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Acute encephalopathy after head trauma in a patient with a RHOBTB2 mutation

Objective

De novo missense mutations in the RHOBTB2 gene have been described as causative for developmental and epileptic encephalopathy.

Methods

The clinical phenotype of this disorder includes early-onset epilepsy, severe intellectual disability, postnatal microcephaly, and movement disorder. Three RHOBTB2 patients have been described with acute encephalopathy and febrile epileptic status. All showed severe EEG abnormalities during this episode and abnormal MRI with hemisphere swelling or reduced diffusion in various brain regions.

Results

We describe the episode of acute encephalopathy after head trauma in a 5-year-old RHOBTB2 patient. At admission, Glasgow coma scale score was E4M4V1. EEG was severely abnormal showing a noncontinuous pattern with slow activity without epileptic activity indicating severe encephalopathy. A second EEG on day 8 was still severely slowed and showed focal delta activity frontotemporal in both hemispheres. Gradually, he recovered, and on day 11, he had regained his normal reactivity, behavior, and mood. Two months after discharge, EEG showed further decrease in slow activity and increase in normal electroencephalographic activity. After discharge, parents noted that he showed more hyperkinetic movements compared to before this period of encephalopathy. Follow-up MRI showed an increment of hippocampal atrophy. In addition, we summarize the clinical characteristics of a second RHOBTB2 patient with increase of focal periventricular atrophy and development of hemiparesis after epileptic status.

Conclusions

Acute encephalopathy in RHOBTB2 patients can also be triggered by head trauma.




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Magnetic resonance imaging of pulmonary arterial compliance after pulmonary endarterectomy

Pulmonary endarterectomy (PEA) is the treatment of choice of chronic thromboembolic pulmonary hypertension (CTEPH) [1]. However, successfully operated patients may continue to suffer from dyspnoea and limitation of exercise capacity, despite improvement or even normalisation of pulmonary artery pressure (PAP), cardiac output (CO) and pulmonary vascular resistance (PVR) [2]. This absence of complete symptomatic recovery has been explained by a decreased right ventricular (RV) function reserve due to persistent increased afterload [3, 4], related to decreased pulmonary arterial compliance (PCa) more than to mildly increased PVR [5, 6]. There is therefore interest in assessing PCa in patients during the follow-up of PEA.




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Risk of stroke after emergency department visits for neurologic complaints

Objective

To assess the risk of subsequent stroke among older patients discharged from an emergency department (ED) without a diagnosis of TIA or stroke.

Methods

Using electronic health record data from a large urban, university hospital and a community-based hospital, we analyzed patients aged 60–89 years discharged to home from the ED without an International Statistical Classification of Diseases and Related Health Problems, 9th or 10th Revision diagnosis of TIA or stroke. Based on the presence/absence of a head CT and the presence/absence of a chief complaint suggestive of TIA or stroke ("symptoms") during the index ED visit, we created 4 mutually exclusive groups (group 1, reference: head CT no, symptoms no; group 2: head CT no, symptoms yes; group 3: head CT yes, symptoms no; and group 4: head CT yes, symptoms yes). We calculated rates of stroke in the 30, 90, and 365 days after the index visit and used multivariable logistic regression to estimate odds ratios (ORs) for subsequent stroke.

Results

Among 35,622 patients (mean age 70 years, 59% women, and 16% African American), unadjusted rates of stroke in 365 days were as follows: group 4: 2.5%; group 3: 1.1%; group 2: 0.69%; and group 1: 0.54%. The adjusted OR for stroke was 3.30 (95% confidence interval [CI], 1.61–6.76) in group 4, 1.56 (95% CI, 1.16–2.09) in group 3, and 0.61 (95% CI, 0.22–1.67) in group 2.

Conclusions

Among patients discharged from the ED without a diagnosis of TIA or stroke, the occurrence of a head CT and/or specific neurologic symptoms established a clinically meaningful risk gradient for subsequent stroke.




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Correction for Pilat et al., Treg-mediated prolonged survival of skin allografts without immunosuppression [Corrections]

IMMUNOLOGY AND INFLAMMATION Correction for “Treg-mediated prolonged survival of skin allografts without immunosuppression,” by Nina Pilat, Mario Wiletel, Anna M. Weijler, Romy Steiner, Benedikt Mahr, Joanna Warren, Theresa M. Corpuz, Thomas Wekerle, Kylie E. Webster, and Jonathan Sprent, which was first published June 13, 2019; 10.1073/pnas.1903165116 (Proc. Natl. Acad. Sci....




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Family Medicine Certification Longitudinal Assessment after One Year




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A Simple Clinical Tool for Stratifying Risk of Clinically Significant CKD after Nephrectomy: Development and Multinational Validation

Background

Clinically significant CKD following surgery for kidney cancer is associated with increased morbidity and mortality, but identifying patients at increased CKD risk remains difficult. Simple methods to stratify risk of clinically significant CKD after nephrectomy are needed.

Methods

To develop a tool for stratifying patients’ risk of CKD arising after surgery for kidney cancer, we tested models in a population-based cohort of 699 patients with kidney cancer in Queensland, Australia (2012–2013). We validated these models in a population-based cohort of 423 patients from Victoria, Australia, and in patient cohorts from single centers in Queensland, Scotland, and England. Eligible patients had two functioning kidneys and a preoperative eGFR ≥60 ml/min per 1.73 m2. The main outcome was incident eGFR <45 ml/min per 1.73 m2 at 12 months postnephrectomy. We used prespecified predictors—age ≥65 years old, diabetes mellitus, preoperative eGFR, and nephrectomy type (partial/radical)—to fit logistic regression models and grouped patients according to degree of risk of clinically significant CKD (negligible, low, moderate, or high risk).

Results

Absolute risks of stage 3b or higher CKD were <2%, 3% to 14%, 21% to 26%, and 46% to 69% across the four strata of negligible, low, moderate, and high risk, respectively. The negative predictive value of the negligible risk category was 98.9% for clinically significant CKD. The c statistic for this score ranged from 0.84 to 0.88 across derivation and validation cohorts.

Conclusions

Our simple scoring system can reproducibly stratify postnephrectomy CKD risk on the basis of readily available parameters. This clinical tool’s quantitative assessment of CKD risk may be weighed against other considerations when planning management of kidney tumors and help inform shared decision making between clinicians and patients.




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Kinetics, Longevity, and Cross-Reactivity of Antineuraminidase Antibody after Natural Infection with Influenza A Viruses [Clinical Immunology]

The kinetics, longevity, and breadth of antibodies to influenza virus neuraminidase (NA) in archival, sequential serum/plasma samples from influenza A virus (IAV) H5N1 infection survivors and from patients infected with the 2009 pandemic IAV (H1N1) virus were determined using an enzyme-linked lectin-based assay. The reverse-genetics-derived H4N1 viruses harboring a hemagglutinin (HA) segment from A/duck/Shan Tou/461/2000 (H4N9) and an NA segment derived from either IAV H5N1 clade 1, IAV H5N1 clade 2.3.4, the 2009 pandemic IAV (H1N1) (H1N1pdm), or A/Puerto Rico/8/1934 (H1N1) virus were used as the test antigens. These serum/plasma samples were also investigated by microneutralization (MN) and/or hemagglutination inhibition (HI) assays. Neuraminidase-inhibiting (NI) antibodies against N1 NA of both homologous and heterologous viruses were observed in H5N1 survivors and H1N1pdm patients. H5N1 survivors who were never exposed to H1N1pdm virus developed NI antibodies to H1N1pdm NA. Seroconversion of NI antibodies was observed in 65% of the H1N1pdm patients at day 7 after disease onset, but an increase in titer was not observed in serum samples obtained late in infection. On the other hand, an increase in seroconversion rate with the HI assay was observed in the follow-up series of sera obtained on days 7, 14, 28, and 90 after infection. The study also showed that NI antibodies are broadly reactive, while MN and HI antibodies are more strain specific.




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Risk of MS relapse after yellow fever vaccination: A self-controlled case series

Objective

To determine whether live-attenuated yellow fever vaccine (YFV) was associated with MS relapse, we evaluated the clinical courses of 23 patients in the year before and the year after immunization at the university hospital of Geneva, Switzerland.

Methods

This self-controlled retrospective cohort included adult patients with MS receiving YFV between 2014 and 2018 and defined the year before vaccination, the 3 months thereafter, and the 9 months following as the pre-exposure (PEP), exposure-risk (ERP), and postrisk (PRP) periods, respectively. The primary outcome was the relative incidence of relapse in the ERP vs the PEP. Secondary end points included the presence of new T2-weighted (T2) or T1-weighted gadolinium-positive (T1Gd+) MRI lesions.

Results

Of 23 patients with MS receiving YFV (20 relapsing MS and 3 primary progressive MS), 17 (74%) were women; mean age was 34 years (SD ±10); and 10 of 23 (40%) were treated with disease-modifying therapies (DMTs). Although 9 patients experienced 12 relapses in the PEP, only one experienced a relapse in the ERP; 3 other patients experienced one relapse each in the PRP. None of the 8 patients receiving natalizumab at the time of vaccination experienced relapse thereafter. In the PEP, ERP, and PRP, 18, 2, and 9 patients had new brain and/or spinal cord lesions on T2 or T1Gd + MRI, respectively.

Conclusions

In this cohort, YF vaccination was associated with neither an increase in MS relapse nor emergence of brain and/or spinal lesions. Further studies are warranted to confirm these findings.

Classification of evidence

This study provides Class IV evidence that for persons with MS, YFV may not increase relapse risk.




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Guillain-Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy after alemtuzumab therapy in kidney transplant recipients

Alemtuzumab is approved for the treatment of relapsing-remitting MS and is used off-label for patients with chronic lymphocytic leukemia and as induction and antirejection therapy in kidney transplant recipients.1 Guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) complicating alemtuzumab treatment was reported in 9 patients with hematologic malignancy or MS.1–3 The risk of GBS or CIDP in solid organ transplant recipients treated with alemtuzumab is unknown.




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27-Hydroxycholesterol Impairs Plasma Membrane Lipid Raft Signaling as Evidenced by Inhibition of IL6-JAK-STAT3 Signaling in Prostate Cancer Cells

We recently reported that restoring the CYP27A1–27hydroxycholesterol axis had antitumor properties. Thus, we sought to determine the mechanism by which 27HC exerts its anti–prostate cancer effects. As cholesterol is a major component of membrane microdomains known as lipid rafts, which localize receptors and facilitate cellular signaling, we hypothesized 27HC would impair lipid rafts, using the IL6–JAK–STAT3 axis as a model given its prominent role in prostate cancer. As revealed by single molecule imaging of DU145 prostate cancer cells, 27HC treatment significantly reduced detected cholesterol density on the plasma membranes. Further, 27HC treatment of constitutively active STAT3 DU145 prostate cancer cells reduced STAT3 activation and slowed tumor growth in vitro and in vivo. 27HC also blocked IL6-mediated STAT3 phosphorylation in nonconstitutively active STAT3 cells. Mechanistically, 27HC reduced STAT3 homodimerization, nuclear translocation, and decreased STAT3 DNA occupancy at target gene promoters. Combined treatment with 27HC and STAT3 targeting molecules had additive and synergistic effects on proliferation and migration, respectively. Hallmark IL6–JAK–STAT gene signatures positively correlated with CYP27A1 gene expression in a large set of human metastatic castrate-resistant prostate cancers and in an aggressive prostate cancer subtype. This suggests STAT3 activation may be a resistance mechanism for aggressive prostate cancers that retain CYP27A1 expression. In summary, our study establishes a key mechanism by which 27HC inhibits prostate cancer by disrupting lipid rafts and blocking STAT3 activation.

Implications:

Collectively, these data show that modulation of intracellular cholesterol by 27HC can inhibit IL6–JAK–STAT signaling and may synergize with STAT3-targeted compounds.




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Imaging DNA Damage Repair In Vivo After 177Lu-DOTATATE Therapy

Molecular radiotherapy using 177Lu-DOTATATE is a most effective treatment for somatostatin receptor–expressing neuroendocrine tumors. Despite its frequent and successful use in the clinic, little or no radiobiologic considerations are made at the time of treatment planning or delivery. On positive uptake on octreotide-based PET/SPECT imaging, treatment is usually administered as a standard dose and number of cycles without adjustment for peptide uptake, dosimetry, or radiobiologic and DNA damage effects in the tumor. Here, we visualized and quantified the extent of DNA damage response after 177Lu-DOTATATE therapy using SPECT imaging with 111In-anti-H2AX-TAT. This work was a proof-of-principle study of this in vivo noninvasive biodosimeter with β-emitting therapeutic radiopharmaceuticals. Methods: Six cell lines were exposed to external-beam radiotherapy (EBRT) or 177Lu-DOTATATE, after which the number of H2AX foci and the clonogenic survival were measured. Mice bearing CA20948 somatostatin receptor–positive tumor xenografts were treated with 177Lu-DOTATATE or sham-treated and coinjected with 111In-anti-H2AX-TAT, 111In-IgG-TAT control, or vehicle. Results: Clonogenic survival after external-beam radiotherapy was cell-line–specific, indicating varying levels of intrinsic radiosensitivity. Regarding in vitro cell lines treated with 177Lu-DOTATATE, clonogenic survival decreased and H2AX foci increased for cells expressing high levels of somatostatin receptor subtype 2. Ex vivo measurements revealed a partial correlation between 177Lu-DOTATATE uptake and H2AX focus induction between different regions of CA20948 xenograft tumors, suggesting that different parts of the tumor may react differentially to 177Lu-DOTATATE irradiation. Conclusion: 111In-anti-H2AX-TAT allows monitoring of DNA damage after 177Lu-DOTATATE therapy and reveals heterogeneous damage responses.




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18F-rhPSMA-7 PET for the Detection of Biochemical Recurrence of Prostate Cancer After Radical Prostatectomy

18F-labeled prostate-specific membrane antigen (PSMA) PET tracers are increasingly used in preference to 68Ga-PSMA-11 for restaging biochemical recurrence (BCR) of prostate cancer. They are associated with longer half-lives, larger-scale production, and lower positron range than their 68Ga-labeled counterparts. Here, we describe the efficacy of an 18F-labeled radiohybrid PSMA, rhPSMA-7, a novel theranostic PSMA-targeting agent for imaging BCR of prostate cancer. Methods: Datasets from 261 consecutive patients with noncastrate BCR after radical prostatectomy who underwent 18F-rhPSMA-7 PET/CT at our institution between June 2017 and March 2018 were reviewed retrospectively. All lesions suspected of being recurrent prostate cancer were recorded. The detection rate for sites of presumed recurrence was correlated with patients’ prostate-specific antigen (PSA) level, primary Gleason score, and prior therapy (androgen deprivation therapy and external-beam radiation therapy). Results: The 261 patients had a median PSA level of 0.96 ng/mL (range, 0.01–400 ng/mL). The median injected activity of 18F-rhPSMA-7 was 336 MBq, with a median uptake time of 76 min. In total, 211 patients (81%) showed pathologic findings on 18F-rhPSMA-7 PET/CT. The detection rates were 71% (42/59), 86% (44/51), 86% (42/49), and 95% (76/80) at PSA levels of 0.2 to <0.5 ng/mL, 0.5 to <1 ng/mL, 1 to <2 ng/mL, and ≥2 ng/mL, respectively. In 32% patients (7/22) with a PSA of less than 0.2 ng/mL, suggestive lesions were present. 18F-rhPSMA-7 PET/CT revealed local recurrence in 43% of patients (113). Lymph node metastases were present in the pelvis in 42% of patients (110), in the retroperitoneum in 17% (45), and in a supradiaphragmatic location in 8.0% (21). Bone and visceral metastases were detected in 21% (54) and 3.8% (10), respectively. Detection efficacy was not influenced by prior external-beam radiation therapy (79.1% vs. 82.1%, P = 0.55), androgen deprivation therapy within the 6 mo preceding imaging (80.6% vs. 80.9%, P = 0.54), or primary Gleason score (77.9% for ≤7 vs. 82.6% for ≥8, P = 0.38). Conclusion: 18F-rhPSMA-7 PET/CT offers high detection rates in early BCR after radical prostatectomy, especially among patients with low PSA values.




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Ivacaftor decreases monocyte sensitivity to interferon-{gamma} in people with cystic fibrosis

Management of cystic fibrosis has been revolutionised by the introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. These compounds treat the underlying molecular basis of the disease by increasing activity of defective CFTR channels, which improves many clinical parameters and enhances patient quality of life [1]. Next-generation modulators, also known as triple combination therapy, promise to be highly efficacious in up to 90% of patients [2] and will likely dramatically change the landscape of cystic fibrosis disease. Studies examining individuals before and after initiation of CFTR modulators have revealed novel functions of CFTR and shown that CFTR modulators do not reverse all disease manifestations [3–5]. Thus, knowledge of the post-modulator cystic fibrosis disease state is crucial for understanding what continued therapies will be needed for people with cystic fibrosis and what new challenges may arise.




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The Transcriptional Aftermath in Two Independently Formed Hybrids of the Opportunistic Pathogen Candida orthopsilosis

ABSTRACT

Interspecific hybridization can drive evolutionary adaptation to novel environments. The Saccharomycotina clade of budding yeasts includes many hybrid lineages, and hybridization has been proposed as a source for new pathogenic species. Candida orthopsilosis is an emerging opportunistic pathogen for which most clinical isolates are hybrids, each derived from one of at least four independent crosses between the same two parental lineages. To gain insight into the transcriptomic aftermath of hybridization in these pathogens, we analyzed allele-specific gene expression in two independently formed hybrid strains and in a homozygous strain representative of one parental lineage. Our results show that the effect of hybridization on overall gene expression is rather limited, affecting ~4% of the genes studied. However, we identified a larger effect in terms of imbalanced allelic expression, affecting ~9.5% of the heterozygous genes in the hybrids. This effect was larger in the hybrid with more extensive loss of heterozygosity, which may indicate a tendency to avoid loss of heterozygosity in these genes. Consistently, the number of shared genes with allele-specific expression in the two independently formed hybrids was higher than random expectation, suggesting selective retention. Some of the imbalanced genes have functions related to pathogenicity, including zinc transport and superoxide dismutase activities. While it remains unclear whether the observed imbalanced genes play a role in virulence, our results suggest that differences in allele-specific expression may add an additional layer of phenotypic plasticity to traits related to virulence in C. orthopsilosis hybrids.

IMPORTANCE How new pathogens emerge is an important question that remains largely unanswered. Some emerging yeast pathogens are hybrids originated through the crossing of two different species, but how hybridization contributes to higher virulence is unclear. Here, we show that hybrids selectively retain gene regulation plasticity inherited from the two parents and that this plasticity affects genes involved in virulence.




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The M Protein of Streptococcus pyogenes Strain AP53 Retains Cell Surface Functional Plasminogen Binding after Inactivation of the Sortase A Gene [Article]

Streptococcus pyogenes (Lancefield group A Streptococcus [GAS]) is a β-hemolytic human-selective pathogen that is responsible for a large number of morbid and mortal infections in humans. For efficient infection, GAS requires different types of surface proteins that provide various mechanisms for evading human innate immune responses, thus enhancing pathogenicity of the bacteria. Many such virulence-promoting proteins, including the major surface signature M protein, are translocated after biosynthesis through the cytoplasmic membrane and temporarily tethered to this membrane via a type 1 transmembrane domain (TMD) positioned near the COOH terminus. In these proteins, a sorting signal, LPXTG, is positioned immediately upstream of the TMD, which is cleaved by the membrane-associated transpeptidase, sortase A (SrtA), leading to the covalent anchoring of these proteins to newly emerging l-Ala–l-Ala cross-bridges of the growing peptidoglycan cell wall. Herein, we show that inactivation of the srtA gene in a skin-tropic pattern D GAS strain (AP53) results in retention of the M protein in the cell membrane. However, while the isogenic AP53 srtA strain is attenuated in overall pathogenic properties due to effects on the integrity of the cell membrane, our data show that the M protein nonetheless can extend from the cytoplasmic membrane through the cell wall and then to the surface of the bacteria and thereby retain its important properties of productively binding and activating fluid-phase host plasminogen (hPg). The studies presented herein demonstrate an underappreciated additional mechanism of cell surface display of bacterial virulence proteins via their retention in the cell membrane and extension to the GAS surface.

IMPORTANCE Group A Streptococcus pyogenes (GAS) is a human-specific pathogen that produces many surface factors, including its signature M protein, that contribute to its pathogenicity. M proteins undergo specific membrane localization and anchoring to the cell wall via the transpeptidase sortase A. Herein, we explored the role of sortase A function on M protein localization, architecture, and function, employing, a skin-tropic GAS isolate, AP53, which expresses a human plasminogen (hPg)-binding M (PAM) Protein. We showed that PAM anchored in the cell membrane, due to the targeted inactivation of sortase A, was nonetheless exposed on the cell surface and functionally interacted with host hPg. We demonstrate that M proteins, and possibly other sortase A-processed proteins that are retained in the cell membrane, can still function to initiate pathogenic processes by this underappreciated mechanism.




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Erratum. Ten-Year Outcome of Islet Alone or Islet After Kidney Transplantation in Type 1 Diabetes: A Prospective Parallel-Arm Cohort Study. Diabetes Care 2019;42:2042-2049




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Intrahepatic Fat and Postprandial Glycemia Increase After Consumption of a Diet Enriched in Saturated Fat Compared With Free Sugars

OBJECTIVE

Debate continues regarding the influence of dietary fats and sugars on the risk of developing metabolic diseases, including insulin resistance and nonalcoholic fatty liver disease (NAFLD). We investigated the effect of two eucaloric diets, one enriched with saturated fat (SFA) and the other enriched with free sugars (SUGAR), on intrahepatic triacylglycerol (IHTAG) content, hepatic de novo lipogenesis (DNL), and whole-body postprandial metabolism in overweight males.

RESEARCH DESIGN AND METHODS

Sixteen overweight males were randomized to consume the SFA or SUGAR diet for 4 weeks before consuming the alternate diet after a 7-week washout period. The metabolic effects of the respective diets on IHTAG content, hepatic DNL, and whole-body metabolism were investigated using imaging techniques and metabolic substrates labeled with stable-isotope tracers.

RESULTS

Consumption of the SFA diet significantly increased IHTAG by mean ± SEM 39.0 ± 10.0%, while after the SUGAR diet IHTAG was virtually unchanged. Consumption of the SFA diet induced an exaggerated postprandial glucose and insulin response to a standardized test meal compared with SUGAR. Although whole-body fat oxidation, lipolysis, and DNL were similar following the two diets, consumption of the SUGAR diet resulted in significant (P < 0.05) decreases in plasma total, HDL, and non-HDL cholesterol and fasting β-hydroxybutyrate plasma concentrations.

CONCLUSIONS

Consumption of an SFA diet had a potent effect, increasing IHTAG together with exaggerating postprandial glycemia. The SUGAR diet did not influence IHTAG and induced minor metabolic changes. Our findings indicate that a diet enriched in SFA is more harmful to metabolic health than a diet enriched in free sugars.




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Pre-transplant testosterone and outcome of men after allogeneic stem cell transplantation

Testosterone is an important determinant of endothelial function and vascular health in men. As both factors play a role in mortality after allogeneic stem cell transplantation (alloSCT), we retrospectively evaluated the impact of pre-transplant testosterone levels on outcome in male patients undergoing alloSCT. In the discovery cohort (n=346), an impact on outcome was observed only in the subgroup of patients allografted for acute myeloid leukemia (AML) (n=176, hereafter termed ‘training cohort’). In the training cohort, lower pre-transplant testosterone levels were significantly associated with shorter overall survival (OS) [hazard ratio (HR) for a decrease of 100 ng/dL: 1.11, P=0.045]. This was based on a higher hazard of non-relapse mortality (NRM) (cause-specific HR: 1.25, P=0.013), but not relapse (cause-specific HR: 1.06, P=0.277) in the multivariable models. These findings were replicated in a confirmation cohort of 168 male patients allografted for AML in a different center (OS, HR: 1.15, P=0.012 and NRM, cause-specific HR: 1.23; P=0.008). Next, an optimized cut-off point for pre-transplant testosterone was derived from the training set and evaluated in the confirmation cohort. In multivariable models, low pre-transplant testosterone status (<250 ng/dL) was associated with worse OS (hazard ratio 1.95, P=0.021) and increased NRM (cause-specific HR 2.68, P=0.011) but not with relapse (cause-specific HR: 1.28, P=0.551). Our findings may provide a rationale for prospective studies on testosterone/androgen assessment and supplementation in male patients undergoing alloSCT for AML.




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Impact of cytogenetic abnormalities on outcomes of adult Philadelphia-negative acute lymphoblastic leukemia after allogeneic hematopoietic stem cell transplantation: a study by the Acute Leukemia Working Committee of the Center for International Blood and

Cytogenetic risk stratification at diagnosis has long been one of the most useful tools to assess prognosis in acute lymphoblastic leukemia (ALL). To examine the prognostic impact of cytogenetic abnormalities on outcomes after allogeneic hematopoietic cell transplantation, we studied 1731 adults with Philadelphia-negative ALL in complete remission who underwent myeloablative or reduced intensity/non-myeloablative conditioning transplant from unrelated or matched sibling donors reported to the Center for International Blood and Marrow Transplant Research. A total of 632 patients had abnormal conventional metaphase cytogenetics. The leukemia-free survival and overall survival rates at 5 years after transplantation in patients with abnormal cytogenetics were 40% and 42%, respectively, which were similar to those in patients with a normal karyotype. Of the previously established cytogenetic risk classifications, modified Medical Research Council-Eastern Cooperative Oncology Group score was the only independent prognosticator of leukemia-free survival (P=0.03). In the multivariable analysis, monosomy 7 predicted post-transplant relapse [hazard ratio (HR)=2.11; 95% confidence interval (95% CI): 1.04-4.27] and treatment failure (HR=1.97; 95% CI: 1.20-3.24). Complex karyotype was prognostic for relapse (HR=1.69; 95% CI: 1.06-2.69), whereas t(8;14) predicted treatment failure (HR=2.85; 95% CI: 1.35-6.02) and overall mortality (HR=3.03; 95% CI: 1.44-6.41). This large study suggested a novel transplant-specific cytogenetic scheme with adverse [monosomy 7, complex karyotype, del(7q), t(8;14), t(11;19), del(11q), tetraploidy/near triploidy], intermediate (normal karyotype and all other abnormalities), and favorable (high hyperdiploidy) risks to prognosticate leukemia-free survival (P=0.02). Although some previously established high-risk Philadelphia-negative cytogenetic abnormalities in ALL can be overcome by transplantation, monosomy 7, complex karyotype, and t(8;14) continue to pose significant risks and yield inferior outcomes.




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Dissecting molecular mechanisms of resistance to NOTCH1-targeted therapy in T-cell acute lymphoblastic leukemia xenografts

Despite substantial progress in treatment of T-cell acute lymphoblastic leukemia (T-ALL), mortality remains relatively high, mainly due to primary or acquired resistance to chemotherapy. Further improvements in survival demand better understanding of T-ALL biology and development of new therapeutic strategies. The Notch pathway has been involved in the pathogenesis of this disease and various therapeutic strategies are currently under development, including selective targeting of NOTCH receptors by inhibitory antibodies. We previously demonstrated that the NOTCH1-specific neutralizing antibody OMP52M51 prolongs survival in TALL patient-derived xenografts bearing NOTCH1/FBW7 mutations. However, acquired resistance to OMP52M51 eventually developed and we used patient-derived xenografts models to investigate this phenomenon. Multi-level molecular characterization of T-ALL cells resistant to NOTCH1 blockade and serial transplantation experiments uncovered heterogeneous types of resistance, not previously reported with other Notch inhibitors. In one model, resistance appeared after 156 days of treatment, it was stable and associated with loss of Notch inhibition, reduced mutational load and acquired NOTCH1 mutations potentially affecting the stability of the heterodimerization domain. Conversely, in another model resistance developed after only 43 days of treatment despite persistent down-regulation of Notch signaling and it was accompanied by modulation of lipid metabolism and reduced surface expression of NOTCH1. Our findings shed light on heterogeneous mechanisms adopted by the tumor to evade NOTCH1 blockade and support clinical implementation of antibody-based target therapy for Notch-addicted tumors.




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Extensive multilineage analysis in patients with mixed chimerism after allogeneic transplantation for sickle cell disease: insight into hematopoiesis and engraftment thresholds for gene therapy

Although studies of mixed chimerism following hematopoietic stem cell transplantation in patients with sickle cell disease (SCD) may provide insights into the engraftment needed to correct the disease and into immunological reconstitution, an extensive multilineage analysis is lacking. We analyzed chimerism simultaneously in peripheral erythroid and granulomonocytic precursors/progenitors, highly purified B and T lymphocytes, monocytes, granulocytes and red blood cells (RBC). Thirty-four patients with mixed chimerism and ≥12 months of follow-up were included. A selective advantage of donor RBC and their progenitors/precursors led to full chimerism in mature RBC (despite partial engraftment of other lineages), and resulted in the clinical control of the disease. Six patients with donor chimerism <50% had hemolysis (reticulocytosis) and higher HbS than their donor. Four of them had donor chimerism <30%, including a patient with AA donor (hemoglobin >10 g/dL) and three with AS donors (hemoglobin <10 g/dL). However, only one vaso-occlusive crisis occurred with 68.7% HbS. Except in the patients with the lowest chimerism, the donor engraftment was lower for T cells than for the other lineages. In a context of mixed chimerism after hematopoietic stem cell transplantation for SCD, myeloid (rather than T cell) engraftment was the key efficacy criterion. Results show that myeloid chimerism as low as 30% was sufficient to prevent a vaso-occlusive crisis in transplants from an AA donor but not constantly from an AS donor. However, the correction of hemolysis requires higher donor chimerism levels (i.e. ≥50%) in both AA and AS recipients. In the future, this group of patients may need a different therapeutic approach.




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Characterization of response and corneal events with extended follow-up after belantamab mafodotin (GSK2857916) monotherapy for patients with relapsed multiple myeloma: a case series from the first-time-in-human clinical trial




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Microencapsulated G3C Hybridoma Cell Graft Delays the Onset of Spontaneous Diabetes in NOD Mice by an Expansion of Gitr+ Treg Cells

As an alternative to lifelong insulin supplementation, potentiation of immune tolerance in patients with type 1 diabetes could prevent the autoimmune destruction of pancreatic islet β-cells. This study was aimed to assess whether the G3c monoclonal antibody (mAb), which triggers the glucocorticoid-induced TNFR-related (Gitr) costimulatory receptor, promotes the expansion of regulatory T cells (Tregs) in SV129 (wild-type) and diabetic-prone NOD mice. The delivery of the G3c mAb via G3C hybridoma cells enveloped in alginate-based microcapsules (G3C/cps) for 3 weeks induced Foxp3+ Treg-cell expansion in the spleen of wild-type mice but not in Gitr–/– mice. G3C/cps also induced the expansion of nonconventional Cd4+Cd25–/lowFoxp3lowGitrint/high (GITR single-positive [sp]) Tregs. Both Cd4+Cd25+GitrhighFoxp3+ and GITRsp Tregs (including also antigen-specific cells) were expanded in the spleen and pancreas of G3C/cps-treated NOD mice, and the number of intact islets was higher in G3C/cps-treated than in empty cps-treated and untreated animals. Consequently, all but two G3C/cps-treated mice did not develop diabetes and all but one survived until the end of the 24-week study. In conclusion, long-term Gitr triggering induces Treg expansion, thereby delaying/preventing diabetes development in NOD mice. This therapeutic approach may have promising clinical potential for the treatment of inflammatory and autoimmune diseases.




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Predicting Opioid Use Following Discharge After Cesarean Delivery [Original Research]

PURPOSE

Although cesarean delivery is the most common surgical procedure in the United States, postoperative opioid prescribing varies greatly. We hypothesized that patient characteristics, procedural characteristics, or both would be associated with high vs low opioid use after discharge. This information could help individualize prescriptions.

METHODS

In this prospective cohort study, we quantified opioid use for 4 weeks following hospital discharge after cesarean delivery. Predischarge characteristics were obtained from health records, and patients self-reported total opioid use postdischarge on weekly questionnaires. Opioid use was quantified in milligram morphine equivalents (MMEs). Binomial and Poisson regression analyses were performed to assess predictors of opioid use after discharge.

RESULTS

Of the 233 patients starting the study, 203 (87.1%) completed at least 1 questionnaire and were included in analyses (86.3% completed all 4 questionnaires). A total of 113 patients were high users (>75 MMEs) and 90 patients were low users (≤75 MMEs) of opioids postdischarge. The group reporting low opioid use received on average 44% fewer opioids in the 24 hours before discharge compared with the group reporting high opioid use (mean = 33.0 vs 59.3 MMEs, P <.001). Only a minority of patients (11.4% to 15.8%) stored leftover opioids in a locked location, and just 31 patients disposed of leftover opioids.

CONCLUSIONS

Knowledge of predischarge opioid use can be useful as a tool to inform individualized opioid prescriptions, help optimize nonopioid analgesia, and reduce opioid use. Additional studies are needed to evaluate the impact of implementing such measures on prescribing practices, pain, and functional outcomes.




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Detection of ctDNA from Dried Blood Spots after DNA Size Selection

Abstract
Background
Recent advances in the study and clinical applications of circulating tumor DNA (ctDNA) are limited by practical considerations of sample collection. Whole-genome sequencing (WGS) is increasingly used for analysis of ctDNA, identifying copy-number alterations and fragmentation patterns. We hypothesized that low-depth/shallow WGS (sWGS) data may be generated from minute amounts of cell-free DNA, and that fragment-size selection may remove contaminating genomic DNA from small blood volumes. Dried blood spots have practical advantages for sample collection, may facilitate serial sampling, and could support novel study designs in humans and animal models.
Methods
We developed a protocol for the isolation and analysis of cell-free DNA from dried blood spots using filter paper cards and bead-based size selection. DNA extracted and size-selected from dried spots was analyzed using sWGS and polymerase chain reaction (PCR).
Results
Analyzing a 50 μL dried blood spot from frozen whole blood of a patient with melanoma, we identified ctDNA based on the presence of tumor-specific somatic copy-number alterations, and found a fragment-size profile similar to that observed in plasma DNA. We found alterations in different chromosomes in blood spots from 2 patients with high-grade serous ovarian carcinoma. Extending this approach to serial dried blood spots from mouse xenograft models, we detect tumor-derived cell-free DNA and identified ctDNA from the originally grafted ascites.
Conclusion
Our data suggest that ctDNA can be detected and monitored in dried blood spots from archived and fresh blood samples, enabling new approaches for sample collection and novel study/trial designs for both patients and in vivo models.




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Lactic Acidosis after Drinking Mysterious Beverage

ethylene glycol poisoninglactateanalytical interference




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Levothyroxine prescribing and laboratory test use after a minor change in reference range for thyroid-stimulating hormone [Research]

BACKGROUND:

Prescribing of levothyroxine and rates of thyroid function testing may be sensitive to minor changes in the upper limit of the reference range for thyroid-stimulating hormone (TSH) that increase the proportion of abnormal results. We evaluated the population-level change in levothyroxine prescribing and TSH testing after a minor planned decrease in the upper limit of the reference range for TSH in a large urban centre with a single medical laboratory.

METHODS:

Using provincial administrative data, we compared predicted volumes of TSH tests with actual TSH test volumes before and after a planned change in the TSH reference range. We also determined the number of new levothyroxine prescriptions for previously untreated patients and the rate of changes to the prescribed dose for those on previously stable, long-term levothyroxine therapy before and after the change in the TSH reference range.

RESULTS:

Before the change in the TSH reference range, actual and predicted monthly volumes of TSH testing followed an identical course. After the change, actual test volumes exceeded predicted test volumes by 7.3% (95% confidence interval [CI] 5.3%–9.3%) or about 3000 to 5000 extra tests per month. The proportion of patients with newly "abnormal" TSH results almost tripled, from 3.3% (95% CI 3.2%–3.4%) to 9.1% (95% CI 9.0%–9.2%). The rate of new levothyroxine prescriptions increased from 3.24 (95% CI 3.15–3.33) per 1000 population in 2013 to 4.06 (95% CI 3.96–4.15) per 1000 population in 2014. Among patients with preexisting stable levothyroxine therapy, there was a significant increase in the number of dose escalations (p < 0.001) and a total increase of 500 new prescriptions per month.

INTERPRETATION:

Our findings suggest that clinicians may have responded to mildly elevated TSH results with new or increased levothyroxine prescriptions and more TSH testing. Knowledge translation efforts may be useful to accompany minor changes in reference ranges.




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Efficacy and Safety of Flow-Diverter Therapy for Recurrent Aneurysms after Stent-Assisted Coiling [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Flow-diverter treatment for previously stented aneurysms has been reported to be less effective and prone to complications. In this study, we evaluated the effectiveness and safety of flow diverters for recurrent aneurysms after stent-assisted coiling.

MATERIALS AND METHODS:

Patients who underwent flow-diverter placement for recurrent aneurysms after stent-assisted coiling between March 2015 and March 2019 were recruited. Clinical and radiographic characteristics and clinical and angiographic outcomes were retrospectively evaluated.

RESULTS:

Among 133 patients who underwent flow-diverter insertion, 17 (male/female ratio = 5:12; mean age, 53.8 years) were treated for recurrent aneurysms after stent placement with (n = 16) or without (n = 1) coiling. Eight patients initially presented with subarachnoid hemorrhage; 7, with headache; and 2, with visual field defects. Angiographic morphology included large/giant saccular in 12 patients, dissecting in 2, fusiform in 1, traumatic pseudoaneurysm in 1, and ruptured blood blister-like aneurysm in 1. The duration between the first treatment and flow-diverter placement ranged from 2 weeks to 15 months (median, 6 months). Flow-diverter placement was successful in all cases without any complications. All patients had favorable outcomes (mRS, 0–2), without any newly appearing symptoms. Aneurysms were followed up with conventional angiography at least once in 6–18 months. Sixteen aneurysms showed complete occlusion, and 1 aneurysm was enlarged.

CONCLUSIONS:

Results from this case series investigating flow-diverter placement for recurrent aneurysms after stent-assisted coiling suggested that the procedure is safe and effective. Further study in a larger population may be warranted.




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MRI Vessel Wall Imaging after Intra-Arterial Treatment for Acute Ischemic Stroke [INTERVENTIONAL]

BACKGROUND AND PURPOSE:

Vessel wall imaging is increasingly performed in the diagnostic work-up of patients with ischemic stroke. The aim of this study was to compare vessel wall enhancement after intra-arterial thrombosuction with that in patients not treated with thrombosuction.

MATERIALS AND METHODS:

From 2009 to 2017, forty-nine patients with an ischemic stroke underwent 7T MR imaging within 3 months after symptom onset as part of a prospective intracranial vessel wall imaging study. Fourteen of these patients underwent intra-arterial treatment using thrombosuction (intra-arterial treatment group). In the intra-arterial treatment group, vessel walls were evaluated for major vessel wall changes. All patients underwent pre- and postcontrast vessel wall imaging to assess enhancing foci of the vessel wall using coregistered subtraction images. A Wilcoxon signed rank test was performed to test for differences.

RESULTS:

In the intra-arterial treatment group, 11 of 14 patients (79%) showed vessel wall enhancement compared with 17 of 35 patients without intra-arterial treatment (49%). In the intra-arterial treatment group, more enhancing foci were detected on the ipsilateral side (n = 18.5) compared with the contralateral side (n = 3, P = .005). Enhancement was more often concentric on the ipsilateral side (n = 8) compared with contralateral side (n = 0, P = .01). No differences were found in the group without intra-arterial treatment between the number and configuration of ipsilateral and contralateral enhancing foci.

CONCLUSIONS:

Patients with intra-arterial treatment by means of thrombosuction showed more (concentric) enhancing foci of the vessel wall ipsilateral compared with contralateral to the treated artery than the patients without intra-arterial treatment, suggesting reactive changes of the vessel wall. This finding should be taken into account when assessing vessel wall MR images in patients with stroke.




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Five most popular regrets after buying home

When it comes to buying a home, many people may not be able to tick all the boxes on the wishlist, so they settle on what fits close to what they believe is an ideal home.




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After the COVID-19 pandemic, older generations should reflect on the need for climate action

The COVID-19 pandemic has prompted a cornucopia of reflections about what is to be learned from it. One of the issues around which this has been the case is climate change.

There are a few ways in which climate change is linked to reflections on the pandemic. One of these links is seeing the pandemic and where there has been relative success in dealing with it as a good case study in the value of scientific advice over politics. The wish is that as a result science might regain a more secure foothold in the debate around climate change. This is generally coupled with a reflection on the extent to which the pandemic might have been even better prepared for and dealt with had early generic warnings about the likelihood of a pandemic been heeded, and also if warnings about the actual pandemic had been acted on earlier than they were at the beginning of 2020. The hope is that this lesson in the consequences of not heeding warnings will rub off on the climate change debate, if not on the most committed climate change deniers.

Another link between the pandemic and climate change is one less reflected on, although I did see at least one article on it, and that is the whole issue of inter-generational ethics that arises. The lock downs associated with COVID-19 tended to be justified on two grounds: One was containing the spread in such a way as to prevent health-care systems from being overwhelmed, and the other had to do with containing the spread of the virus for the sake of the those who were most likely to die from it, namely the elderly, an argument certainly borne out by the statistics even if it is the case that some younger people seem, for reasons yet to be determined, very vulnerable.

And so it was that multitudes of young people have had to put their lives and dreams on hold in order to safeguard the lives of many who are much older than them.  Young people have mostly willingly and without complaint acceded to the moral imperative and practical wisdom of sacrificing things like their personal, educational, athletic, travel, financial and/or employment hopes for the greater good, specifically for the older generation in their society. 

Other groups, like frontline health-care workers, and those newly classified as working in essential jobs, like grocery store workers, have also been asked to make a disproportionate sacrifice. But that is for another article on how their real value has been revealed -- and how that value should be recognized in the post-pandemic world (better wages for one thing). 

Unfortunately, the link between the demands on the young in the pandemic containment strategy and the debate on climate change manifests itself in observing, so far, the unwillingness of populations, and their governments, to demand a reverse moral imperative from older citizens when it comes to sacrifices they might make for the sake of younger and future generations. What are older citizens prepared to sacrifice to safeguard the quality of the lives younger citizens will lead in the coming decades, by substantially reducing our carbon footprint, and seriously dealing with other environmental challenges?

One could argue that, in the case of Canadians, the population has done its part by electing a majority of MPs committed to action on climate change, only to be let down by a government that wants to have its cake and eat it too on climate change by imposing a carbon tax and buying a pipeline. Nevertheless, as we emerge on the other side of the pandemic, hopefully sooner rather than later, it seems to me that there will be a new opportunity for moral reflection on what the generations owe each other. Of course right-wing politicians are always claiming to be worried about passing on fiscal debt to the next generation. But passing on an environmental deficit is a much more real and  serious issue. Part of the moral logic of pandemic containment has been asking one generation to sacrifice for another. It seems only fair then that the political debate about climate change should at some point soon become much more focused on what the older generation can do for the younger generation. Demanding real action from their political leaders, even if it means locking down or at the very least winding down lifestyles that have become ingrained would be a good start. And for those who can afford it, showing a willingness to pay higher taxes to build the infrastructure of a sustainable and livable future would also be in order.     

Bill Blaikie, former MP and MLA, writes on Canadian politics, political parties and Parliament.

Image: John Englart/Flickr

May 8, 2020




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Mortal Kombat 11: Aftermath Expansion Announced, Adds 3 New Characters and New Story

Publisher Warner Bros. Interactive Entertainment and developer NetherRealms Studios have announced a new expansion for Mortal Kombat 11 called Aftermath. It will release on May 26.

The Mortal Kombat 11: Aftermath expansion adds a new cinematic story, three characters and three new skins for $39.99. The three new characters are Fujin, Sheeva, and RoboCop).

A $59.99 Mortal Kombat: Aftermath Kollection has also been announced. It includes the base game, Kombat Pack DLC and the Aftermath expansion. 

View the announcement trailer for the expansion and RoboCop reveal trailer below:

Here is an overview of the expansion:

Mortal Kombat 11: Aftermath is a new expansion for the hit videogame, Mortal Kombat 11, the best-selling title in franchise history that was named Fighting Game of the Year at the 2019 D.I.C.E. Awards. Developed by award-winning NetherRealm Studios, Mortal Kombat 11: Aftermath expands the critically acclaimed story campaign with an all-new, cinematic narrative centered around trust and deceit, while also adding new playable characters in returning Mortal Kombat fighters, Fujin and Sheeva, and guest character, RoboCop, who is making his series debut.

Key Features:

  • Franchise-First Story Expansion – The critically acclaimed story campaign continues with an all-new cinematic narrative that picks up directly where Mortal Kombat 11 left off. Fire God Liu Kang, the new keeper of time and protector of Earthrealm, must now enlist the help of unlikely allies and familiar foes to forge a new history as the fate of two worlds hang in the balance.
  • Exciting New Characters Join the Roster – New playable characters join the fight with the triumphant return of Fujin, the God of Wind who serves as Earthrealm’s protector alongside his brother Raiden, and Sheeva, the fourarmed, half-human and half-dragon queen of the ancient Shokan race. RoboCop, the iconic, highly advanced cybernetic police officer, makes his first appearance in the franchise, continuing the pedigree of popular Mortal Kombat guest fighters. RoboCop in Mortal Kombat 11: Aftermath features the voice and likeness of actor Peter Weller, who portrayed the popular character in both the original RoboCop (1987) film and RoboCop 2 (1990) sequel. Mortal Kombat 11: Aftermath will also include three new character skin packs to be released over time.
  • Fan-Favorite Stages, Stage Fatalities & Friendships Return – In conjunction with the Mortal Kombat 11: Aftermath release, all Mortal Kombat 11 owners will have access to a free content update featuring new Stages, including the return of the Klassic Dead Pool and Soul Chamber arenas; Stage Fatalities, the fan-favorite finishing moves that use the environment to destroy opponents; and the popular Friendships feature, allowing players to take down their adversaries with a hint of kindness.
  • New Players Can Join the Fight with Mortal Kombat 11: Aftermath Kollection – Offers the perfect opportunity for new players to join the fight, featuring all characters, story content, game modes and pre-order bonuses in one ultimate package. This compilation includes Mortal Kombat 11 along with all content from Mortal Kombat 11: Aftermath and the previously released Mortal Kombat 11 Kombat Pack, containing six playable characters—Shang Tsung, Nightwolf, Sindel, Terminator T-800, The Joker and Spawn – plus 25 additional character skins. The Mortal Kombat 11: Aftermath Kollection can be pre-ordered for $59.99 (SRP) with digital pre-orders offering immediate access to Mortal Kombat 11 and the Kombat Pack upon purchase. The physical version will be available this June in the Americas only.
  • Upgrade Options for Current Mortal Kombat 11 Owners – Those who have already purchased Mortal Kombat 11 can pre-order the Mortal Kombat 11 Aftermath expansion for $39.99 (SRP) or the Mortal Kombat 11: Aftermath + Kombat Pack Bundle for $49.99 (SRP).
  • Pre-order for Exclusive Content – All preorders* receive the Eternal Klash Skin Pack at launch, featuring three new character skin variants – “Unbound Rage” Scorpion inspired by Mortal Kombat (2011), “Son of Arctika” Sub-Zero inspired by Mortal Kombat: Deception and “Kori Power” Frost, a Klassic version of the Lin Kuie warrior.
  • Best-In-Class, Brutal Kombat  Mortal Kombat 11 is the latest installment in the critically acclaimed franchise, providing a deeper and more personalized experience than ever before. The best-selling title is packed to the brim with multiple features and modes for all players, including the Story mode, Custom Character Variation System, Towers of Time, Kombat League, The Krypt and the signature roster returning and franchise-first fighters, all equipped with powerful Krushing Blows and unique Fatalities that display devastatingly brutal cinematic visuals.

A life-long and avid gamer, William D'Angelo was first introduced to VGChartz in 2007. After years of supporting the site, he was brought on in 2010 as a junior analyst, working his way up to lead analyst in 2012. He has expanded his involvement in the gaming community by producing content on his own YouTube channel and Twitch channel dedicated to gaming Let's Plays and tutorials. You can contact the author at wdangelo@vgchartz.com or on Twitter @TrunksWD.

Full Article - https://www.vgchartz.com/article/443404/mortal-kombat-11-aftermath-expansion-announced-adds-3-new-characters-and-new-story/




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Small robots could help look after salmon without stressing them out

Robots are being developed to help with tasks like fixing the sea cages where fish are farmed, and their size seems to be all that affects how the fish react




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How to Watch the Xbox Series X First Look Stream This Afternoon

Watch everything unfold in real time, rather than reading about it later.




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Scientists Cry Foul After Government Redacts Criticism of Its Response in Key Coronavirus Report

"This government has failed to show any self-criticism whatsoever, when it is glaringly obvious to everybody that big mistakes have been made."




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After Five Bloody Years in Syria, Russia Is Turning Against Iran—and Assad

Photo Illustration by The Daily Beast/Getty

GAZIANTEP, Turkey—After five years fighting to preserve Bashar al-Assad’s regime in Syria, Russia now appears inclined to dispose of its infamous client. Assad’s persistent brutality and corruption, and his inability to establish even the semblance of a functioning state, has grown to be a burden Moscow would prefer not to bear.

And then there’s the problem of Iran. Assad, members of his family, and his Alawite clansmen enjoy close, perhaps unbreakable, bonds to the regime in Tehran and to Iranian-backed militias in Syria. All of which undermines Moscow’s primary mission there: to rehabilitate the Assad regime as a symbol of stability capable of attracting hundreds of billions of dollars of foreign investment for reconstruction, which Russian firms would then be poised to receive. 

As long as Assad’s relatives continue to function as a mafia and give free rein to Iranian troops using Syria as base of operations to threaten Israel and plan attacks against U.S. troops in Iraq, those countries likely to foot the bill for Syrian reconstruction—the nations of Europe and the Gulf—are unlikely to come up with the cash. 

Read more at The Daily Beast.




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Cork-coated spacecraft to be chucked out of the ISS for re-entry test

A spacecraft designed to study re-entry into Earth's atmosphere has a nose coated in cork, a cheap and lightweight alternative to other materials




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A giant raft of rock may once have floated across Mars’s ancient ocean

Mars could have had an ancient ocean in its northern hemisphere, and a large raft of volcanic rock may have floated across it to settle into mounds we can see today




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China just tested a spacecraft that could fly to the moon and beyond

China just tested its biggest rocket yet, along with a new capsule designed to carry humans to its planned space station, the moon and beyond




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RPGCast – Episode 279: “RPGamer: The After Years”

RPGamer’s hosts battle through various ailments to bring you this week’s show. Jon gets ready for National StreetPass day, Anna gets stops Activision Blizzard from...





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Could hotel service robots help the hospitality industry after COVID-19?

A new research study, investigating how service robots in hotels could help redefine leadership and boost the hospitality industry, has taken on new significance in the light of the seismic impact of the Covid-19 outbreak on tourism and hospitality.




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Accumulation of gene mutations in chronic Graft-versus-host disease

Mutations in white blood cells can contribute to abnormal immune profile after hematopoietic stem cell transplantation.




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Czech Airlines to restart some flights after coronavirus grounding




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Protesters demand closure of LG Polymers plant in India after toxic gas leak




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Taking on COVID-19, South Africa Goes After Cigarettes and Booze, Too

JOHANNESBURG -- The dealer had a stash, but the young woman wasn't getting through the door without an introduction. That's where her friend, already a trusted customer, came in. And even then there were complications.The woman wanted Stuyvesants. The dealer had Courtleighs. But in a South Africa where the sale of cigarettes is newly illegal, quibblers risk nicotine fits.She took the Courtleighs and high-tailed it out of there."I feel like I'm buying cocaine," said the woman, 29, who asked not to be named for fear of being fined or arrested.In late March, in the midst of the coronavirus outbreak, the South African government banned the sale of tobacco and alcohol as part of a broad lockdown -- one of the strictest anywhere. But even as the government has begun rolling back the lockdown, the bans remain in effect.A government minister, Nkosazana Dlamini-Zuma, cited "COVID-19 reasons" for maintaining the ban.Dlamini-Zuma, a doctor who served as health minister in the 1990s and is now cooperative governance minister, said that "besides the effects itself on the person's lungs," there were concerns that smoking could promote coronavirus infection."The way sometimes tobacco is shared does not allow for social distancing," she said, "but actually encourages the spread of the virus."Defending the ban of alcohol sales amid cries of protest from the liquor industry, President Cyril Ramaphosa said alcohol was "a hindrance to the fight against coronavirus.""There are proven links between the sale and consumption of alcohol and violent crime, motor vehicle accidents and other medical emergencies at a time when all public and private resources should be preparing to receive and treat vast numbers of COVID-19 patients," the president said in a statement.The government has also cited the risk of domestic violence in households where families are isolated at home.Perhaps not surprisingly, an underground market in both cigarettes and alcohol quickly sprung up.Like bootleg markets everywhere, it relies on word-of-mouth, as the 29-year-old woman who settled for the Courtleighs soon learned.She made her purchase in a suburb of Vereeniging, a city south of Johannesburg, where dealers are said to sell only to buyers referred by someone they know. And they sell only from their homes to avoid driving around with large quantities of cigarettes, since if they were to be caught at one of the dozens of police roadblocks set up around the country, they could be arrested on the spot.Instead, the smoker carries the risk -- and the cost. A pack of 20 cigarettes now goes for upward of 150 rand (about $8), three times the old legal price. Underground alcohol prices have also skyrocketed. A bottle of low-end vodka that usually sells for 120 rand ($6) now sells for at least 400 rand ($21).South Africa lifted its nationwide lockdown on May 1 but is continuing to implement strict social distancing and face mask rules. Already under siege from HIV, the country has around 8,200 confirmed cases of the coronavirus and has reported about 160 deaths.The country had implemented one of the world's most stringent lockdowns after recording its first coronavirus-related death in March. In addition to banning the sale of cigarettes and alcohol, the regulations banned jogging and dog-walking, and shuttered parks.Before the lockdown, with a ban looming, some smokers stocked up on cartons of cigarettes. But when the ban on cigarettes was extended beyond May 1, things for smokers began to grow tense.Now it's a matter of who you know. The cafe owner willing to slip a box under a container of milk, perhaps, or a supermarket cashier willing to steal and resell cigarettes languishing in the storeroom.In one Pretoria township where everyone knows everyone -- including the police -- few dare sell cigarettes from their homes. Instead, dealers hide among young men milling around on the neighborhood corner.A 23-year-old smoker said that when he saw a group of four men sharing a cigarette, he approached them to find out where they had found the contraband. They just so happened to be selling, they told him.Desperate after a failed attempt to quit smoking, he said, he paid 160 rand for his favorite brand and "ran home," where he took a photograph of the sealed pack, planning to share it on WhatsApp with envious fellow smokers.But when he opened the pack, a cloud of sawdust choked him. There was not a cigarette to be found.Smokers say they are finding fake cigarettes in sealed boxes that look exactly like legitimate brands. And those who are desperate enough are buying unknown brands that have appeared during the lockdown, with names like Pineapple and Chestel, and are notorious for inducing immediate coughing.The tobacco industry has not taken kindly to the government's new policy.The ban has fueled an underground cigarette trade that was thriving even before the lockdown. By some estimates, it made up more than 30% of the market, depriving the above-ground tobacco industry of profit and the government of tax revenue.Now both industry and government are losing even more.The country's largest cigarette manufacturer, British American Tobacco South Africa, at one point threatened legal action if the government did not drop its ban, but Wednesday changed course. "We have taken the decision not to pursue legal action at this stage," it said in a statement, "but, instead, to pursue further discussions with government."The company said, "We are convinced that by working together we can find a better solution that works for all South Africans and removes the threat of criminal sanction from 11 million tobacco consumers in the country."The ban on cigarettes and alcohol has set off a debate on civil liberties in a country with one of the world's most liberal constitutions. While South Africa was an early adopter of public smoking regulations, many see the bans as a symbol of government overreach.Though its coronavirus policies may have succeeded in keeping the outbreak in check, some are calling the government hypocritical. Junk food remains readily available. And officials strictly limited outdoor exercise during the lockdown.In a country increasingly struggling with diabetes and obesity, such inconsistencies undercut the government's argument that it is guarding the public's health, said one South African constitutional law expert, Pierre De Vos."In the long term, if the government overreaches and it wants to continue imposing these limits when the threat has subsided, I think the courts will invalidate this," he said.Still, the ban may have yielded at least one former smoker: the man who bought the box of sawdust."I cannot just go around losing money like that," he said. "I just said to myself, 'Nah, man, it's not worth it. I'll stay home and eat sweets, as that's what's legal now.'"This article originally appeared in The New York Times.(C) 2020 The New York Times Company





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UK coastguard urges people to stay home after increase in calls

Meanwhile police in London say they’re ‘losing the battle’ as people gather in parks despite coronavirus clockdown

The coastguard has urged the public not to ignore the government’s stay-at-home message after recording its highest number of distress calls in a single day since the lockdown began.

The rescue service said it dealt with 97 incidents on Friday, more than half the daily average over the previous month.

Continue reading...




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Ice busy signing draft selections to contracts

It’s that time of the year in the WHL. News of player signings are a daily occurrence and the Winnipeg Ice’s management team has been busy. On Monday, the club announced ...




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Texas Residents Warned Not to Flush Gloves and Face Masks, After Workers Unclog Sewage Pumps 20 Times in a Day

Water utility workers in El Paso, Texas were forced to unclog pumps over 20 times in 24 hours after residents refused to heed their call to refrain from flushing personal protective equipment and other coronavirus-related items down the toilet.




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Scammers Could Be After Your Stimulus Check. Here’s How to Avoid Them

There's been a spike in scam calls, emails and texts