochemistry showed intralymphatic, intravascular, and interstitial malignant cells in the dermis. To our knowledge, this is the second reported case of inflammatory carcinoma arising from metastatic carcinoma of the rectum. However, tumor cell spread to the skin by three routes has not previously been demonstrated.