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BACKGROUND Acute aortic dissection (AAD) is a life-threatening medical emergency that requires a high index of clinical suspicion to be diagnosed promptly. The variability in the clinical presentation of AAD has historically made it difficult to identify in the acute setting. There remains significant inter-physician variability in the use of imaging. The median time to diagnosis in the Emergency Department is over 4 h and AAD has a mortality rate of 68% when diagnosis is delayed by over 48 h after onset of symptoms. CASE REPORT We discuss a case of a 69-year-old woman presenting with gastrointestinal symptoms in the Emergency Department who ultimately was found to have AAD. The patient had delayed presentation by 12 h due to misattribution of her rectal tenesmus to irritable bowel syndrome. However, after a thorough history and physical exam, the Emergency Medicine physician appropriately risk-stratified the patient and correctly diagnosed her with a Stanford Type A aortic dissection using a computed tomography study of the chest, abdomen, and pelvis with intravenous contrast. CONCLUSIONS AAD is an uncommon disease often requiring emergency intervention. We summarize the research and scoring systems and discuss the physical exam findings, comorbidities, imaging modalities, and risk stratification tools. Although imperfect, the Aortic Dissection Detection Risk Score with the addition of a D-dimer test is currently the best-validated tool and should be an important part of clinical decision making prior to performing computed tomography imaging.

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Spinel (magnesium aluminate MgAl2 O4 ) ceramic-based polyphasic composite scaffold has been recently reported for craniofacial bone tissue engineering. Improving the osteogenic effects of such composite scaffolds with bone morphogenetic proteins (BMP2) is an intensely researched area. This study investigated the gene interactions of this scaffold with BMP2 and mesenchymal stem cells (MSCs). Human bone marrow MSCs were cultured in 3 groups: Group 1-Control (BMSCs), Group 2-BMSC with BMP2, and Group 3-BMSC with scaffold and BMP2. After RNA isolation, gene expression analysis was done by microarray. Differentially expressed genes (DEGs) (-1.0 > fold changes>1 and p value <.05) were studied for their function and gene ontologies using Database for Annotation, Visualization and Integrated Discovery (DAVID). They were further studied by protein-protein interaction network analysis using STRING and MCODE Cytoscape plugin database. Group 3 showed up regulation of 3222 genes against 2158 of Group 2. Group 3 had five annotation clusters with enrichment scores from 2.08 to 3.93. Group 2 had only one cluster. Group 3 showed activation of all major osteogenic pathways: TGF, BMP2, WNT, SMAD, and Notch gene signaling with effects of calcium and magnesium released from the scaffold. Downstream effect of all these caused significant activation of RUNX2, the key transcriptional regulator of osteogenesis in Group 3. STRING and MCODE Cytoscape plugin demonstrated the interactions. The enhanced MSC differentiation for osteogenesis with the addition of BMP2 to the polyphasic composite scaffold proposed promising clinical applications for bone tissue engineering.

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We present a case of acute cauda equina syndrome caused by an epidural steroid injection in the setting of a previously undiagnosed spinal dural arteriovenous fistula (SDAVF). Our patient was a 61-year-old man who presented to the emergency department with low back pain, inability to walk, paresthesias of his bilateral lower extremities, bowel and bladder incontinence, and saddle anesthesia. Physical examination revealed weakness and decreased sensation of the lower extremities as well as poor rectal tone and urinary retention. Magnetic resonance imaging (MRI) revealed evidence of spinal cord edema in the T9-10 region and a probable SDAVF with secondary distal thoracic cord ischemia. This case highlights the importance of prompt recognition of cauda equina syndrome in the emergency department, expedient imaging, and efficient transfers of care, which allowed this patient to quickly undergo necessary surgery that led to an almost complete recovery. It also highlights the importance of recognizing subtle changes on lumbar MRI.

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MgAl2O4 spinel mesh with micro-features of 410 and 250 µm unit cell length and rib thickness, respectively, was three-dimensional (3D) printed and sintered followed by Hot Isostatic Pressing (HIPing). A stable colloidal dispersion of spinel in polymer-water solution was prepared and 3D-printed using a 30-gauge needle (∼100 µm inner diameter) on a regenHU 3D-Discovery bioprinter. Samples were characterized for their density and microstructure. Samples with near theoretical density after HIPing was subjected to mechanical property evaluation such as hardness by Vickers indentation and elastic modulus using nanoindentation technique. Microstructure of sintered samples across the ribs have shown graded grain structure with finer grains near the edges (0.7 µm average) with occasional porosity and coarser grains toward the center of the rib (5.2 µm average). HIPing resulted in substantial grain growth and the average grain size was found to be 10.9 µm (with a variation in the grain size of 2.2 µm along the edges and 13.1 µm at the center of the rib) exhibiting close packed and dense microstructure. Finer grains toward the edges may probably be due to the flow behavior during printing process and lower distribution of the powder loading along the edges resulting in low green density. This relatively higher porosity pining the grain growth under the extremely low heating rate employed for the controlled shrinkage to maintain the integrity of the sample. 3D printed samples after HIPing exhibited a density of 3.57 g/cc and hardness of 12.95 GPa, which are at par with the samples processed through conventional ceramic processing techniques. Nanoindentation studies employing maximum load of 45 mN with depth have shown an elastic modulus of 238 ± 15 GPa. MgAl2O4 spinel mesh 3D printed in this study is a potential prospective candidate that can be explored for cranioplasty procedures and other biomedical applications.

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Vertebrate glycoproteins and glycolipids are synthesized in complex biosynthetic pathways localized predominantly within membrane compartments of the secretory pathway. The enzymes that catalyze these reactions are exquisitely specific, yet few have been extensively characterized because of challenges associated with their recombinant expression as functional products. We used a modular approach to create an expression vector library encoding all known human glycosyltransferases, glycoside hydrolases, and sulfotransferases, as well as other glycan-modifying enzymes. We then expressed the enzymes as secreted catalytic domain fusion proteins in mammalian and insect cell hosts, purified and characterized a subset of the enzymes, and determined the structure of one enzyme, the sialyltransferase ST6GalNAcII. Many enzymes were produced at high yields and at similar levels in both hosts, but individual protein expression levels varied widely. This expression vector library will be a transformative resource for recombinant enzyme production, broadly enabling structure-function studies and expanding applications of these enzymes in glycochemistry and glycobiology.

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Hydroxyapatite ceramics synthesized through sonochemical route were processed and densified through ramp & hold (R&H) and Spark Plasma Sintering (SPS) routes. The effect of processing route on the relative density and electrical conductivity were studied. Further, the samples were Hot Isostatically Pressed (HIP) under argon pressure at elevated temperature to further densify the sample. All these samples processed under different conditions were characterized by X-ray diffraction, Scanning Electron Microscopy and AC Conductivity. The samples have exhibited hydroxyapatite phase; however, microstructures exhibited distinctly different grain morphologies and grain sizes. AC impedance spectroscopic measurement was carried out on hydroxyapatite samples processed through different routes and the corresponding spectra were analyzed by the analogy to equivalent circuit involving resistors and capacitors. SPS sintered sample after HIPing has exhibited the highest conductivity. This can be attributed to the higher density in combination with finer grain sizes. Activation energy based on Arrhenius equation is calculated and the prominent conduction mechanism is proposed.

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The art of producing recombinant proteins with complex post-translational modifications represents a major challenge for studies of structure and function. The rapid establishment and high recovery from transiently-transfected mammalian cell lines addresses this barrier and is an effective means of expressing proteins that are naturally channeled through the ER and Golgi-mediated secretory pathway. Here is one protocol for protein expression using the human HEK293F and HEK293S cell lines transfected with a mammalian expression vector designed for high protein yields. The applicability of this system is demonstrated using three representative glycoproteins that expressed with yields between 95-120 mg of purified protein recovered per liter of culture. These proteins are the human FcγRIIIa and the rat α2-6 sialyltransferase, ST6GalI, both expressed with an N-terminal GFP fusion, as well as the unmodified human immunoglobulin G1 Fc. This robust system utilizes a serum-free medium that is adaptable for expression of isotopically enriched proteins and carbohydrates for structural studies using mass spectrometry and nuclear magnetic resonance spectroscopy. Furthermore, the composition of the N-glycan can be tuned by adding a small molecule to prevent certain glycan modifications in a manner that does not reduce yield.

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Adult orthodontics is recently gaining popularity due to its importance in esthetics, oral and general health. However, none of the currently available alumina or zirconia based ceramic orthodontic brackets meet the esthetic demands of adult patients. Inherent hexagonal lattice structure and associated birefringence limits the visible light transmission in polycrystalline alumina and make them appear white and non transparent. Hence focus of the present study was to assess the feasibility of using magnesium aluminate (MgAl2O4) spinel; a member of the transparent ceramic family for esthetic orthodontic brackets. Transparent spinel specimens were developed from commercially available white spinel powder through colloidal shaping followed by pressureless sintering and hot isostatic pressing at optimum conditions of temperature and pressure. Samples were characterized for chemical composition, phases, density, hardness, flexural strength, fracture toughness and optical transmission. Biocompatibility was evaluated with in-vitro cell line experiments for cytotoxicity, apoptosis and genotoxicity. Results showed that transparent spinel samples had requisite physico-chemical, mechanical, optical and excellent biocompatibility for fabricating orthodontic brackets. Transparent spinel developed through this method demonstrated its possibility as a prospective biomaterial for developing esthetic orthodontic brackets.

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Mucin type O-glycosylation is initiated by a large family of polypeptide GalNAc transferases (ppGalNAc Ts) that add α-GalNAc to the Ser and Thr residues of peptides. Of the 20 human isoforms, all but one are composed of two globular domains linked by a short flexible linker: a catalytic domain and a ricin-like lectin carbohydrate binding domain. Presently, the roles of the catalytic and lectin domains in peptide and glycopeptide recognition and specificity remain unclear. To systematically study the role of the lectin domain in ppGalNAc T glycopeptide substrate utilization, we have developed a series of novel random glycopeptide substrates containing a single GalNAc-O-Thr residue placed near either the N or C terminus of the glycopeptide substrate. Our results reveal that the presence and N- or C-terminal placement of the GalNAc-O-Thr can be important determinants of overall catalytic activity and specificity that differ between transferase isoforms. For example, ppGalNAc T1, T2, and T14 prefer C-terminally placed GalNAc-O-Thr, whereas ppGalNAc T3 and T6 prefer N-terminally placed GalNAc-O-Thr. Several transferase isoforms, ppGalNAc T5, T13, and T16, display equally enhanced N- or C-terminal activities relative to the nonglycosylated control peptides. This N- and/or C-terminal selectivity is presumably due to weak glycopeptide binding to the lectin domain, whose orientation relative to the catalytic domain is dynamic and isoform-dependent. Such N- or C-terminal glycopeptide selectivity provides an additional level of control or fidelity for the O-glycosylation of biologically significant sites and suggests that O-glycosylation may in some instances be exquisitely controlled.

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Anemia is a common worldwide problem that is associated with nonspecific complaints. The initial focus for the emergency evaluation of anemia is to determine whether the problem is acute or chronic. Acute anemia is most commonly associated with blood loss, and the patient is usually symptomatic. Chronic anemia is usually well tolerated and is often discovered coincidentally. Once diagnosed, the etiology of anemia can often be determined by applying a systematic approach to its evaluation. The severity of the anemia impacts clinical outcomes, particularly in critically ill patients; however, the specific threshold to transfuse is uncertain. Evaluation of the current literature and clinical guidelines does not settle this controversy, but it does help clarify that a restrictive transfusion strategy (ie, for patients with a hemoglobin < 6-8 g/dL) is associated with better outcomes than a more liberal transfusion strategy. Certain anemias may have well-defined treatment options (eg, sickle cell disease), but empiric use of nutritional supplements to treat anemia of uncertain etiology is discouraged.

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The terminal carbohydrate residues of the N-glycan on the immunoglobulin G (IgG) fragment crystallizable (Fc) determine whether IgG activates pro- or anti-inflammatory receptors. The IgG Fc alone becomes potently anti-inflammatory upon addition of α2-6-linked N-acetylneuraminic acid residues to the N-glycan, stimulating interest in use of this entity in novel therapies for autoimmune disease [Kaneko et al. (2006) Science313, 670-3]. Complete Fc sialylation has, however, been deemed challenging due to a combination of branch specificity and perceived protection by glycan-protein interactions. Here we report the preparation of high levels of disialylated Fc by using sufficient amounts of a highly active α2-6 sialyltransferase (ST6Gal1) preparation expressed in a transiently transformed human cell culture. Surprisingly, ST6Gal1 sialylated the two termini of the complex-type binantennary glycan in a manner remarkably similar to that observed for the free N-glycan, suggesting the Fc polypeptide does not greatly influence ST6Gal1 specificity. In addition, sialylation of either branch terminus does not appear to dramatically alter the motional behavior of the N-glycan as judged by solution NMR spectroscopy. Together these, data suggest the N-glycan occupies two distinct states: one with both glycan termini sequestered from enzymatic modification by an α1-6Man-branch interaction with the polypeptide surface and the other with both glycan termini exposed to the bulk solvent and free from glycan-polypeptide interactions. The results suggest new modes by which disialylated Fc can act as an anti-inflammatory effector.

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Swine influenza viruses (SIV) have been shown to sporadically infect humans and are infrequently identified by the Influenza Division of the Centers for Disease Control and Prevention (CDC) after being received as unsubtypeable influenza A virus samples. Real-time reverse transcriptase PCR (rRT-PCR) procedures for detection and characterization of North American lineage (N. Am) SIV were developed and implemented at CDC for rapid identification of specimens from cases of suspected infections with SIV. These procedures were utilized in April 2009 for detection of human cases of 2009 A (H1N1) pandemic (pdm) influenza virus infection. Based on genetic sequence data derived from the first two viruses investigated, the previously developed rRT-PCR procedures were optimized to create the CDC rRT-PCR Swine Flu Panel for detection of the 2009 A (H1N1) pdm influenza virus. The analytical sensitivity of the CDC rRT-PCR Swine Flu Panel was shown to be 5 copies of RNA per reaction and 10(-1.3 - -0.7) 50% infectious doses (ID(50)) per reaction for cultured viruses. Cross-reactivity was not observed when testing human clinical specimens or cultured viruses that were positive for human seasonal A (H1N1, H3N2) and B influenza viruses. The CDC rRT-PCR Swine Flu Panel was distributed to public health laboratories in the United States and internationally from April 2009 until June 2010. The CDC rRT-PCR Swine Flu Panel served as an effective tool for timely and specific detection of 2009 A (H1N1) pdm influenza viruses and facilitated subsequent public health response implementation.

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OBJECTIVE: Identify factors associated with obstructive sleep apnea (OSA) risk during commercial driver medical examinations. METHODS: A case-control study was conducted at an occupational health clinic by reviewing the commercial driver medical examinations medical records performed from January 2007 to December 2008. The magnitude of association with OSA was estimated with logistic regression. RESULTS: Among 1890 commercial motor vehicle drivers, 51 were confirmed positive for OSA by polysomnography after initial screening by Joint Task Force guidelines, yielding estimated positive predictive values of 78.5% for the screening criteria. Multivariable logistic regression showed that body mass index ≥ 30 (odds ratio: 26.86), hypertension (odds ratio: 2.57), and diabetes (odds ratio: 2.03) were independently associated with OSA. CONCLUSION: Medical examiners' use of objectively measurable risk factors, such as obesity, history of hypertension, and/or diabetes, rather than symptoms, may be more effective in identifying undiagnosed OSA in commercial drivers during the commercial driver medical examinations.

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To study the viral sequence diversity that is characteristic of HIV infection, PCR amplification and sequencing of viral genes is an essential step. However, a limitation of traditional PCR methods is that one viral target may be preferentially amplified over another when multiple sequences are present. This presents a particular problem when conclusions about diversity are made from one or only a few PCRs. One way to avoid resampling is to perform a large number of PCR amplifications on a single template; however, this requires that extensive dilution series be carried out on each patient sample to identify the appropriate concentration of input DNA. Here we describe the development and implementation of a quantitative real-time PCR (qPCR) method that detects a short sequence in gag and is optimized to detect subtype C HIV sequences. The standard curve was externally validated using two chronically infected cell lines carrying a known number of HIV copies per genome, and this assay yielded reproducible and accurate measurements on patient DNA samples over a wide range of input targets. The qPCR assay results were consistent with those obtained by the traditional limiting dilution method yet entailed only a fraction of the time and reagents required for the latter. This robust and quantitative real-time assay can be used to ensure that each viral sequence obtained through PCR represents a single template for studies in which the diversity of the entire population must be accurately portrayed, and can readily be applied to other research settings and viral subtypes.

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Information about neutralizing antibody responses in subtype C-infected individuals is limited, even though this viral subtype causes the majority of AIDS cases worldwide. Here we compared the course and magnitude of the autologous neutralizing antibody (NAb) response against viral envelope (Env) glycoproteins present during acute and early infection with subtypes B and C human immunodeficiency virus type 1 (HIV-1). NAb responses were evaluated in 6 subtype B-infected and 11 subtype C-infected subjects over a mean evaluation period of 25 months using a pseudovirus reporter gene assay. All subjects in the C cohort were infected through heterosexual contact, while five of the six subjects in the B cohort were infected via male-to-male contact. The kinetics and magnitude of the NAb responses varied among subjects in the B and C cohorts; however, the median 50% inhibitory concentration (IC(50) titer) reached by antibody in the plasma of subtype C-infected subjects, overall, was 3.5-fold higher than in the subtype B-infected subjects (P = 0.06). The higher titers of NAbs in the C cohort were associated with viruses having significantly shorter amino acid length (P = 0.002) in the V1 to V4 region of the surface Env glycoprotein, gp120, compared to the B cohort. Despite the potency of the autologous subtype C NAb response, it was not directed against cross-neutralizing epitopes. These data demonstrate that subtype C Envs elicit a potent yet restricted NAb response early in infection that frequently reaches IC(50) titers in excess of 1:1,000 and suggest that clade-specific differences may exist in Env immunogenicity or susceptibility to neutralization.

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It provides guidance on the prevention and control of wildland fires, the use of protective devices, and contingency planning. Document in pdf format; Acrobat Reader required.

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A series of N-substituted bridgehead azabicycloalkanes has been prepared and examined as substrates for microbiological oxygenation using the fungi Beauveria bassiana, Rhizopus nigricans, Aspergillus ochraceus, and Rhizopus arrhizus. Oxygenation using B. bassiana of N-tosyl-7-azabicyclo[2.2.1]heptane gave N-[p-(hydroxymethyl)benzenesulfonyl]-7-azabicyclo[2.2.1]heptane (56% yield), of N-(phenyloxycarbonyl)-7-azabicyclo[2.2.1]heptane gave the 2-endo-ol (56% yield, 51% ee), of N-BOC-7-azabicyclo[2.2.1]heptane gave the 2-endo-ol (10% yield), of N-Cbz-7-azabicyclo[2.2.1]heptane gave the 2-endo-ol (28%), of N-(phenyloxycarbonyl)-8-azabicyclo[3.2.1]octane gave the 3-endo-ol, and of N-(phenyloxycarbonyl)-9-azabicyclo[3.3.1]nonane gave the 3-exo-ol (30%) and 3-one (16%). Oxygenation using R. nigricans of N-BOC-7-azabicyclo[2.2.1]heptane gave the 2-endo-ol (62% yield, 28% ee) and the 2-exo-ol (27% yield, 42% ee). Oxidation of the N-BOC-7-azabicyclo[2.2.1]heptan-2-ols gives the 2-ketone, a synthetic intermediate useful for conversion to the natural product, epibatidine. Oxygenation of N-(phenyloxycarbonyl)-7-azabicyclo[2.2.1]heptane using R. arrhizus gives the 2-endo-ol (5% yield, 31% ee) and the 2-exo-ol (18% yield, 22% ee). Oxygenation of N-(phenyloxycarbonyl)-8-azabicyclo[3.2.1]octane using A. ochraceous gives the 3-endo-ol (36%) and the 3-one (4%).