Training program for pain assessment in the newborn.

AIM: Pain management is correlated with pain assessment in the newborn infant. The aim of this study was to assess the impact of a 2-week training program composed of short (20min), repeated training sessions conducted in the unit. METHODS: Pain assessment was studied by means of audits. Each audit included data recorded from the newborn infant's medical charts on the day the infant was admitted to the unit and 3 days before the audit. An audit was performed before the training program and then repeated every month for 12 months. RESULTS: Eighty-eight (53.7%) members of the neonatology staff were trained during the 2-week training program. After the training program, pain assessment "at least once a day" increased by 39.0% and pain assessment "at least once a shift" increased by 21.5% compared to baseline (P<0.05). The effects of the training program were maintained after 12 months (P<0.05). CONCLUSION: A training program with short, repeated sessions conducted in the unit trained 53.7% of the neonatology staff and increased the frequency of pain assessment.

[Maternal anxiety related to how the pediatrician provided prenatal information about preterm birth]. / Évaluation de l'anxiété maternelle liée aux modalités d'informations sur la prématurité chez les patientes présentant un risque d'accouchement prématuré.

INTRODUCTION: Women hospitalized for preterm labor require clear information about prematurity. This study assessed whether or not specific written information about prematurity delivered at admission to the unit combined with an oral explanation from a pediatrician would decrease women's anxiety compared to an oral explanation alone. MATERIAL AND METHODS: This was a prospective, single-center observational study. Women were included in the high-risk pregnancies department and distributed into two groups: receiving "only oral" information for a prenatal clinical consultation with a senior pediatrician or receiving "combined" oral information+a booklet about prematurity given to the women at admission. The primary endpoint was the change in anxiety-state (before and after the information procedure) evaluated by the State Trait Anxiety Inventory-Y (STAI-Y). RESULTS: The anxiety score before receiving information did not differ between the two groups (STAI-Y-A "combined" group: 46.7±3.0 vs. "only oral" group: 42.7±2.74; P=0.55). After consultation with a pediatrician, the acute anxiety-state score STAI-Y-A decreased significantly in the "combined" group (-6.7±1.9) compared to the "only oral" group (-2.5±4.6; P<0.05). DISCUSSION: A booklet about prematurity combined with oral information from a pediatrician reduced patients' anxiety more than oral information alone. Given that the psychology of the mother interacts with the pregnancy, it is necessary to provide clear and adapted information. Giving a booklet appears to be one of the modalities to improve information. Other modalities such as video documents have to be studied.

Safety and tolerability of subcutaneous treprostinil in newborns with congenital diaphragmatic hernia and life-threatening pulmonary hypertension.

BACKGROUND: Prolonged pulmonary hypertension (PH) is highly predictive for pulmonary morbidity and death in infants with congenital diaphragmatic hernia (CDH). OBJECTIVES: To report the effects and tolerability of subcutaneous treprostinil in newborns with severe CDH and late life-threatening PH. METHODS: We recorded clinical and echocardiography data before and after starting subcutaneous treprostinil, on patients with severe CDH and late PH, refractory to inhaled nitric oxide and oral sildenafil. RESULTS: 14 patients were treated with treprostinil (gestational age: 39.1±2.0weeks; birth weight: 3200±600g). Prior to treatment, the pre- and post-ductal SpO2 difference (Δ SpO2) was 14±10%. Treprostinil was initiated at a median age of 12days [5-157]. After starting treprostinil, ΔSpO2 decreased to 3% at day 7 (p<0.05), and the mean blood flow velocities in the right pulmonary arteries increased by 110% (p<0.05). 2 of the 14 patients died. At the age of follow up (12months to 3years), the 12 surviving infants were all weaned from respiratory support and discharged home. CONCLUSION: The subcutaneous treprostinil improves pulmonary hemodynamics and outcomes in infants with CDH and life-threatening PH. We suggest that the treatment should be considered in infants with severe CDH and late PH. TYPE OF STUDY: Case series with no comparison group. LEVEL OF EVIDENCE: Level IV.

Innate immunity and testosterone rapidly respond to acute stress, but is corticosterone at the helm?

When faced with a stressor, vertebrates can rapidly increase the secretion of glucocorticoids, which is thought to improve the chances of survival. Concurrent changes in other physiological systems, such as the reproductive endocrine or innate immune systems, have received less attention, particularly in wild vertebrates. It is often thought that glucocorticoids directly modulate immune performance during a stress response, but, in many species, androgens also rapidly respond to stress. However, to our knowledge, no study has simultaneously examined the interactions between the glucocorticoid, androgen, and innate immune responses to stress in a wild vertebrate. To address this issue, we tested the hypothesis that the change in plasma corticosterone (CORT) in response to the acute stress of capture and restraint is correlated with the concurrent changes in plasma testosterone (T) and innate immune performance (estimated by the capacity of plasma to agglutinate and lyse foreign cells) in the Abert's Towhee (Melozone aberti). Furthermore, to broaden the generality of the findings, we compared male and female towhees, as well as males from urban and non-urban populations. Acute stress increased plasma CORT, decreased plasma T in males, and decreased innate immune performance, but the increase in CORT during stress was not correlated with the corresponding decreases in either plasma T or innate immunity. By contrast, the plasma T stress response was positively correlated with the innate immune stress response. Collectively, our results challenge the proposition that the glucocorticoid stress response is correlated with the concurrent changes in plasma T, a key reproductive hormone, and innate immunity, as estimated by agglutination and lysis.

[Impact on the healthcare team and parents of the type of cardiorespiratory monitoring during phototherapy]. / Impact sur le personnel et les parents du mode de monitorage cardio-respiratoire lors de la photothérapie.

INTRODUCTION: Neonatal jaundice is treated with phototherapy and requires continuous cardiorespiratory monitoring, which can induce parental anxiety. Within a very short time, parents receive the announcement of the diagnosis and of the need for a treatment in another unit with a new team of caregivers. OBJECTIVE: To evaluate parents' anxiety and their feelings concerning the location of treatment concerning cardiorespiratory monitoring equipment (wired vs Wi-Fi wireless monitoring equipment) and treatment location (neonatology vs maternity wards) during a phototherapy treatment in the neonatology unit, located in the maternity wards. METHODS: This was a prospective and monocentric study. Parental anxiety was assessed using the STAI-Y score. Their feelings on the location of treatment were assessed using a specific questionnaire. Three successive periods were considered: period I "wired with neonatology team," period II "Wi-Fi with neonatology team," and period III "Wi-Fi with maternity wards". Comparison between periods I and II evaluated the impact of the monitoring equipment and comparison between periods II and III assessed the impact of the treatment location. RESULTS: No effects of the monitoring equipment were observed. We found an impact of the treatment location in charge of the newborn: the parent's anxiety (STAI-Y score) was lower in the maternity wards, whereas the maternity ward personnel considered the protocol as an increased workload (p<0.001). CONCLUSION: The monitoring equipment had little effect. Parental anxiety decreased when monitoring took place in the usual maternity wards, underscoring the advantages of a close relationship between maternity and neonatology units.

[Skin-to-skin care in the delivery room: impact of SpO2 monitoring]. / Peau-à-peau en salle de naissance : impact du monitorage de la saturation pulsée en oxygène.

BACKGROUND: Skin-to-skin care in the delivery room increases mother-newborn bonding, reduces the newborn's stress level, and facilitates breastfeeding. However, a few reports of life-threatening events in newborn infants during skin-to-skin care have prompted suggestions that SpO2 monitoring may be of value in the delivery room. The present study compared SpO2 monitoring with standard clinical practices during skin-to-skin care in the delivery room. The midwife's opinion and the mother's anxiety level were assessed for both procedures. MATERIALS AND METHODS: The midwife's opinion was measured on a Likert scale and the mother's anxiety level was measured on the State-Trait Anxiety Inventory Y-A and Y-B scales. Two procedures (standard clinical practice vs. SpO2 monitoring) were compared prospectively in two consecutive 3-month periods. RESULTS: Seventy case report forms were completed for the "standard clinical practice" group and 62 were completed for the "SpO2 monitoring" group. The care procedure was considered to be satisfactory or quite satisfactory in 60 cases (96.8%) in the "SpO2 monitoring" group and in 57 cases (81.4%; P<0.05) in the "standard clinical practice" group. There was no significant difference between the groups in terms of the mean maternal anxiety level. CONCLUSION: SpO2 monitoring during skin-to-skin care in the delivery room was well accepted by the midwife. Relative to standard clinical practice alone, SpO2 monitoring was not associated with elevated maternal anxiety levels.

Characteristics of endobronchial primitive tumors in children.

Primary endobronchial tumors are rare in children and they include a broad spectrum of lesions. The aim of this study was to determine the characteristic features, treatments and outcomes of these tumors. We report a retrospective analysis of all patients treated for endobronchial tumor in nine French hospitals between 1990 and 2010 and a comparison of the results with those reported in the medical literature. Twelve tumors were reported: five low grade muco epidermoid carcinomas, two inflammatory myofibroblastic tumors, two hemangiomas, one anaplastic large cell lymphoma, one carcinoid tumor, and one juvenile xanthogranuloma. The mean age of the patients was 7.5 ± 3.5 years. The most common sign revealing the disease was persistent atelectasis or recurrent pneumonia (eight cases). The other revealing signs were a persistent bronchospasm (three cases) and hemoptysis (one case). The clinical presentation, biology, serum tumor markers, and chest X-ray abnormalities were not specific to a particular histological diagnosis. Chest CT scan revealed the presence of an endobronchial tumor in 11 cases. Nine tumors could be diagnosed from a biopsy obtained by video endoscopy. Complete surgical resection was performed in seven patients. Bronchoscopic removal was performed in five cases and was successful in three. There were no deaths. Endobronchial tumors are rare in childhood and their histology is diverse. Chest CT scan and per-endoscopic endobronchial biopsies are required for diagnosis, when possible. Surgical or endoscopic treatment should be discussed by a multidisciplinary team. Despite the multiple etiologies, the prognosis of these tumors is good if diagnosis is early and if resection is complete. Long-term recurrences have been described, so long-term follow-up of these children is recommended.

[Subcutaneous teicoplanin for children with infectious endocarditis]. / Teicoplanine par voie sous-cutanée chez l'enfant présentant une endocardite infectieuse.

BACKGROUND: Infectious endocarditis in children requires prolonged antibiotic therapy. In adults, antibiotics administrated subcutaneously such as teicoplanin are an alternative to intravenous treatment. CASE REPORT: We report the use of subcutaneous teicoplanin, after an initial antibiotic treatment administrated intravenously, for 2 children treated for infectious endocarditis following an initial cardiac surgery. Serum concentrations of teicoplanin were within the target range after the adaptation in the teicoplanin subcutaneous dosages. The treatment was effective for both cases. No specific side effects related to the treatment were reported. DISCUSSION: Subcutaneous administration could be used for prolonged antibiotic therapy for the treatment of infectious endocarditis in children, after an initial intravenous treatment. Variability of the bioavailability of antibiotics administrated subcutaneously requires regular testing. Prospective, randomized trials comparing intravenous and subcutaneous administration of teicoplanin should be conducted to assess the efficacy and safety of this treatment.

A simple surgical treatment for acute traumatic sternoclavicular dislocation.

Sternoclavicular lesions may sometimes require surgery. Many techniques have been described and they appear to be very demanding. We describe a simple technique using two screws and a strong suture (Arthrex Inc. Naples. FL 34108 USA). Level of evidence; Level IV, Case Series, Treatment Study.

Wormian bones in a general paediatric population.

UNLABELLED: Wormian bones are small bones that are often found within the sutures and fontanelles of the skull. When a child presents an unexplained fracture or fracture(s), osteogenesis imperfecta is usually suggested when an "abnormally high number" of fractures are seen. PURPOSE: To assess the frequency, number, and topography of wormian bones in a "normal" paediatric population. MATERIALS AND METHODS: In a population aged from 0 to 3 years, we retrospectively analysed 605 CT brain scans carried out for a range of indications, excluding cases in which there was a suspicion of constitutional bone disease. RESULTS: In our population, wormian bones were found in 53% of children (n=320): 43% of the children had between one and three (n=260), 10% had four or more (n=60), and 6% had five or more (n=40). There was no significant relationship between the number of wormian bones and the various indications that had led to the CT scan being carried out. Wormian bones in the lambdoid suture were found in by far the greatest numbers. CONCLUSION: Wormian bones are common and can sometimes be numerous without necessarily pointing to osteogenesis imperfecta, since 10% of the children in our study had at least four.

The concordance of MRI and arthroscopy in traumatic meniscal lesions in children.

INTRODUCTION: Traumatic meniscal lesions in children must be diagnosed quickly and efficiently as a priority in order to conserve the meniscus and safeguard the future of the knee. They are often isolated and difficult to identify clinically. In the diagnostic work up stage, an excessive resort to diagnostic arthroscopy has given way to increasing use of MRI by radiologists without pediatric specialization. The present study examined the agreement between MRI aspect and arthroscopic exploration in traumatic meniscal lesions in children. PATIENTS AND METHODS: Sixty-nine knees in children aged 9 to 16 years having undergone MRI followed by arthroscopy for knee trauma between 1995 and 2008 were included in a retrospective design. Discoid meniscus was excluded. Files were reviewed by a single clinician and MRI scans by a radiologist specialized in pediatric pathology. Cases of epiphyseal fusion were excluded. All files were analyzable. Agreement with arthroscopic findings as reference was assessed for presence, location and type of meniscal lesion. RESULTS: Overall agreement with arthroscopy was respectively 78% and 82% on first and second MRI readings: 77% and 80% for the medial, and 78% and 84% for the lateral meniscus. On the first reading, there were 13 false positives for the medial and 5 for the lateral meniscus, versus 9 and 0 respectively on second reading. Overall sensitivity was 70% on first reading and 64% on second, and overall specificity 81% and 90%, respectively. DISCUSSION: The present results, in line with the literature, may appear encouraging, but hide considerable disparity between analysis of the medial and of the lateral meniscus: MRI overestimated medial and underestimated lateral meniscus lesions. CONCLUSION: MRI serves only as a support and does not provide sure diagnosis of meniscus lesion. Interpretation should take account of the clinical examination and the pediatric orthopedic specialist's experience.

[Imaging of anorectal malformations in the neonatal period]. / Imagerie des malformations anorectales en période néonatale.

PURPOSE: The classification of anorectal malformations (ARM) as high or low is based on clinical and anatomical characteristics. It has an impact on the surgical management but also on the functional prognosis. In the absence of consensus, our goal was to determine the value of imaging in the neonatal period for diagnosis and management of infants with ARM. MATERIALS AND METHODS: Retrospective study of 43 infants imaged over a 9 year period. The different imaging studies (abdominal and pelvic ultrasound, radiographs, percutaneous opacifications and fistulograms) performed for each infant were collected and analyzed then correlated to clinical and surgical findings. RESULTS: Clinical evaluation could classify 30 ARM as low and 4 ARM as high while 9 ARM without fistula remained indeterminate. Imaging findings were mixed: on ultrasound, the rectal cul-de-sac to perineum distance did not appear to be determinant, contrary to published data. Pelvimetry showed limitations, irrespective of the technique. Morphological evaluation provided the following data: presence of fistula, sphincter anatomy, rectal cul-de-sac to perineum distance. CONCLUSION: Classification relies on clinical evaluation in most cases. Opacification techniques and ultrasound remain useful in some cases. MRI could become the preferred imaging modality.

[Volar fixed angle plate LCP 3.5 for dorsally distal radius fracture. About 24 cases]. / Ostéosynthèse antérieure par plaque à vis verrouillée LCP 3.5 dans les fractures de l'extrémité inférieure du radius à déplacement postérieur. A propos de 24 cas.

PURPOSE OF THE STUDY: Fracture of the distal radius with posterior displacement is the most common wrist fracture. Pinning is generally proposed. The problem is that a secondary displacement may persist, even for the least complex fractures. With the advent of the fixed-angle plate with a self-locking screw, we considered using this method in combination with an anterior approach to the radius. We report our preliminary results. MATERIAL AND METHODS: From November 1 to March 31, 2003, among the 195 fractures of the distal radius with posterior displacement which we treated in our unit, 135 were treated with orthopedic reduction, 36 with Kapandji pinning and 24 with a T-shaped anterior locking compression plate (Synthès, LCP 3.5. During the early part of this series, the LCP was used for emergency situations in young adults with a posterior displacement exceeding 20 degrees . Starting in November 2002, the technique was also proposed for revisions for secondary displacements after orthopedic reduction or pinning procedures. Secondary displacement was noted on the standard X-rays and the clinical analysis included a measurement of muscle strength, the DASH score and the clinical evaluation score used by the SOFCOT symposium in November 2000. RESULTS: Twenty-four patients (14 female, 10 male, mean age: 54.5 years) presented 14 extra-articular fractures and ten articular fractures. At admission, mean frontal inclination of the radial glenoid was 13 degrees with a posterior displacement of 25.45 degrees and an ulnar variance measuring+4mm. Eighteen patients were reviewed at mean 16 months follow-up. Mean frontal inclination of the glenoid was 23.95 degrees with mean anteversion 5.45 degrees . Using the SOFCOT criteria, 11 outcomes were anatomic and seven presented moderate displaced healing. The wrist force (Jamar was 95% of the value measured on the healthy side. The mean DASH score was 38.47. Outcome was considered excellent for nine cases, good for six, fair for three and poor for zero. Complications were: reflex dystrophy (n=4), carpal tunnel syndrome (n=1), cheloid scar (n=1), glenoids in the pulse gutter (n=10), and secondary fracture along the upper border of the plate (n=3). CONCLUSION: This study demonstrated that, used on the anterior aspect of the radius, the locking compression plate provides satisfactory treatment for fractures of the distal radius with posterior displacement. Because of the angular stability, the reduction can be maintained over time so that secondary displacement is no longer a problem. This is a difficult technique which requires particular skill. We no longer recommend the LCP 3.5 plate due to the poorly adapted ergonometry, the late fracture over the plate and the fact that the material is not removed.

[Hepatic splenosis: a rare etiology of hepatic nodules]. / Splénose hépatique: une étiologie rare de nodules hépatiques.

Splenosis is the autotransplantation of splenic tissue, generally after traumatic splenic rupture. Usually, the peritoneal surface is affected. The viscera are rarely involved in this graft. We report a case of intrahepatic splenosis, which presented as a liver tumour on imagery in a 55-year-old man followed for lung carcinoma and chronic hepatitis C and who had undergone a splenectomy for trauma 22 years before. The different characteristics and diagnostic methods of 16 cases of hepatic splenosis are presented from the literature. These different reports emphasize the necessity of considering splenosis in the differential diagnosis of hepatic tumours.

[Using the DRP 2.4 device for volar plating of distal radius for dorsally displaced wrist fractures. Report of 22 cases]. / Ostéosynthèse antérieure par plaque à tête de vis verrouillée DRP 2.4 dans les fractures à déplacement postérieur de l'extrémité distale du radius. A propos de 22 cas.

OBJECTIVE: Our first experience of palmar plating for dorsally displaced distal radius fracture with locking compression plate showed good results. But ancillary tools was ineffective, so we report our early experience with the DRP 2,4 device. METHODS: Between January and October 2004, 22 patients (16 women, 6 men), mean age 56,8 years (age range: 24-77 years), underwent internal reduction and fixation using DRP 2.4 by Henry's approach. By AO classification there was 10 A3 and 12 C1 or C2 fracture. On pre operative X Ray, radial inclination was 13.9 degrees , and dorsal tilt was 27 degrees . RESULTS: Seventeen patients were reviewed with mean follow-up of 11 months (5 to 17). On postoperative X Ray, radial inclination was 22,7 degrees and palmar tilt was 2,1 degrees. At 6 month radiological findings found no loss of postoperative reduction. According to SOFCOT's criteria's, we noticed 9 anatomical results and 8 moderate malunion. Clinical results (Green and O'Brien) showed 6 excellent, 7 good, 4 fair and no poor results. Mean DASH score was 13.5. Strength recovery was 82% of opposite side. Complications concerning 6 patients with, 4 reflex sympathetic dystrophy, and 2 screwdriver breakage during insertion. DISCUSSION: Volar plating with DRP 2.4 is an effective technique, but obtain anatomical reduction remind challenging for the surgeon. CONCLUSION: DRP 2.4 volar plating is an effective treatment for dorsally displaced fracture. Controlled study with orthopaedic reduction and K Wire fixation are need for determining the place of each treatment.

[Can US-guided vacuum-assisted biopsies be an alternative to diagnostic surgery in cases of non-diagnostic core needle biopsy?]. / Les macrobiopsies echoguidées assistées par le vide peuvent-elles constituer une alternative a la chirurgie diagnostique en cas de microbiopsies non contributives?

PURPOSE: To assess US-guided vacuum-assisted biopsies in the diagnosis of suspicious sonographic breast lesions after non-diagnostic core needle biopsies (CNB). PATIENTS AND METHODS: Retrospective study of 42 females with suspicious breast lesions at US. CNB previously performed were non-diagnostic. Because of the larger sample size, vacuum-assisted biopsies were performed, instead of surgical biopsy. RESULTS: Vacuum-assisted biopsies showed 32 benign lesions. Histologic examination of the CNB showed non-specific fibrous tissue in 43% of cases as opposed to 7.1% for vacuum-assisted biopsies. The latter provided a more specific diagnosis (mainly fibrocystic breast disease). From a total of 4 lesions that were suspicious at CNB, 3 were diagnosed as malignancies after vacuum-assisted biopsy and one case was a "borderline" lesion. Three additional malignant and three additional borderline lesions were diagnosed on vacuum-assisted biopsies. In 11 cases, surgical excision was performed, and all diagnoses from vacuum-assisted biopsies were confirmed at microscopy, except in one case where it was underestimated (ADH versus DCIS). CONCLUSION: US-guided vacuum-assisted biopsy is a reliable technique. Because it provides more tissue than CNB, it can be an alternative to diagnostic surgery after non-diagnostic CNB. Indeed, it allows confirmation of the diagnosis and provides a more specific diagnosis of benign lesions. With regards to malignant and borderline lesions, it avoids the risk of false-negative CNB and overlooking carcinomas.

Transient gene expression in HEK293 cells: peptone addition posttransfection improves recombinant protein synthesis.

Gene expression by large-scale transfection of mammalian cells is becoming an established technology for the fast production of milligram and even gram amounts of recombinant proteins (r-proteins). However, efforts are still needed to optimize production parameters in order to maximize volumetric productivities while maintaining product quality. In this study, transfection efficiency and volumetric productivity following transient gene expression in HEK293 cells were evaluated using green fluorescent protein (GFP) and human placental secreted alkaline phosphatase (SEAP) as reporter genes. We show that a single pulse of peptones (protein hydrolysates) to the cultures performed in a low serum (1%, v/v) and in serum-free medium results in a significant increase in volumetric protein productivity. Sixteen peptones from different sources were tested and almost all of them showed a positive effect on r-protein production. This effect, however, is time- and concentration-dependent. By using Tryptone N1 (a casein peptone, TN1) to feed the cultures at 24 h posttransfection (hpt), a 2-fold increase in volumetric SEAP productivity was obtained 5 days posttransfection. This effect was shown to be equal to that obtained when the culture was fed with a supplementary 4% (v/v) of serum. The positive effect of TN1 on protein production was also demonstrated with Tie2 protein ectodomain produced in serum-free medium. HPLC analysis of amino acids consumption/production during control batch and TN1 pulse culture showed some major differences in amino acid metabolism when using TN1 pulse. Asparagine, glycine, histidine, threonine, leucine, and valine show accumulation in the medium over the cultivation period instead of being consumed as observed in unfed sample (except for asparagine, which remained unchanged). Isoleucine, tyrosine, methionine, and phenylalanine all remained unchanged or slightly fluctuated in TN1-fed culture after the feeding pulse, while they were all steadily consumed in the control run. The relative abundance of SEAP's mRNA suggests that the improvement in protein yield results both from an increase of the translational activity and transcription efficiency. Further understanding of mechanisms by which amino acids/peptides regulate transcriptional and translational machinery in mammalian cells should facilitate the design of new strategies for the improvement of r-protein production by large-scale transfection.

Increased production of active human beta(2)-adrenergic/G(alphas) fusion receptor in Sf-9 cells using nutrient limiting conditions.

Using the baculovirus/insect-cell expression vector system, we succeeded in obtaining a high yield of active human beta(2)-adrenergic receptor/G(alphas) fusion protein. This was achieved following high cell density production under nutrient-limiting conditions using a very low multiplicity of infection (MOI). This approach was found to significantly reduce inactive protein accumulation that occurred when production was done using conventional high MOI procedures. The maximum specific and volumetric yields of active receptor using this strategy increased by factors of two- and sixfold, respectively. Our results suggest that the increase in the ratio of active/total protein produced results from production under nutrient limitation. Since low multiplicity of infection offers many advantages for large-scale applications, we suggest that this simple production method should be considered when optimizing expression of G-protein-coupled receptors and other complex proteins.