Stamford Hospital

OBJECTIVES: To determine the effect of glycemic variability, assessed by the standard deviation of each patient's mean glucose level, on mortality in a population of critically ill adult patients. DESIGN: Retrospective review of a large cohort of prospectively evaluated patients. SETTING: Fourteen-bed medical surgical adult intensive care unit of a university affiliated community hospital. PATIENTS: Three thousand two hundred fifty-two patients consecutively admitted between October 1999 and October 2007 with at least three venous glucose samples. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mean (sd) Acute Physiology and Chronic Health Evaluation II score of the 3252 patients was 20.0 (8.9) and their mortality was 24.4%, ranging from 18.1% among patients with mean glucose level 70 mg/dL to 99 mg/dL to 35.9% among patients with mean glucose level 180+ mg/dL. The relationship between glycemic variability and mortality was strongest in the euglycemic range. For the 410 patients with mean glucose level 70 mg/dL to 99 mg/dL, mortality ranged from 5.9% in the first quartile of glycemic variability to 30.1% in the fourth; for the 1031 patients with mean glucose level 100 mg/dL to 119 mg/dL the corresponding range was 9.7% to 31.0%. Mortality among patients in the entire cohort with the lowest quartile of glycemic variability was 12.1%, increasing to 19.9%, 27.7%, and 37.8% in the second, third, and fourth quartiles. Intensive care unit length of stay was shorter among patients in the first quartile compared with those in the other three (p < .001). CONCLUSIONS: This study demonstrates that increasing glycemic variability conferred a strong independent risk of mortality in this heterogeneous population of critically ill patients. Previously published interventional studies of glycemic control may be reinterpreted using the metric of glycemic variability. Measures to ensure a low degree of glycemic variability may improve outcomes in intensive care unit's implementing glycemic control. Finally, ongoing and future investigations should consider including this new metric in their study design.

OBJECTIVE: To determine the risk factors for development of severe hypoglycemia (defined as glucose <40 mg/dL) in critically ill patients and define the outcomes of this complication. DESIGN: Retrospective database review, including a case-control analysis that matched each patient with severe hypoglycemia with three controls. SETTING: Adult intensive care unit of a university-affiliated community hospital. PATIENTS: A total of 102 patients with at least one episode of severe hypoglycemia extracted from a series of 5,365 medical, surgical, and cardiac patients admitted consecutively between October 1, 1999, and June 15, 2006. INTERVENTIONS: A program of intensive glycemic monitoring and management, or tight glycemic control, was implemented on February 1, 2003; 2,666 patients were treated before and 2,699 after this date. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis identified diabetes, septic shock, renal insufficiency, mechanical ventilation, severity of illness, reflected by Acute Physiology and Chronic Health Evaluation II score with the age component deleted, and treatment in the tight glycemic control period as independent risk factors for the development of severe hypoglycemia. Mortality was 55.9% among the 102 patients with severe hypoglycemia and 39.5% among the 306 controls (p = .0057). Multivariable logistic regression analysis identified severe hypoglycemia as an independent predictor of mortality for the entire cohort (odds ratio, 2.28; 95% confidence interval, 1.41-3.70; p = .0008). Among patients with severe hypoglycemia, only modified Acute Physiology and Chronic Health Evaluation II score and mechanical ventilation were identified as independent predictors of mortality. A sensitivity analysis was constructed that suggested that quadrupling the rate of severe hypoglycemia and doubling the mortality attributable to severe hypoglycemia would negate the survival benefit of tight glycemic control in this series. CONCLUSIONS: Case-control methodology and multivariable logistic regression analysis concurred that even a single episode of severe hypoglycemia was independently associated with increased risk of mortality. Safe implementation of tight glycemic control requires appropriate monitoring to reduce the risk of this complication.

OBJECTIVE: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. METHODS: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. RECOMMENDATIONS: The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. CONCLUSIONS: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

BACKGROUND: Screening can detect prostate cancer at earlier, asymptomatic stages, when treatments might be more effective. PURPOSE: To update the 2002 and 2008 U.S. Preventive Services Task Force evidence reviews on screening and treatments for prostate cancer. DATA SOURCES: MEDLINE (2002 to July 2011) and the Cochrane Library Database (through second quarter of 2011). STUDY SELECTION: Randomized trials of prostate-specific antigen-based screening, randomized trials and cohort studies of prostatectomy or radiation therapy versus watchful waiting, and large observational studies of perioperative harms. DATA EXTRACTION: Investigators abstracted and checked study details and quality using predefined criteria. DATA SYNTHESIS: Of 5 screening trials, the 2 largest and highest-quality studies reported conflicting results. One found that screening was associated with reduced prostate cancer-specific mortality compared with no screening in a subgroup of men aged 55 to 69 years after 9 years (relative risk, 0.80 [95% CI, 0.65 to 0.98]; absolute risk reduction, 0.07 percentage point). The other found no statistically significant effect after 10 years (relative risk, 1.1 [CI, 0.80 to 1.5]). After 3 or 4 screening rounds, 12% to 13% of screened men had false-positive results. Serious infections or urine retention occurred after 0.5% to 1.0% of prostate biopsies. There were 3 randomized trials and 23 cohort studies of treatments. One good-quality trial found that prostatectomy for localized prostate cancer decreased risk for prostate cancer-specific mortality compared with watchful waiting through 13 years of follow-up (relative risk, 0.62 [CI, 0.44 to 0.87]; absolute risk reduction, 6.1%). Benefits seemed to be limited to men younger than 65 years. Treating approximately 3 men with prostatectomy or 7 men with radiation therapy instead of watchful waiting would each result in 1 additional case of erectile dysfunction. Treating approximately 5 men with prostatectomy would result in 1 additional case of urinary incontinence. Prostatectomy was associated with perioperative death (about 0.5%) and cardiovascular events (0.6% to 3%), and radiation therapy was associated with bowel dysfunction. LIMITATIONS: Only English-language articles were included. Few studies evaluated newer therapies. CONCLUSION: Prostate-specific antigen-based screening results in small or no reduction in prostate cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Introduction: Intravenous(IV) immunoglobulin(Ig) treatment is known to alleviate behavioral deficits in the experimentally induced model of sepsis. To delineate the mechanisms by which IVIg treatment prevents neuronal dysfunction, an array of immunological and apoptosis markers was investigated. Methods: Sepsis was induced by cecal ligation perforation(CLP) in rats. The animals were divided into five groups; sham, control, CLP + saline, CLP + immunoglobulin G IgG(250 mg/kg,iv), and CLP + immunoglobulins enriched with immunoglobulin M-IgGAM(250 mg/kg,iv). Blood and brain samples were taken in two sets of experiments after CLP to see the early(24 hrs) and late(10 days) effects of treatment. Total complement activity, complement 3(C3) and soluble complement C5b-9 levels were measured in sera of rats using ELISA-based methods. Cerebral complement content was analyzed by Western Blot. Immune cell infiltration and gliosis were examined by immunohistochemistry using cluster of differentiation 3, CD4, CD8, CD11b, CD19 and glial fibrillary acidic protein antibodies. Apoptotic neuronal death was investigated by TUNEL staining and Western Blot-based semi-quantitative evaluation of brain homogenates by bax and bcl-2 antibodies. Results: IV IgG and IgGAM administration significantly reduced systemic complement activity but increased serum C3 and soluble C5b-9 levels. Likewise, Western Blot data showed slightly increased C5b-9 expression and significantly reduced C1q expression in brain samples of IgGAM-treated but not IgG-treated septic rats especially in the first day of administration. No cerebral cellular infiltrates were observed in treated and non-treated septic rats. By contrast, IV IgG and IgGAM treatment induced considerable amelioration in glial cell proliferation which was increased in non-treated rats. IgG and IgGAM treated rats exhibited significantly reduced numbers of apoptotic neurons and cerebral expression levels of bax and bcl-2 as compared to nontreated rats. Conclusions: We suggest that IV IgG and IgGAM administration ameliorates neuronal dysfunction and behavioral deficits by reducing apoptotic cell death and glial cell proliferation. IgGAM treatment might be suppressing classical complement pathway by reducing C1q expression.

PURPOSE: Approximately 3% to 10% of EGFR (epidermal growth factor receptor) -mutant non-small cell lung cancers (NSCLCs) undergo transformation to small-cell lung cancer (SCLC), but their clinical course is poorly characterized. METHODS: We retrospectively identified patients with EGFR-mutant SCLC and other high-grade neuroendocrine carcinomas seen at our eight institutions. Demographics, disease features, and outcomes were analyzed. RESULTS: We included 67 patients-38 women and 29 men; EGFR mutations included exon 19 deletion (69%), L858R (25%), and other (6%). At the initial lung cancer diagnosis, 58 patients had NSCLC and nine had de novo SCLC or mixed histology. All but these nine patients received one or more EGFR tyrosine kinase inhibitor before SCLC transformation. Median time to transformation was 17.8 months (95% CI, 14.3 to 26.2 months). After transformation, both platinum-etoposide and taxanes yielded high response rates, but none of 17 patients who received immunotherapy experienced a response. Median overall survival since diagnosis was 31.5 months (95% CI, 24.8 to 41.3 months), whereas median survival since the time of SCLC transformation was 10.9 months (95% CI, 8.0 to 13.7 months). Fifty-nine patients had tissue genotyping at first evidence of SCLC. All maintained their founder EGFR mutation, and 15 of 19 with prior EGFR T790M positivity were T790 wild-type at transformation. Other recurrent mutations included TP53, Rb1, and PIK3CA. Re-emergence of NSCLC clones was identified in some cases. CNS metastases were frequent after transformation. CONCLUSION: There is a growing appreciation that EGFR-mutant NSCLCs can undergo SCLC transformation. We demonstrate that this occurs at an average of 17.8 months after diagnosis and cases are often characterized by Rb1, TP53, and PIK3CA mutations. Responses to platinum-etoposide and taxanes are frequent, but checkpoint inhibitors yielded no responses. Additional investigation is needed to better elucidate optimal strategies for this group.

BACKGROUND: The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). METHODS: Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. RESULTS: A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure. CONCLUSION: In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.

BACKGROUND: Lyme disease is a multisystem inflammatory disease caused by infection with the tick-borne spirochete Borrelia burgdorferi and is the most common vector-borne infection in the United States. We assessed the efficacy of a recombinant vaccine consisting of outer-surface protein A (OspA) without adjuvant in subjects at risk for Lyme disease. METHODS: For this double-blind trial, 10,305 subjects 18 years of age or older were recruited at 14 sites in areas of the United States where Lyme disease was endemic; the subjects were randomly assigned to receive either placebo (5149 subjects) or 30 microg of OspA vaccine (5156 subjects). The first two injections were administered 1 month apart, and 7515 subjects also received a booster dose at 12 months. The subjects were observed for two seasons during which the risk of transmission of Lyme disease was high. The primary end point was the number of new clinically and serologically confirmed cases of Lyme disease. RESULTS: The efficacy of the vaccine was 68 percent in the first year of the study in the entire population and 92 percent in the second year among the 3745 subjects who received the third injection. The vaccine was well tolerated. There was a higher incidence of mild, self-limited local and systemic reactions in the vaccine group, but only during the seven days after vaccination. There was no significant increase in the frequency of arthritis or neurologic events in vaccine recipients. CONCLUSIONS: In this study, OspA vaccine was safe and effective in the prevention of Lyme disease.

INTRODUCTION: Hyperglycemia, hypoglycemia, and increased glycemic variability have each been independently associated with increased risk of mortality in critically ill patients. The role of diabetic status on modulating the relation of these three domains of glycemic control with mortality remains uncertain. The purpose of this investigation was to determine how diabetic status affects the relation of hyperglycemia, hypoglycemia, and increased glycemic variability with the risk of mortality in critically ill patients. METHODS: This is a retrospective analysis of prospectively collected data involving 44,964 patients admitted to 23 intensive care units (ICUs) from nine countries, between February 2001 and May 2012. We analyzed mean blood glucose concentration (BG), coefficient of variation (CV), and minimal BG and created multivariable models to analyze their independent association with mortality. Patients were stratified according to the diagnosis of diabetes. RESULTS: Among patients without diabetes, mean BG bands between 80 and 140 mg/dl were independently associated with decreased risk of mortality, and mean BG bands>or=140 mg/dl, with increased risk of mortality. Among patients with diabetes, mean BG from 80 to 110 mg/dl was associated with increased risk of mortality and mean BG from 110 to 180 mg/dl with decreased risk of mortality. An effect of center was noted on the relation between mean BG and mortality. Hypoglycemia, defined as minimum BG<70 mg/dl, was independently associated with increased risk of mortality among patients with and without diabetes and increased glycemic variability, defined as CV>or=20%, was independently associated with increased risk of mortality only among patients without diabetes. Derangements of more than one domain of glycemic control had a cumulative association with mortality, especially for patients without diabetes. CONCLUSIONS: Although hyperglycemia, hypoglycemia, and increased glycemic variability is each independently associated with mortality in critically ill patients, diabetic status modulates these relations in clinically important ways. Our findings suggest that patients with diabetes may benefit from higher glucose target ranges than will those without diabetes. Additionally, hypoglycemia is independently associated with increased risk of mortality regardless of the patient's diabetic status, and increased glycemic variability is independently associated with increased risk of mortality among patients without diabetes.

This study examines the clinical features, pathologic findings, and outcome of 24 patients with biopsy-proven lithium toxicity. The patient population was 50% male, 87.5% Caucasian, and had a mean age of 42.5 yr (range, 26 to 57). Mean duration of lithium therapy for bipolar disorder was 13.6 yr (range, 2 to 25). All patients were biopsied for renal insufficiency (mean serum creatinine 2.8 mg/dl; range, 1.3 to 8.0), with associated proteinuria >1.0 g/d in 41.7%. Nephrotic proteinuria (>3.0 g/d) was present in 25%. Other features included nephrogenic diabetes insipidus in 87% and hypertension in 33.3%. Renal biopsy revealed a chronic tubulointerstitial nephropathy in 100%, with associated cortical and medullary tubular cysts (62.5%) or dilatation (33.3%). All of the renal cysts stained for epithelial membrane antigen, while 51.4% stained with lectin Arachis hypogaea, and only 3.8% stained with Tetragonolobus purpureas, indicating they originated from distal and collecting tubules. The degree of tubular atrophy and interstitial fibrosis was graded as severe in 58.3%, moderate in 37.5%, and mild in 4.2% of cases. There was a surprisingly high prevalence of focal segmental glomerulosclerosis (50%) and global glomerulosclerosis (100%), sometimes of equivalent severity to the chronic tubulointerstitial disease. The significant degree of foot process effacement (mean 34%, five of 14 cases with >50%) suggests a potential direct glomerular toxicity. Focal segmental glomerulosclerosis correlated with proteinuria >1.0 g/d (P = 0.0014, Fisher exact test). Despite discontinuation of lithium, seven of nine patients with initial serum creatinine values >2.5 mg/dl progressed to end-stage renal disease (ESRD). Only three patients, all with initial serum creatinine <2.1 mg/dl, had subsequent improvement in renal function. By Kaplan-Meier survival analysis, the only significant predictor of progression to ESRD was serum creatinine >2.5 mg/dl at biopsy (P = 0. 008). In conclusion, lithium nephrotoxicity primarily targets distal and collecting tubules, with a higher incidence of proteinuria and associated glomerular pathology than recognized previously. Renal dysfunction is often irreversible despite lithium withdrawal, and early detection is essential to prevent progression to ESRD.

OBJECTIVE: To determine whether the use of assisted reproductive technology (ART) is associated with an increase in chromosomal abnormalities, fetal malformations, or adverse pregnancy outcomes. METHODS: A prospective database from a large multicenter investigation of singleton pregnancies, the First And Second Trimester Evaluation of Risk trial, was examined. Subjects were divided into 3 groups: no ART use, use of ovulation induction (with or without intrauterine insemination), and use of in vitro fertilization (IVF). Multivariate logistic regression analysis was used to assess association between ART and adverse pregnancy outcomes (significance of differences was accepted at P < .05). RESULTS: A total of 36,062 pregnancies were analyzed: 34,286 (95.1%) were spontaneously conceived, 1,222 (3.4%) used ovulation induction, and 554 (1.5%) used IVF. There was no association between ART and fetal growth restriction, aneuploidy, or fetal anomalies after adjustment for age, race, marital status, years of education, prior preterm delivery, prior fetal anomaly, body mass index, smoking history, and bleeding in the current pregnancy. Ovulation induction was associated with a statistically significant increase in placental abruption, fetal loss after 24 weeks, and gestational diabetes after adjustment. Use of IVF was associated with a statistically significant increase in preeclampsia, gestational hypertension, placental abruption, placenta previa, and risk of cesarean delivery. CONCLUSION: Patients who undergo IVF are at increased risk for several adverse pregnancy outcomes. Although many of these risks are not seen in patients undergoing ovulation induction, several adverse pregnancy outcomes are still increased in this group. There was no increased incidence of fetal chromosomal or structural abnormalities in the women who used any type of ART compared with the women who conceived spontaneously. LEVEL OF EVIDENCE: II-2.

MicroRNAs (miRNAs) are endogenous short (∼22) nucleotide RNAs that regulate gene function by modification of target mRNAs. miRNA-1 (miR-1) and miRNA-206 (miR-206) are highly expressed in skeletal muscle. Due to the tissue-specific nature of miR-1/206 for skeletal muscles, we investigated the role of miR-1/206 in the development of rhabdomyosarcoma. Initially, we demonstrated that miR-1/206 expression was suppressed in rhabdomyosarcomas and found at very low levels in a rhabdomyosarcoma RD cell line. Transient transfection of miR-1/206 into cultured RD cells led to a significant decrease in cell growth and migration. Using bioinformatics, we identified two putative miR-1/206 binding sites within the 3′-untranslated region of the human c-Met mRNA. miR-1/206 was then shown to have activity on mRNA expression by targeting the c-Met 3′-untranslated region. The expression of c-Met protein was shown to be down-regulated by subsequent Western blot analysis. Conversely, up-regulation of c-Met was confirmed in tissue samples of human rhabdomyosarcoma, with its level inversely correlated with miR-1/206 expression. In vivo, miR-1/206-expressing tumor cells showed growth delay in comparison with negative control. Our results demonstrated that miR-1/206 suppressed c-Met expression in rhabdomyosarcoma and could function as a potent tumor suppressor in c-Met-overexpressing tumors. Inhibition of miR-1/206 function could contribute to aberrant cell proliferation and migration, leading to rhabdomyosarcoma development. MicroRNAs (miRNAs) are endogenous short (∼22) nucleotide RNAs that regulate gene function by modification of target mRNAs. miRNA-1 (miR-1) and miRNA-206 (miR-206) are highly expressed in skeletal muscle. Due to the tissue-specific nature of miR-1/206 for skeletal muscles, we investigated the role of miR-1/206 in the development of rhabdomyosarcoma. Initially, we demonstrated that miR-1/206 expression was suppressed in rhabdomyosarcomas and found at very low levels in a rhabdomyosarcoma RD cell line. Transient transfection of miR-1/206 into cultured RD cells led to a significant decrease in cell growth and migration. Using bioinformatics, we identified two putative miR-1/206 binding sites within the 3′-untranslated region of the human c-Met mRNA. miR-1/206 was then shown to have activity on mRNA expression by targeting the c-Met 3′-untranslated region. The expression of c-Met protein was shown to be down-regulated by subsequent Western blot analysis. Conversely, up-regulation of c-Met was confirmed in tissue samples of human rhabdomyosarcoma, with its level inversely correlated with miR-1/206 expression. In vivo, miR-1/206-expressing tumor cells showed growth delay in comparison with negative control. Our results demonstrated that miR-1/206 suppressed c-Met expression in rhabdomyosarcoma and could function as a potent tumor suppressor in c-Met-overexpressing tumors. Inhibition of miR-1/206 function could contribute to aberrant cell proliferation and migration, leading to rhabdomyosarcoma development. Soft tissue sarcomas are a heterogeneous group of mesenchymal tumors that carries a guarded prognosis due to the aggressive local invasion and metastatic potential of these tumors. Progress in the search for etiology and treatment of soft tissue sarcomas is hampered by the fact that they represent a small proportion of all malignancies. Rhabdomyosarcoma (RMS) 3The abbreviations used are: RMSrhabdomyosarcomamiRNAmicroRNAHGFhepatocyte growth factorDIGdigoxigeninGAPDHglyceraldehyde-3-phosphate dehydrogenaseUTRuntranslated regionDMEMDulbecco's modified Eagle's mediumMTS3-(4,5-dimethylthiazol-2-yl)-5-(3- carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner saltERK1/2extracellular signal-regulated kinases 1 and 2FAKfocal adhesion kinaseNCnegative control. is a distinct soft tissue sarcoma that likely originates from cells of the myogenic lineage (1Breitfeld P.P. Meyer W.H. Oncologist. 2005; 10: 518-527Crossref PubMed Scopus (97) Google Scholar). On the basis of histology, three main subgroups are often described: alveolar, embryonal, and pleomorphic RMS (2Ferrari A. Dileo P. Casanova M. Bertulli R. Meazza C. Gandola L. Navarria P. Collini P. Gronchi A. Olmi P. Fossati-Bellani F. Casali P.G. Cancer. 2003; 98: 571-580Crossref PubMed Scopus (293) Google Scholar). Alveolar RMS consists of small, round, and densely packed cells and occurs mainly in the trunk and extremities and carries with it a more unfavorable prognosis (1Breitfeld P.P. Meyer W.H. Oncologist. 2005; 10: 518-527Crossref PubMed Scopus (97) Google Scholar, 3Taulli R. Scuoppo C. Bersani F. Accornero P. Forni P.E. Miretti S. Grinza A. Allegra P. Schmitt-Ney M. Crepaldi T. Ponzetto C. Cancer Res. 2006; 66: 4742-4749Crossref PubMed Scopus (135) Google Scholar). Embryonal RMS typically consists of spindle-shaped cells and occurs mainly in the head and neck region (1Breitfeld P.P. Meyer W.H. Oncologist. 2005; 10: 518-527Crossref PubMed Scopus (97) Google Scholar, 3Taulli R. Scuoppo C. Bersani F. Accornero P. Forni P.E. Miretti S. Grinza A. Allegra P. Schmitt-Ney M. Crepaldi T. Ponzetto C. Cancer Res. 2006; 66: 4742-4749Crossref PubMed Scopus (135) Google Scholar). Pleomorphic RMS is uncommon and usually occurs in the adult population (2Ferrari A. Dileo P. Casanova M. Bertulli R. Meazza C. Gandola L. Navarria P. Collini P. Gronchi A. Olmi P. Fossati-Bellani F. Casali P.G. Cancer. 2003; 98: 571-580Crossref PubMed Scopus (293) Google Scholar). Until now, treatment of RMS has largely been based on local regional control and toxic systemic chemotherapy regimens without directed cellular therapy (2Ferrari A. Dileo P. Casanova M. Bertulli R. Meazza C. Gandola L. Navarria P. Collini P. Gronchi A. Olmi P. Fossati-Bellani F. Casali P.G. Cancer. 2003; 98: 571-580Crossref PubMed Scopus (293) Google Scholar, 3Taulli R. Scuoppo C. Bersani F. Accornero P. Forni P.E. Miretti S. Grinza A. Allegra P. Schmitt-Ney M. Crepaldi T. Ponzetto C. Cancer Res. 2006; 66: 4742-4749Crossref PubMed Scopus (135) Google Scholar). Recent investigations, however, are improving our understanding of its tumor biology and are helping to identify novel prognostic factors and targets for clinical therapy (1Breitfeld P.P. Meyer W.H. Oncologist. 2005; 10: 518-527Crossref PubMed Scopus (97) Google Scholar). rhabdomyosarcoma microRNA hepatocyte growth factor digoxigenin glyceraldehyde-3-phosphate dehydrogenase untranslated region Dulbecco's modified Eagle's medium 3-(4,5-dimethylthiazol-2-yl)-5-(3- carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner salt extracellular signal-regulated kinases 1 and 2 focal adhesion kinase negative control. MicroRNAs (miRNAs) are endogenously expressed, non-protein-coding RNAs that can influence a wide variety of biological processes including development, metabolism, proliferation, differentiation, and oncogenesis (4He L. Hannon G.J. Nat. Rev. Genet. 2004; 5: 522-531Crossref PubMed Scopus (5701) Google Scholar). Aberrant post-transcriptional regulation of mRNAs by miRNAs can lead to oncogenesis with increased cell proliferation, decreased apoptosis, and enhanced metastatic potential of affected cells (5Zhang B. Pan X. Cobb G.P. Anderson T.A. Dev. Biol. 2007; 302: 1-12Crossref PubMed Scopus (2204) Google Scholar). Following the discovery of miRNA let-7, multiple miRNAs were linked to oncogenes and tumor suppressor genes including the Ras proto-oncogene, the antiapoptotic gene BCL2, the potent p53 tumor suppressor gene, and the MET oncogene (5Zhang B. Pan X. Cobb G.P. Anderson T.A. Dev. Biol. 2007; 302: 1-12Crossref PubMed Scopus (2204) Google Scholar, 6Cho W.C. Mol. Cancer. 2007; 6: 60Crossref PubMed Scopus (638) Google Scholar). The MET oncogene encodes a cell surface receptor tyrosine kinase, c-Met, that is up-regulated in a variety of tumors including rhabdomyosarcoma (7Birchmeier C. Birchmeier W. Gherardi E. Vande Woude G.F. Nat. Rev. Mol. Cell Biol. 2003; 4: 915-925Crossref PubMed Scopus (2240) Google Scholar, 8Mazzone M. Comoglio P.M. FASEB J. 2006; 20: 1611-1621Crossref PubMed Scopus (111) Google Scholar). c-Met is a disulfide-linked heterodimer consisting of an extracellular α-subunit and a β-subunit that spans the plasma membrane and contains the catalytic region with tyrosine kinase activity (7Birchmeier C. Birchmeier W. Gherardi E. Vande Woude G.F. Nat. Rev. Mol. Cell Biol. 2003; 4: 915-925Crossref PubMed Scopus (2240) Google Scholar). Binding of hepatocyte growth factor (HGF)/scatter factor induces c-Met dimerization and autophosphorylation, which leads to cellular activation (7Birchmeier C. Birchmeier W. Gherardi E. Vande Woude G.F. Nat. Rev. Mol. Cell Biol. 2003; 4: 915-925Crossref PubMed Scopus (2240) Google Scholar). c-Met activation, through aberrant HGF stimulation, can contribute to tumor growth, invasiveness, and metastasis (9Danilkovitch-Miagkova A. Zbar B. J. Clin. Invest. 2002; 109: 863-867Crossref PubMed Scopus (268) Google Scholar). c-Met has been predicted and shown to be the target gene of multiple miRNAs including miRNA-206 (miR-206) (10McCarthy J.J. Biochim. Biophys. Acta. 2008; 1779: 682-691Crossref PubMed Scopus (322) Google Scholar). miR-206 and miRNA-1 (miR-1) are members of the muscle-specific miR-1 family of so-called myomiRs that currently consists of six members (10McCarthy J.J. Biochim. Biophys. Acta. 2008; 1779: 682-691Crossref PubMed Scopus (322) Google Scholar). Based on sequence conservation of the seed region, the miR-1 family can be divided into miR-1/206 or miR-133a/b subgroups (11Chen J.F. Mandel E.M. Thomson J.M. Wu Q. Callis T.E. Hammond S.M. Conlon F.L. Wang D.Z. Nat. Genet. 2006; 38: 228-233Crossref PubMed Scopus (2254) Google Scholar, 12Kim H.K. Lee Y.S. Sivaprasad U. Malhotra A. Dutta A. J. Cell Biol. 2006; 174: 677-687Crossref PubMed Scopus (653) Google Scholar). Although miR-1 is highly enriched in both cardiac and skeletal muscle, miR-206 is exclusively expressed in skeletal muscle (11Chen J.F. Mandel E.M. Thomson J.M. Wu Q. Callis T.E. Hammond S.M. Conlon F.L. Wang D.Z. Nat. Genet. 2006; 38: 228-233Crossref PubMed Scopus (2254) Google Scholar, 12Kim H.K. Lee Y.S. Sivaprasad U. Malhotra A. Dutta A. J. Cell Biol. 2006; 174: 677-687Crossref PubMed Scopus (653) Google Scholar). Therefore, it can be deduced that these miRNAs play an important role in the myogenesis and development of cardiac and skeletal muscles. miR-1 knock-out mice confirmed that this miRNA is necessary for cardiac development and physiology (13Zhao Y. Ransom J.F. Li A. Vedantham V. von Drehle M. Muth A.N. Tsuchihashi T. McManus M.T. Schwartz R.J. Srivastava D. Cell. 2007; 129: 303-317Abstract Full Text Full Text PDF PubMed Scopus (1196) Google Scholar). miR-206, which is specifically expressed in skeletal muscle and rarely detected in the heart, plays an important role in skeletal muscle development (12Kim H.K. Lee Y.S. Sivaprasad U. Malhotra A. Dutta A. J. Cell Biol. 2006; 174: 677-687Crossref PubMed Scopus (653) Google Scholar, 14Anderson C. Catoe H. Werner R. Nucleic Acids Res. 2006; 34: 5863-5871Crossref PubMed Scopus (327) Google Scholar). However, development and progression of skeletal muscle tumors such as rhabdomyosarcoma based on the presence or absence of miR-1 and miR-206 remain largely unknown. In this study, we attempted to decipher the biological function of miR-1/206 in human rhabdomyosarcoma specimens and rhabdomyosarcoma RD cells. By causal association following the identification of cell specificity for miR-1/206, we surmised that miR-1/206 acted as a suppressor of RD cell proliferation and migration. Furthermore, we set out to elucidate the cellular mechanisms responsible for its activity and to identify its target, c-Met, so that it may one day serve as a potential target in the treatment of rhabdomyosarcoma. The human rhabdomyosarcoma cell line, RD, purchased from ATCC (Manassas, VA), was grown in Dulbecco's modified Eagle's medium (DMEM; Invitrogen) supplemented with 10% fetal bovine serum (Hyclone, Logan, UT) and incubated at 37 °C in a humidified incubator containing 5% CO2. HEK-293 cells were grown under the same conditions. Eight rhabdomyosarcoma specimens and normal donor skeletal muscle tissues were obtained from the Eye Hospital and the First Affiliated Hospital of Wenzhou Medical College (Wenzhou, China). All studies and procedures involving human tissue samples were approved by the Wenzhou Medical College Institutional Review Board. Total RNA was extracted from cell lines or tissue samples with TRIzol reagent (Invitrogen), and the integrity was confirmed using spectrophotometry and formaldehyde/agarose gel electrophoresis. 10 μg of total RNA were dissolved in gel loading buffer II (Ambion, Austin, TX), heated at 95 °C for 3 min, loaded onto denaturing 15% Tris borate-EDTA-urea gels, and separated on a 15% denaturing urea-PAGE gel for 1 h and then transferred onto positively charged nylon membranes (GE Healthcare) followed by a cross-linking with UV irradiation. The RNA blots were prehybridized at 68 °C for 1 h using ULTRAhyb ultrasensitive hybridization buffer (Ambion) and subjected to hybridization with 3′-digoxigenin (DIG)-labeled locked nucleic acid probe for miR-1 or miR-206 (100 ng/ml) overnight at 42 °C. The locked nucleic acid-modified oligonucleotide probe was obtained from Exiqon (Vedbaek, Denmark). 100 pmol of the probe were DIG-labeled using DIG oligonucleotide 3′-end labeling kit (Roche Applied Science, Mannheim, Germany). Following hybridization, membranes were rinsed and then washed three times using a low stringency buffer (2× SSC and 0.1% SDS). Detection was performed using the DIG luminescent detection kit (Roche Applied Science) according to manufacturer's instructions. In brief, membranes were blocked in blocking buffer for 30 min and then incubated with alkaline phosphatase-conjugated anti-DIG antibody for 60 min followed by washing three times in washing buffer. After equilibration in detection buffer, blots were incubated with chemiluminescent substrate CDP-Star and exposed to a Kodak Biomax MR film (Eastman Kodak Co.). DIG-labeled U6 small nuclear RNA probe was used as an internal control. RD cells were plated at 3 × 103 cells/well in 96-well plates for each transfection. Transfections were performed using Lipofectamine 2000 (Invitrogen). For each well, 50 nm miR-1 or miR-206 precursor molecule or a negative control precursor miRNA was employed. For convenience, the miR-1 precursor or the miR-206 precursor is termed miR-1 or miR-206, respectively, following transfection throughout this report. Pre-miRTM miRNA precursor molecules (Ambion) are small, chemically modified double-stranded RNA molecules designed to mimic endogenous mature miRNAs once properly transfected and expressed by recipient cells. The negative control is a scrambled oligonucleotide that has been validated to not produce identifiable effects on known miRNA function (Ambion). After a 24-h culture, cell proliferation was assessed using the CellTiter 96 AQueous MTS [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner salt] assay (Promega, Madison, WI) according to the manufacturer's instructions. Briefly, the CellTiter 96 AQueous one solution reagent was added to each well and incubated at 37 °C for 3 h. Cell proliferation was assessed by measuring the absorbance at 490 nm using a microtiter plate reader (Molecular Devices, Sunnyvale, CA). RD cells were plated in 24-well plates and transfected with different miRNAs as described above. 24 h later, doxorubicin (0.1 μg/ml; Sigma) was added to each well prior to staining with Hoechst 33342 (5 μg/ml; Sigma) to visualize nuclear condensation and DNA fragmentation. After 20 min of staining at 25 °C, the cells were examined under fluorescence microscopy (Zeiss, Oberkochen, Germany). Apoptosis in RD cells was determined using the Caspase-Glo 3/7 assay kit according to the manufacturer's instructions (Promega). RD cells were first plated in triplicates in 96-well plates and transfected with different miRNAs as described above. Samples were then incubated with the caspase substrate for 2 h followed with measurements by a microtiter plate reader (Molecular Devices). RD cells were transfected with 50 nm miR-1 or miR-206 precursor molecule or a negative control. After 48 h, the cells were collected, washed with phosphate-buffered saline, and stained with propidium iodide using the BD Cycletest Plus DNA reagent kit (BD Biosciences). The stained cells (1 × 105) were then analyzed for DNA content with a flow cytometer (FACScaliber, BD Biosciences). The 3′-untranslated region (UTR) of human c-Met was amplified from human genomic DNA and individually cloned into the pMIR-REPORT vector (Ambion) by directional cloning. Seed regions were mutated to remove all complementarity to nucleotides 1–7 of miR-1/206 by using the QuikChange XL mutagenesis kit (Stratagene, La Jolla, CA). HEK-293 cells were co-transfected with 0.4 μg of firefly luciferase reporter vector and 0.02 μg of the control vector containing Renilla luciferase, pRL-SV40 (Promega), using Lipofectamine 2000 (Invitrogen) in 24-well plates. Each transfection was carried out in four wells. For each well, 50 nm miR-1 or miR-206 precursor molecule (Ambion) or a negative control precursor miRNA (Ambion) was co-transfected with the reporter constructs. Luciferase assays were performed 24 h after transfection using the Dual-Luciferase reporter assay system (Promega). Firefly luciferase activity was normalized to Renilla luciferase activity. RD cells were grown in DMEM containing 10% fetal bovine serum to ∼60% confluence and transfected with 50 nm miR-1 or miR-206 precursor molecule or a negative control. After 24 h, the cells were harvested by trypsinization and washed once with Hanks' balanced salt solution (Invitrogen). To measure cell migration, 8-mm pore size culture inserts (Transwell; Costar, High Wycombe, UK) were placed into the wells of 24-well culture plates, separating the upper and the lower chambers. In the lower of DMEM containing human hepatocyte growth factor 20 ng/ml) were HGF was purchased from 1 × cells were added to the upper After 24 h of at 37 °C with 5% the of cells that through the was by 10 under the using a and cell was by staining with and RD cells (1 × 105) were and grown in DMEM with 10% fetal bovine serum in plates for 24 h. After the cells were washed with phosphate-buffered and subjected to in a buffer 1 20 10 of protein μg and (GE Healthcare) were separated by 10% and then to The membranes were blocked with a buffer containing 5% in phosphate-buffered with 20 for 2 h and incubated overnight with antibody at °C. After a with phosphate-buffered containing the membranes were incubated with and with an enhanced detection kit dehydrogenase was used as a loading control. for total extracellular signal-regulated kinases 1 and 2 total total focal adhesion kinase and were from Cell and for c-Met, and were from The expression and control vector were purchased from CA). The was according to the manufacturer's instructions. RD cells were with miR-206, or negative mice of were used for RD cells × miR-1/206 or negative control were into the of All mice were after of tumor cells. size was with a and was using the following × × and according to the S. von R. Cancer Res. Google Scholar). All studies and procedures were approved by the Wenzhou Medical College and All were shown as the samples were analyzed using the was at To miRNA was in the of rhabdomyosarcoma we first miR-1/206 expression in normal skeletal muscle and rhabdomyosarcoma. blot was performed using DIG-labeled locked nucleic acid probe for miR-1 or miR-206 to its expression in tissue specimens and the rhabdomyosarcoma RD cell line. miR-1 and miR-206 were highly expressed in normal skeletal muscle In expression of miR-1/206 was decreased in RD cells To the expression of miR-1/206 in human rhabdomyosarcoma, total RNA from human rhabdomyosarcoma specimens was analyzed by with results from the RD miR-1/206 expression was suppressed or not detected in all samples and results that miR-1/206 expression is down-regulated in human rhabdomyosarcoma and a role of miR-1/206 in rhabdomyosarcoma development. miR-1/206 expression was down-regulated in rhabdomyosarcoma, we to its biological activity on cell RD cells were first transfected with the the miR-206 precursor or a negative control. Although transfection with the negative control not RD cell both miR-1 and miR-206 a significant of RD cell growth as with that of control the MTS assay was carried out to growth at after transfection. miR-1 or miR-206 transfected cells a of RD cell proliferation as with that of control a The decrease in cell was significant cells transfected with miR-1/206 and cells transfected with a negative control at day led to miR-206 led to To of cell proliferation, we the of cell using Hoechst RD cells showed and of DNA following Hoechst staining RD cells transfected with miR-1 or miR-206 a and in cell as with control. then investigated as a of cell by caspase activity. 3/7 activity was increased in miR-1/206 transfected cells in comparison with negative control after 48 h to the that miR-1/206 cell proliferation, these cells were found to have cell 48 h after cells were stained with propidium iodide and analyzed by flow transfected with miR-1 or miR-206 showed and in comparison with with transfection and with negative control of miR-1/206 down-regulated cell including and which are important for cell progression and In which the cell was up-regulated these results that miR-1/206 expression suppressed RD cell growth by and by cell Cell migration, a for and was assessed using a RD cells were first transfected with the miR-1/206 precursor or a control were on culture and the of cells to to the of the inserts was determined in the presence of shown in the was decreased cells with negative control for 10 for miR-206, 3 Therefore, of miR-1/206 in cell in to demonstrated a role for miR-1/206 in RD we attempted to the cellular mechanisms cell proliferation and migration. was for miR-1/206 target potential binding sites of miR-1/206 were predicted in the c-Met the predicted miR-1/206 target sites and miR-1/206, the seed sequence for is shown To the regulation of c-Met through the two predicted binding we amplified the c-Met sequence and it of the firefly luciferase region of a vector with the putative binding sites were as described of miR-1 or miR-206 in cells with the significant of luciferase activity as to negative control of the two binding using a vector the of miR-1 or miR-206 to regulate luciferase expression results demonstrated that c-Met was a potential target of To that miR-1/206 was responsible for the of c-Met, RD cells were transfected with the miR-1/206 molecule or a negative control. Western blot showed that c-Met expression was not affected by the transfection of a negative c-Met expression was transfected with miR-1 or miR-206

The EuroCMR registry sought to evaluate indications, image quality, safety and impact on patient management of clinical routine CMR in a multi-national European setting. Furthermore, interim analysis of the specific protocols should underscore the prognostic potential of CMR. Multi-center registry with consecutive enrolment of patients in 57 centers in 15 countries. More than 27000 consecutive patients were enrolled. The most important indications were risk stratification in suspected CAD/Ischemia (34.2%), workup of myocarditis/cardiomyopathies (32.2%), as well as assessment of viability (14.6%). Image quality was diagnostic in more than 98% of cases. Severe complications occurred in 0.026%, always associated with stress testing. No patient died during or due to CMR. In 61.8% CMR findings impacted on patient management. Importantly, in nearly 8.7% the final diagnosis based on CMR was different to the diagnosis before CMR, leading to a complete change in management. Interim analysis of suspected CAD and risk stratification in HCM specific protocols revealed a low rate of adverse events for suspected CAD patients with normal stress CMR (1.0% per year), and for HCM patients without LGE (2.7% per year). The most important indications in Europe are risk stratification in suspected CAD/Ischemia, work-up of myocarditis and cardiomyopathies, as well as assessment of viability. CMR imaging is a safe procedure, has diagnostic image quality in more than 98% of cases, and its results have strong impact on patient management. Interim analyses of the specific protocols underscore the prognostic value of clinical routine CMR in CAD and HCM. The EuroCMR registry sought to evaluate indications, image quality, safety and impact on patient management of clinical routine CMR in a multi-national European setting in a large number of cases (n > 27000). Based on our data CMR is frequently performed in European daily clinical routine. The most important indications in Europe are risk stratification in suspected CAD/Ischemia, work-up of myocarditis and cardiomyopathies, as well as assessment of viability. CMR imaging is a safe procedure, has diagnostic image quality in more than 98% of cases, and its results have strong impact on patient management. Interim analyses of the specific protocols underscore the prognostic value of clinical routine CMR in CAD and HCM.

BACKGROUND: Treatment of rheumatoid arthritis with anti-tumour necrosis factor alpha (TNFalpha) agents may lead to autoantibody formation and flares of vasculitis, but renal complications are rare. METHODS: We report the clinical and pathologic findings in five patients with longstanding rheumatoid arthritis (duration of rheumatoid arthritis, 10-30 years; mean, 23 years) who developed new onset of glomerular disease after commencing therapy with anti-TNFalpha agents (duration of therapy, 3-30 months; median, 6 months). RESULTS: At presentation, three patients were receiving etanercept, one adalimumab and one infliximab. Two subjects presented with acute renal insufficiency, haematuria, nephrotic-range proteinuria, positive lupus serologies, and hypocomplementemia, and renal biopsies showed proliferative lupus nephritis. Two individuals presented with new onset renal insufficiency, haematuria and proteinuria, and renal biopsies showed pauci-immune necrotizing and crescentic glomerulonephritis. One of these subjects, who had anti-myeloperoxidase autoantibodies, also developed pulmonary vasculitis. The fifth patient presented with nephrotic syndrome and renal biopsy findings of membranous glomerulonephritis, associated with immune complex renal vasculitis. A pathogenic role for anti-TNFalpha therapy is suggested by the close temporal relationship with development of glomerular disease, and by the improvement in clinical and laboratory abnormalities after drug withdrawal and initiation of immunosuppressive therapy in most cases. CONCLUSIONS: Rheumatoid arthritis patients receiving anti-TNFalpha agents may develop glomerulonephritis via the induction of rheumatoid arthritis-related nephropathy or de novo autoimmune disorders.

OBJECTIVE: The prevalence of serious infections caused by multidrug-resistant pathogens transmitted in the hospital setting has reached alarming levels, despite intensified interventions. In the context of mandates that hospitals ensure compliance with disinfection procedures of surfaces in the environment surrounding the patient, we implemented a multihospital project to both evaluate and improve current cleaning practices. DESIGN: Prospective quasi-experimental, before-after, study. SETTING: Thirty-six acute care hospitals in the United States ranging in size from 25 to 721 beds. METHODS: We used a fluorescent targeting method to objectively evaluate the thoroughness of terminal room disinfection cleaning before and after structured educational and procedural interventions. RESULTS: Of 20,646 standardized environmental surfaces (14 types of objects), only 9,910 (48%) were cleaned at baseline (95% confidence interval, 43.4-51.8). Thoroughness of cleaning at baseline correlated only with hospital expenditures for environmental services personnel (P = .02). After implementation of interventions and provision of objective performance feedback to the environmental services staff, it was determined that 7,287 (77%) of 9,464 standardized environmental surfaces were cleaned (P < .001). Improvement was unrelated to any demographic, fiscal, or staffing parameter but was related to the degree to which cleaning was suboptimal at baseline (P < .001). CONCLUSIONS: Significant improvements in disinfection cleaning can be achieved in most hospitals, without a substantial added fiscal commitment, by the use of a structured approach that incorporates a simple, highly objective surface targeting method, repeated performance feedback to environmental services personnel, and administrative interventions. However, administrative leadership and institutional flexibility are necessary to achieve success, and sustainability requires an ongoing programmatic commitment from each institution.

OBJECTIVE: The quality of environmental hygiene in hospitals is under increasing scrutiny from both healthcare providers and consumers because the prevalence of serious infections due to multidrug-resistant pathogens has reached alarming levels. On the basis of the results from a small number of hospitals, we undertook a study to evaluate the thoroughness of disinfection and cleaning in the patient's immediate environment and to identify opportunities for improvement in a diverse group of acute care hospitals. METHODS: Prospective multicenter study to evaluate the thoroughness of terminal room cleaning in hospitals using a novel targeting method to mimic the surface contamination of objects in the patient's immediate environment. SETTING: Twenty-three acute care hospitals. RESULTS: The overall thoroughness of terminal cleaning, expressed as a percentage of surfaces evaluated, was 49% (range for all 23 hospitals, 35%-81%). Despite the tight clustering of overall cleaning rates in 21 of the hospitals, there was marked variation within object categories, which was particularly notable with respect to the cleaning of toilet handholds, bedpan cleaners, light switches, and door knobs (mean cleaning rates, less than 30%; institutional ranges, 0%-90%). Sinks, toilet seats, and tray tables, in contrast, were consistently relatively well cleaned (mean cleaning rates, over 75%). Patient telephones, nurse call devices, and bedside rails were inconsistently cleaned. CONCLUSION: We identified significant opportunities in all participating hospitals to improve the cleaning of frequently touched objects in the patient's immediate environment. The information obtained from such assessments can be used to develop focused administrative and educational interventions that incorporate ongoing feedback to the environmental services staff, to improve cleaning and disinfection practices in healthcare institutions.

As the pace of competition intensifies in the 80’s, the use of information systems as competitive weapons is accelerating. Among the now classic cases are the computerized reservation system of American Airlines, the Cash Management Account of Merrill Lynch, and the order entry system of American Hospital Supply. These are examples of strategic information systems (SIS). The work that gave rise to this paper addresses the question, “How can an organization discover such SIS opportunities systematically?’’ The authors developed and implemented a five-phase planning process to identify and evaluate SIS and to win top management support. Underlying their approach is a conceptual framework that views an enterprise’s suppliers, customers, and competitors as the strategic targets of five strategic thrusts: differentiation, cost, innovation, growth, and alliance. Strategic thrusts represent the fundamental link between the firm’s strategy and its use of information technology. Strategic information systems support and shape the organization’s strategic thrusts.

OBJECTIVES: To present the updated results of systematic review of the current evidence for the effectiveness of hip protectors from reports of completed randomised trials, and to explore the evolution of that evidence. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Cochrane Bone, Joint, and Muscle Trauma Group trials register (January 2005), Cochrane central register of controlled trials (Cochrane Library Issue 1, 2005), Medline (1966 to January 2005), Embase (1988 to January 2005), and CINAHL (1982 to December 2004). Other databases and reference lists of relevant articles were searched and some trialists were contacted. REVIEW METHODS: Randomised or quasirandomised controlled trials reporting the incidence of hip fractures, pelvic fractures, and other fractures in elderly people offered hip protectors compared with a control group that was not. RESULTS: Outcomes for fracture were available from 14 randomised and quasirandomised trials. Pooling of data from 11 trials carried out in nursing or residential care settings, including six cluster randomised studies, showed evidence of a marginally statistically significant reduction in incidence of hip fracture (relative risk 0.77, 95% confidence interval 0.62 to 0.97). Pooling of data from three individually randomised trials of 5135 community dwelling participants showed no reduction in hip fracture incidence with provision of hip protectors (1.16, 0.85 to 1.59). No evidence was found of any significant effect of hip protectors on incidence of pelvic or other fractures. No important adverse effects of hip protectors were reported, but compliance, particularly in the long term, was poor. CONCLUSIONS: On the basis of early reports of randomised trials, hip protectors were advocated. Accumulating evidence indicates that hip protectors are an ineffective intervention for those living at home and that their effectiveness in an institutional setting is uncertain.

PURPOSE: MicroRNAs (miRNAs) are endogenously expressed, noncoding, small RNAs that inhibit protein translation through binding to target mRNAs. Recent studies have demonstrated that miRNAs can regulate tumor cell proliferation and migration. MicroRNA-34a (miR-34a), a potential key effector of the p53 tumor-suppressor gene, was studied as a potential tumor suppressor in uveal melanoma. METHODS: Northern blot analysis was performed to detect the expression level of miR-34a in uveal melanoma cells and melanocytes. Subsequently, melanoma cell proliferation and migration were examined by MTS cell proliferation and transwell migration assays, respectively. The target of miR-34a was predicted by bioinformatics and confirmed using a luciferase assay. In addition, expression of c-Met and cell cycle-related proteins was determined by Western blotting and immunofluorescence after the introduction of miR-34a. RESULTS: miR-34a is actively expressed in melanocytes but not in uveal melanoma cells based on Northern blot analysis. Transfection of miR-34a into uveal melanoma cells led to a significant decrease in cell growth and migration. After identification of two putative miR-34a binding sites within the 3' UTR of the human c-Met mRNA, miR-34a was shown to suppress luciferase activity using HEK293 cells with a luciferase reporter construct containing the binding sites. miR-34a was confirmed to downregulate the expression of c-Met protein by Western blotting and immunofluorescence. Furthermore, the introduction of miR-34a downregulated phosphorylated Akt and cell cycle-related proteins. CONCLUSIONS: These results demonstrate that miR-34a acts as a tumor suppressor in uveal melanoma cell proliferation and migration through the downregulation of c-Met.

The management reporting and assessment of glycemic control lacks standardization. The use of different methods to measure the blood glucose concentration and to report the performance of insulin treatment yields major disparities and complicates the interpretation and comparison of clinical trials. We convened a meeting of 16 experts plus invited observers from industry to discuss and where possible reach consensus on the most appropriate methods to measure and monitor blood glucose in critically ill patients and on how glycemic control should be assessed and reported. Where consensus could not be reached, recommendations on further research and data needed to reach consensus in the future were suggested. Recognizing their clear conflict of interest, industry observers played no role in developing the consensus or recommendations from the meeting. Consensus recommendations were agreed for the measurement and reporting of glycemic control in clinical trials and for the measurement of blood glucose in clinical practice. Recommendations covered the following areas: How should we measure and report glucose control when intermittent blood glucose measurements are used? What are the appropriate performance standards for intermittent blood glucose monitors in the ICU? Continuous or automated intermittent glucose monitoring - methods and technology: can we use the same measures for assessment of glucose control with continuous and intermittent monitoring? What is acceptable performance for continuous glucose monitoring systems? If implemented, these recommendations have the potential to minimize the discrepancies in the conduct and reporting of clinical trials and to improve glucose control in clinical practice. Furthermore, to be fit for use, glucose meters and continuous monitoring systems must match their performance to fit the needs of patients and clinicians in the intensive care setting.