Social value,clinical equipoise,and research in a public health emergency

The 2016 CIOMS International ethical guidelines for health‐related research involving humans states that ‘health‐related research should form an integral part of disaster response’ and that, ‘widespread emergency use [of unproven interventions] with inadequate data collection about patient outcomes must therefore be avoided’ (Guideline 20). This position is defended against two lines of criticism that emerged during the 2014 Ebola outbreak. One holds that desperately ill patients have a moral right to try unvalidated medical interventions (UMIs) and that it is therefore unethical to restrict access to UMIs to the clinical trial context. The second holds that clinical trials in contexts of high‐mortality diseases are morally suspect because equipoise does not exist between a standard of care that offers little prospect of clinical benefit and a UMI that might offer some clinical advantage.     

CASANOVA: Permutation inference in factorial survival designs

We propose inference procedures for general factorial designs with time-to-event endpoints. Similar to additive Aalen models, null hypotheses are formulated in terms of cumulative hazards. Deviations are measured in terms of quadratic forms in Nelson–Aalen-type integrals. Different from existing approaches, this allows to work without restrictive model assumptions as proportional hazards. In particular, crossing survival or hazard curves can be detected without a significant loss of power. For a distribution-free application of the method, a permutation strategy is suggested. The resulting procedures' asymptotic validity is proven and small sample performances are analyzed in extensive simulations. The analysis of a data set on asthma illustrates the applicability.     

Analysis of maternal-zygotic ugdh mutants reveals divergent roles for HSPGs in vertebrate embryogenesis and provides new insight into the initiation of left–right asymmetry

Growth factors and morphogens regulate embryonic patterning, cell fate specification, cell migration, and morphogenesis. The activity and behavior of these signaling molecules are regulated in the extracellular space through interactions with proteoglycans (Bernfield et al., 1999, Perrimon and Bernfield, 2000, Lander and Selleck, 2000 and Selleck, 2000). Proteoglycans are high molecular-weight proteins consisting of a core protein with covalently linked glycosaminoglycan (GAG) side chains, which are thought to mediate ligand interaction. Drosophila mutant embryos deficient for UDP-glucose dehydrogenase activity (Ugdh, required for GAG synthesis) exhibit abnormal Fgf, Wnt and TGFß signaling and die during gastrulation, indicating a broad and critical role for proteoglycans during early embryonic development (Lin et al., 1999 and Lin and Perrimon, 2000) (Hacker et al., 1997). Mouse Ugdh mutants also die at gastrulation, however, only Fgf signaling appears disrupted ( Garcia-Garcia and Anderson, 2003). These findings suggested a possible divergence in the requirement for proteoglycans during Drosophila and mouse embryogenesis, and that mammals may have evolved alternative means of regulating Wnt and TGFß activity. To further examine the function of proteoglycans in vertebrate development, we have characterized zebrafish mutants devoid of both maternal and zygotic Ugdh/Jekyll activity (MZjekyll). We demonstrate that MZjekyll mutant embryos display abnormal Fgf, Shh, and Wnt signaling activities, with concomitant defects in central nervous system patterning, cardiac ventricular fate specification and axial morphogenesis. Furthermore, we uncover a novel role for proteoglycans in left–right pattern formation. Our findings resolve longstanding questions into the evolutionary conservation of Ugdh function and provide new mechanistic insights into the initiation of left–right asymmetry.     

A Novel Scoring System for the Risk of Papillary Thyroid Cancer Metastases in Lymph Nodes Posterior to the Right of the Recurrent Laryngeal Nerve

ObjectiveSome surgeons believe that dissection posterior to the right recurrent laryngeal nerve lymph node (PRRLN-LN) is unnecessary for the low metastasis rate and high complication risk. However, persistent metastatic lymph nodes may have a higher recurrence rate, surgical risk, and complications. Thus, it is important to distinguish patients who require PRRLN-LN dissection. To identify the risk factors for lymph nodes posterior to the right recurrent laryngeal nerve metastasis (LN-prRLN) and establish a scoring system to help determine whether PRRLN-LN dissection is required in patients with papillary thyroid carcinoma.Methods821 participants were randomly allocated to the development and validation cohorts in a 2:1 ratio. A nomogram-based predictive model for LN-prRLN was established based on the risk factors identified in the development cohort.ResultsLN-prRLN was diagnosed pathologically in 124 of 821 patients (15.1%) from the entire cohort. Multivariate analysis identified age (odds ratio [OR], 0.964; 95% CI, 0.945-0.983; P < .001), tumor size (OR, 1.536; 95% CI, 1.135-2.079; P = .005), extrathyroidal extension (OR 2.271, 95% CI, 1.368-3.770; P = .002), clinically involved right central compartment lymph node metastasis (OR 1.643, 95% CI, 1.055-2.559; P = .028), and right lateral lymph node metastasis (OR 4.271, 95% CI, 2.325-7.844; P < .001) as the predictors of LN-prRLN. A risk model was established and well validated. Calibration curves to evaluate the nomogram in both the development and validation cohorts revealed a concordance index of 0.756 ± 0.058 and 0.745 ± 0.042, respectively.ConclusionOur scoring system may be useful for helping the surgeons decide which patients should undergo the dissection of PRRLN-LN.     

Two new Raabena species and a new Pararaabena species (Ciliophora,Entodiniomorphida) with redescriptions of Raabena bella and Pararaabena dentata

The genera Raabena and Pararaabena (Ciliophora, Entodiniomorphida, Blepharocorythidae) were monospecific, and their type species are Raabena bella Wolska, 1967 and Pararaabena dentata Wolska, 1968. They have been found in Asian elephants and closely resemble each other: ovoid and laterally compressed body; non-retractable adoral ciliary zone; funnel-shaped vestibulum; three non-retractable somatic ciliary arches. Furthermore, the positional relationship between the vestibular ciliary zone and the anterior dorsal ciliary zone identifies Raabena and Pararaabena: these two ciliary zones are connected in Raabena while they are separated in Pararaabena. While investigating entodiniomorphid ciliates of Asian elephants, the author often encountered ciliates similar to Raabena bella but with a sinuous body or with a small body and ciliates similar to Pararaabena dentata but with a slender body or with no or two caudal lobes. In this study, their general morphology and infraciliature were compared to R. bella and P. dentata to know whether they are new species or morphological variations in a species. As a result, the present study redescribed R. bella and P. dentata, and described R. sinuosa n. sp., R. bellafilia n. sp., P. gracilis n. sp., and morphotypes of P. dentata.     

Alternating wide complex tachycardia after surgical aortic valve replacement

A 51-year-old male developed recurrent episodes of palpitations and pre-syncope after surgical aortic valve replacement. Electrocardiograms after surgery revealed a wide complex tachycardia with alternating left bundle branch and right bundle branch block morphologies. An electrophysiology study (EPS) demonstrated typical bundle branch reentry ventricular tachycardia (BBRVT) treated successfully with right bundle ablation. We demonstrate the key diagnostic features of BBRVT on EPS, describe the circuit of BBRVT with explanation of the HV pseudointerval, and highlight the association of BBRVT and valve replacement.     

Is there spatial segregation between reproductive groups of southern right whales along the coastline of southern Brazil?

Santa Catarina State, in southern Brazil, is an important breeding ground for the southern right whale and it is possible to record mother-calf pairs and unaccompanied adults that migrate to this coast to either give birth, mate, or socialize. From the geographical position of the sightings, spatial segregation was evaluated between mother-calf pairs and unaccompanied whales. Using GAM, we analyzed 15 years of aerial survey data from 2003 to 2018. The study area (780 km²) was divided into 500 × 500 m grid cells. Whale count per grid cell was modeled using a set of explanatory variables. The explanatory variables of latitude, coast distance, seabed, and maximum SST were selected for both classes. However, coast type was also selected for unaccompanied whales, while coast linearity and bathymetric slope were additionally selected for mother-calf pairs. The response curves fitted by models indicated a certain degree of spatial segregation, by which mother-calf pairs remained closer to the coast, where the curve peak is reached at 500 m from the coast, compared to unaccompanied whales where the curve peaked near 1,000 m from the coast. Also, unaccompanied whales more frequently appeared in the southern boundaries of the study area, at latitudes south from 28.4°S.     

Intracerebroventricular Glucocorticoid Infusion in Normal Rats: Induction of Parasympathetic‐Mediated Obesity and Insulin Resistance

Objective: The aims of the present study were to determine whether increased body weight resulting from intracerebroventricular (ICV) glucocorticoid (dexamethasone) infusion in normal rats is associated, as in obesity, with changes in glucose metabolism and to investigate whether the parasympathetic nervous system is involved in the glucocorticoid‐induced effects. Research Methods and Procedures: Male Sprague–Dawley rats were infused with ICV dexamethasone (2.5 μg/d) or its vehicle for 2 days during which food intake, body weight, and basal insulinemia were measured. Euglycemic–hyperinsulinemic clamps associated with the labeled 2‐deoxyglucose technique were then performed to determine the total rate of glucose disappearance and the tissue glucose use indices. Similar experiments were carried out in vagotomized rats. Results: Two days of ICV glucocorticoid infusion in normal rats resulted in increases in food intake, body weight, basal insulinemia, and produced decreases in the insulin‐stimulated total rate of glucose disappearance, as well as in glucose use indices of all muscle types studied. None of these alterations was observed when glucocorticoid infusion was carried out in vagotomized rats. Discussion: These data show that central glucocorticoid infusion favors anabolic processes, such as feeding behavior, body weight gain, and insulin output, while promoting muscle insulin resistance. These effects seem to be mediated by an activation of the parasympathetic nervous system, because they all disappear when tested in vagotomized rats.