Antimicrobial Drug Prescribing for Pneumonia in Ambulatory Care

Higher levels of fluoroquinolone use were associated with increasing age and later study year

Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial.

BACKGROUND: Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes. METHODS: In this multicentre, open-label, randomised controlled trial, we recruited women aged 18-40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA1c). The primary outcome was change in HbA1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527. FINDINGS: Between March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA1c in pregnant women using CGM (mean difference -0·19%; 95% CI -0·34 to -0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most common adverse events were skin reactions occurring in 49 (48%) of 103 CGM participants and eight (8%) of 104 control participants during pregnancy and in 23 (44%) of 52 CGM participants and five (9%) of 57 control participants in the planning pregnancy trial. The most common serious adverse events were gastrointestinal (nausea and vomiting in four participants during pregnancy and three participants planning pregnancy). INTERPRETATION: Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use. FUNDING: Juvenile Diabetes Research Foundation, Canadian Clinical Trials Network, and National Institute for Health Research

A History of Discrete Event Simulation Programming Languages

The history of simulation programming languages is organized as a progression in periods of similar developments. The five periods, spanning 1955-1986, are labeled: The Period of Search (1955-1960); The Advent (1961-1965); The Formative Period (1966-1970); The Expansional Period (1971-1978); and The Period of Consolidation and Regeneration (1979-1986). The focus is on recognizing the people and places that have made important contributions in addition to the nature of the contribution. A balance between comprehensive and in-depth treatment has been reached by providing more detailed description of those languages which have or have had major use. Over 30 languages are mentioned, and numerous variations are described in the major contributors. A concluding summary notes the concepts and techniques either originating with simulation programming languages or given significant visibility by them

Mutations in DONSON disrupt replication fork stability and cause microcephalic dwarfism

To ensure efficient genome duplication, cells have evolved numerous factors that promote unperturbed DNA replication and protect, repair and restart damaged forks. Here we identify downstream neighbor of SON (DONSON) as a novel fork protection factor and report biallelic DONSON mutations in 29 individuals with microcephalic dwarfism. We demonstrate that DONSON is a replisome component that stabilizes forks during genome replication. Loss of DONSON leads to severe replication-associated DNA damage arising from nucleolytic cleavage of stalled replication forks. Furthermore, ATM- and Rad3-related (ATR)-dependent signaling in response to replication stress is impaired in DONSON-deficient cells, resulting in decreased checkpoint activity and the potentiation of chromosomal instability. Hypomorphic mutations in DONSON substantially reduce DONSON protein levels and impair fork stability in cells from patients, consistent with defective DNA replication underlying the disease phenotype. In summary, we have identified mutations in DONSON as a common cause of microcephalic dwarfism and established DONSON as a critical replication fork protein required for mammalian DNA replication and genome stability

Expression of protein kinase A holoenzymes in human myometrium during pregnancy and labour

There is substantial data indicating that components of the cAMP signalling pathway are differentially expressed in the human myometrium during pregnancy. The effects of cAMP in most tissues and cell types are mainly modulated via protein kinase A, a heterotetrameric protein complex consisting of two regulatory (R) and two catalytic (C) subunits. In this thesis Western-blotting/immuno-precipitation, RT-PCR and functional PKA phosphorylation assays. have been used to determine the PKA holoenzymes that are expressed in the human myometrium throughout pregnancy and labour. As early as the second trimester of pregnancy a significant increase in expression of the regulatory RIIct protein subunit of PKA in the myometrium was seen. This increase in protein expression is also mirrored at the mRNA level indicating transcriptional control throughout pregnancy, whereas during parturition both transcript and protein are significantly decreased. This increase in RIIa protein also resulted in increased particulate PKA activity in the myometrium during gestation, which was subsequently decreased during labour. The RIIa subunit is associated with A kinase anchoring proteins thus directing the cAMP quiescence signal to specific sub-cellular loci within myometrial smooth muscle cells including the contractile machinery at the cytoskeleton, this effect is then removed during parturition.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Evidence of Lithospheric Boudinage in the Grand Banks of Newfoundland from Geophysical Observations

The evolution of the passive margin off the coast of Eastern Canada has been characterized by a series of rifting episodes which caused widespread extension of the lithosphere and associated structural anomalies, some with the potential to be classified as a result of lithospheric boudinage. Crustal thinning of competent layers is often apparent in seismic sections, and deeper Moho undulations may appear as repeating elongated anomalies in gravity and magnetic surveys. By comparing the similar evolutions of the Grand Banks and the Norwegian Lofoten-Vesterålen passive margins, it is reasonable to explore the potential of the same structures being present. This investigation supplements our knowledge of analogous examples in the Norwegian Margin and the South China Sea with a thorough investigation of seismic, gravity and magnetic signatures, to determine that boudinage structures are evident in the context of the Grand Banks. Through analysis of geophysical data (including seismic, gravity and magnetic observations), a multi-stage boudinage mechanism is proposed, which is characterized by an upper crust short-wavelength deformation ranging from approximately 20–80 km and a lower crust long-wavelength deformation exceeding 200 km in length. In addition, the boudinage mechanism caused slightly different structures which are apparent in the block geometry and layeredness. Based on these results, there are indications that boudinage wavelength increases with each successive rifting phase, with geometry changing from domino style to a more shearband/symmetrical style as the scale of deformation is increased to include the entire lithosphere