Mattel Children's Hospital

Epilepsy was defined conceptually in 2005 as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. This definition is usually practically applied as having two unprovoked seizures >24 h apart. The International League Against Epilepsy (ILAE) accepted recommendations of a task force altering the practical definition for special circumstances that do not meet the two unprovoked seizures criteria. The task force proposed that epilepsy be considered to be a disease of the brain defined by any of the following conditions: (1) At least two unprovoked (or reflex) seizures occurring >24 h apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; (3) diagnosis of an epilepsy syndrome. Epilepsy is considered to be resolved for individuals who either had an age-dependent epilepsy syndrome but are now past the applicable age or who have remained seizure-free for the last 10 years and off antiseizure medicines for at least the last 5 years. "Resolved" is not necessarily identical to the conventional view of "remission or "cure." Different practical definitions may be formed and used for various specific purposes. This revised definition of epilepsy brings the term in concordance with common use. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement.

Since the original descriptions of postconcussive pathophysiology, there has been a significant increase in interest and ongoing research to study the biological underpinnings of concussion. The initial ionic flux and glutamate release result in significant energy demands and a period of metabolic crisis for the injured brain. These physiological perturbations can now be linked to clinical characteristics of concussion, including migrainous symptoms, vulnerability to repeat injury, and cognitive impairment. Furthermore, advanced neuroimaging now allows a research window to monitor postconcussion pathophysiology in humans noninvasively. There is also increasing concern about the risk for chronic or even progressive neurobehavioral impairment after concussion/mild traumatic brain injury. Critical studies are underway to better link the acute pathobiology of concussion with potential mechanisms of chronic cell death, dysfunction, and neurodegeneration. This "new and improved" article summarizes in a translational fashion and updates what is known about the acute neurometabolic changes after concussive brain injury. Furthermore, new connections are proposed between this neurobiology and early clinical symptoms as well as to cellular processes that may underlie long-term impairment.

For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

Hippocampal sclerosis (HS) is the most frequent histopathology encountered in patients with drug-resistant temporal lobe epilepsy (TLE). Over the past decades, various attempts have been made to classify specific patterns of hippocampal neuronal cell loss and correlate subtypes with postsurgical outcome. However, no international consensus about definitions and terminology has been achieved. A task force reviewed previous classification schemes and proposes a system based on semiquantitative hippocampal cell loss patterns that can be applied in any histopathology laboratory. Interobserver and intraobserver agreement studies reached consensus to classify three types in anatomically well-preserved hippocampal specimens: HS International League Against Epilepsy (ILAE) type 1 refers always to severe neuronal cell loss and gliosis predominantly in CA1 and CA4 regions, compared to CA1 predominant neuronal cell loss and gliosis (HS ILAE type 2), or CA4 predominant neuronal cell loss and gliosis (HS ILAE type 3). Surgical hippocampus specimens obtained from patients with TLE may also show normal content of neurons with reactive gliosis only (no-HS). HS ILAE type 1 is more often associated with a history of initial precipitating injuries before age 5 years, with early seizure onset, and favorable postsurgical seizure control. CA1 predominant HS ILAE type 2 and CA4 predominant HS ILAE type 3 have been studied less systematically so far, but some reports point to less favorable outcome, and to differences regarding epilepsy history, including age of seizure onset. The proposed international consensus classification will aid in the characterization of specific clinicopathologic syndromes, and explore variability in imaging and electrophysiology findings, and in postsurgical seizure control.

BACKGROUND: The Primary Immune Deficiency Treatment Consortium was formed to analyze the results of hematopoietic-cell transplantation in children with severe combined immunodeficiency (SCID) and other primary immunodeficiencies. Factors associated with a good transplantation outcome need to be identified in order to design safer and more effective curative therapy, particularly for children with SCID diagnosed at birth. METHODS: We collected data retrospectively from 240 infants with SCID who had received transplants at 25 centers during a 10-year period (2000 through 2009). RESULTS: Survival at 5 years, freedom from immunoglobulin substitution, and CD3+ T-cell and IgA recovery were more likely among recipients of grafts from matched sibling donors than among recipients of grafts from alternative donors. However, the survival rate was high regardless of donor type among infants who received transplants at 3.5 months of age or younger (94%) and among older infants without prior infection (90%) or with infection that had resolved (82%). Among actively infected infants without a matched sibling donor, survival was best among recipients of haploidentical T-cell-depleted transplants in the absence of any pretransplantation conditioning. Among survivors, reduced-intensity or myeloablative pretransplantation conditioning was associated with an increased likelihood of a CD3+ T-cell count of more than 1000 per cubic millimeter, freedom from immunoglobulin substitution, and IgA recovery but did not significantly affect CD4+ T-cell recovery or recovery of phytohemagglutinin-induced T-cell proliferation. The genetic subtype of SCID affected the quality of CD3+ T-cell recovery but not survival. CONCLUSIONS: Transplants from donors other than matched siblings were associated with excellent survival among infants with SCID identified before the onset of infection. All available graft sources are expected to lead to excellent survival among asymptomatic infants. (Funded by the National Institute of Allergy and Infectious Diseases and others.).

OBJECTIVE: Our objective was to summarize important advances in the management of children with idiopathic short stature (ISS). PARTICIPANTS: Participants were 32 invited leaders in the field. EVIDENCE: Evidence was obtained by extensive literature review and from clinical experience. CONSENSUS: Participants reviewed discussion summaries, voted, and reached a majority decision on each document section. CONCLUSIONS: ISS is defined auxologically by a height below -2 sd score (SDS) without findings of disease as evident by a complete evaluation by a pediatric endocrinologist including stimulated GH levels. Magnetic resonance imaging is not necessary in patients with ISS. ISS may be a risk factor for psychosocial problems, but true psychopathology is rare. In the United States and seven other countries, the regulatory authorities approved GH treatment (at doses up to 53 microg/kg.d) for children shorter than -2.25 SDS, whereas in other countries, lower cutoffs are proposed. Aromatase inhibition increases predicted adult height in males with ISS, but adult-height data are not available. Psychological counseling is worthwhile to consider instead of or as an adjunct to hormone treatment. The predicted height may be inaccurate and is not an absolute criterion for GH treatment decisions. The shorter the child, the more consideration should be given to GH. Successful first-year response to GH treatment includes an increase in height SDS of more than 0.3-0.5. The mean increase in adult height in children with ISS attributable to GH therapy (average duration of 4-7 yr) is 3.5-7.5 cm. Responses are highly variable. IGF-I levels may be helpful in assessing compliance and GH sensitivity; levels that are consistently elevated (>2.5 SDS) should prompt consideration of GH dose reduction. GH therapy for children with ISS has a similar safety profile to other GH indications.

Rather than being a passive, haphazard process of wear and tear, lifespan can be modulated actively by components of the insulin/insulin-like growth factor I (IGFI) pathway in laboratory animals. Complete or partial loss-of-function mutations in genes encoding components of the insulin/IGFI pathway result in extension of life span in yeasts, worms, flies, and mice. This remarkable conservation throughout evolution suggests that altered signaling in this pathway may also influence human lifespan. On the other hand, evolutionary tradeoffs predict that the laboratory findings may not be relevant to human populations, because of the high fitness cost during early life. Here, we studied the biochemical, phenotypic, and genetic variations in a cohort of Ashkenazi Jewish centenarians, their offspring, and offspring-matched controls and demonstrated a gender-specific increase in serum IGFI associated with a smaller stature in female offspring of centenarians. Sequence analysis of the IGF1 and IGF1 receptor (IGF1R) genes of female centenarians showed overrepresentation of heterozygous mutations in the IGF1R gene among centenarians relative to controls that are associated with high serum IGFI levels and reduced activity of the IGFIR as measured in transformed lymphocytes. Thus, genetic alterations in the human IGF1R that result in altered IGF signaling pathway confer an increase in susceptibility to human longevity, suggesting a role of this pathway in modulation of human lifespan.

IMPORTANCE: Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health care in the United States and incentivizing integrated medical-behavioral health care as a strategy for improving access to high-quality care for behavioral health conditions, enhancing patient outcomes, and containing costs. OBJECTIVE: To conduct a systematic meta-analysis of randomized clinical trials to evaluate whether integrated medical-behavioral health care for children and adolescents leads to improved behavioral health outcomes compared with usual primary care. DATA SOURCES: Search of the PubMed, MEDLINE, PsycINFO, and Cochrane Library databases from January 1, 1960, through December 31, 2014, yielded 6792 studies, of which 31 studies with 35 intervention-control comparisons and 13,129 participants met the study eligibility criteria. STUDY SELECTION: We included randomized clinical trials that evaluated integrated behavioral health and primary medical care in children and adolescents compared with usual care in primary care settings that met prespecified methodologic quality criteria. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened citations and extracted data, with raw data used when possible. Magnitude and direction of effect sizes were calculated. MAIN OUTCOMES AND MEASURES: Meta-analysis with a random effects model were conducted to examine an overall effect across all trials, and within intervention and prevention trials. Subsequent moderator analyses for intervention trials explored the relative effects of integrated care type on behavioral health outcomes. RESULTS: Meta-analysis with a random-effects model indicated a significant advantage for integrated care interventions relative to usual care on behavioral health outcomes (d = 0.32; 95% CI, 0.21-0.44; P < .001). Moderator analyses indicated larger effects for treatment trials that targeted diagnoses and/or elevated symptoms (d = 0.42; 95% CI, 0.29-0.55; P < .001) relative to prevention trials (d = 0.07; 95% CI, -0.13 to 0.28; P = .49). The probability was 66% that a randomly selected youth would have a better outcome after receiving integrated medical-behavioral treatment than a randomly selected youth after receiving usual care. The strongest effects were seen for treatment interventions that targeted mental health problems and those that used collaborative care models. CONCLUSIONS AND RELEVANCE: Our results, demonstrating the benefits of integrated medical-behavioral primary care for improving youth behavioral health outcomes, enhance confidence that the increased incentives for integrated health and behavioral health care in the US health care system will yield improvements in the health of children and adolescents.

Importance: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

OBJECTIVE: To evaluate the use of pulse oximetry to screen for early detection of life threatening congenital heart disease. DESIGN: Prospective screening study with a new generation pulse oximeter before discharge from well baby nurseries in West Götaland. Cohort study comparing the detection rate of duct dependent circulation in West Götaland with that in other regions not using pulse oximetry screening. Deaths at home with undetected duct dependent circulation were included. SETTING: All 5 maternity units in West Götaland and the supraregional referral centre for neonatal cardiac surgery. PARTICIPANTS: 39,821 screened babies born between 1 July 2004 and 31 March 2007. Total duct dependent circulation cohorts: West Götaland n=60, other referring regions n=100. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values, and likelihood ratio for pulse oximetry screening and for neonatal physical examination alone. RESULTS: In West Götaland 29 babies in well baby nurseries had duct dependent circulation undetected before neonatal discharge examination. In 13 cases, pulse oximetry showed oxygen saturations <or=90%, and (in accordance with protocol) clinical staff were immediately told of the results. Of the remaining 16 cases, physical examination alone detected 10 (63%). Combining physical examination with pulse oximetry screening had a sensitivity of 24/29 (82.8% (95% CI 64.2% to 95.2%)) and detected 100% of the babies with duct dependent lung circulation. Five cases were missed (all with aortic arch obstruction). False positive rate with pulse oximetry was substantially lower than that with physical examination alone (69/39 821 (0.17%) v 729/38 413 (1.90%), P<0.0001), and 31/69 of the "false positive" cases with pulse oximetry had other pathology. Thus, referral of all cases with positive oximetry results for echocardiography resulted in only 2.3 echocardiograms with normal cardiac findings for every true positive case of duct dependent circulation. In the cohort study, the risk of leaving hospital with undiagnosed duct dependent circulation was 28/100 (28%) in other referring regions versus 5/60 (8%) in West Götaland (P=0.0025, relative risk 3.36 (95% CI 1.37 to 8.24)). In the other referring regions 11/25 (44%) of babies with transposition of the great arteries left hospital undiagnosed versus 0/18 in West Götaland (P=0.0010), and severe acidosis at diagnosis was more common (33/100 (33%) v 7/60 (12%), P=0.0025, relative risk 2.8 (1.3 to 6.0)). Excluding premature babies and Norwood surgery, babies discharged without diagnosis had higher mortality than those diagnosed in hospital (4/27 (18%) v 1/110 (0.9%), P=0.0054). No baby died from undiagnosed duct dependent circulation in West Götaland versus five babies from the other referring regions. CONCLUSION: Introducing pulse oximetry screening before discharge improved total detection rate of duct dependent circulation to 92%. Such screening seems cost neutral in the short term, but the probable prevention of neurological morbidity and reduced need for preoperative neonatal intensive care suggest that such screening will be cost effective long term.

BACKGROUND: Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited. METHODS: We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest. RESULTS: A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality. CONCLUSIONS: In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

BACKGROUND: In previous clinical trials involving children with X-linked severe combined immunodeficiency (SCID-X1), a Moloney murine leukemia virus-based γ-retrovirus vector expressing interleukin-2 receptor γ-chain (γc) complementary DNA successfully restored immunity in most patients but resulted in vector-induced leukemia through enhancer-mediated mutagenesis in 25% of patients. We assessed the efficacy and safety of a self-inactivating retrovirus for the treatment of SCID-X1. METHODS: We enrolled nine boys with SCID-X1 in parallel trials in Europe and the United States to evaluate treatment with a self-inactivating (SIN) γ-retrovirus vector containing deletions in viral enhancer sequences expressing γc (SIN-γc). RESULTS: All patients received bone marrow-derived CD34+ cells transduced with the SIN-γc vector, without preparative conditioning. After 12.1 to 38.7 months of follow-up, eight of the nine children were still alive. One patient died from an overwhelming adenoviral infection before reconstitution with genetically modified T cells. Of the remaining eight patients, seven had recovery of peripheral-blood T cells that were functional and led to resolution of infections. The patients remained healthy thereafter. The kinetics of CD3+ T-cell recovery was not significantly different from that observed in previous trials. Assessment of insertion sites in peripheral blood from patients in the current trial as compared with those in previous trials revealed significantly less clustering of insertion sites within LMO2, MECOM, and other lymphoid proto-oncogenes in our patients. CONCLUSIONS: This modified γ-retrovirus vector was found to retain efficacy in the treatment of SCID-X1. The long-term effect of this therapy on leukemogenesis remains unknown. (Funded by the National Institutes of Health and others; ClinicalTrials.gov numbers, NCT01410019, NCT01175239, and NCT01129544.).

The proteome contains hundreds of proteins that in theory could be excellent therapeutic targets for the treatment of human diseases. However, many of these proteins are from functional classes that have never been validated as viable candidates for the development of small molecule inhibitors. Thus, to exploit fully the potential of the Human Genome Project to advance human medicine, there is a need to develop generic methods of inhibiting protein activity that do not rely on the target protein's function. We previously demonstrated that a normally stable protein, methionine aminopeptidase-2 or MetAP-2, could be artificially targeted to an Skp1-Cullin-F-box (SCF) ubiquitin ligase complex for ubiquitination and degradation through a chimeric bridging molecule or Protac (proteolysis targeting chimeric molecule). This Protac consisted of an SCFβ-TRCP-binding phosphopeptide derived from IκBα linked to ovalicin, which covalently binds MetAP-2. In this study, we employed this approach to target two different proteins, the estrogen (ER) and androgen (AR) receptors, which have been implicated in the progression of breast and prostate cancer, respectively. We show here that an estradiol-based Protac can enforce the ubiquitination and degradation of the α isoform of ER in vitro, and a dihydroxytestosterone-based Protac introduced into cells promotes the rapid disappearance of AR in a proteasome-dependent manner. Future improvements to this technology may yield a general approach to treat a number of human diseases, including cancer. The proteome contains hundreds of proteins that in theory could be excellent therapeutic targets for the treatment of human diseases. However, many of these proteins are from functional classes that have never been validated as viable candidates for the development of small molecule inhibitors. Thus, to exploit fully the potential of the Human Genome Project to advance human medicine, there is a need to develop generic methods of inhibiting protein activity that do not rely on the target protein's function. We previously demonstrated that a normally stable protein, methionine aminopeptidase-2 or MetAP-2, could be artificially targeted to an Skp1-Cullin-F-box (SCF) ubiquitin ligase complex for ubiquitination and degradation through a chimeric bridging molecule or Protac (proteolysis targeting chimeric molecule). This Protac consisted of an SCFβ-TRCP-binding phosphopeptide derived from IκBα linked to ovalicin, which covalently binds MetAP-2. In this study, we employed this approach to target two different proteins, the estrogen (ER) and androgen (AR) receptors, which have been implicated in the progression of breast and prostate cancer, respectively. We show here that an estradiol-based Protac can enforce the ubiquitination and degradation of the α isoform of ER in vitro, and a dihydroxytestosterone-based Protac introduced into cells promotes the rapid disappearance of AR in a proteasome-dependent manner. Future improvements to this technology may yield a general approach to treat a number of human diseases, including cancer. One of the major pathways to regulate protein turnover is ubiquitin-dependent proteolysis. Post-translational modification of proteins with ubiquitin occurs through the activities of ubiquitin activating enzyme (E1), ubiquitin-conjugating enzymes (E2), and ubiquitin ligases (E3), which act sequentially to catalyze the attachment of ubiquitin to lysine residues in an energy-dependent manner (1Deshaies R.J. SCF and Cullin/Ring H2-based ubiquitin ligases.Annu. Rev. Cell Dev. Biol. 1999; 15: 435-467Google Scholar, 2Ciechanover A. Orian A. Schwartz A.L. Ubiquitin-mediated proteolysis: Biological regulation via destruction.Bioessays. 2000; 22: 442-451Google Scholar). Among the hundreds of E3s encoded within the human genome, the Skp1-Cullin-F-box (SCF) 1The abbreviations used are: SCFβ-TRCP, Skp1-Cullin-F-box; Protac, proteolysis targeting chimeric molecule; E2, estradiol; DHT, dihydroxytestosterone; MetAP-2, methionine aminopeptidase-2; ER, estrogen receptor; AR, androgen receptor; DMF, dimethylformamide; DMSO, dimethylsulfoxide; ES, electrospray; GFP, green fluorescence protein; β-TRCP, β-transducin repeat-containing protein. ubiquitin ligases comprise a heterotetrameric group of proteins consisting of Skp-1, Cul1, a RING-H2 protein Hrt1 (also known as Roc1 or Rbx1), and an F-box protein (1Deshaies R.J. SCF and Cullin/Ring H2-based ubiquitin ligases.Annu. Rev. Cell Dev. Biol. 1999; 15: 435-467Google Scholar, 3Winston J.T. Koepp D.M. Zhu C. Elledge S.J. Harper J.W. A family of mammalian F-box proteins.Curr. Biol. 1999; 9: 1180-1182Google Scholar). The mammalian F-box protein β-transducin repeat-containing protein (β-TRCP) of SCFβ-TRCP binds IκBα, the negative regulator of NF-κB, and promotes its ubiquitination and degradation (4Yaron A. Hatzubai A. Davis M. Lavon I. Amit S. Manning A.M. Andersen J.S. Mann M. Mercurio F. Ben-Neriah Y. Identification of the receptor component of the IκBα-ubiquitin ligase.Nature. 1998; 396: 590-594Google Scholar). A 10-aa phosphopeptide segment of IκBα is both necessary and sufficient to mediate its binding to SCFβ-TRCP and subsequent ubiquitination and degradation (4Yaron A. Hatzubai A. Davis M. Lavon I. Amit S. Manning A.M. Andersen J.S. Mann M. Mercurio F. Ben-Neriah Y. Identification of the receptor component of the IκBα-ubiquitin ligase.Nature. 1998; 396: 590-594Google Scholar). There is a pressing unmet need to develop effective drugs to treat cancer and other diseases that afflict humans. The recent completion of the human genome sequence coupled with basic studies in molecular and cellular biology have revealed hundreds to thousands of proteins that could conceivably serve as targets for rational drug therapy. Unfortunately, many of these protein targets are not considered to be readily “drugable,” in that they are not enzymes and it is not obvious how to inhibit their function with small molecule drugs. Thus, it would be valuable to have a generic method that would enable specific and efficacious inhibition of any desired protein target, regardless of its biochemical function. Short interfering RNA (siRNA) represents one such method (5Timmons L. The long and short of siRNAs.Mol. Cell. 2002; 10: 435-437Google Scholar, 6Tuschl T. Expanding small RNA interference.Nat. Biotechnol. 2002; 20: 446-448Google Scholar), but it remains unclear whether siRNA will work as therapeutic agents in humans. We sought to develop a different approach, taking advantage of the 10-aa phosphopeptide sequence of IκBα described above to target proteins for ubiquitination and degradation (4Yaron A. Hatzubai A. Davis M. Lavon I. Amit S. Manning A.M. Andersen J.S. Mann M. Mercurio F. Ben-Neriah Y. Identification of the receptor component of the IκBα-ubiquitin ligase.Nature. 1998; 396: 590-594Google Scholar). As proof of concept, we previously synthesized a chimeric molecule or Protac (proteolysis targeting chimeric molecule) consisting of the IκBα phosphopeptide linked to ovalicin, which covalently binds methionine aminopeptidase-2 (MetAP-2). We showed that this Protac (Protac-1) recruits MetAP-2 to the SCFβ-TRCP ubiquitin ligase resulting in both ubiquitination and degradation of MetAP-2 (7Sakamoto K.M. Kim K.B. Kumagai A. Mercurio F. Crews C.M. Deshaies R.J. Protacs: Chimeric molecules that target proteins to the Skp1-Cullin-F box complex for ubiquitination and degradation.Proc. Natl. Acad. Sci. U. S. A. 2001; 98: 8554-8559Google Scholar). MetAP-2 is not known to be an endogenous substrate of SCFβ-TRCP (8Sin N. Meng L. Wang M.Q. Wen J.J. Bornmann W.G. Crews C.M. The anti-angiogenic agent fumagillin covalently binds and inhibits the methionine aminopeptidase, MetAP-2.Proc. Natl. Acad. Sci. U. S. A. 1997; 94: 6099-6103Google Scholar), and was not ubiquitinated by SCFβ-TRCP in the absence of Protac-1. Although this experiment demonstrated that Protacs could work as envisioned, it left open a number of critical questions. For example, can Protacs be used more generically to target other substrates, including proteins of potential therapeutic interest? Can a Protac recruit a target to SCFβ-TRCP through a noncovalent interaction? Can a Protac work within the context of a cell? Both estrogen receptor α (ER) and androgen receptor (AR) have been demonstrated to promote the growth of breast and prostate cancer cells (9Howell A. Howell S.J. Evans D.G. New approaches to the endocrine prevention and treatment of breast cancer.Cancer Chemother. Pharmacol. 2003; 52 (Suppl 1): 39-44Google Scholar, 10Debes J.D. Schmidt L.J. Huang H. Tindall D.J. P300 mediates androgen-independent transactivation of the androgen receptor by interleukin 6.Cancer Res. 2002; 62: 5632-5636Google Scholar). In fact, there are several treatment modalities such as Tamoxifen and Faslodex, which control breast tumor cell growth through inhibition of ER activity. In early prostate cancer, tumor cells are often androgen responsive. Patients with prostate cancer receive hormonal therapy to control tumor growth. Recent evidence suggests that even in androgen-independent prostate cancer, the AR may promote tumor growth (10Debes J.D. Schmidt L.J. Huang H. Tindall D.J. P300 mediates androgen-independent transactivation of the androgen receptor by interleukin 6.Cancer Res. 2002; 62: 5632-5636Google Scholar). Similarly, many tamoxifen-resistant tumors still express ER (11Levenson A.S. Svoboda K.M. Pease K.M. Kaiser S.A. Chen B. Simons L.A. Jovanovic B.D. Dyck P.A. Jordan V.C. Gene expression profiles with activation of the estrogen receptor alpha-selective estrogen receptor modulator complex in breast cancer cells expressing wild-type estrogen receptor.Cancer Res. 2002; 62: 4419-4426Google Scholar). Thus, new drugs that down-regulate AR and ER by novel mechanisms may be of potential benefit in treating breast and prostate cancers. To address the key questions about Protacs raised by our first study, we set out to develop Protacs comprising the IκBα phosphopeptide linked to either estradiol (E2) or dihydroxytestosterone (DHT) to recruit ER or AR to SCFβ-TRCP to accelerate their ubiquitination and degradation. Recently, both the ER and AR have been shown to be regulated by proteasome-dependent proteolysis (12Cardozo C.P. Michaud C. Ost M.C. Fliss A.E. Yang E. Patterson C. Hall S.J. Caplan A.J. C-terminal Hsp-interacting protein slows androgen receptor synthesis and reduces its rate of degradation.Arch. Biochem. Biophys. 2003; 410: 134-140Google Scholar, 13Lonard D.M. Nawaz Z. Smith C.L. O'Malley B.W. The 26S proteasome is required for estrogen receptor-alpha and coactivator turnover and for efficient estrogen receptor-alpha transactivation.Mol. Cell. 2000; 5: 939-948Google Scholar, 14Nawaz Z. Lonard D.M. Dennis A.P. Smith C.L. O'Malley B.W. Proteasome-dependent degradation of the human estrogen receptor.Proc. Natl. Acad. Sci. U. S. A. 1999; 96: 1858-1862Google Scholar). We reasoned that Protacs might mimic the action of the human papillomavirus E6 protein, which accelerates the turnover of the already unstable p53 to the point where p53 can no longer accumulate, resulting in loss of its function (15Zhou P. Bogacki R. McReynolds L. Howley P.M. Harnessing the ubiquitination machinery to target the degradation of specific cellular proteins.Mol. Cell. 2000; 6: 751-756Google Scholar). In this paper, we report the feasibility of using Protacs to target degradation of proteins known to promote tumor growth. We show that Protacs can recruit the ER for ubiquitination and degradation in a cell-free system. Furthermore, our results demonstrate that in cells, Protacs can promote the degradation of AR in a proteasome-dependent manner. Thus, Protacs may be a useful therapeutic approach to destroy proteins that promote tumor growth in patients with cancer. To generate GA-1-monosuccinimidyl suberate, the estradiol derivative, GA-1 (7 mg, 11.5 μmol), was dissolved in 1 ml of anhydrous dimethylformamide (DMF), and disuccinimidyl suberate (21 mg, 57.0 μmol) was added at room temperature. After overnight stirring, DMF was removed under high vacuum, and the resulting white solid was flash-chromatographed to give GA-1-monosuccinimidyl suberate (6.3 mg, 7.3 μmol, 63.5%). For synthesis of GA-1-IκBα phosphopeptide, GA-1-monosuccinimidyl suberate (6 mg, 6.9μmol) in DMSO (1 ml) was added to dimethylsulfoxide (DMSO) solution (0.4 ml) containing IκBα phosphopeptide (1.5 mg, 0.92μmol) and dimethylaminopyridine (0.5 mg). After 30 min stirring at room temperature, the coupling reaction was completed, which was confirmed by a Kaiser test. DMSO was removed under high vacuum, and the resulting crude product was repeatedly washed with dichloromethane and methanol to remove excess GA-1-monosuccinimidyl suberate to give the final product, GA-1-IκBα phosphopeptide (1.5 mg, 0.63 μmol, 68.5%). The final product was characterized by electrospray (ES) mass spectrometry. ES-MS (M+H)+ for GA-1-IκBα phosphopeptide was 2384.0 Da. All other intermediates were characterized by 500-MHz 1H nuclear magnetic resonance spectroscopy. For DHT-Gly-monosuccinimidyl suberate, DMF (28 μl, 0.33 mmol) was added to dichloromethane solution (20 ml) containing Fmoc-Gly-OH (1.06 g, 3.57 mmol) and oxalyl chloride (0.62 ml, 7.10 mmol) at 0 °C. After 3 of stirring at room temperature, dichloromethane was removed under The resulting solid was in dichloromethane ml) and was with g, mmol) and dimethylaminopyridine g, mmol) in dichloromethane (20 ml) at 0 °C. The reaction was overnight at room temperature. After dichloromethane was removed under the resulting was flash-chromatographed to g, g, mmol) was with ml, 1 in at room for and the DMF was removed under high The resulting was flash-chromatographed to mg, disuccinimidyl suberate mmol) was added to DMF solution (1 ml) containing mg, mmol) at room temperature. After overnight stirring, DMF was removed under high vacuum, and the resulting crude product was flash-chromatographed to give DHT-Gly-monosuccinimidyl suberate mg, DHT-Gly-monosuccinimidyl suberate mg, μmol) in DMSO ml) was added to DMSO solution (1 ml) containing IκBα phosphopeptide mg, μmol) and dimethylaminopyridine mg, After min of stirring at room temperature, the coupling reaction was completed, which was confirmed by a Kaiser test. DMF was removed under high vacuum, and the resulting crude product was repeatedly washed with dichloromethane and methanol to remove excess DHT-Gly-monosuccinimidyl suberate to give the final product, phosphopeptide mg, μmol, The final product was characterized by mass spectrometry. ES-MS (M+H)+ for was Da. All other intermediates were characterized by 500-MHz 1H nuclear magnetic resonance spectroscopy. cells were in with and were the to and with of were in on the of were with of and of using method as described (7Sakamoto K.M. Kim K.B. Kumagai A. Mercurio F. Crews C.M. Deshaies R.J. Protacs: Chimeric molecules that target proteins to the Skp1-Cullin-F box complex for ubiquitination and degradation.Proc. Natl. Acad. Sci. U. S. A. 2001; 98: 8554-8559Google Scholar). were 30 of a containing the linked to the green protein was into cells at the to were at the of cell were with of 1 from cells with or were for on for After at in an for min at the was added to of which were washed with were with the on a for at by one with A and one with the was by the E2, from ubiquitin or ubiquitin (1.5 Protac final ER from and (1 final in reaction of μl, which was added to of washed (7Sakamoto K.M. Kim K.B. Kumagai A. Mercurio F. Crews C.M. Deshaies R.J. Protacs: Chimeric molecules that target proteins to the Skp1-Cullin-F box complex for ubiquitination and degradation.Proc. Natl. Acad. Sci. U. S. A. 2001; 98: 8554-8559Google Scholar). were for 1 at 30 in a with was added to the was by methods using were as described 26S of were added to the ubiquitinated ER on and the reaction was with of 1 of and ubiquitin final as previously described R. Chen S. R. Deshaies R.J. Identification of proteins by mass of Biol. Cell. 2000; Scholar, R. L. R. Deshaies R.J. of in and degradation by the 26S 2002; Scholar). The reaction was for min at 30 with in a For proteasome inhibition 26S were min at 30 with the or at 1 final to to ubiquitinated cells were with a that by of as described were with and in with and to cells were in Protac to in with mass was into cells through a using a The was of the cell For proteasome inhibition cells were with for or with and Protac Kim K.B. Crews C.M. of proteasome as revealed by Cell. 2001; Scholar, R. M. green proteins for proteolysis in Biotechnol. 2000; Scholar). were using a and fluorescence were with a Protacs consisting of the 10-aa on the covalently linked to either estradiol or were synthesized We first in ubiquitination with both but our on to with expression of To whether promotes the ubiquitination of ER by SCFβ-TRCP in a we ubiquitination with of Protac ER was ubiquitinated at a of with at we no longer ubiquitination of ER by SCFβ-TRCP, which may be to a the of excess inhibits the of efficient ubiquitination of ER, we to this for the of our studies as be that we ubiquitination of ER in the absence of A and This may be to the of an SCF ubiquitin ligase in the these were of molecular mass and from the high molecular by and of ubiquitination of ER in of ER ubiquitination by ER was with E2, and SCFβ-TRCP from cells by of on and were with the of for min at 30 and by by with an of high molecular on as that ubiquitin was added in the of ubiquitin estradiol and IκBα phosphopeptide be covalently linked to promote ER The reaction was as described in that IκBα phosphopeptide and estradiol were added to the ubiquitination reaction of and IκBα phosphopeptide and estradiol out Protac activity. as that was used at 1 of IκBα phosphopeptide or of IκBα that is was added to ubiquitination Protacs are target as that and IκBα Protacs were used in of as To address the of action of we whether the IκBα phosphopeptide and estradiol can out and whether these added as can mimic the action of A excess of either IκBα phosphopeptide or estradiol in cells the activity of 1 added as and IκBα phosphopeptide to the of results are with our that as a bridging molecule in that the estradiol with the ER the other the IκBα phosphopeptide, recruits the ER to the We the of with ER were in the of either or a Protac that consisted of the phosphopeptide, which is by the ubiquitin ligase N. Wang P. of a function in 2000; and ovalicin, which binds MetAP-2 (8Sin N. Meng L. Wang M.Q. Wen J.J. Bornmann W.G. Crews C.M. The anti-angiogenic agent fumagillin covalently binds and inhibits the methionine aminopeptidase, MetAP-2.Proc. Natl. Acad. Sci. U. S. A. 1997; 94: 6099-6103Google Scholar). As shown in ER was not ubiquitinated by SCFβ-TRCP in the of either or are to targeting to the proteasome C.M. in Biochem. Sci. 2000; Scholar), and as a ubiquitinated under the in can be for the proteasome Deshaies R.J. of attachment the rate of Cell. 2003; Scholar). Thus, we sought to whether by were by the 26S To this 26S proteasome R. Chen S. R. Deshaies R.J. Identification of proteins by mass of Biol. Cell. 2000; was added to ubiquitinated ER in the of SCFβ-TRCP and disappearance of high molecular mass ubiquitin was within min and was by the inhibits the activity of the but not by the R. L. R. Deshaies R.J. of in and degradation by the 26S 2002; results with the IκBα Protac demonstrated that a target protein can be to a ubiquitin ligase through noncovalent and be ubiquitinated and in We to whether a Protac could promote the degradation of proteins in For these we used we in with cells that an protein and a cell that was readily to We employed the on the IκBα phosphopeptide its efficient into cells were with 1 and for or absence of by fluorescence A was and degradation was 1 of Protac not We that the of cells with Protac of This was not to cells with were not 1 by the cells shown in To the of we cells and the in 1 of cells demonstrated or disappearance of In cells that to be 1 were experiment was on at with cells of or not in disappearance of from cells not We that the of phosphopeptide and was required for degradation. of IκBα phosphopeptide and into cells not in that Protac is necessary to promote degradation of To whether degradation was on IκBα phosphopeptide and binding to their we with a excess of phosphopeptide or into In both degradation of was All were on with cells The results shown are of the in of cells these the that degradation by targeting to To whether the disappearance of was proteasome cells were with the proteasome for to with In cells with was not that the Protac mediates degradation through a proteasome-dependent were with Protac and in the absence of resulting in inhibition of degradation not The shown is of on 3 different with at 30 cells As demonstrated previously the IκBα but not ubiquitination of ER in The is on the of to be by the ubiquitin ligase as as its to to The of Protac action to in cells, not degradation of The and and targeted critical to the biology of and cells are regulated by ubiquitin-dependent including from of the cell and of which are by degradation of and the regulator IκBα M. Ben-Neriah Y. The control of Rev. 2000; Scholar, is Cell and the Dev. 1999; Scholar). To the of the for therapeutic we are Protacs to recruit proteins to ubiquitin ligases to promote their ubiquitination and degradation. of the Protacs approach is that it in theory can be to any protein in the or of a and may enable the development of a of proteins in the The of our approach is a small molecule that as a to a target protein to a ubiquitin we demonstrated that a Protac comprising a phosphopeptide that binds SCFβ-TRCP and a small molecule that binds MetAP-2 the ubiquitination of MetAP-2 by SCFβ-TRCP ubiquitin ligase in vitro, and targets MetAP-2 for degradation by the proteasome in (7Sakamoto K.M. Kim K.B. Kumagai A. Mercurio F. Crews C.M. Deshaies R.J. Protacs: Chimeric molecules that target proteins to the Skp1-Cullin-F box complex for ubiquitination and degradation.Proc. Natl. Acad. Sci. U. S. A. 2001; 98: 8554-8559Google Scholar). in the work were to show that Protacs can the turnover of a target protein in cells, and to the Protacs approach to proteins that a in human diseases. We the estrogen and androgen for our studies to their with estrogen and respectively. Furthermore, both have been with the development and progression of cancer. The results here that Protacs by a bridging to enable efficient and specific of ER in and AR in our in it is that Protacs can be different targets ER, and and that Protacs promote ubiquitination of these targets in a manner that is both target and it is that Protacs can AR turnover in the context of the cellular degradation This degradation was to be specific and on both of the Protac the proteasome the of Protacs to promote AR that the degradation is proteasome specific and not to such as or to other such as To Protacs to cells in the described we employed to the of the SCFβ-TRCP-binding IκBα phosphopeptide A key for Protac technology is to develop cell molecules that can be used to for in cell and of cancer. work in our suggests that Protacs on the of may be used to target ubiquitination and degradation of proteins in cells through the ubiquitin ligase M. R. and C. M. in We that many Protac can be to treat a of diseases. of hundreds of ubiquitin ligases that can be as agents of Protac action have been by the Human Genome it is to that Protacs not be to with such as AR and In any protein that binds a small molecule through high can be a studies that Protacs technology is not but as an to inhibition of proteins that promote human treatment of cancer drugs that inhibit the cell and Protacs a of targeting a protein that is known to regulate growth and of cancer cells, in the that the of patients by inhibiting the agent C.L. H. D.J. R. M. of a specific of the in the of and with the 2001; Scholar). The is that by a generic method that to target the proteins for the regardless of their of action or functional it will be to cancer to We for the expression and of for of the and We are to Mercurio for GA-1-monosuccinimidyl

Modern electroencephalographic (EEG) technology contributed to the appreciation that the EEG signal outside the classical Berger frequency band contains important information. In epilepsy, research of the past decade focused particularly on interictal high-frequency oscillations (HFOs) > 80 Hz. The first large application of HFOs was in the context of epilepsy surgery. This is now followed by other applications such as assessment of epilepsy severity and monitoring of antiepileptic therapy. This article reviews the evidence on the clinical use of HFOs in epilepsy with an emphasis on the latest developments. It highlights the growing literature on the association between HFOs and postsurgical seizure outcome. A recent meta-analysis confirmed a higher resection ratio for HFOs in seizure-free versus non-seizure-free patients. Residual HFOs in the postoperative electrocorticogram were shown to predict epilepsy surgery outcome better than preoperative HFO rates. The review further discusses the different attempts to separate physiological from epileptic HFOs, as this might increase the specificity of HFOs. As an example, analysis of sleep microstructure demonstrated a different coupling between HFOs inside and outside the epileptogenic zone. Moreover, there is increasing evidence that HFOs are useful to measure disease activity and assess treatment response using noninvasive EEG and magnetoencephalography. This approach is particularly promising in children, because they show high scalp HFO rates. HFO rates in West syndrome decrease after adrenocorticotropic hormone treatment. Presence of HFOs at the time of rolandic spikes correlates with seizure frequency. The time-consuming visual assessment of HFOs, which prevented their clinical application in the past, is now overcome by validated computer-assisted algorithms. HFO research has considerably advanced over the past decade, and use of noninvasive methods will make HFOs accessible to large numbers of patients. Prospective multicenter trials are awaited to gather information over long recording periods in large patient samples.

AIM OR OBJECTIVE: The aim of this study is to consolidate studies of physiological measures following sport-related concussion (SRC) to determine if a time course of postinjury altered neurobiology can be outlined. This biological time course was considered with respect to clinically relevant outcomes such as vulnerability to repeat injury and safe timing of return to physical contact risk. DESIGN: Systematic review. DATA SOURCES: PubMed, CINAHL, Cochrane Central, PsychINFO. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were included if they reported original research on physiological or neurobiological changes after SRC. Excluded were cases series <5 subjects, reviews, meta-analyses, editorials, animal research and research not pertaining to SRC. RESULTS: A total of 5834 articles were identified, of which 80 were included for full-text data extraction and review. Relatively few longitudinal studies exist that follow both physiological dysfunction and clinical measures to recovery. SUMMARY/CONCLUSIONS: Modalities of measuring physiological change after SRC were categorised into the following: functional MRI, diffusion tensor imaging, magnetic resonance spectroscopy, cerebral blood flow, electrophysiology, heart rate, exercise, fluid biomarkers and transcranial magnetic stimulation. Due to differences in modalities, time course, study design and outcomes, it is not possible to define a single 'physiological time window' for SRC recovery. Multiple studies suggest physiological dysfunction may outlast current clinical measures of recovery, supporting a buffer zone of gradually increasing activity before full contact risk. Future studies need to use generalisable populations, longitudinal designs following to physiological and clinical recovery and careful correlation of neurobiological modalities with clinical measures.

IL-17 and its receptor are founding members of a novel family of inflammatory cytokines. IL-17 plays a pathogenic role in rheumatoid arthritis (RA)-associated bone destruction. However, IL-17 is also an important regulator of host defense through granulopoiesis and neutrophil trafficking. Therefore, the role of IL-17 in pathogen-initiated bone loss was not obvious. The most common form of infection-induced bone destruction occurs in periodontal disease (PD). In addition to causing significant morbidity, PD is a risk factor for atherosclerotic heart disease and chronic obstructive pulmonary disease (COPD). Similar to RA, bone destruction in PD is caused by the immune response. However, neutrophils provide critical antimicrobial defense against periodontal organisms. Since IL-17 is bone destructive in RA but a key regulator of neutrophils, we examined its role in inflammatory bone loss induced by the oral pathogen Porphyromonas gingivalis in IL-17RA-deficient mice. These mice showed enhanced periodontal bone destruction, suggesting a bone-protective role for IL-17, reminiscent of a neutrophil deficiency. Although IL-17RA-deficient neutrophils functioned normally ex vivo, IL-17RA knock-out (IL-17RA(KO)) mice exhibited reduced serum chemokine levels and concomitantly reduced neutrophil migration to bone. Consistently, CXCR2(KO) mice were highly susceptible to alveolar bone loss; interestingly, these mice also suggested a role for chemokines in maintaining normal bone homeostasis. These results indicate a nonredundant role for IL-17 in mediating host defense via neutrophil mobilization.

Adolescents face a variety of challenges in their transition to adulthood; lesbian, gay, and bisexual adolescents face these typical challenges as well as additional challenges that are related to the social stigma of their sexual orientation. For some lesbian, gay, and bisexual adolescents, this stigma may induce psychosocial stress, leading to increased health risk behaviors and poorer health outcomes. In this article, we review data on the health and health care of LGB adolescents. We examine health indicators and health risks for LGB youth, including substance use, eating disorders, suicidality, risky sexual behaviors, violence exposure and victimization, and homelessness. We also examine health care provision and utilization for LGB youth. Lastly, we discuss ways in which researchers and clinicians can improve LGB adolescent health and health care.

BACKGROUND: Cancer-related fatigue afflicts up to 33% of breast cancer survivors, yet there are no empirically validated treatments for this symptom. METHODS: The authors conducted a 2-group randomized controlled trial to determine the feasibility and efficacy of an Iyengar yoga intervention for breast cancer survivors with persistent post-treatment fatigue. Participants were breast cancer survivors who had completed cancer treatments (other than endocrine therapy) at least 6 months before enrollment, reported significant cancer-related fatigue, and had no other medical conditions that would account for fatigue symptoms or interfere with yoga practice. Block randomization was used to assign participants to a 12-week, Iyengar-based yoga intervention or to 12 weeks of health education (control). The primary outcome was change in fatigue measured at baseline, immediately post-treatment, and 3 months after treatment completion. Additional outcomes included changes in vigor, depressive symptoms, sleep, perceived stress, and physical performance. Intent-to-treat analyses were conducted with all randomized participants using linear mixed models. RESULTS: Thirty-one women were randomly assigned to yoga (n = 16) or health education (n = 15). Fatigue severity declined significantly from baseline to post-treatment and over a 3-month follow-up in the yoga group relative to controls (P = .032). In addition, the yoga group had significant increases in vigor relative to controls (P = .011). Both groups had positive changes in depressive symptoms and perceived stress (P < .05). No significant changes in sleep or physical performance were observed. CONCLUSIONS: A targeted yoga intervention led to significant improvements in fatigue and vigor among breast cancer survivors with persistent fatigue symptoms.

RATIONALE: Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. OBJECTIVES: (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. METHODS: This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. MEASUREMENTS AND MAIN RESULTS: ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. CONCLUSIONS: The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.