The spread of the Leu-Phe kdr mutation through Anopheles gambiae complex in Burkina Faso: genetic introgression and de novo phenomena

During extensive sampling in Burkina Faso and other African countries, the Leu-Phe mutation producing the kdr pyrethroid resistance phenotype was reported in both Anopheles gambiae ss and A. arabiensis. This mutation was widely distributed at high frequency in the molecular S form of A. gambiae while it has been observed at a very low frequency in both the molecular M form and A. arabiensis in Burkina Faso. While the mutation in the M form is inherited through an introgression from the S form, its occurrence is a new and independent mutation event in A. arabiensis. Three nucleotides in the upstream intron of the kdr mutation differentiated A. arabiensis from A. gambiae ss and these specific nucleotides were associated with kdr mutation in A. arabiensis. Ecological divergences which facilitated the spread of the kdr mutation within the complex of A. gambiae ss in West Africa, are discussed.     

An assessment of the management of acute bleeding varices: a multicenter prospective member-based study

OBJECTIVE: Bleeding from esophagogastric varices is a major complication of portal hypertension. Despite recent practice guidelines for the management of bleeding esophageal or gastric varices, the widespread application of these measures by gastroenterologists has not been evaluated. The purpose of this study was to continue the concept of membership-based research within diverse practice settings by expanding the American College of Gastroenterology (ACG) GI Bleeding Registry to assess the management and outcome of acute variceal bleeding. METHODS: All ACG members (domestic and foreign) were invited to participate during the 1997 Annual Fall meeting and by mail. Data were collected over 12 months. Information obtained included physician training, practice demographics, patient demographics, disease etiology and severity, clinical presentation, medications, transfusion needs, therapy, complications, and rebleeding within 2 wk. RESULTS: A total of 93 physicians/centers (79.6% domestic, 26.9% university and affiliated, 3.2% Veterans Affairs) participated. Complete demographic data were available for 725 of the 741 patients enrolled with index bleeding. The median age of these 725 patients was 52 yr and 73.3% were male. The most common single etiology for portal hypertension was cirrhosis (94.3%). The most common causes of cirrhosis were alcohol (56.7%), hepatitis C virus (30.3%), and hepatitis B virus (10.0%). Hemodynamic instability was noted in 60.7% of the patients (22.3% tachycardic, 9.7% orthostatic, 28.7% hypotensive). Index interventions included banding (40.8%; median five bands), sclerotherapy (36.3%), combination banding/sclerotherapy (6.2%), octreotide (52.6%; median 3 days), balloon tamponade (5.5%), transjugular intrahepatic portosystemic shunt (TIPS) (6.6%), liver transplantation (1.1%), surgical shunt (0.7%), and embolization (0.1%). Transfusion of packed red blood cells, fresh frozen plasma, and platelets was given in 83.4%, 44.7%, and 24.6% of the patients with index bleeding, respectively. Median transfusion was four units of packed red blood cells, three units of fresh frozen plasma, and 1.5 units of platelets. Rebleeding occurred in 92 of the 741 patients (12.6%) at a median of 7 days (mean 11 days) and was treated by banding (18.5%; median six bands), sclerotherapy (30.4%), octreotide (63%; median 2 days), balloon tamponade (17.4%), TIPS (15.2%), and surgical shunt (3.3%). Complications from the index bleeding and rebleeding within 2 wk included ulceration (2.6%, 2.2%), aspiration (2.4%, 3.3%), medication side effects (0.8%, 0%), dysphagia (2.3%, 0%), odynophagia (2.2%,0%), encephalopathy (13%,17.4%), and hepatorenal syndrome (2.4%, 2.2%), respectively. After the index bleeding, 46.2% of patients were treated with beta-blockers and 8.2% with nitrates. The majority of patients with index bleeding had Child's B cirrhosis (61.5%). Patients presenting with recurrent bleeding had mostly Child's B (46.7%) or Child's C cirrhosis (44.6%). The overall short-term mortality after index bleeding was 12.9%. CONCLUSIONS: Acute variceal hemorrhage occurs more often in patients with Child's B and C cirrhosis. Endoscopic banding is the most common single endoscopic intervention. Adjunctive pharmacotherapy is prevalent acutely and after stabilization. Both morbidity and mortality may be lower than reported in previous studies.     

Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest-Pain-Units“

The Chest Pain Unit (CPU) Task Force of the German Cardiac Society has elaborated prerequisites for a CPU certification program. To become a certified CPU, a facility must have 24-h cath lab capabilities, 24-h access to clinical chemistry, at least four intermediate care beds, and the capability for echocardiography, computed tomography (CT), magnetic resonance imaging (MRI) and abdominal ultrasound. The transfer time from the CPU to the cath lab should not exceed 15 minutes. The facility must demonstrate well-defined processes to evaluate moderate- and low-risk patients with chest pain that minimize unnecessary admissions and inappropriate discharges. This means that CPUs must have well-defined pathways when an acute coronary syndrome (ACS) patient arrives at their facility, including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), unstable angina (UA) and low-risk patients. Nurses and doctors in the CPU should have education and training opportunities and undergo practice drills. Doctors should have a sound knowledge of echocardiography and intensive care medicine. The Chest Pain Unit must be headed by a cardiologist.     

Primary prevention of coronary heart disease with aspirin

According to meta-analysis and the results of the two studies with the highest power, aspirin is effective in primary prevention of coronary heart disease. These beneficial effects, however, are at least partially out-weight by unwanted effects-such as intense gastrointestinal bleeding and hemorrhagic stroke. These side effects remain constant with increasing risk of coronary heart disease, whereas the protective effects increase. If an annual risk of coronary heart disease of < or =0.6% exists, aspirin is normally not indicated; for a risk of 0.7-1.4% the facts should be discussed with the patient. If a risk of > or =1.5% exists, aspirin should be given. Problems of aspirin therapy--such as "aspirin paradox" and "aspirin resistance"--have been documented for secondary prevention; they might, however, have likewise clinical implications in primary prevention.     

Effects of pH and Nutrients (Nitrogen) on Growth and Toxin Profile of the Ciguatera-Causing Dinoflagellate Gambierdiscus polynesiensis (Dinophyceae)

Ciguatera poisoning is a foodborne disease caused by the consumption of seafood contaminated with ciguatoxins (CTXs) produced by dinoflagellates in the genera Gambierdiscus and Fukuyoa. Ciguatera outbreaks are expected to increase worldwide with global change, in particular as a function of its main drivers, including changes in sea surface temperature, acidification, and coastal eutrophication. In French Polynesia, G. polynesiensis is regarded as the dominant source of CTXs entering the food web. The effects of pH (8.4, 8.2, and 7.9), Nitrogen:Phosphorus ratios (24N:1P vs. 48N:1P), and nitrogen source (nitrates vs. urea) on growth rate, biomass, CTX levels, and profiles were examined in four clones of G. polynesiensis at different culture age (D10, D21, and D30). Results highlight a decrease in growth rate and cellular biomass at low pH when urea is used as a N source. No significant effect of pH, N:P ratio, and N source on the overall CTX content was observed. Up to ten distinct analogs of Pacific ciguatoxins (P-CTXs) could be detected by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in clone NHA4 grown in urea, at D21. Amounts of more oxidized P-CTX analogs also increased under the lowest pH condition. These data provide interesting leads for the custom production of CTX standards.     

Mesoporous-silica-coated palladium-nanocubes as recyclable nanocatalyst in C–C-coupling reaction – a green approach

We report the straightforward design of a recyclable palladium-core–silica-shell nanocatalyst showing an excellent balance between sufficient stability and permeability. The overall process – design, catalysis and purification – is characterized by its sustainability and simplicity accompanied by a great recycling potential and ultra high yields in C–C-coupling reactions.

A green approach: in a single-step coating process a mesoporous silica shell was tailored onto palladium-nanocubes. Along with a PEG-matrix this core–shell-nanocatalyst could be recovered after C–C-coupling reactions and reused without any significant decrease in product yield.

In contrast to bulk materials, metal-nanocyrstals (NC) possess unique physical and chemical properties. Both, nano-scale and geometry can dictate their optical, electronic and catalytic behavior.^1–3 Consequently, nanomaterials have been implemented already in various fields like medicine,⁴ sensing,⁵ nano-electronics⁶ and organic synthesis.⁷ Smart strategies for a sustainable usage of limited resources such as precious metals and hydrocarbons are inevitable due to the consistently growing population and economy.^8–10 Generally, catalysis gives rise to novel and energy-saving synthetic routes. However, homogeneous catalysis is not widely used in industrial processes, due to the need of mostly toxic ligands and the costly purification along with a restricted reusability potential.^11–13 Heterogeneous catalysis based on the utilization of metal nanocrystals overcomes most of these limitations. Caused by its high surface-to-volume ratio, catalytic activities are drastically increased in comparison to bulk materials. However, the most common disadvantage in NC-based catalysis lies in the occurrence of aggregates during the reaction, which leads to a decrease of the catalytic active surface. Several studies were already presented in literature to delay that phenomenon using micelle-like- or core–shell-nanostructures as potential nanocatalytic systems.^14–20 However, these surfactants or shells are either potentially harmful for the environment or very step-inefficient to produce. Other approaches used the deposition of small NCs in a mesoporous support which offers a large active surface area.^21–24 In this context, it is crucial to find an adequate balance between permeability for small organic molecules and the overall stability of the nanocatalyst. Overcoming these obstacles can contribute to a sustainable supply of drugs and other organic substances.In the present work palladium-nanocubes (Pd-NCubes) were fabricated in aqueous solution using cetyltrimethyl-ammoniumbromide (CTAB) as surfactant. The procedure is adapted from a previously published study.^25,26 The respective transmission electron microscopy (TEM) image and the selected area electron diffraction (SAED) pattern of the as-obtained Pd-NCubes are depicted in Fig. S1.^† The SAED confirms the single-crystallinity of Pd-NCubes bound by {100}-facets. TE micrographs of Pd-NCubes revealed an average edge-length of (18 ± 2) nm (for histogram see Fig. S2^†). The formation of polyhedra and nanorods was found to be less than 1%.To the best of our knowledge, there is no procedure reported that showed the direct fabrication of a mesoporous silica (mSi) shell tailored on Pd-NCs. However, Matsuura et al. demonstrated a single-step coating approach of CTAB-capped gold-nanorods and CdSe/ZnS quantum dots obtaining a mesoporous silica shell.²⁷ The pores were determined to be 4 nm in width with 2 nm thick walls. Since the Pd-NCubes are covered by CTAB, already no surfactant exchange is necessary. Consequently, this procedure could be directly transferred to the as-obtained Pd-NCubes (∼10¹⁵ particles per L) of this study using tetraethyl orthosilicate (TEOS) as silica precursor in an alkaline solution. Here, CTAB serves as organic template for the formation of the mesoporous silica shell.TE micrographs of individual Pd-mSi-nanohybrids are depicted in Fig. 1 showing a spherical silica coating with a thickness of (17 ± 2) nm (for histogram see Fig. S3^†). The porosity is essential to ensure that vacant coordination sites on the palladium-core are present and accessible for catalysis. In contrast to other multistep approaches, pores are formed in situ with no additional etching step necessary.^28,29 This avoids the usage of harmful etching agents such as fluorides or ammonia.³⁰ The silica shell then served as platform for further surface modification using two different PEG-silanes (M_n = 5000 g mol⁻¹ and M_n = 20 000 g mol⁻¹). TE microscopy did not reveal any changes in the structure of the PEG functionalized Pd-mSi-nanohybrids opposed to the unfunctionalized nanocatalyst, since the contrast of polymer is too low (see Fig. S4^†). However, dynamic light scattering (DLS) measurements in diluted aqueous solutions proved an increased hydrodynamic radius with increasing molecular weight of the PEG-chain grafted onto the silica shell (see Fig. 2). These results provide evidence that only individual nanostructures are formed while no larger aggregates are present.Open in a separate windowFig. 1Exemplary TE micrographs of Pd-mSi-nanohybrids.Open in a separate windowFig. 2DLS results along the different stages of the hierarchal fabrication process of the nanocatalyst.The successful functionalization of the Pd-mSi-nanohybrid with PEG provides the dispersibility for the overall nanocatalyst in a PEG matrix. Due to its lack of toxicity and its simple recovery, caused by its melting point at ∼50 °C, PEG is considered as a “green” reaction medium.³¹ It has already been shown that PEG can act as suitable solvent for both homogeneous and heterogeneous catalysis.^32–34 Consequently, further experiments were performed using only the Pd-mSi-nanohybrid functionalized with PEG-silane having an average molecular weight of M_n = 5000 g mol⁻¹ (PEG-5k). For catalytic reactions, Pd-mSi-PEG-5k was dispersed in a PEG matrix (PEG-2000, M_n = 2000 g mol⁻¹) and charged into a Teflon centrifuge tube. Using only one tube for the reaction and the product separation avoids an additional transfer step and prevents any loss of the nanocatalyst between reaction cycles (see recycling Scheme 1). Here, the C–C-coupling between ethyl acrylate and p-iodoanisole served as model Heck-reaction to prove the catalytic activity of the designed catalyst (4.4 mol% overall Pd conc. equal to ca. 0.3 mol% surface-available Pd; conc. is determined by ICP-MS measurements, see Table S1^†). Sodium phosphate was used as base providing the largest product yield when compared to other bases, such as Na₂CO₃, K₂CO₃ and K₃PO₄. Once the catalysis was performed and the PEG-2000 was cooled down, diethyl ether was added to extract the product and separated from the reaction medium via centrifugation.Open in a separate windowScheme 1Recycling process of the Pd-mSi-PEG-5k-nanocatalyst and PEG-2000 as solvent after the Heck-reaction between ethyl acrylate and p-iodoanisole to form ethyl p-methoxycinnamate.To exclude any suspended compounds from the desired product, the mixture was passed through a PTFE-filter. Et₂O was removed in vacuo without the need of column chromatography. Comparing the ¹H-NMR spectra of the as-obtained product with the educts indicate a yield of 98% with only small amounts of PEG-2000 present (identified by the signal at ∼3.6 ppm, < 1 weight-%). The results show that both educts and the base Na₃PO₄ are able to diffuse through the mesoporous silica shell to the palladium core (see Fig. 3). A detailed ¹H-NMR signal assignment of the product is given in Fig. S5.^†Open in a separate windowFig. 3 ¹H-NMR spectra of the educts ethyl acrylate (top) and p-iodoanisole (center) and the product ethyl p-methoxycinnamate (bottom).After recovering the reaction mixture containing Pd-mSi-PEG-5k and PEG-2000, seven further Heck-reaction-cycles were conducted under the same conditions. Results obtained from ¹H-NMR and gravimetry indicate no significant decrease in catalytic activity (see ¹H-NMR spectra in Fig. 4). Along the eight Heck-reactions, product yields were determined between 94% and 99%. Only small traces of p-iodoanisole (identified by the signal at ∼6.75 ppm) were still present while ethyl acrylate could be fully removed in vacuo. The yields obtained after each cycle are displayed in Fig. 5. ICP-MS measurements of the catalysis product were performed to determine the palladium leaching out of the catalytic system. The results are displayed in Table S1^† indicating that leaching is strongly suppressed since the overall Pd-content in the product ranges from 0.3–5.7 ng, only. This corresponds to 0.002–0.044 ppm palladium with respect to the product mass. The data are in good agreement with the high product yields along the eight Heck-reactions. To trace the evolution of the nanocatalyst along the cycles, TE micrographs were taken after the 1^st and the 8^th Heck-cycle (see Fig. 6). It can be seen that the cubical structure of the palladium vanishes during the first reaction (left TEM image). Inside the silica shell spherical palladium particles were formed. An explanation for this rearrangement lies in the suggested Heck-mechanism.³⁵ Here, a Pd²⁺-species forms after the oxidative addition of the p-iodoanisole which can desorb from the Pd-NCube. Once the reductive elimination of the product occurs the Pd⁰-species is generated again that can re-deposit on the palladium-core.²¹ Since the spherical geometry possesses the lowest free surface energy, globules were eventually formed.³ The mesoporous silica shell is not affected significantly by the catalysis and the rearrangement of the palladium. The porosity appears to stay intact, enabling the penetration of further small organic molecules. Control experiments were performed to validate whether these observations are based on either a thermally or a chemically induced rearrangement process of the palladium core. Therefore, only the nanocatalyst was dispersed in PEG-2000 and heated at 110 °C for 24 h without any conducted catalysis reaction. TEM results showed no changes in the structure of neither the palladium core nor the silica shell (see Fig. S6^†). After the 8^th reaction, no core–shell-nanostructures could be detected anymore via TEM. Only small randomly shaped Pd-nanoparticles (≤20 nm) were found indicating a slow leaching of the palladium out of the silica shell. However, no larger aggregates were formed (see right TE micrograph in Fig. 6) which explains the continuously high catalytic activity.Open in a separate windowFig. 4 ¹H-NMR spectra of the product ethyl p-methoxycinnamate after the 1^st Heck-reaction (bottom) up to the 8^th reaction (top).Open in a separate windowFig. 5Conversions of ethyl p-methoxycinnamate obtained via NMR and gravimetry after each respective Heck-reaction (1–8).Open in a separate windowFig. 6TE micrographs of the Pd-mSi-PEG-5k-nanocatalyst taken after the 1^st (left) and the 8^th Heck-reaction (right).     

Educational Impact on Apixaban Adherence in Atrial Fibrillation (the AEGEAN STUDY): A Randomized Clinical Trial

Adherence to non-vitamin-K oral anticoagulants (NOACs) may be lower than to vitamin K antagonists because NOACs do not require routine monitoring. We assessed the impact of an educational program on adherence and persistence with apixaban in patients with non-valvular atrial fibrillation (NVAF). Patients with NVAF eligible for NOACs with one or more stroke risk factor (prior stroke/transient ischemic attack, age ≥ 75 years, hypertension, diabetes, or symptomatic heart failure) were randomized (1:1) to standard of care (SOC) or SOC with additional educational (information booklet, reminder tools, virtual clinic access). The primary outcome was adherence to apixaban (2.5 or 5 mg twice daily) at 24 weeks. Patients receiving the educational program were re-randomized (1:1) to continue the program for 24 further weeks or to switch to secondary SOC. Implementation adherence and persistence were reassessed at 48 weeks. In total, 1162 patients were randomized (SOC, 583; educational program, 579). Mean implementation adherence ± standard deviation (SD) at 24 weeks was 91.6% ± 17.1 for SOC and 91.9% ± 16.1 for the educational program arm; results did not differ significantly between groups at any time-point. At 48 weeks, implementation adherence was 90.4% ± 18.0, 90.1% ± 18.6, and 89.3% ± 18.1 for continued educational program, SOC, and secondary SOC, respectively; and corresponding persistence was 86.1% (95% confidence interval [CI] 81.3–89.7), 85.2% (95% CI 81.5–88.2), and 87.8% (95% CI 83.4–91.1). Serious adverse events were similar across groups. High implementation adherence and persistence with apixaban were observed in patients with NVAF receiving apixaban. The educational program did not show additional benefits. This study is registered at ClinicalTrials.gov [NCT01884350].     

Repeat liver resection for recurrent colorectal metastases: a single-centre, 13-year experience

Objectives: Isolated intrahepatic recurrence is noted in up to 40% of patients following curative liver resection for colorectal liver metastases (CLM). The aims of this study were to analyse the outcomes of repeat hepatectomy for recurrent CLM and to identify factors predicting survival.Methods: Data for all liver resections for CLM carried out at one centre between 1998 and 2011 were analysed.Results: A total of 1027 liver resections were performed for CLM. Of these, 58 were repeat liver resections performed in 53 patients. Median time intervals were 10.5 months between the primary resection and first hepatectomy, and 15.4 months between the first and repeat hepatectomies. The median tumour size was 3.0 cm and the median number of tumours was one. Six patients had a positive margin (R1) resection following first hepatectomy. There were no perioperative deaths. Significant complications included transient liver dysfunction in one and bile leak in two patients. Rates of 1-, 3-and 5-year overall survival following repeat liver resection were 85%, 61% and 52%, respectively, at a median follow-up of 23 months. R1 resection at first hepatectomy (P = 0.002), a shorter time interval between the first and second hepatectomies (P = 0.02) and the presence of extrahepatic disease (P = 0.02) were associated with significantly worse overall survival.Conclusions: Repeat resection of CLM is safe and can achieve longterm survival in carefully selected patients. A preoperative knowledge of poor prognostic factors helps to facilitate better patient selection.