University of Kansas Medical Center

In 2008 we published the first set of guidelines for standardizing research in autophagy. Since then, research on this topic has continued to accelerate, and many new scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Accordingly, it is important to update these guidelines for monitoring autophagy in different organisms. Various reviews have described the range of assays that have been used for this purpose. Nevertheless, there continues to be confusion regarding acceptable methods to measure autophagy, especially in multicellular eukaryotes. For example, a key point that needs to be emphasized is thatthere is a difference between measurements that monitor the numbers or volume of autophagic elements (e.g., autophagosomes or autolysosomes) at any stage of the autophagic process versus those that measure flux through the autophagy pathway (i.e., the completeprocess including the amount and rate of cargo sequestered and degraded). In particular, a block in macroautophagy that results in autophagosome accumulation must be differentiated from stimuli that increase autophagic activity, defined as increasedautophagy induction coupled with increased delivery to, and degradation within, lysosomes (inmost higher eukaryotes and some protists such as Dictyostelium) or the vacuole (in plants and fungi). In other words, it is especially important that investigators new to the field understand that the appearance of more autophagosomes does not necessarily equate with more autophagy. In fact, in manycases, autophagosomes accumulate because of a block in trafficking to lysosomes without a concomitant change in autophagosome biogenesis, whereas an increase in autolysosomes may reflect a reduction in degradative activity. It is worth emphasizing here that lysosomal digestion is a stage of autophagy and evaluating its competence is a crucial part of the evaluation of autophagic flux, or complete autophagy. Here, we present a set of guidelines for the selection and interpretation of methods for use by investigators who aim to examine macroautophagy and related processes, as well as forreviewers who need to provide realistic and reasonable critiques of papers that are focused on these processes. These guidelines are not meant to be a formulaic set of rules, because the appropriate assays depend in part on the question being asked and the system being used. In addition, we emphasize that no individual assay is guaranteed to be the most appropriate one in every situation, and we strongly recommend the use of multipleassays to monitor autophagy. Along these lines, because of the potential for pleiotropic effects due to blocking autophagy through genetic manipulation, it is imperative to target by gene knockout or RNA interference more than one autophagyrelated protein. In addition, some individual Atg proteins, or groups of proteins, are involved in other cellular pathways implying that not all Atg proteins can be used as a specific marker for an autophagic process. In these guidelines, we consider these various methods of assessing autophagy and what information can, or cannot, be obtained from them. Finally, by discussing the merits and limits of particular assays, we hope to encourage technical innovation in the field.

BACKGROUND: The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy. METHODS: We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days. RESULTS: A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P=0.50), nor did 90-day mortality (19% and 18%, respectively; P=1.00). CONCLUSIONS: Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283 .).

The timely breakdown of extracellular matrix (ECM)1 is essential for embryonic development, morphogenesis, reproduction, and tissue resorption and remodeling. The matrix metalloproteinases (MMPs), also called matrixins, are thought to play a central role in these processes. The expression of most matrixins is transcriptionally regulated by growth factors, hormones, cytokines, and cellular transformation (1, 2). The proteolytic activities of MMPs are precisely controlled during activation from their precursors and inhibition by endogenous inhibitors, α-macroglobulins, and tissue inhibitors of metalloproteinases (TIMPs).

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

A symptom index for benign prostatic hyperplasia (BPH) was developed and validated by a multidisciplinary measurement committee of the American Urological Association (AUA). Validation studies were conducted involving a total of 210 BPH patients and 108 control subjects. The final AUA symptom index includes 7 questions covering frequency, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying and urgency. On revalidation, the index was internally consistent (Cronbach's alpha = 0.86) and the score generated had excellent test-retest reliability (r = 0.92). Scores were highly correlated with subjects' global ratings of the magnitude of their urinary problem (r = 0.65 to 0.72) and powerfully discriminated between BPH and control subjects (receiver operating characteristic area 0.85). Finally, the index was sensitive to change, with preoperative scores decreasing from a mean of 17.6 to 7.1 by 4 weeks after prostatectomy (p < 0.001). The AUA symptom index is clinically sensible, reliable, valid and responsive. It is practical for use in practice and for inclusion in research protocols.

Since its initial release in 2000, the human reference genome has covered only the euchromatic fraction of the genome, leaving important heterochromatic regions unfinished. Addressing the remaining 8% of the genome, the Telomere-to-Telomere (T2T) Consortium presents a complete 3.055 billion-base pair sequence of a human genome, T2T-CHM13, that includes gapless assemblies for all chromosomes except Y, corrects errors in the prior references, and introduces nearly 200 million base pairs of sequence containing 1956 gene predictions, 99 of which are predicted to be protein coding. The completed regions include all centromeric satellite arrays, recent segmental duplications, and the short arms of all five acrocentric chromosomes, unlocking these complex regions of the genome to variational and functional studies.

BACKGROUND: Although it has been demonstrated that physical performance measures predict incident disability in previously nondisabled older persons, the available data have not been fully developed to create usable methods for determining risk profiles in community-dwelling populations. Using several populations and different follow-up periods, this study replicates previous findings by using the Established Populations for the Epidemiologic Study of the Elderly (EPESE) performance battery and provides equations for the prediction of disability risk according to age, sex, and level of performance. METHODS: Tests of balance, time to walk 8 ft, and time to rise from a chair 5 times were administered to 4,588 initially nondisabled persons in the four sites of the EPESE and to 1,946 initially nondisabled persons in the Hispanic EPESE. Follow-up assessment for activity of daily living (ADL) and mobility-related disability occurred from 1 to 6 years later. RESULTS: In the EPESE, compared with those with the best performance (EPESE summary performance score of 10-12), the relative risks of mobility-related disability for those with scores of 4-6 ranged from 2.9 to 4.9 and the relative risk of disability for those with scores of 7-9 ranged from 1.5 to 2.1, with similar consistent results for ADL disability. The observed rates of incident disability according to performance level in the Hispanic EPESE agreed closely with rates predicted from models developed from the EPESE sites. Receiver operating characteristic curves showed that gait speed alone performed almost as well as the full battery in predicting incident disability. CONCLUSIONS: Performance tests of lower extremity function accurately predict disability across diverse populations. Equations derived from models using both the summary score and the gait speed alone allow for the estimation of risk of disability in community-dwelling populations and provide valuable information for estimating sample size for clinical trials of disability prevention.

INTRODUCTION Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (1). Sepsis and septic shock are major healthcare problems, impacting millions of people around the world each year and killing between one in three and one in six of those it affects (2–4). Early identification and appropriate management in the initial hours after the development of sepsis improve outcomes. The recommendations in this document are intended to provide guidance for the clinician caring for adult patients with sepsis or septic shock in the hospital setting. Recommendations from these guidelines cannot replace the clinician’s decision-making capability when presented with a unique patient’s clinical variables. These guidelines are intended to reflect best practice (Table 1). TABLE 1. - Table of Current Recommendations and Changes From Previous 2016 Recommendations Recommendations 2021 Recommendation Strength and Quality of Evidence Changes From 2016 Recommendations 1. For hospitals and health systems, we recommend using a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment. Strong , moderate-quality evidence (for screening) Changed from Best practice statement “We recommend that hospitals and hospital systems have a performance improvement program for sepsis including sepsis screening for acutely ill, high-risk patients.” Strong , very low-quality evidence (for standard operating procedures) 2. We recommend against using qSOFA compared with SIRS, NEWS, or MEWS as a single-screening tool for sepsis or septic shock. Strong , moderate-quality evidence NEW 3. For adults suspected of having sepsis, we suggest measuring blood lactate. Weak , low quality of evidence INITIAL RESUSCITATION 4. Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately. Best practice statement 5. For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hr of resuscitation. Weak, low quality of evidence DOWNGRADE from Strong , low quality of evidence “We recommend that in the initial resuscitation from sepsis-induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hr” 6. For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation, over physical examination, or static parameters alone. Weak , very low quality of evidence 7. For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate. Weak , low quality of evidence 8. For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion. Weak , low quality of evidence NEW MEAN ARTERIAL PRESSURE 9. For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets. Strong , moderate-quality evidence ADMISSION TO INTENSIVE CARE 10. For adults with sepsis or septic shock who require we suggest the patients to the within Weak , low quality of evidence For adults with suspected sepsis or septic shock we recommend and for and an of is or Best practice statement For adults with septic shock or a for sepsis, we recommend within hr of Strong , low quality of evidence from “We recommend that of should be as as after and within one for septic shock and sepsis Strong , very low quality of evidence , quality of evidence For adults with sepsis shock, we recommend of the of of Best practice statement For adults with sepsis shock, we suggest a of and for infection the of within 3 hr from the time when sepsis first Weak , very low quality of evidence NEW from “We recommend that of IV should be as as after and within hr for septic shock and sepsis , quality of evidence For adults with a low of infection and shock, we suggest to the Weak , very low quality of evidence NEW from “We recommend that of IV should be as as after and within hr for septic shock and sepsis , quality of evidence For adults with suspected sepsis or septic shock, we suggest against using clinical to when to as compared to clinical alone. Weak , very low quality of evidence For adults with sepsis or septic shock at of we recommend using with over using Best practice statement NEW from “We recommend with one or for patients with sepsis or septic shock to and or Strong , quality of evidence For adults with sepsis or septic shock at low of we suggest against using with as compared with using Weak , low quality of evidence NEW from “We recommend with one or for patients with sepsis or septic shock to and or Strong , quality of evidence For adults with sepsis or septic shock and for we suggest using with for treatment over one Weak , very low quality of evidence For adults with sepsis or septic shock and low for we suggest against using for as compared to one Weak , very low quality of evidence For adults with sepsis or septic shock, we suggest against using the and the are Weak , very low quality of evidence For adults with sepsis or septic shock at of we suggest using over Weak , low quality of evidence NEW from “We recommend with one or for patients with sepsis or septic shock to and or Strong , quality of evidence For adults with sepsis or septic shock at low of we suggest against of Weak , low quality of evidence NEW from “We recommend with one or for patients with sepsis or septic shock to and or Strong , quality of evidence We on the of For adults with sepsis or septic shock, we suggest using of for an initial over Weak , moderate-quality evidence For adults with sepsis or septic shock, we recommend of on and Best practice statement For adults with sepsis or septic shock, we recommend or a of infection that and as as and Best practice statement For adults with sepsis or septic shock, we recommend of that are a of sepsis or septic shock after other Best practice statement For adults with sepsis or septic shock, we suggest for of over using of for Weak , very low quality of evidence For adults with an initial of sepsis or septic shock and we suggest using over of Weak , very low quality of evidence For adults with an initial of sepsis or septic shock and of is we suggest using clinical to when to over clinical alone. Weak , low quality of evidence For adults with sepsis or septic shock, we recommend using as fluid for resuscitation. Strong , moderate-quality evidence For adults with sepsis or septic shock, we suggest using of for resuscitation. Weak , low quality of evidence from , low quality of “We suggest using or for fluid resuscitation of patients with sepsis or septic For adults with sepsis or septic shock, we suggest using in patients who of Weak , moderate-quality evidence For adults with sepsis or septic shock, we recommend against using for resuscitation. Strong , evidence For adults with sepsis and septic shock, we suggest against using for resuscitation. Weak , moderate-quality evidence from , low quality of evidence “We suggest using over when patients with sepsis or septic For adults with septic shock, we recommend using as the over other Strong evidence evidence quality of evidence quality of evidence low-quality evidence For adults with septic shock on with mean arterial pressure we suggest of the of Weak , quality evidence For adults with septic shock and mean arterial pressure and we suggest Weak , low quality of evidence For adults with septic shock, we suggest against using Weak , low quality of evidence For adults with septic shock and dysfunction with hypoperfusion and arterial blood we suggest to or using alone. Weak , low quality of evidence For adults with septic shock and dysfunction with hypoperfusion and arterial blood we suggest against using Weak , low quality of evidence NEW For adults with septic shock, we suggest of arterial blood pressure over as as and are Weak , very low quality of evidence For adults with septic shock, we suggest to mean arterial pressure a is Weak , very low quality of evidence NEW is evidence to a on the of fluid in the first hr of resuscitation in patients with sepsis and septic shock who have of hypoperfusion and after the initial resuscitation. NEW “We suggest using or for fluid resuscitation of patients with sepsis or septic Weak , low quality of evidence “We suggest using over when patients with sepsis or septic Weak , low quality of evidence is evidence to a on the of in adults with sepsis-induced For adults with sepsis-induced we suggest the of over Weak , low quality of evidence NEW is evidence to a on the of in to for adults with sepsis-induced For adults with sepsis-induced we recommend using a low over a Strong , evidence For adults with sepsis-induced we recommend using an for of 30 over higher Strong , moderate-quality evidence For adults with to sepsis-induced we suggest using higher over Weak , moderate-quality evidence For adults with sepsis-induced we suggest using low as compared with Weak , low quality of evidence For adults with sepsis-induced we suggest using Weak , moderate-quality evidence using we recommend against using Strong , moderate-quality evidence For adults with sepsis-induced we recommend using for hr Strong , moderate-quality evidence For adults with sepsis induced we suggest using over Weak , moderate-quality evidence For adults with sepsis-induced we suggest using when in with the in to Weak , low quality of evidence NEW For adults with septic shock and an for we suggest using IV Weak , moderate-quality evidence from Weak , low quality of evidence “We suggest against using IV to septic shock patients fluid resuscitation and are to for this is not we suggest IV at a of For adults with sepsis or septic shock we suggest against using Weak , low quality of evidence NEW from “We the of blood is evidence to a on the of other blood For adults with sepsis or septic shock we recommend using a Strong , moderate-quality evidence For adults with sepsis or septic shock we suggest against using IV Weak , low quality of evidence For adults with sepsis or septic shock, and who have for we suggest using Weak , moderate-quality evidence For adults with sepsis or septic shock, we recommend using a to Strong , moderate-quality evidence For adults with sepsis or septic shock, we recommend using low over for Strong , moderate-quality evidence For adults with sepsis or septic shock, we suggest against using in to over alone. Weak , low quality of evidence adults with sepsis or septic shock and we suggest using or Weak , low quality of evidence adults with sepsis or septic shock and with for we suggest against using Weak , moderate-quality evidence For adults with sepsis or septic shock, we recommend at a of Strong , moderate-quality evidence For adults with sepsis or septic shock we suggest against using IV Weak , low quality of evidence NEW For adults with septic shock and we suggest against using to improve or to Weak , low quality of evidence For adults with septic shock and and or we suggest using Weak , low quality of evidence For adult patients with sepsis or septic shock who be we suggest of Weak , very low quality of evidence CARE For adults with sepsis or septic shock, we recommend of and with patients and over Best practice statement For adults with sepsis or septic shock, we suggest of over hr or Weak , low quality of evidence For adults with sepsis or septic shock, is evidence to a on to of For adults with sepsis or septic shock, we recommend that the of on clinician be the treatment when to and and Best practice statement For adults with sepsis or septic shock, we suggest against for patients over on clinician Weak , low quality of evidence For adult of sepsis or septic shock and we suggest to over Weak , very low quality of evidence For adults with sepsis or septic shock, we suggest using a of at of over Weak , very low quality of evidence For adults with sepsis or septic shock, is evidence to a on the of tool over For adults with sepsis or septic shock and we recommend screening for and and and to these Best practice statement For adults with sepsis or septic shock and we suggest and sepsis and to hospital and in the setting. Weak , very low quality of evidence For adults with sepsis or septic shock and we recommend the clinical provide the to in in and hospital to are and Best practice statement For adults with sepsis and septic shock and we suggest using a compared with to the Weak , very low quality of evidence For adults with sepsis and septic shock, we recommend at and hospital Best practice statement For adult of sepsis and septic shock and we recommend including the sepsis and and after sepsis in the and hospital Best practice statement For adults with sepsis or septic shock who we recommend hospital with to and and Best practice statement For adults with sepsis or septic shock and is evidence to a on compared with For adults with sepsis or septic shock, is evidence to a for or against For adult of sepsis or septic shock, we recommend and for and after hospital Best practice statement For adult of sepsis or septic shock, we suggest to a program Weak , very low quality of evidence For adult of sepsis or septic shock for or an of we suggest to a Weak , very low quality of evidence are to in the be at for Sepsis and - Recommendation 1. For hospitals and health systems, we recommend using a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment. Strong quality of evidence for Strong very low-quality evidence for standard operating Sepsis performance improvement of sepsis of sepsis and for a of on the of performance improvement that these with to sepsis with a in in patients with sepsis and septic shock The of performance improvement not to be as as the of a program that sepsis screening and Sepsis screening are to identification of sepsis and of or of the health is in of these with having the of with in of clinical and are for sepsis as response of or Early or Early improve performance of screening and in a of patients from for hospital sepsis the the operating and higher for the for screening as MEWS and target patients in as or of three not a of screening is in and of sepsis screening are an of sepsis for operating procedures are a of that a response to clinical Sepsis standard operating as Early have to a standard with of the sepsis and the between of sepsis and of sepsis to hospitals in the in a and after of sepsis with a from other this time in hospitals with higher with the sepsis a of in higher with standard operating procedures compared with it in one - Recommendation 2. We recommend against using qSOFA compared with SIRS, NEWS, or MEWS as a screening tool for sepsis or septic shock. Strong moderate-quality The qSOFA three to and in patients with or suspected a a and a blood pressure mm of these are the is qSOFA to the recommendations of the on the of Sepsis qSOFA as a of in patients with or suspected to as a screening tool that time have the of the qSOFA as a screening tool for sepsis The have as to have that qSOFA is having of for identification of infection induced organ dysfunction qSOFA are screening for sepsis and the clinician to the of the that of patients a qSOFA or these patients for of have when against the Early and the Early the of a qSOFA should the clinician to the of sepsis in given the of the the a against as a screening - Recommendation 3. For adults suspected of having sepsis, we suggest measuring blood lactate. Weak low-quality The of lactate with in patients with suspected infection and sepsis is is as of the sepsis for those patients with sepsis and an elevated lactate is of the of septic shock that lactate be to for the of sepsis adult patients with suspected not have the of lactate in this The lactate an elevated from of the from with from and from the three are and an between the of lactate at and the are the of an elevated or lactate or the of a of sepsis in patients with suspected lactate is to or the on not be in we a the of serum lactate as an to the of sepsis in patients with suspected not - Recommendations 4. Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately. Best practice 5. For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hours of resuscitation. Weak low-quality 6. For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation over physical or static parameters alone. Weak very low-quality parameters response to a or a fluid using pressure or 7. For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate. Weak low-quality resuscitation, serum lactate should be the clinical and other of elevated lactate. 8. For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion. Weak low-quality fluid resuscitation is for the of sepsis-induced hypoperfusion in sepsis and septic shock. Previous guidelines recommend appropriate resuscitation of sepsis or septic shock and having a low for it in those patients sepsis is not is the evidence from this is a best practice and are that a is The 2016 a for using a of 30 mL/kg of IV in initial fluid resuscitation. of initial resuscitation on evidence are for initial resuscitation in sepsis or septic shock. of adults to an with sepsis or septic shock that to 30 mL/kg of crystalloid fluid within 3 hours of sepsis with of of and of in of including and the and the of fluid in the of 30 that this fluid in clinical practice patients require fluid initial resuscitation. to be with the of fluid and with fluid of and of the of septic patients is the for a initial and of the response to treatment. and fluid the initial resuscitation should be by of and organ perfusion. pressure and blood pressure are of fluid measures have at fluid compared with static measures with fluid against pressure or and of in response to in a and dynamic to guide fluid with to of to and of to in one other in between septic patients with a compared with standard from and a of evidence in to guide of fluid resuscitation as as the appropriate in patients with sepsis and in that resuscitation with of IV by and arterial with fluid in the first hours and higher hospital standard fluid the initial 30 mL/kg is by measures of fluid of mL/kg compared to to 3 mL/kg the of fluid and on of of or not be a in pressure that the is fluid a for lactate is an of and is not a of of septic shock in lactate as evidence of to (1). Previous of these guidelines have using lactate as a target of resuscitation in the of sepsis and septic shock, on to and of in serum lactate in with or in The that serum lactate are not in patients with septic shock, these that decrease lactate lactate should be the clinical and other of elevated lactate. with sepsis lactate not be in is not measures of organ be to the and of of the and capillary refill time have and to be of The a resuscitation a resuscitation at or lactate by hours in the first hours of septic shock the organ dysfunction as by in the and in the lactate this not the of a on using resuscitation and is and this should be by and to or fluid are of the or to the should management - Recommendation 9. For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets. Strong moderate-quality MAP is a of mean in is the major of and MAP in blood and the of perfusion. as the and have the to blood a to be mm are with organ with MAP Previous guidelines a MAP of 65 mm Hg for initial resuscitation. The on a in septic shock patients who given to target a MAP of mm a target of mm Hg in a a in with higher MAP patients with higher MAP with with a higher of of this that the MAP in the of on this that higher MAP not improve in septic shock to and MAP target compared a mm with a that and MAP by the in patients 65 and with septic shock The in this a mean MAP of mm compared with mm Hg in the to in the by of and in in the and the of with higher MAP and the of patients with MAP of mm the a MAP of 65 mm Hg in the initial resuscitation of patients with septic shock who require to - Recommendation 10. For adults with sepsis or septic shock who require we suggest the patients to the within Weak low-quality The of patients on of in an appropriate the septic patients are in the and hospital of patients from are with sepsis and and and hospital of on the time for to the from and an of an in of for each of to of patients in the a higher hospital for the higher to time hr and compared with the to time for of an to time hr with hospital in patients with higher of with sepsis not patients to when hours hospital the a hospital higher and higher of and of patients in hospitals in the that to to higher and on of patients to an in outcomes. is evidence of and are best in an are of patients with sepsis to an not be in in and be this and appropriate treatment should not be of of - Recommendation For adults with suspected sepsis or septic shock we recommend and for and an of is or Best practice of these we the of a for to it is to in a a best practice we that appropriate should be in patients with suspected sepsis and septic shock it in in the of not in this as as The and of sepsis are and other is to sepsis, the cannot have a of sepsis in a with organ a or of patients with sepsis to have Best practice is to the to other are or a patient’s clinical after hospital or the of a of this be in when it is to or major is a that to on the that the is each as in and of the that by or in each in of or that the for a in the or a We not or evidence this are to a an that not from is or this is not of the should the of patients and patients that is not to - Recommendations For adults with septic shock or a for sepsis, we recommend within one of Strong low quality of evidence very low quality of evidence For adults with sepsis shock, we recommend of the of of Best practice and clinical examination, for and of and treatment for that this should be within 3 hours of that a be as to the of an of the patient’s and the of sepsis is to be For adults with sepsis shock, we suggest a of and for infection the of within 3 hours from the time when sepsis first Weak very low quality of For adults with a low of infection and shock, we suggest to the Weak very low quality of Early of appropriate is one of the to in patients with sepsis to patients with sepsis or septic shock should be as an The to provide as as be against the with to patients infection These a of as or and sepsis is as sepsis in and that first to be sepsis to be the of infection and of for each with suspected sepsis should the and of The with in patients with septic shock, have a between time to and in patients with septic shock in patients septic shock a of patients at each of time from to of with of for patients for patients not on a of patients at each of time from to of with of for patients with sepsis at least one of or or organ and for patients with septic to a for sepsis and a for septic shock in a of patients in each in time from to of with of and of in patients with in patients not an between and should be that the and at of to the of with or other patients with sepsis shock, the between time to and within the first hours from is have one to a in between and the other in a in time to suggest that after hours from hospital sepsis We suggest in patients with sepsis shock as as sepsis to be the and 3 hours after sepsis first suspected for sepsis at that given the of with septic shock and the of and the a to and within one in patients with septic shock. for patients with sepsis, we recommend be 1). For patients with sepsis shock, we recommend a of and of be to within 3 should be or should be to the Recommendations on of from suggest that of in patients with sepsis and septic shock is and and of a of in The and time for by and the of and of on is to recommendations to the of in patients with sepsis and septic shock in are in with the recommendations to - Recommendation For adults with suspected sepsis or septic shock, we suggest against using clinical to when to as compared to clinical alone. Weak very low quality of is in in response to in with clinical the of and of a of 30 a of and of for sepsis in patients We evidence from three that compared for of the three in to of to or of to and not in of the and on the with of the and the quality of evidence very guidelines for the management of recommend of for patients with of and in including the a against using to guide in to clinical - Recommendations For adults with sepsis or septic shock at of we recommend using with over using Best practice For adults with sepsis or septic shock at low of we suggest against using with as compared with using Weak low quality of The on to an against in an treatment for sepsis and septic shock the that the patient’s infection is caused by the of with treatment for in a with and the of with treatment in a for of patients and be to The of by from in to in and by for of infection or IV of or of hospital and of on the of including in on patients with the of in patients with of hours are with in not in patients with or sepsis, including against with higher patients The with are by an between of and in patients with or to for in a with be in a be from including the of to for are and on and clinical for are - Recommendations For adults with sepsis or septic shock and for we suggest using with for treatment over one Weak very low quality of For adults with sepsis or septic shock and low for we suggest against using for compared with one Weak very low quality of For adults with sepsis or septic shock, we suggest against using the and the are Weak very low quality of the of in of the world and between in and the initial of is to the at least one that is against the the and are the of on the of for and the of the and are is for patients with in a with of in or other between in adult patients with sepsis or septic shock when from the in the of of and in a low with the from the Recommendations the of one for treatment over one are given clinical including of and the of the of sepsis is to the appropriate For this we from recommendations in patients with sepsis or septic shock recommend the of on of to guide this infection or with within the of within the to a within the and within the the and are is not for patients with with and quality of evidence very and the of with the of for treatment. have an in in patients at for we suggest using for treatment to the of in patients with a low for we suggest using a for as are of using and the a of including infection and development of of is in patients at for with septic shock. - Recommendations For adults with sepsis or septic shock at of we suggest using over Weak low quality of For adults with sepsis or septic shock at low of we suggest against of Weak low quality of Sepsis and septic shock to are in and are with that of appropriate

autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field.

Characterization of the genetic landscape of Alzheimer's disease (AD) and related dementias (ADD) provides a unique opportunity for a better understanding of the associated pathophysiological processes. We performed a two-stage genome-wide association study totaling 111,326 clinically diagnosed/'proxy' AD cases and 677,663 controls. We found 75 risk loci, of which 42 were new at the time of analysis. Pathway enrichment analyses confirmed the involvement of amyloid/tau pathways and highlighted microglia implication. Gene prioritization in the new loci identified 31 genes that were suggestive of new genetically associated processes, including the tumor necrosis factor alpha pathway through the linear ubiquitin chain assembly complex. We also built a new genetic risk score associated with the risk of future AD/dementia or progression from mild cognitive impairment to AD/dementia. The improvement in prediction led to a 1.6- to 1.9-fold increase in AD risk from the lowest to the highest decile, in addition to effects of age and the APOE ε4 allele.

BACKGROUND: Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. METHODS: We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. RESULTS: By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). CONCLUSIONS: ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.).

BACKGROUND: mutation and a minimal-function mutation (Phe508del-minimal function genotype), the next-generation CFTR corrector elexacaftor, in combination with tezacaftor and ivacaftor, improved Phe508del CFTR function and clinical outcomes. METHODS: ) at week 4. RESULTS: that was 13.8 points higher at 4 weeks and 14.3 points higher through 24 weeks, a rate of pulmonary exacerbations that was 63% lower, a respiratory domain score on the Cystic Fibrosis Questionnaire-Revised (range, 0 to 100, with higher scores indicating a higher patient-reported quality of life with regard to respiratory symptoms; minimum clinically important difference, 4 points) that was 20.2 points higher, and a sweat chloride concentration that was 41.8 mmol per liter lower (P<0.001 for all comparisons). Elexacaftor-tezacaftor-ivacaftor was generally safe and had an acceptable side-effect profile. Most patients had adverse events that were mild or moderate. Adverse events leading to discontinuation of the trial regimen occurred in 1% of the patients in the elexacaftor-tezacaftor-ivacaftor group. CONCLUSIONS: Elexacaftor-tezacaftor-ivacaftor was efficacious in patients with cystic fibrosis with Phe508del-minimal function genotypes, in whom previous CFTR modulator regimens were ineffective. (Funded by Vertex Pharmaceuticals; VX17-445-102 ClinicalTrials.gov number, NCT03525444.).

The factors regulating the expression of microRNAs (miRNAs), a ubiquitous family of approximately 22-nt noncoding regulatory RNAs, remain undefined. However, it is known that miRNAs are first transcribed as a largely unstructured precursor, termed a primary miRNA (pri-miRNA), which is sequentially processed in the nucleus, to give the approximately 65-nt pre-miRNA hairpin intermediate, and then in the cytoplasm, to give the mature miRNA. Here we have sought to identify the RNA polymerase responsible for miRNA transcription and to define the structure of a full-length human miRNA. We show that the pri-miRNA precursors for nine human miRNAs are both capped and polyadenylated and report the sequence of the full-length, approximately 3433-nt pri-miR-21 RNA. This pri-miR-21 gene sequence is flanked 5' by a promoter element able to transcribe heterologous mRNAs and 3' by a consensus polyadenylation sequence. Nuclear processing of pri-miRNAs was found to be efficient, thus largely preventing the nuclear export of full-length pri-miRNAs. Nevertheless, an intact miRNA stem-loop precursor located in the 3' UTR of a protein coding gene only moderately inhibited expression of the linked open reading frame, probably because the 3' truncated mRNA could still be exported and expressed. Together, these data show that human pri-miRNAs are not only structurally similar to mRNAs but can, in fact, function both as pri-miRNAs and mRNAs.

OBJECTIVE: To define and investigate key issues in the management of dementia and to make literature-based treatment recommendations. METHODS: The authors searched the literature for four clinical questions: 1) Does pharmacotherapy for cognitive symptoms improve outcomes in patients with dementia? 2) Does pharmacotherapy for noncognitive symptoms improve outcomes in patients with dementia? 3) Do educational interventions improve outcomes in patients and/or caregivers? 4) Do other nonpharmacologic interventions improve outcomes in patients and/or caregivers? RESULTS: Cholinesterase inhibitors benefit patients with AD (Standard), although the average benefit appears small; vitamin E likely delays the time to clinical worsening (Guideline); selegiline, other antioxidants, anti-inflammatories, and estrogen require further study. Antipsychotics are effective for agitation or psychosis in patients with dementia where environmental manipulation fails (Standard), and antidepressants are effective in depressed patients with dementia (Guideline). Educational programs should be offered to family caregivers to improve caregiver satisfaction and to delay the time to nursing home placement (Guideline). Staff of long-term care facilities should also be educated about AD to minimize the unnecessary use of antipsychotic medications (Guideline). Behavior modification, scheduled toileting, and prompted voiding reduce urinary incontinence (Standard). Functional independence can be increased by graded assistance, skills practice, and positive reinforcement (Guideline).

To evaluate the dynamic range of tissue imaged by elastography, the mechanical behavior of breast and prostate tissue samples subject to compression loading has been investigated. A model for the loading was validated and used to guide the experimental design for data collection. The model allowed the use of small samples that could be considered homogeneous; this assumption was confirmed by histological analysis. The samples were tested at three strain rates to evaluate the viscoelastic nature of the material and determine the validity of modeling the tissue as an elastic material for the strain rates of interest. For loading frequencies above 1 Hz, the storage modulus accounted for over 93 percent of the complex modulus. The data show that breast fat tissue has a constant modulus over the strain range tested while the other tissues have a modulus that is dependent on the strain level. The fibrous tissue samples from the breast were found to be 1 to 2 orders of magnitude stiffer than fat tissue. Normal glandular breast tissue was found to have an elastic modulus similar to that of fat at low strain levels, but the modulus of the glandular tissue increased by an order of magnitude above fat at high strain levels. Carcinomas from the breast were stiffer than the other tissues at the higher strain level; intraductal in situ carcinomas were like fat at the low strain level and much stiffer than glandular tissue at the high strain level. Infiltrating ductal carcinomas were much stiffer than any of the other breast tissues. Normal prostate tissue has a modulus that is lower than the modulus of the prostate cancers tested. Tissue from prostate with benign prostatic hyperplasia (BPH) had modulus values significantly lower than normal tissue. There was a constant but not significant difference in the modulus of tissues taken from the anterior and posterior portions of the gland.

Association analysis identifies 65 new breast cancer risk loci, predicts target genes for known risk loci and demonstrates a strong overlap with somatic driver genes in breast tumours. Genome-wide association studies for breast cancer have identified common genetic variation that influences susceptibility to this disease, but much of the genetic risk remains unexplained. Doug Easton and colleagues report a genome-wide association study for breast cancer in more than 122,000 cases and 105,000 controls. The authors genotyped a subset of these cases using OncoArray, a new, custom genome-wide single-nucleotide polymorphism (SNP) array for cancer genomics. Overall, they identify 65 loci newly associated with breast cancer susceptibility, and estimate that, together with 107 previously identified breast cancer susceptibility loci, these explain about 18 per cent of the familial relative risk of breast cancer. Polygenic risk scores may be used in risk prediction models and may improve early detection and targeted prevention of the disease. Breast cancer risk is influenced by rare coding variants in susceptibility genes, such as BRCA1, and many common, mostly non-coding variants. However, much of the genetic contribution to breast cancer risk remains unknown. Here we report the results of a genome-wide association study of breast cancer in 122,977 cases and 105,974 controls of European ancestry and 14,068 cases and 13,104 controls of East Asian ancestry1. We identified 65 new loci that are associated with overall breast cancer risk at P < 5 × 10−8. The majority of credible risk single-nucleotide polymorphisms in these loci fall in distal regulatory elements, and by integrating in silico data to predict target genes in breast cells at each locus, we demonstrate a strong overlap between candidate target genes and somatic driver genes in breast tumours. We also find that heritability of breast cancer due to all single-nucleotide polymorphisms in regulatory features was 2–5-fold enriched relative to the genome-wide average, with strong enrichment for particular transcription factor binding sites. These results provide further insight into genetic susceptibility to breast cancer and will improve the use of genetic risk scores for individualized screening and prevention.

BACKGROUND: The course of autosomal dominant polycystic kidney disease (ADPKD) is often associated with pain, hypertension, and kidney failure. Preclinical studies indicated that vasopressin V(2)-receptor antagonists inhibit cyst growth and slow the decline of kidney function. METHODS: In this phase 3, multicenter, double-blind, placebo-controlled, 3-year trial, we randomly assigned 1445 patients, 18 to 50 years of age, who had ADPKD with a total kidney volume of 750 ml or more and an estimated creatinine clearance of 60 ml per minute or more, in a 2:1 ratio to receive tolvaptan, a V(2)-receptor antagonist, at the highest of three twice-daily dose regimens that the patient found tolerable, or placebo. The primary outcome was the annual rate of change in the total kidney volume. Sequential secondary end points included a composite of time to clinical progression (defined as worsening kidney function, kidney pain, hypertension, and albuminuria) and rate of kidney-function decline. RESULTS: Over a 3-year period, the increase in total kidney volume in the tolvaptan group was 2.8% per year (95% confidence interval [CI], 2.5 to 3.1), versus 5.5% per year in the placebo group (95% CI, 5.1 to 6.0; P<0.001). The composite end point favored tolvaptan over placebo (44 vs. 50 events per 100 follow-up-years, P=0.01), with lower rates of worsening kidney function (2 vs. 5 events per 100 person-years of follow-up, P<0.001) and kidney pain (5 vs. 7 events per 100 person-years of follow-up, P=0.007). Tolvaptan was associated with a slower decline in kidney function (reciprocal of the serum creatinine level, -2.61 [mg per milliliter](-1) per year vs. -3.81 [mg per milliliter](-1) per year; P<0.001). There were fewer ADPKD-related adverse events in the tolvaptan group but more events related to aquaresis (excretion of electrolyte-free water) and hepatic adverse events unrelated to ADPKD, contributing to a higher discontinuation rate (23%, vs. 14% in the placebo group). CONCLUSIONS: Tolvaptan, as compared with placebo, slowed the increase in total kidney volume and the decline in kidney function over a 3-year period in patients with ADPKD but was associated with a higher discontinuation rate, owing to adverse events. (Funded by Otsuka Pharmaceuticals and Otsuka Pharmaceutical Development and Commercialization; TEMPO 3:4 ClinicalTrials.gov number, NCT00428948.).

Cervical cancer remains one of the leading causes of cancer-related deaths worldwide. Here we report the extensive molecular characterization of 228 primary cervical cancers, one of the largest comprehensive genomic studies of cervical cancer to date. We observed notable APOBEC mutagenesis patterns and identified SHKBP1, ERBB3, CASP8, HLA-A and TGFBR2 as novel significantly mutated genes in cervical cancer. We also discovered amplifications in immune targets CD274 (also known as PD-L1) and PDCD1LG2 (also known as PD-L2), and the BCAR4 long non-coding RNA, which has been associated with response to lapatinib. Integration of human papilloma virus (HPV) was observed in all HPV18-related samples and 76% of HPV16-related samples, and was associated with structural aberrations and increased target-gene expression. We identified a unique set of endometrial-like cervical cancers, comprised predominantly of HPV-negative tumours with relatively high frequencies of KRAS, ARID1A and PTEN mutations. Integrative clustering of 178 samples identified keratin-low squamous, keratin-high squamous and adenocarcinoma-rich subgroups. These molecular analyses reveal new potential therapeutic targets for cervical cancers. This paper describes molecular subtypes of cervical cancers, including squamous cell carcinoma and adenocarcinoma clusters defined by HPV status and molecular features, and distinct molecular pathways that are activated in cervical carcinomas caused by different somatic alterations and HPV types. Cervical cancer is one of the main causes of cancer-related deaths worldwide, and 95% of cases result from human papilloma virus (HPV) infection. The Cancer Genome Atlas Research Network now reports the genomic and molecular characterization of 228 primary cervical cancers. The authors identify significantly mutated genes and pathways that differ by cervical cancer subtype, and find that keratin-low squamous, keratin-high squamous and adenocarcinoma-rich clusters are marked by different HPV types and molecular features.

OBJECTIVE: The purpose of this study is to investigate differences in sensory processing among age-matched children between ages 3 and 6 years with autism spectrum disorders (ASD) and those who are typically developing. METHOD: Reported sensory processing abilities of 281 children with ASD were compared to age-matched peers who were typically developing, using the Short Sensory Profile (SSP). RESULTS: Ninety-five percent of the sample of children with ASD demonstrated some degree of sensory processing dysfunction on the SSP Total Score, with the greatest differences reported on the Underresponsive/ Seeks Sensation, Auditory Filtering, and Tactile Sensitivity sections. The ASD group also performed significantly differently (p < .001) on 92% of the items, total score, and all sections of the SSP. CONCLUSION: These findings, considered with similar published studies, begin to confirm the prevalence and types of sensory processing impairments in autism. Further research is needed to more clearly define patterns of sensory processing in people with ASD.

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.