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BACKGROUND:: Volatile anesthetic prices differ substantially. But differences in drug-acquisition cost would be inconsequential if hospitalization was prolonged by more soluble anesthetics. The authors tested the hypothesis that the duration of hospitalization is prolonged with isoflurane anesthesia.

METHODS:: Initially, the authors queried their electronic records and used propensity matching to generate homogeneous sets of adults having inpatient noncardiac surgery who were given desflurane, sevoflurane, and isoflurane. The authors then conducted a prospective alternating intervention trial in which adults (mostly having colorectal surgery) were assigned to isoflurane or sevoflurane, based on protocol.

RESULTS:: In the retrospective analysis, the authors identified 3,488 triplets matched on isoflurane, desflurane, or sevoflurane from among 43,352 adults. The adjusted geometric mean (95% CI) hospital length-of-stay for the isoflurane cases was 2.76 days (2.69-2.83); this was longer than that observed for both desflurane (2.56 [2.50-2.63]; P < 0.001) and sevoflurane (2.49 [2.43-2.56]; P < 0.0001). In the prospective trial (N = 1,584 operations), no difference was found; the adjusted ratio of means (95% CI) of hospital length-of-stay in patients receiving isoflurane versus sevoflurane was 0.98 (0.88-1.10), P = 0.77, with adjusted geometric means (95% CI) estimated at 4.1 (3.8-4.4) and 4.2 days (3.8-.5), respectively.

CONCLUSIONS:: Results of the propensity-matched retrospective analysis suggested that avoiding isoflurane significantly reduced the duration of hospitalization. In contrast, length-of-stay was comparable in our prospective trial. Volatile anesthetic choice should not be based on concerns about the duration of hospitalization. These studies illustrate the importance of following even the best retrospective analysis with a prospective trial.

This theme issue provides a comprehensive collection of original research articles as well as reviews on the creation of diverse types of theranostic upconversion nanoparticles, their fundamental interactions in biology, as well as their biophotonic applications in noninvasive diagnostics and therapy.

A previously unrecognized mechanism through which large ribonucleoprotein (megaRNP) granules exit the nucleus is by budding through the nuclear envelope (NE). This mechanism is akin to the nuclear egress of herpes-type viruses and is essential for proper synapse development. However, the molecular machinery required to remodel the NE during this process is unknown. Here, we identify Torsin, an AAA-ATPase that in humans is linked to dystonia, as a major mediator of primary megaRNP envelopment during NE budding. In torsin mutants, megaRNPs accumulate within the perinuclear space, and the messenger RNAs contained within fail to reach synaptic sites, preventing normal synaptic protein synthesis and thus proper synaptic bouton development. These studies begin to establish the cellular machinery underlying the exit of megaRNPs via budding, offer an explanation for the "nuclear blebbing" phenotype found in dystonia models, and provide an important link between Torsin and the synaptic phenotypes observed in dystonia.

Horace Wells, a contender for recognition as the discoverer of anesthesia, is celebrated in the town where he conducted most of his work, Hartford, CT. His only descendant was his son, Charles Thomas Wells (1839-1909), an influential and successful business executive at Aetna Insurance Company. He was a man of considerable influence, and he worked tirelessly with city officials and the Connecticut Dental Association in celebrating the 50th anniversary of his father's contribution to medicine. This discovery is unique because events and individuals in 1 country, the United States, contributed entirely to the birth of a medical specialty. Sites in Jefferson, GA; Hartford, CT; and Boston, MA and their environs celebrate this most precious contribution to modern medicine, especially since the introduction of safe anesthesia permitted the development of surgical specialties and obstetrics. We trace the history and relationship between Horace Wells and several sites and artifacts in Hartford, CT. These sites span the most important, distinctive, and attractive parts of the city: Bushnell Park, Trinity College, Cedar Hill Cemetery, the Athenaeum, and the Connecticut Historical Society.

The amino acid sequence of a protein governs its function. We used bulk competition and focused deep sequencing to investigate the effects of all ubiquitin point mutants on yeast growth rate. Many aspects of ubiquitin function have been carefully studied, which enabled interpretation of our growth analyses in light of a rich structural, biophysical and biochemical knowledge base. In one highly sensitive cluster on the surface of ubiquitin, almost every amino acid substitution caused growth defects. In contrast, the opposite face tolerated virtually all possible substitutions. Surface locations between these two faces exhibited intermediate mutational tolerance. The sensitive face corresponds to the known interface for many binding partners. Across all surface positions, we observe a strong correlation between burial at structurally characterized interfaces and the number of amino acid substitutions compatible with robust growth. This result indicates that binding is a dominant determinant of ubiquitin function. In the solvent-inaccessible core of ubiquitin, all positions tolerated a limited number of substitutions, with hydrophobic amino acids especially interchangeable. Some mutations null for yeast growth were previously shown to populate folded conformations indicating that, for these mutants, subtle changes to conformation caused functional defects. The most sensitive region to mutation within the core was located near the C-terminus that is a focal binding site for many critical binding partners. These results indicate that core mutations may frequently cause functional defects through subtle disturbances to structure or dynamics.

Alcohol-induced neuroinflammation is mediated by proinflammatory cytokines, including IL-1beta. IL-1beta production requires caspase-1 activation by inflammasomes-multiprotein complexes that are assembled in response to danger signals. We hypothesized that alcohol-induced inflammasome activation contributes to increased IL-1beta in the brain. WT and TLR4-, NLRP3-, and ASC-deficient (KO) mice received an ethanol-containing or isocaloric control diet for 5 weeks, and some received the rIL-1ra, anakinra, or saline treatment. Inflammasome activation, proinflammatory cytokines, endotoxin, and HMGB1 were measured in the cerebellum. Expression of inflammasome components (NLRP1, NLRP3, ASC) and proinflammatory cytokines (TNF-alpha, MCP-1) was increased in brains of alcohol-fed compared with control mice. Increased caspase-1 activity and IL-1beta protein in ethanol-fed mice indicated inflammasome activation. TLR4 deficiency protected from TNF-alpha, MCP-1, and attenuated alcohol-induced IL-1beta increases. The TLR4 ligand, LPS, was not increased in the cerebellum. However, we found up-regulation of acetylated and phosphorylated HMGB1 and increased expression of the HMGB1 receptors (TLR2, TLR4, TLR9, RAGE) in alcohol-fed mice. NLRP3- or ASC-deficient mice were protected from caspase-1 activation and alcohol-induced IL-1beta increase in the brain. Furthermore, in vivo treatment with rIL-1ra prevented alcohol-induced inflammasome activation and IL-1beta, TNF-alpha, and acetylated HMGB1 increases in the cerebellum. Conversely, intracranial IL-1beta administration induced TNF-alpha and MCP-1 in the cerebellum. In conclusion, alcohol up-regulates and activates the NLRP3/ASC inflammasome, leading to caspase-1 activation and IL-1beta increase in the cerebellum. IL-1beta amplifies neuroinflammation, and disruption of IL-1/IL-1R signaling prevents alcohol-induced inflammasome activation and neuroinflammation. Increased levels of acetylated and phosphorylated HMGB1 may contribute to alcoholic neuroinflammation.

Because small molecules enter Gram-negative bacteria via outer membrane (OM) channels, understanding OM transport is essential for the rational design of improved and new antibiotics. In the human pathogen Pseudomonas aeruginosa, most small molecules are taken up by outer membrane carboxylate channel (Occ) proteins, which can be divided into two distinct subfamilies, OccD and OccK. Here we characterize substrate transport mediated by Occ proteins belonging to both subfamilies. Based on the determination of the OccK2-glucuronate co-crystal structure, we identify the channel residues that are essential for substrate transport. We further show that the pore regions of the channels are rigid in the OccK subfamily and highly dynamic in the OccD subfamily. We also demonstrate that the substrate carboxylate group interacts with central residues of the basic ladder, a row of arginine and lysine residues that leads to and away from the binding site at the channel constriction. Moreover, the importance of the basic ladder residues corresponds to their degree of conservation. Finally, we apply the generated insights by converting the archetype of the entire family, OccD1, from a basic amino acid-specific channel into a channel with a preference for negatively charged amino acids.

Comment on: Circulation. 2013 May 28;127(21):2097-106. doi: 10.1161/CIRCULATIONAHA.112.000882.

After neuronal injury or death glial cells become reactive, exhibiting dramatic changes in morphology and patterns of gene expression and ultimately engulfing neuronal debris. Rapid clearance of degenerating neuronal material is thought to be crucial for suppression of inflammation and promotion of functional recovery. Here we demonstrate that Drosophila c-Jun N-terminal kinase (dJNK) signaling is a critical in vivo mediator of glial engulfment activity. In response to axotomy, we find glial dJNK signals through a cascade involving the upstream mitogen-activated protein kinase kinase kinases Slipper and Tak1, the mitogen-activated protein kinase kinase MKK4, and ultimately the Drosophila activator protein 1 (AP-1) transcriptional complex composed of Jra and Kayak to initiate glial phagocytosis of degenerating axons. Interestingly, loss of dJNK also blocked injury-induced upregulation of Draper levels in glia, and glial-specific overexpression of Draper was sufficient to rescue engulfment defects associated with loss of dJNK signaling. This work identifies that the dJNK pathway is a novel mediator of glial engulfment activity and a primary role for the glial Slipper/Tak1short right arrowMKK4short right arrowdJNKshort right arrowdAP-1 signaling cascade appears to be activation of draper expression after axon injury.Cell Death and Differentiation advance online publication, 26 April 2013; doi:10.1038/cdd.2013.30.

FUsed in Sarcoma/Translocated in LipoSarcoma (FUS/TLS or FUS) has been linked to several biological processes involving DNA and RNA processing, and has been associated with multiple diseases, including myxoid liposarcoma and amyotrophic lateral sclerosis (ALS). ALS-associated mutations cause FUS to associate with stalled translational complexes called stress granules under conditions of stress. However, little is known regarding the normal role of endogenous (non-disease linked) FUS in cellular stress response. Here, we demonstrate that endogenous FUS exerts a robust response to hyperosmolar stress induced by sorbitol. Hyperosmolar stress causes an immediate re-distribution of nuclear FUS to the cytoplasm, where it incorporates into stress granules. The redistribution of FUS to the cytoplasm is modulated by methyltransferase activity, whereas the inhibition of methyltransferase activity does not affect the incorporation of FUS into stress granules. The response to hyperosmolar stress is specific, since endogenous FUS does not redistribute to the cytoplasm in response to sodium arsenite, hydrogen peroxide, thapsigargin, or heat shock, all of which induce stress granule assembly. Intriguingly, cells with reduced expression of FUS exhibit a loss of cell viability in response to sorbitol, indicating a prosurvival role for endogenous FUS in the cellular response to hyperosmolar stress. J. Cell. Physiol. (c) 2013 Wiley Periodicals, Inc.

Sodium bicarbonate is central to the treatment of many poisonings. When it was placed on the FDA drug shortage list in 2012, alternative treatment strategies to specific poisonings were considered. Many hospital pharmacies, poison centers, and medical toxicologists proposed sodium acetate as an adequate alternative, despite a paucity of data to support its use in medical toxicology. The intention of this review is to educate the clinician on the use of sodium acetate and to advise them on the potential adverse events when given in excess. We conducted a literature search focused on the pharmacology of sodium acetate, its use as a buffer in pathologic acidemia and dialysis baths, and potential adverse events associated with excess sodium acetate infusion. It appears safe to replace sodium bicarbonate infusion with sodium acetate on an equimolar basis. The metabolism of acetate, however, is more complex than bicarbonate. Future prospective studies will be needed to confirm the efficacy of sodium acetate in the treatment of the poisoned patient.

Alcohol and nicotine are often co-abused. As many as 80-95% of alcoholics are also smokers, suggesting that ethanol and nicotine, the primary addictive component of tobacco smoke, may functionally interact in the central nervous system and/or share a common mechanism of action. While nicotine initiates dependence by binding to and activating neuronal nicotinic acetylcholine receptors (nAChRs), ligand-gated cation channels normally activated by endogenous acetylcholine (ACh), ethanol is much less specific with the ability to modulate multiple gene products including those encoding voltage-gated ion channels, and excitatory/inhibitory neurotransmitter receptors.

However, emerging data indicate that ethanol interacts with nAChRs, both directly and indirectly, in the mesocorticolimbic dopaminergic (DAergic) reward circuitry to affect brain reward systems. Like nicotine, ethanol activates DAergic neurons of the ventral tegmental area (VTA) which project to the nucleus accumbens (NAc). Blockade of VTA nAChRs reduces ethanol-mediated activation of DAergic neurons, NAc DA release, consumption, and operant responding for ethanol in rodents. Thus, ethanol may increase ACh release into the VTA driving activation of DAergic neurons through nAChRs. In addition, ethanol potentiates distinct nAChR subtype responses to ACh and nicotine in vitro and in DAergic neurons. The smoking cessation therapeutic and nAChR partial agonist, varenicline, reduces alcohol consumption in heavy drinking smokers and rodent models of alcohol consumption.

Finally, single nucleotide polymorphisms in nAChR subunit genes are associated with alcohol dependence phenotypes and smoking behaviors in human populations. Together, results from pre-clinical, clinical, and genetic studies indicate that nAChRs may have an inherent role in the abusive properties of ethanol, as well as in nicotine and alcohol co-dependence.

OBJECTIVE: This study examined the effect of adjunctive intranasal insulin therapy on body metabolism in patients with schizophrenia.

METHOD: Each subject had a DSM-IV diagnosis of schizophrenia or schizoaffective disorder and had been on stable dose of antipsychotic agent for at least one month. In an 8-week randomized, double-blind, placebo-controlled study, subjects received either intranasal insulin (40 IU 4 times per day) or placebo. The whole body dual-energy X-ray absorptiometry (DXA) was used to assess body composition. Lipid particles were assessed using nuclear magnetic resonance (NMR) spectroscopy. All assessments were conducted at baseline, and repeated at week 8.

RESULTS: A total number of 39 subjects completed the study (18 in the insulin group, 21 in the placebo group). There were no significant differences between the two groups in week 8 changes for body weight, body mass index, waist circumference, as well as various measures of lipid particles (p's>0.100). The DXA assessment showed no significant differences between the two groups in week 8 changes for fat mass, lean mass or total mass (p's>0.100).

CONCLUSION: In the present study, adjunctive therapy of intranasal insulin did not seem to improve body metabolism in patients with schizophrenia. The implications for future studies were discussed.

Relapsing polychondritis (RP) is a rare systemic autoimmune disease characterized by episodic, progressive inflammatory destruction of cartilage. It can occur as an overlap syndrome in patients with other rheumatologic conditions. The disease usually follows an indolent relapsing-remitting course, but occasionally it can progress rapidly and even cause death. Although auricular or nasal chondritis or peripheral arthritis without other significant organ involvement are usually treated with low-dose corticosteroids, other more severe disease manifestations may require treatment with high-dose corticosteroids or other immunosuppressive agents. Biological targeted therapies might prove to be effective treatments of this condition.

The popularity of the Internet and online media has led to the increased availability of prescription-strength, skin-lightening products contributing to a rise in their use among people with various skin pigment disorders. These products may contain a wide variety of active ingredients such as heavy metals, hydroquinone, and corticosteroids that can be highly toxic, especially after prolonged application. For decades, there have been case reports of both corticosteroid and heavy metal toxicity related to skin-lightening cream use. We report a case of a child who developed status epilepticus after ingesting a skin-lightening solution containing 2% hydroquinone. The toxicodynamics of hydroquinone and its effects on the central nervous system are discussed.

The first report of spinous follicular lichen nitidus with perifollicular granulomas was by Madhok and Winkelmann in 1988. Since this report, a few cases of follicular or periappendageal lichen nitidus have been described, in a more localized form or without perifollicular granulomas. We describe a 5-year-old girl with the rare generalized spinous follicular variant of lichen nitidus with perifollicular granulomas.

We report experiments on the connection between nucleolar stress and cell cycle progression, using HeLa cells engineered with the fluorescent ubiquitinylation-based cell cycle indicator. Nucleolar stress elicited by brief exposure of cells to a low concentration of actinomycin D that selectively inhibits rRNA synthesis had no effect on traverse of G1 or S, but stalled cells in very late interphase. Additional experiments revealed that a switch occurs during a specific temporal window during nucleolar stress and that the subsequent cell cycle arrest is not triggered simply by the stress-induced decline in the synthesis of rRNA or by a ribosome starvation phenomenon.

Further experiments revealed that this nucleolus stress-induced cell cycle arrest involves the action of a G2 checkpoint mediated by the ataxia telangiectasia and Rad3-related protein (ATR)-checkpoint kinase 1 (Chk1) pathway.

Based on analysis of the cell cycle stages at which this nucleolar stress effect is put into action, to become manifest later, our results demonstrate a feedforward mechanism that leads to G2 arrest and identify ATR and Chk1 as molecular agents of the requisite checkpoint.

OBJECTIVE:: To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality.

METHODS:: We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use.

RESULTS:: Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures.

CONCLUSIONS:: The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations. LEVEL OF EVIDENCE:: II.

The centromeric histone H3 variant (CenH3) is essential for chromosome segregation in eukaryotes. We have identified posttranslational modifications of S. cerevisiae CenH3, Cse4. Functional characterization of cse4 phosphorylation mutants showed growth and chromosome segregation defects when combined with kinetochore mutants okp1 and ame1. Using a phosphoserine-specific antibody we showed that the association of phosphorylated Cse4 with centromeres is increased in response to defective microtubule attachment or reduced cohesion. We determined that evolutionarily conserved Ipl1/Aurora B contributes to phosphorylation of Cse4, as levels of phosphorylated Cse4 were reduced at centromeres in ipl1 strains in vivo and in vitro assays showed phosphorylation of Cse4 by Ipl1. Consistent with these results we observed that a phosphomimetic cse4-4SD mutant suppressed the temperature sensitive growth of ipl1-2 and Ipl1 substrate mutants dam1 spc34 and ndc80 that are defective for chromosome biorientation. Furthermore, cell biology approaches using a GFP labeled chromosome showed that cse4-4SD suppressed chromosome segregation defects in dam1 spc34 strains. Based these results we propose that phosphorylation of Cse4 destabilizes defective kinetochores to promote biorientation and ensure faithful chromosome segregation. Taken together, our study provides a detailed analysis, in vivo and in vitro, of Cse4 phosphorylation and its role in promoting faithful chromosome segregation.