The aim of this study was to investigate the kinetics of immunoglobulin M (IgM) during the different stages of sepsis.In this prospective multicenter study, blood sampling for IgM measurement was done within the first 24 hours from diagnosis in 332 critically ill patients; in 83 patients this was repeated upon progression to more severe stages. Among these 83 patients, 30 patients with severe sepsis progressed into shock and IgM was monitored daily for seven consecutive days. Peripheral blood mononuclear cells (PBMCs) were isolated from 55 patients and stimulated for IgM production.Serum IgM was decreased in septic shock compared to patients with systemic inflammatory response syndrome (SIRS) and patients with severe sepsis. Paired comparisons at distinct time points of the sepsis course showed that IgM was decreased only when patients deteriorated from severe sepsis to septic shock. Serial measurements in these patients, beginning from the early start of vasopressors, showed that the distribution of IgM over time was significantly greater for survivors than for non-survivors. Production of IgM by PBMCs was significantly lower at all stages of sepsis compared with healthy controls.Specific changes of circulating IgM occur when patients with severe sepsis progress into septic shock. The distribution of IgM is lower among non-survivors. Although initially considered a state of hyperactivity of the innate and adaptive immune systems, it is currently understood that severe sepsis and septic shock are characterized by a functional state of immunoparalysis . This inTo this end, it was expected that the intravenous administration of immunoglobulin preparations enriched in IgM would be beneficial for patients with severe sepsis and septic shock. On the contrary, most of the conducted randomized clinical trials (RCT) yielded contradictory results ,5, despiThe existing controversies of conducted RCTs may derive from our incomplete understanding of the kinetics of IgM over the time course of sepsis. The current study was designed in order to embed into the changes of circulating IgM levels of patients upon progression to the more severe stages of sepsis in relation with the production of IgM from circulating lymphocytes and with the final outcome.This prospective multicenter study was conducted from January 2010 to December 2010 in 27 departments across Greece participating in the Hellenic Sepsis Study Group. The participating departments were 15 intensive care units (ICUs), seven departments of Internal Medicine, two departments of pulmonary medicine, two departments of surgery and one department of urology.Patients with signs of systemic inflammatory response syndrome (SIRS) either admitted to the emergency department or hospitalized in the general ward or in the ICU were eligible. Written informed consent was provided by the patients or by their first-degree relatives for patients unable to consent. The study protocol was approved by the Ethics Committees of the participating hospitals . Each patient was enrolled once.Inclusion criteria were: (a) age ≥18 years; (b) diagnosis of SIRS, sepsis, severe sepsis or septic shock; and (c) SIRS due to acute pancreatitis or sepsis due to specific infections. These infections were: community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP), acute pyelonephritis (UTI), acute intra-abdominal infection (IAI) and primary bacteremia (BSI); and (d) first blood sampling within 24 hours from diagnosis.3; (c) chronic intake of corticosteroids defined as systemic intake of more than 1 mg/kg of equivalent prednisone for more than one month; and (d) other types of immunodeficiency like organ transplantation, hematologic malignancies and intake of chemotherapy.Exclusion criteria were (a) infection by the human immunodeficiency virus type 1; (b) neutropenia defined as less than 1,000 neutrophils/mmco2<32 mmHg or more than 20 breaths/min, (c) pulse rate >90/min, and (d) white blood cells >12,000/mm3 or <4,000/mm3 or >10% of band forms. Sepsis was defined as any microbiologically or clinically documented infection complicated by SIRS. Patients with sepsis were classified as suffering from uncomplicated sepsis, severe sepsis or septic shock, according to standard definitions [SIRS was diagnosed by the presence of at least two of the following : (a) corinitions . Multiplinitions . Acute pinitions -11.For each patient a complete diagnostic workup was performed comprising history, thorough physical examination, white blood cell (WBC) count, blood biochemistry, arterial blood gas, blood cultures from peripheral veins and central lines, urine cultures, chest X-ray and chest and abdominal computed tomography if appropriate. If necessary, quantitative cultures of tracheobronchial secretions (TBS) or bronchoalveolar lavage (BAL) were performed and evaluated as previously described . Survivath Department of Internal Medicine at ATTIKON University Hospital of Athens. Tubes were centrifuged and serum was kept frozen at -70°C until assayed. IgM was estimated in duplicate by an enzyme-linked immunosorbent assay  following the manufacturer’s instructions; the lower detection limit was 20 ng/ml. All estimations were performed and reported by two technicians who were blinded to clinical information.For all enrolled patients and for 35 healthy volunteers 5 ml of blood was sampled within the first 24 hours from diagnosis. From this volume: (a) 2 ml was collected into sterile, pyrogen- and anticoagulant-free tubes  for quantitative measurement of IgM; and (b) 3 ml was collected into EDTA-coated tubes (Vacutainer) for the measurement of the absolute counts of B lymphocytes. From 55 patients and 20 healthy volunteers another 8 ml was collected into heparin-coated tubes (Vacutainer) and used for the isolation of peripheral blood mononuclear cells (PBMCs). For 83 patients, blood sampling was repeated on the day of worsening of sepsis stage. For 30 patients who progressed into septic shock, blood was sampled daily for seven days starting immediately after the start of vasopressors. Tubes were transported by a courier service within the same day to the Laboratory of Immunology of Infectious Diseases of the 4The central laboratory of the study participates in the UK NEQAS quality control system for leukocyte immunophenotyping (registration number 40926). In this laboratory, the absolute count of B lymphocytes was measured as described elsewhere . Briefly6 cells/ml. PBMCs were incubated in the absence or presence of 5 μg/ml of the lymphocyte agonist phytohemagglutin (PHA) of Phaseolus vulgaris  for 24 or 72 hours at 37°C in 5% CO2 atmosphere.The isolation of PBMCs was limited to 55 patients because these samples should come from patients hospitalized at study sites close to the central laboratory. This allowed the time from blood collection until processing to be less than 30 minutes. As such, PBMCs were studied from patients hospitalized at the ATTIKON University Hospital that is close to the central laboratory of the study. Production of IgM was studied according to a procedure described elsewhere . HeparinAt the end of the incubation, the plates were centrifuged. Supernatants were kept stored at -70°C until assayed. Concentrations of IgM were measured at the end of the 72-hour incubation period; those of tumor necrosis factor alpha (TNFα) were measured at the end of the 24-hour incubation period. Measurements were done in duplicate and IgM was measured as described above. TNFα was measured by an enzyme-linked immunosorbent assay . The lower detection limit was 40 pg/ml.The primary endpoint was the over-time changes of IgM serum levels of patients upon progression to septic shock in relation with the final outcome that is survival or 28-day mortality. The secondary study endpoint was the impact of sepsis on production of IgM from circulating lymphocytes.X2 test for qualitative variables and by ANOVA with post hoc Bonferroni corrections for quantitative variables.Demographic characteristics of enrolled patients were provided as percentages for qualitative variables and as means ± standard error of the mean (SE) or medians and interquartile ranges for quantitative variables. Comparisons between groups were done by the U test with corrections by Bonferroni for multiple testing. Paired comparisons of serum IgM at baseline and upon progression of the same patients to a more severe stage were done by the Wilcoxon’s rank sum test. For every patient with septic shock, the area under the curve (AUC) of IgM over time for seven days was measured by the linear trapezoidal rule. Comparison between survivors and non-survivors was done by Student’s t test.Serum concentrations of IgM were expressed as medians and 95% confidence intervals (CI). Comparisons between groups were done by the Mann-Whitney X2 test.Concentrations of IgM and of TNFα in supernatants of PBMCs were expressed as means ± SE. Comparisons between groups were done by the Kruskal-Wallis test with corrections by Bonferroni for multiple testing. Patients were also divided into 'non-IgM’ and 'IgM-producers’ if the concentrations of IgM in supernatants of PBMCs were below the limit of detection or not. Comparisons were done by the P below 0.05 were considered significant.Values of A total of 351 patients were screened and 332 were enrolled  circP = 0.001), to patients with SIRS (P = 0.028) and to patients with severe sepsis (P <0.0001) but not to patients with uncomplicated sepsis (P = 0.754) .Paired comparisons of IgM were done for 83 patients at two specific time points: on initial diagnosis and on worsening. These measurements involved: 13 patients initially diagnosed with uncomplicated sepsis who worsened into severe sepsis; 16 patients initially diagnosed with uncomplicated sepsis who worsened into septic shock; 49 patients initially diagnosed with severe sepsis who worsened into septic shock; and five patients initially diagnosed with septic shock who worsened into MODS . The time curves of IgM were designed for 30 patients with severe sepsis who progressed into septic shock. Sampling was started on the day of the start of vasopressors and lasted for seven consecutive days. Separate curves were designed for survivors and non-survivors. These curves suggested that circulating IgM remained stable and at low levels in non-survivors whereas IgM of survivors increased to an early peak and then gradually decreased. As a consequence, the distribution of IgM expressed by the AUC of serum IgM over time was significantly greater for survivors than for non-survivors. This finding was similar both when outcome was assessed after 28 days and at hospital discharge  the lack of explanation why septic shock is a specific condition where circulating IgM is depleted. It is most probable that this is related with the consumption of circulating IgM during sepsis worsening and with the inability of B lymphocytes for IgM production; and (b) the lack of explanation from our findings why circulating IgM does not differ between uncomplicated sepsis and septic shock.The present study managed to identify specific changes of the kinetics of circulating IgM that are related with final outcome. These occur when patients with severe sepsis progress to septic shock. In these patients, the distribution of IgM is lower among non-survivors. These findings may guide the design of future RCTs for the management of septic shock.● Serum levels of IgM are significantly decreased in septic shock but not in severe sepsis.● Dramatic changes of serum IgM occur when patients at severe sepsis progress into septic shock. In these cases, the distribution of IgM is lower among non-survivors.● Circulating lymphocytes of patients render anergic for the production of IgM.APACHE II: Acute physiology and chronic health evaluation II; ARDS: Acute respiratory distress syndrome; BSI: Primary bacteremia; CAP: Community-acquired pneumonia; IAI: Intra-abdominal infection; IgM: Immunoglobulin M; IRA: Innate response activator; MODS: Multiple organ dysfunction syndrome; PBMC: Peripheral blood mononuclear cell; PHA: Phytohemagglutin; RCT: Randomized controlled trial; SIRS: Systemic inflammatory response syndrome; TNFα: Tumor necrosis factor alpha; UTI: Acute pyelonephritis; VAP: Ventilator-associated pneumonia; WBC: White blood cell.The authors declare that they have no competing interests related to this submission.EJGB designed the study and performed the analysis, wrote the manuscript and agreed to the final submitted version. EA, ML, IP, NKG, IT, MB, KS and AK provided clinical data, drafted the manuscript and agreed to the final submitted version. MG and TK conducted laboratory experiments, drafted the manuscript and agreed to the final submitted version. MAK validated the statistical analysis, drafted the manuscript and agreed to the final submitted version. AA participated in study design and interpretation of data, drafted the manuscript and agreed to the final submitted version. All authors read and approved the final manuscript.


ARID1A mutations are observed in various tumors, including ovarian clear cell (OCCC) and endometrioid carcinomas, endometrial, and breast carcinomas. They commonly result in loss of ARID1A-protein expression and frequently co-occur with PI3K/AKT-pathway activating mechanisms. The aim of this study was to test the hypothesis as to whether PI3K/AKT-pathway activation is a critical mechanism in ARID1A-mutated tumors and if consequently ARID1A-deficient tumors show increased sensitivity to treatment with PI3K- and AKT-inhibitors. Upon ARID1A knockdown, MCF7 breast cancer cells and primary MRC5 cells exhibited a significantly increased sensitivity towards the AKT-inhibitors MK-2206 and perifosine, as well as the PI3K-inhibitor buparlisib. Knockdown of ARID1A in MCF7 led to an increase of pAKT-Ser473. AKT-inhibition with MK-2206 led to increased apoptosis and to a decrease of pS6K in ARID1A-depleted MCF7 cells but not in the controls. In five OCCC cell lines ARID1A-deficiency correlated with increased pAKT-Ser473 levels and with sensitivity towards treatment with the AKT-inhibitor MK-2206. In conclusion, ARID1A-deficient cancer cells demonstrate an increased sensitivity to treatment with small molecule inhibitors of the PI3K/AKT-pathway. These findings suggest a specific requirement of the PI3K/AKT pathway in ARID1A-deficient tumors and reveal a synthetic lethal interaction between loss of ARID1A expression and inhibition of the PI3K/AKT pathway. AT-rich interacting domain containing protein 1A (ARID1A) are frequently observed in a wide variety of gynecological and non-gynecological cancers [ARID1A has recently been identified as a bona fide tumor suppressor gene and is currently being intensively investigated, the knowledge about the function and the consequences of a loss of expression of this protein is relatively limited [Mutations in the gene encoding the  cancers . These o cancers , 4, in e cancers , 6, as w cancers , 8. Non- cancers , 10, gas cancers -13, hepa cancers -16, as w cancers , 18. The cancers . Althoug limited .ARID1A mutations frequently coexist with activating mutations of PIK3CA [PIK3CA mutations and loss of PTEN expression were excluded [Interestingly, f PIK3CA , 19 and/f PIK3CA , which bf PIK3CA . Similarexcluded .ARID1A mutations and PI3K/AKT pathway activation, indicating that tumor cells with loss of ARID1A expression may be dependent on constitutive activation of the PI3K/AKT-pathway and consequently may also be more vulnerable to its inhibition [These observations strongly suggest interdependency between hibition . This isARID1A-mutated tumors on activating mechanisms of the PI3K/AKT-pathway, which may be exploited therapeutically.In this study, we demonstrate that depletion of ARID1A protein expression significantly increases the sensitivity of cancer cells towards PI3K- and AKT-inhibitors, which is reflected by increased rates of apoptosis in treated ARID1A-depleted cells. Our findings suggest a dependency of ARID1A-depleted MCF7 cells were found to be significantly more sensitive to treatment with the AKT-inhibitors MK-2206 and perifosine, as demonstrated in Figure We performed the same experiment in the primary fibroblast cell line MRC5 to verify our observations in a cell line without any oncogenic mutations and, similarly, we found an increased sensitivity of ARID1A-depleted MRC5 cells towards treatment with MK-2206 with LogIC50 of −6.307 ±0.173 as compared to −5.316 ±0.236 for the control (p=0.002). This meant an approximately 10-fold increase in sensitivity. For treatment with perifosine the LogIC50 values were −5.867 ±0.135 in ARID1A-depleted MRC5 cells, as compared to −5.024 ±0.199 in the controls: equivalent to an increase in sensitivity of approximately 7-fold in ARID1A-depleted MRC5 cells (p=0.004).As a control, no significant difference in sensitivity to treatment with MK-2206 or perifosine was found in the ARID1A-deficient OCCC cell line OVSAYO after transfection with ARID1A siRNA.The sensitivity to treatment with the PI3K inhibitor buparlisib in ARID1A-depleted MCF7 and MRC5 cells was shown to increase significantly with comparison to the controls, but less pronounced than for inhibition of AKT Figure . The Log473) as has been described in endometrial cancer cell lines [473 as well as an increased downstream phosphorylation of p70S6kinase (pS6K) as shown in Figure First, we verified that loss of ARID1A increases phosphorylation of AKT at Ser-473  was observed in the MCF7 control cells (transfected with siLUC) with or without treatment with the AKT-inhibitor, MK-2206. In contrast, PARP1 cleavage was discretely detectable in ARID1A-depleted MCF7 cells and substantially increased after treatment with the AKT-inhibitor MK-2206 Figure . Similard Figure .473- and AKT- levels, and led to a decreased level of pS6K, but did not lead to a difference in the amount of viable MCF7 cells after 5 days  scored as the second top candidate preferentially necessary for the growth of ARID1A-mutated cancer cell lines in the project, ‘Achilles’ [ARID1A-mutated tumors on activation of the PI3K/AKT pathway is further supported by a study in ARID1A-knockout and ARID1A/PTEN-double-knockout mice, where it was observed that only mice with simultaneous loss of ARID1A and PTEN expression developed poorly differentiated ovarian tumors, in contrast to mice with loss of only ARID1A that did not develop ovarian tumors [An interdependency between chilles’ . A depenn tumors . This inn tumors .ARID1A-mutated OCCC have been reported to be associated with resistance to conventional platinum-based chemotherapy regimens in a recent study [Interestingly, nt study . If thisin vitro. The findings suggest a specific requirement of the PI3K/AKT pathway in ARID1A-deficient cancer cells and reveal a synthetic lethal interaction between loss of ARID1A expression and inhibition of the PI3K/AKT pathway.In conclusion, ARID1A deficiency leads to a significantly increased sensitivity towards PI3K- and AKT-inhibition in tumor cells The breast carcinoma cell line MCF7  and the human primary lung fibroblasts MRC5 (ATCC) were grown in Dulbecco's modified Eagle's medium (DMEM) . The OCCC cell lines ES-2, RMG-1, OVSAYO, OVISE, HCH-1  were grown in RPMI 1640 medium (Gibco). All cell lines used in this study were verified by short tandem repeat (STR) DNA identity testing. All growing media were supplemented with 10% (v/v) fetal bovine serum (Gibco) and Antibiotic-Antimycotic  (Gibco). Cell cultures were maintained at 37°C in a humidified atmosphere at 5% CO2. Cells were passaged at 90% confluency.Transient knockdown of ARID1A was performed with four different ARID1A siRNAs  using RNAimax (Gibco) according to the manufacturer's instructions. The control cells were transfected with siRNA against luciferase (sense): CGUACGCGGAAUACUUCGATTdTd . The AKT1 knockdown control experiments were performed with a siRNA smart-pool  siRNA, Dharmacon). Cells were transfected overnight and the medium was replaced the following morning. The size of culture dishes and length of transfection is indicated for the specific experiments.Selleckchem.com . The inhibitors were diluted according to the manufacturer's protocol (MK-2206 and buparlisib in DMSO and perifosine in sterile ddH2O) and prepared freshly for each treatment. Vehicle substance was used in the highest corresponding concentration for the treatment of the controls.The AKT-inhibitors MK-2206, perifosine, and the pan-PI3K-inhibitor buparlisib (BKM120) were all obtained from Selleckchem.com). In brief, cells were seeded in 96-well plates at concentrations of 1000-2000 cells per well (MRC5 cells were seeded at a density of 10'000 cells per well). On the following day, cells were transiently transfected overnight with the corresponding siRNAs and then treated with the corresponding drugs at the indicated concentrations or vehicle substance as described above. Treatment was repeated after 2-3 days. After a total period of 4-5 days' treatment, the medium was replaced by phenol-red free medium and the quantity of viable cells was assessed using a MTS assay  according to the manufacturer's protocol. Plate absorbances were obtained using a spectrophotometer . Each experiment was performed on at least two separate occasions for every unique ARID1A siRNA sequence and each of them run in triplicates.Drug sensitivity assays were performed according to the drug manufacturer's recommendations (473) , phospho-Thr421/Ser424-p70 S6 Kinase (pS6K) , PARP-1 , beta-Actin . Incubation with the primary antibody was followed by incubation with a HRP-conjugated secondary antibody  and chemiluminescent detection of proteins .Cells were seeded in 6cm culture dishes and transfected with the corresponding siRNAs the following day as described above, followed by the drug treatment where indicated. Whole-cell protein extracts were prepared from cells lysed before reaching confluence with an SDS lysis buffer. Western blotting was performed with primary antibodies against ARID1A , AKT1 , phopho-Ser473-AKT  based on labelling of DNA strand breaks was used to directly visualize apoptosis in the treated cell cultures. In brief, cells were directly plated on microscopy coverslips transfected with siRNAs and treated for 60h with MK-2206 or vehicle substance as described above. Positive controls were obtained by treatment of fixated non-apoptotic cells with 30U/l recombinant DNase (in 1% (w/v) BSA / PBS) for 1h immediately prior to the addition of the incubation mix. Negative controls were obtained by omission of the TUNEL enzyme in the incubation mix. The coverslips were mounted in DAPI mounting medium . A Leica DMI6000B microscope was used for analysis of the specimens.Statistical analysis was performed with graph pad prism version 6 . Results are expressed as mean ± standard error of the mean (SEM). Significance was assumed if p<0.05 (F-test) in comparison to the respective controls.


When a long distance oil pipeline crosses an earthquake disaster area, inertial force and strong ground motion can cause the pipeline stress to exceed the failure limit, resulting in bending and deformation failure. To date, researchers have performed limited safety analyses of oil pipelines in earthquake disaster areas that include stress analysis. Therefore, using the spectrum method and theory of one-dimensional beam units, CAESAR II is used to perform a dynamic earthquake analysis for an oil pipeline in the XX earthquake disaster area. This software is used to determine if the displacement and stress of the pipeline meet the standards when subjected to a strong earthquake. After performing the numerical analysis, the primary seismic action axial, longitudinal and horizontal displacement directions and the critical section of the pipeline can be located. Feasible project enhancement suggestions based on the analysis results are proposed. The designer is able to utilize this stress analysis method to perform an ultimate design for an oil pipeline in earthquake disaster areas; therefore, improving the safe operation of the pipeline. Seismic activity is a sudden movement of the earth’s crust caused by a rapid release of earth crust energy. A seismic event is a relatively severe geological disaster, which not only destroys houses and buildings but also results in secondary disasters. In pipeline projects, an earthquake is one important cause of pipeline failure. According to statistical data provided by the Federal Emergency Management Agency (FEMA), there are two types of pipeline failure caused by earthquakes: pipeline breakage  and pipeline leakage . According to a statistical data report from the European Gas pipeline Incident data Group (EGIG), by the end of December 2005, gas pipeline fracture accidents caused by earthquakes represented 7.1% of total accidents  = W+P .SH should be smaller than 0.72 times the yield strength, which is SH < 0.72SMYS, therefore:D is pipe outside diameter, mm; P is the design pressure for the pipeline, bar; SH is the hoop stress from the internal pressure of the pipeline, MPa; t is the pipe thickness, mm; and SMYS is the minimum yield stress of pipeline, MPa.Based on the term 402.3.1 in ASME standard B31.4：For the restricted pipeline, 2. Dynamic calibration. The dynamic stress calibration of an oil transportation pipeline focuses on the incidental load condition. In the Cartesian coordinate system, the direction of earthquake load is divided into the following three directions: axial (X direction), longitudinal (Y direction) and transverse (Z direction). Their calibration bases are same. In CAESAR II, the dynamic load condition of an earthquake is normally expressed as [OCC] = W+P+D (D is the dynamic load).SL ≤ 0.80SMYS, therefore:SL is longitudinal stresses, MPa; SMYS is the minimum yield strength of the pipe, MPa; E is the modulus of elasticity of steel, MPa; Sh is the hoop stress from fluid pressure, MPa; T1 is the temperature at time of installation, °C; T2 is the maximum or minimum operating temperature, °C; α is the linear coefficient of thermal expansion, mm/mm°C; ν is Poisson’s ratio (ν = 0.30 for steel).Based on the term 402.3.1 in ASME standard B31.4: The sum of the longitudinal stresses produced by pressure, live and dead loads, and those produced by occasional loads, such as wind or earthquake, shall not exceed 80% of the specified minimum yield strength of the pipe, which is 3. Displacement calibration. There is no accurate standard for the pipeline displacement calibration. In section 5.6.2 of GB50253 Code for design for oil transportation pipeline engineering, there is a general specification for the displacement condition of a steel pipeline: the maximum displacement of a steel pipeline in the horizontal direction should not exceed 0.03 times the average diameter of the steel pipeline, which isx is the maximum displacement of the steel pipeline in the horizontal direction, m; and D is the average diameter of the steel pipeline, m.Based on the design materials for the XX earthquake disaster location, X80 steel pipe is used for the oil pipeline, the installation temperature is 20°C, the running temperature is 80°C and the operating pressure is 8 MPa. The ambient temperature of the pipeline is 20°C, the backfill soil is saturated coarse sand and the seismic intensity level is 7, (a low probability earthquake for limit-state design consideration). The basic seismic acceleration is 0.30 g, the elevation of the bottom slope at the west side of the pipeline is 361.66 m, the elevation of the middle slope is 383.95 m and the elevation of the top slope is 408.33 m. The direction of the pipeline is shown as R = 10D, in which D is the outside diameter [The pipe is a spatial model, i.e., there are the length components in all three directions of X, Y, Z. The total length of the pipeline model is 780 m. fixed piers 1 and 2 are set at the start and end points, respectively, of the pipeline. There is 30 m of pipeline before the west side soil entrance (guidance point B), and the entrance angle is 30°. The west horizontal section is 110 m and the inclined pipeline is 215 m. There is 30 m of pipeline after the east exit (guidance point I), and the exit angle is 30°. The east horizontal section is 105 m and the east inclined pipeline is 290 m. The curvature radius of the bended pipeline is diameter .SS of the short period design spectrum of the damping coefficient is 4%  and the response acceleration S1 of the design spectrum with a one second period is calculated. Based on Tables Fa and Fv are determined. After inputting the related earthquake frequency spectrum parameters into the frequency spectrum analysis modules, the analysis chart will be generated by the software. The frequency spectrum parameters of the XX pipeline are shown in αmax is the maximum value of the horizontal earthquake affecting factor, 0.72 in this case; and Tg is the characteristic period of the ground.Based on the earthquake related materials for the XX pipeline and the GB50011–2010 Code for seismic design of buildings, the ground’s characteristic period and the maximum value of the horizontal seismic coefficient can be obtained. According to Formulas (4) and (5), the response acceleration After loading the spectrum to the pipeline model, the earthquake working conditions must be established. We analysed one static working condition and four dynamic working conditions. The dynamic condition comprises occasional load condition in each of the axial direction (X direction), the longitudinal direction (Y direction) and the transverse direction (Z direction), as well as the occasional load condition with three directions combined with the stress checking method identical to one-direction occasional load conditions. Of particular note is that the combined occasional load condition is established through transforming into seismic action the acceleration calculated based on the spectrum in three directions, and loading the seismic action on the pipeline by combining load conditions. The integrated seismic acceleration (force) is calculated following acceleration (force) synthesis theorem in the Cartesian coordinate system. The working condition combinations are listed After building the dynamic load and combining the working conditions, the CAESAR II software can produce the dynamic stress analysis report, which includes the details of the pipeline stress, displacement, constraints loading, etc. Because the pipeline start points, end points, west side guidance section and east side guidance section aim to reduce the influence from the pipeline located outside the model, when performing the stress analysis, the displacement and stress of these four special locations can be neglected in the XX earthquake disaster section. Consequently, the pipeline is studied from 32 m-740 m .D = 12.2 mm, which meets the displacement requirement. Comparing the maximum axial displacement and the longitudinal displacement during seismic activity, the maximum transverse displacement is larger. Therefore, in actual projects, it is suggested to add the corresponding pipeline parts necessary to restrain the transverse displacement of the pipeline.After gathering the maximum displacement and stress Tables  and 9, iCompared to the transverse and longitudinal earthquake action, the axial (X direction) earthquake action causes greater changes to the axial, longitudinal and transverse displacements, which suggests the necessity to include axial earthquake action controls into the design.The pipeline stress distribution trends during earthquake activity and static conditions exhibit a high degree of unity; the stress value under dynamic earthquake activity is relatively greater. For earthquake action in a single direction, the transverse earthquake activity effect is slightly larger than the effects of the earthquake activity in the other two directionsUnder combined seismic activity, the displacement and stress of a pipeline are greater than any one single direction seismic activity, indicating that the combined earthquake activity causes the greatest damage to the pipeline.The maximum displacement value and maximum stress are generated at the bent pipe on the top of the slope and on the bottom of the west slope; the stress value at the bent pipe changes suddenly. Consequently, during oil pipeline operation, there is a stress concentration at the bend location, which is the critical section of the oil pipeline in an earthquake disaster area. The stress calibrations for the bent pipeline at the top and bottom of the slope must be calculated. If the stress and displacement exceed the limits, a reinforcement measure must be implemented.Stress analysis usually occurs before the pipeline is put into production, and the objects of the analysis are new steel pipes. In actual engineering, there may be cracks on the pipe due to construction and other reasons. Based on the analysis results, we can conclude that the earthquake will exacerbate cracks in the pipe in varying degrees. As the earthquake has significant impact on the lateral displacement of the pipeline, it means that the earthquake has great impact on the extension of cracks along the axial direction of the pipeline. It is therefore proposed that in oil pipeline defect detection in earthquake regions, attention should be paid to issues such as crack repair.Figs. In order to verify the correctness of the numerical simulation results and the reasonableness of the model, field experiments were conducted and the results were compared with numerical simulation results. As the test system, which includes the work strain gauges, compensation strain gages, strain gauges and computers installed on the multiple sections of the pipe, had been installed before the pipeline was put into production, we selected earlier recorded results of stress and strain with the seismic intensity of 7. Because the pipeline was long, we only selected data at the section of critical stress (bends 2 to 7), and compared them with the numerical simulation results. Relative error analysis  of the numerical simulation and field experimental data is calculated as follows:Oil transmission pipelines adopt the elastic laying method, that is, when the line direction changes, the spatial direction of the pipe can be changed relying on the gravity and elastic bending, without on-site installation of cold simmer bends. Different bend angles have different impacts on stress and displacement. In this real engineering case, the bend angle range was 25°- 45°. Based on the stress analysis report, we obtained the stresses and displacements of the bends (bends 2 to 7) under different working conditions.As can be seen from Tables Through the above analysis, we have come to the conclusion that the bend angle had varying degrees of impact on the stress value and displacement value. In order to ensure the safe operation of the oil pipeline during the earthquake, we propose that at the stage of pipeline design, bend angle should be reduced as much as possible. In addition, in order to effectively reduce the bend angle, the “ladder” laying  reducing the bend angle could reduce the stress and displacement of the underground pipe during an earthquake, and “Ladder” could be adopted for laying pipes; (2) appropriately reducing the degree of soil compaction could reduce the impact of the earthquake on the stress and displacement.The proposed calibration standard, frequency analysis method and working condition loading for earthquake stress on a pipeline provides a safety reference for the design of an oil pipeline crossing an earthquake disaster area. This also fills the technology gap for the stress analysis of an oil transportation pipeline in seismic disaster locations.


In recent years, Lean principles have been applied to improve wait times in the Emergency Department (ED). In 2009, an ED Process Improvement Program based on Lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay (LOS) and improve patient flow. This study sought to determine the effect of this program on ED wait times and quality of care.We conducted a retrospective cohort study of all ED visits at program and control sites over 3 program waves from April 1, 2007 to June 30, 2011 in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted.th percentile ED LOS did not change in Wave 1  but decreased after Wave 2  and Wave 3 ; median ED LOS decreased after Wave 1 , Wave 2 , and Wave 3 ; in all Waves, decreases were observed in time to physician assessment, left without being seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, where changes in program sites were compared with controls, the program was associated with no change in the 90th percentile ED LOS in Wave 2  and increases in Wave1 ; modest reductions in median ED LOS in Waves 2 and 3 alone; and a decrease in time to physician assessment in Wave 3 alone.In before-after models among program sites alone, 90Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with control sites, which were exposed to system-wide initiatives such as public reporting and pay-for-performance. This study suggests that further evaluation of the effectiveness of Lean methods in the ED is warranted before widespread implementation.


Emphasis has increased recently on disseminating high-impact, population-wide strategies for the prevention of chronic diseases. However, such strategies are typically not effective at reaching Asian Americans, Native Hawaiians, Pacific Islanders, or other underserved communities. The objectives of this article were to 1) present the methods of the Strategies to Reach and Implement the Vision of Health Equity program in which 15 community-based organizations in the United States and the Pacific region implemented evidence-based policy, systems, and environmental improvements in their local communities and 2) provide recommendations for using these tailored approaches in other communities and geographic locations. Further support is needed for organizations in tailoring these types of population-wide strategies. Implementing population health improvements should be adapted to maximize effectiveness to decrease chronic diseases in these populations and ultimately eliminate racial/ethnic health disparities. Asian Americans and Native Hawaiians and Pacific Islanders (NHPIs) are a rapidly growing population in the United States . They enGaps in the literature and a lack of disaggregated data on nutrition and physical activity prevent in-depth understanding of the health of Asian Americans and NHPIs. However, some research does indicate poor nutrition patterns for certain Asian American and NHPI subgroups, including Chinese, Filipinos, Japanese, and Native Hawaiians . SimilarLack of physical activity also appears to be a challenge in these populations. For example, nearly 48% of Asian Americans do not meet US guidelines for aerobic or muscle-strengthening activity . The YouThe Centers for Disease Control and Prevention (CDC) encourages the dissemination of evidence-based strategies that use a policy, systems, and environmental (PSE) improvement approach  for the The objective of this article was to present the methods of the STRIVE program in which community-based organizations (CBOs) implemented PSE improvements in their local communities and provide recommendations for using these tailored approaches in other communities.The aim of the STRIVE program was to reduce chronic disease health disparities among Asian Americans and NHPIs by implementing PSE improvements focused on physical activity and healthy eating. The 3 primary goals for the program wereTo ensure meaningful involvement and input from Asian American and NHPI communities in the development and implementation of a community action plan to address chronic disease health disparities;To increase the ability of CBOs and multisector partnerships to implement evidence-based PSE improvements that reduce health disparities among Asian American and NHPI communities that have a high burden of risk factors related to physical activity, poor nutrition, and weight management; andTo strengthen and expand a national network of Asian American and NHPI stakeholders focused on PSE improvements through training and technical assistance.To achieve these goals and manage the program, APIAHF and CSAAH forged a co-lead structure in which each institution leveraged its expertise and strengths to provide training and technical assistance to the program and program staff served as project officers. Project officers were the primary liaison to the CBOs, tracking and monitoring CBOs’ deliverables and performance  and providing training and technical assistance.STRIVE launched a competitive request-for-proposal process . Reviewers independently reviewed 17 proposals and rated the following 3 criteria: understanding of community needs related to physical activity and nutrition, experience in partnering with multiple sectors, and experience in addressing health disparities through population-based strategies. Given the short time frame of the program, the review committee also evaluated organizational capacity to implement PSE improvements. In addition, CDC’s geographic funding preferences and coordination with the other 5 REACH national awardees were considered to maximize impact across the country and minimize geographic overlap. The committee selected 15 CBOs and, on February 22, 2013, distributed $3 million in grants ranging from $75,000 to $300,000; program funding ended September 29, 2013. Funded organizations had 7 months to implement their proposed projects. As part of its grant application, each CBO identified a jurisdiction  and a target population. The STRIVE program identified 2 levels of reach for each CBO. The first level was a PSE improvement that would reach at least 75% of the target population in the jurisdiction. This percentage was calculated by dividing the number of Asian Americans and NHPIs reached by a PSE improvement by the total number of Asian Americans and NHPIs in the jurisdiction. For example, estimates of the potential reach of nutrition policies in faith-based institutions were calculated by dividing the number of Asian Americans and NHPIs who could be reached through the institutions by the total number of Asian Americans and NHPIs in the jurisdiction. Reach estimates were verified by program staff using publicly available data sources, such as the US Census 2010. For the second level of reach, because the strategies implemented by the CBOs were population-based strategies, CDC anticipated that PSE improvements would also have an impact beyond the CBOs’ jurisdictions and target populations.The grant application also required each CBO to include a plan for the following: enhancing a multisector partnership; conducting a community health assessment and policy scan; developing and implementing a community action plan with PSE improvements.Enhancing multisector partnerships. Each CBO enhanced a multisector partnership within the first month of its project. This partnership helped achieve the first program goal to support engagement of community stakeholders across multiple sectors. The partnership was central to planning and implementing the overall project for each organization and could include representatives from such areas as public health, education, economic development, transportation, faith-based communities, or the business sector. Multisector partnerships have been shown to improve population health  tool. The tool was designed by CDC to help communities gather and organize data on assets and areas for improvement before deciding on critical issues identified in a community action plan . Several CBOs targeted subgroups such as Fijians, Samoans, Tongans, and Vietnamese.Four CBOs elected to implement PSE improvements related to both nutrition and physical activity. These CBOs had the potential to reach 241,208 Asian Americans and NHPIs. PSE improvements included working with a city master planning group to guide the development of bicycle lanes in a community with a large Asian American population , developing worksite policies to create spaces for physical activity, and working with cultural community schools  to develop and implement a nutrition curriculum for students. PSE improvements took place at various sites: schools, faith-based institutions, cultural or language schools, and refugee community centers. Several CBOs focused on population subgroups, including Chamorro, Korean, Sikh, and Vietnamese.The following 5 key recommendations build on lessons learned during the STRIVE program and should be considered by organizations working with Asian Americans and NHPIs to implement PSE improvements or similar population-wide health strategies.CBOs play critical roles in their local communities and across multiple sectors. Their history of implementing interventions makes them well-positioned to navigate local culture and adapt strategies to the needs of their communities. Also, these organizations have strong relationships with local community members. Because they often serve as gatekeepers, their involvement can be vital to successful implementation of PSE improvements. Hard-to-reach communities may also be more likely to go to CBOs to access culturally and linguistically appropriate information and services because trust has been established .It is essential to fund organizations that have the capacity and systems in place to implement population-wide strategies. Organizational capacity to implement PSE improvements was a criterion for selection during the request-for-proposal process, and it was especially critical because of the short time frame for CBOs to implement their projects.PSE improvement is a relatively new concept for CBOs serving Asian Americans and NHPIs. Project officers found it was important to provide culturally sensitive training and technical assistance to increase CBOs’ understanding of and skills in the PSE planning and implementation processes. For example, CBOs were given specialized training to implement the CHANGE assessment tool in their communities. The findings from the tool guided the development and implementation of a community action plan.The collection and analysis of disaggregated data for Asian Americans and NHPIs is essential to understand the health disparities and needs of these populations, which are diverse in ethnicity, culture, and language. Because many publicly funded entities  do not collect disaggregated data, the CBOs in our program often used other sources of disaggregated data, including quantitative data from nontraditional sources such as churches  and businesses . CBOs also conducted key informant interviews with community stakeholders. APIAHF and CSAAH forged a co-lead structure that involved staff in the leadership and management of the program. Moreover, these 2 institutions harnessed their own expertise and strengths. APIAHF’s experience in funding CBOs to implement public health interventions in various disease areas and CSAAH’s expertise in community-based participatory research was critical in developing and delivering technical assistance to develop Asian American and NHPI multisector partnerships across the country into a national network. Additionally, this partnership had systems and an infrastructure in place to support CBOs. Lastly, this combined partnership allowed each institution to have access to a larger network of CBOs serving Asian Americans and NHPIs.This analysis of the STRIVE program has at least 2 limitations. First, disaggregated data for Asian Americans and NHPIs were lacking at the community level. Second, much of the data for the community health and policy scan and for measuring reach were not up-to-date. Because of these limitations, the data on reach in this analysis are only estimates.Nonetheless, as part of the STRIVE program, organizations implemented PSE strategies to reach a substantial proportion of Asian Americans and NHPIs in their communities. As public health resources become more constrained and health disparities in certain disease areas  increase among Asian Americans and NHPIs ,22, an iTo accomplish the STRIVE program’s goals, the co-lead institutions selected CBOs according to their organizational capacity and estimated reach. They were first required to have a multisector partnership and use a community health needs assessment and policy scan to support the development and implementation of their PSE-focused community action plan. These preparatory steps were essential to accomplishing the third goal, to strengthen and expand a national network of Asian American and NHPI stakeholders focused on PSE improvements. Recommendations from the program demonstrate how such an approach should be adapted to maximize effectiveness and mitigate racial and ethnic health disparities.


Streptococcus (S.) suis is one of the most important pathogens in pigs causing meningitis, arthritis, endocarditis and serositis. Furthermore, it is also an emerging zoonotic agent. In our previous work we identified a highly specific IgM protease in S. suis, designated IdeSsuis. The objective of this study was to characterize the function of IdeSsuis in the host-pathogen interaction. Edman-sequencing revealed that IdeSsuis cleaves the heavy chain of the IgM molecule between constant domain 2 and 3. As the C1q binding motif is located in the C3 domain, we hypothesized that IdeSsuis is involved in complement evasion. Complement-mediated hemolysis induced by porcine hyperimmune sera containing erythrocyte-specific IgM was abrogated by treatment of these sera with recombinant IdeSsuis. Furthermore, expression of IdeSsuis reduced IgM-triggered complement deposition on the bacterial surface. An infection experiment of prime-vaccinated growing piglets suggested attenuation in the virulence of the mutant 10ΔideSsuis. Bactericidal assays confirmed a positive effect of IdeSsuis expression on bacterial survival in porcine blood in the presence of high titers of specific IgM. In conclusion, this study demonstrates that IdeSsuis is a novel complement evasion factor, which is important for bacterial survival in porcine blood during the early adaptive (IgM-dominated) immune response.The online version of this article (doi:10.1186/s13567-015-0171-6) contains supplementary material, which is available to authorized users. Streptococcus (S.) suis colonizes different mucosa of pigs, its main host. Virulent strains might, however, cross the mucosal barrier, cause bacteremia and infect various tissues leading to severe pathologies, such as meningitis, arthritis, endocarditis and serositis. Suppurative meningitis caused by S. suis is one of the most important diseases in modern swine production as it is associated with severe economic losses. S. suis exhibits a high degree of diversity among and within different serotypes. Serotype 2 is worldwide the most important serotype isolated from affected tissues in piglets and also an important zoonotic agent ). Each immunization dose contained approximately 109 bacteria.All piglets were prime-vaccinated at an age of 5–6 weeks with a bacterin generated with At an age of 7 to 8 weeks piglets were challenged 12 days after prime vaccination. Piglets were intranasally infected after predisposition through intranasal treatment with 1% acetic acid as described previously . Criterimax/nanimals). Isolation of the challenge strains was confirmed in a PCR for detection of epf and cps2 [ideSsuis-specific PCRs using oligonucleotide primers specified in Additional file After euthanasia every animal went through the same procedure of necropsy including predefined collection of samples for histological and bacteriological investigations. Fibrinous-suppurative inflammations were scored in blinded experiments as described previously . To alloand cps2  and in iS. suis pathotype [S. suis IgM or IgG antibody titers Maxisorb® plates  were coated with 1 × 107 inactivated S. suis wt bacteria/well. Every sample and the controls were measured in a duplicate series of four (reference serum: seven) twofold dilutions in PBST starting with a dilution of 1:50. For the detection of S. suis specific IgM antibodies the plates were incubated with a dilution of 1:10 000 of a POD-conjugated goat anti-porcine IgM antibody  for 1 h at 37 °C. Blocking, washing and development of ELISA plates as well as calculation of ELISA units was conducted as previously described [MRP, used as antigen for the IgG ELISA, is a dominant immunogen of this athotype ,23,27. Tathotype . For theescribed . Data wep < 0.05 *, p < 0.01 ** and p < 0.001 ***).Experiments were performed at least three times and if not stated otherwise one-way analysis of variance (ANOVA) using Dunnetts adjustment or Tukeys multiple comparison test was used. ELISA-values were compared using the Mann–Whitney U-Test. Statistical analysis of Kaplan-Meier diagrams was conducted with the log-rank test. Means and standard deviation of the results are shown. Probabilities lower than 0.05 were considered significant .Cleavage of IgM by Idenditions . In thisn Figure . This aln Figure . Based oSsuis only at the indicated site. IgM bound to the bacterial surface is also cleaved by IdeSsuis and results in release of Fcμ cleavage products [Cysteines involved in disulphide bonds are conserved between human and porcine IgM.products , which mproducts ,29.Ssuis on complement activation in a hemolysis assay including sera drawn from piglets vaccinated with erythrocytes (αEry sera). In accordance with complement activation, treatment of αEry sera with heat, EDTA or EGTA plus MgCl2 completely abolished the hemolytic activity of the αEry sera , almost completely abolished this hemolysis  in comparison to the post booster serum. Vice versa, IgG staining on erythrocytes resulted in a much higher MFI after incubation in post booster serum Figures A and B.  Figures C and D iSsuis interferes with the classical complement activation pathway. The results of the hemolysis assay suggest that IdeSsuis interferes with complement activation by two mechanisms, firstly, by its IgM protease activity and, secondly, by some yet unknown function of the large non-proteolytic C-terminal domain.In conclusion, IdeS. suis strains by flow cytometry to further investigate the hypothesis that IdeSsuis is involved in complement evasion. After opsonization of S. suis wt and 10ΔideSsuis with different porcine sera with moderate to high specific IgM titers the percentage of bacteria with stained C3 antigen (most likely C3b/C3i) was slightly increased in the mutant 10ΔideSsuis  bacteria were C3-labelled after opsonization in sera of bacterin-primed piglets  and αS. suis IgG (69 – 161 ELISA units) but low αMRP titers (below 15 ELISA units). After addition of EGTA and MgCl2 to these sera only 7.1% (SD = 4.8%) and 7.7% (SD = 6.8%) of wt and 10ΔideSsuis bacteria, respectively, were labelled with the αC3 antibody indicating that complement is mainly activated by the classical activation pathway during early adaptive immune responses  to avoid complement inhibition through the sialylated capsule of S. suis serotype 2. Furthermore, effects of specific IgG were excluded using serum from colostrum-deprived piglets (SCDP). As shown in Figure cpsΔEF or 10cpsΔEFΔideSsuis bacteria were stained with C3 after opsonization with SCDP. Importantly, the percentages of C3-stained 10cpsΔEF increased to about 20% after addition of purified porcine IgM to SCDP prior to opsonization, but fourfold (to 40%) for 10cpsΔEFΔideSsuis bacteria lacking IgM protease activity  reduced the percentage of C3 labelled bacteria to 4.7% (10cpsΔEF) and 4.9% (10cpsΔEFΔideSsuis) and diminished the phenotype of the double mutant. These results confirm that C3 deposition on the surface of S. suis might be determined by IgM-mediated activation of the classical complement pathway and show that S. suis reduces this IgM-mediated C3 deposition by expression of IdeSsuis.We hypothesized that activation of the classical complement pathway in this assay was determined by specific IgM and IgG and that redundant complement evasion mechanisms in rfold to 0% for 10rfold to 0% for 10Ssuis interfered with complement activation using sera with specific antibodies, we hypothesized that expression of the IgM protease IdeSsuis contributes to survival in opsonophagocytosis assays including a porcine serum with specific IgM and comparatively low specific IgG titers (αS. suis IgM: 29.2 ELISA-units and for comparison: αMRP IgG: 12.8 ELISA-units). Phenotypic analysis of S. suis was conducted in this study using the mutant 10ΔideSsuis [Ssuis constructs. These new mutants, designated 10ΔideSsuis_C-terminus and 10ΔideSsuis_homologue, expressed the N-terminal part homologous to IdeS and the large C-terminal part lacking homologies, respectively   in comparison to wt infected animals  Figure A. Furthep p = 0.15  are significantly attenuated in survival in blood drawn from piglets prime-vaccinated with a bacterin. In contrast, the mutant expressing the truncated N-terminal domain with IgM protease activity (10ΔideSsuis_C-terminus) was not attenuated in growth in porcine blood ex vivo.As bacteremia is considered to be a critical step in the pathogenesis of invasive Ssuis promotes increased survival of S. suis in porcine blood ex vivo, at least in the presence of specific IgM.In conclusion, expression of the IgM protease IdeSsuis occurs at a site located between the antigen-recognizing part and the Fc-part containing the putative C1q binding motif, it was reasonable to hypothesize that IgM cleavage by IdeSsuis is an important complement evasion mechanism of S. suis. In this study we obtained in vitro data supporting the hypothesis that IdeSsuis is involved in complement evasion: (i) different recombinant IdeSsuis constructs abolished the hemolysis induced by activation of the classical complement pathway in serum with specific IgM directed against erythrocytes; (ii) attenuation of the mutant 10ΔideSsuis in opsonophagocytosis assays was complement-dependent; (iii) IgM-triggered deposition of C3 on the bacterial surface is reduced by IdeSsuis expression and (iv) attenuation of 10ΔideSsuis in survival in porcine blood ex vivo was observed in blood from piglets with high specific IgM titers.The IgM pentamer is a very important activator of the classical complement pathway. It has been estimated that the efficiency of one pentameric IgM molecule to activate complement is equivalent to the respective efficiency of 1000 IgG molecules . As cleaSsuis interferes substantially with activation of the classical complement pathway. Importantly, IdeSsuis mediated inhibition of complement activation by erythrocyte specific IgM was abrogated by pretreatment of IdeSsuis and IdeSsuis_homologue with the protease inhibitor iodoacetamide. As IgM is the only known substrate of this protease [Ssuis with complement activation. Accordingly, C3 deposition on 10cpsΔEFΔideSsuis bacteria in serum from colostrum-deprived piglets spiked with specific IgM is significantly higher compared to C3 deposition on the IdeSsuis expressing strain 10cpsΔEF.The hemolysis assays of this study showed that Ideprotease  and inhiSsuis with IgM-mediated complement activation is important for pathogenesis, since survival of S. suis in porcine blood of prime-vaccinated piglets is significantly increased by IdeSsuis expression and clinical as well as pathological findings after experimental infection of respective piglets suggested attenuation of the isogenic mutant 10ΔideSsuis.Though IgM is much more powerful in activation of the classical complement pathway than IgG, immune evasion mechanism of bacteria counteracting the classical complement pathway have so far only been described for factors interacting with IgG. Specifically, protein H expressed by group A streptococci (GAS) reduces C3 deposition on IgG-coated beads and inhibits immune hemolysis of IgG-sensitized erythrocytes . FurtherS. suis serotype 2 strains was only slightly determined by IdeSsuis expression under the chosen experimental conditions. The percentage of bacteria with detectable C3b deposition was below 16% after incubation of S. suis strains 10 and 10ΔideSsuis in serum of colostrum-deprived piglets supplemented with purified porcine IgM (results not shown) in contrast to the results shown for the unencapsulated mutants  during reduced capsule expression, (ii) in the presence of very high IgM titers against the polysaccharide capsule and (iii) in strains of serotypes that lack capsular sialic acid [Deposition of C3b on the surface of the encapsulated s Figure . This inlic acid .S. suis [S. suis serves as a cofactor for the factor-I mediated cleavage of C3b [fhb encoding one of the factor H binding proteins led to a significant increase in C3b/iC3b deposition after opsonization with human serum. Activation of human complement was elicited by S. suis mainly via the alternative pathway under the chosen experimental conditions. However, in this work we demonstrate that in growing piglets with high titers of specific IgM the percentage of bacteria with antibody-labelled C3 is mainly determined by the classical pathway. This is important, because piglets with early adaptive immune responses are often affected by S. suis diseases and development of vaccines eliciting protection during this early immune response stage would substantially improve animal health.Two factor H binding proteins, have recently been identified in S. suis ,13. Facte of C3b . DeletioSsuis activity should lead to release of a pentameric Fc-molecule including only C3 and C4 domains of the heavy IgM chains. We speculate that the cleavage product detected above the 250 kDa marker lane in Western blot analysis under non-reducing conditions [Cleavage of IgM might have important biological consequences in addition to prevention of C3b deposition on the bacterial surface. Based on the identified cleavage site in the IgM heavy chain, Idenditions  constitunditions . This minditions .Ssuis. However, the mutant expressing only the C-terminus of IdeSsuis (10ΔideSsuis_homologue) caused morbidity in prime-vaccinated piglets comparable to the wt and unlike the mutant 10ΔideSsuis, which suggests that IgM proteolysis as such was not crucial for the outcome of the animal experiment and that the C-terminus of IdeSsuis carries out important, yet unknown functions. Accordingly, the recombinant truncated protein consisting only of the C-terminus of IdeSsuis showed also a significant interference with complement activation in the hemolysis assay suggesting an additional function of IdeSsuis in complement inhibition but IgM proteolysis. Interestingly, the interference of this non-proteolytic construct did not seem to depend on the ratio of erythrocyte-specific IgM and IgG titers, in contrast to the interference by the IgM protease domain . Further studies are certainly needed to decipher further functions of IdeSsuis in complement evasion and their role in host-pathogen interaction.The results of the experimental infection suggested attenuation of the mutant 10ΔideS. suis was investigated during early adaptive immune responses in this study. Survival in porcine blood with high specific IgM titers is significantly determined by expression of the IgM protease IdeSsuis. Accordingly, the in vitro results of this study demonstrate that IdeSsuis abrogates activation of the classical complement system. As IdeSsuis is expressed by all investigated S. suis strains [Host-pathogen interaction of  strains , this un


Conventional cardiac rehabilitation (CR) programs are traditionally based on time-constrained, structured, group-based programs, usually set in hospitals or leisure centers. Uptake for CR remains poor, despite the ongoing evidence demonstrating its benefits. Additional alternative forms of CR are needed. An Internet-based approach may offer an alternative mode of delivering CR that may improve overall uptake. Activate Your Heart (AYH) is a Web-based CR program that has been designed to support individuals with coronary heart disease (CHD).The aim of this pilot study was to observe the outcome for participants following the AYH program.We conducted a prospective observational trial, recruiting low-risk patients with CHD. Measures of exercise, exercise capacity, using the Incremental Shuttle Walk Test (ISWT), dietary habits, and psychosocial well-being were conducted by a CR specialist at baseline and at 8 weeks following the Web-based intervention.P<.001), and Quality of Life (QOL) . Dietary habits improved with an increased proportion of patients consuming at least 5 portions of fruit and vegetables per day, (22 [71%] to 29 [94%] P=.01) and an increased proportion of patients consuming at least 2 portions of oily fish per week . We did not detect changes in anxiety and depression scores or exercise behavior.We recruited 41 participants; 33 completed the program. We documented significant improvements in the ISWT distance (mean change 49.69 meters, SD 68.8, We observed important improvements in exercise capacity, QOL, and dietary habits in a group of participants following a Web-based CR program. The program may offer an alternative approach to CR. A mobile version has been developed and we need to conduct further trials to establish its value compared to supervised CR. Coronary heart disease (CHD) is the world’s leading cause of mortality . CardiacThe limited uptake of conventional CR would suggest that alternative forms of delivering CR need to be developed . Other fThere is considerable interest in digital health as a means of delivering care for individuals with long-term conditions of which CHD is an important one, delivering a standard intervention that is not geographically or time restrained. An increasing proportion of retired people are using the Internet , reflectThe use of the Internet allows for greater flexibility as patients are able to complete their CR program at a place and time that suits them. It is also capable of reaching a wider audience, especially those patients that live in rural areas . This grThere is little literature describing initiatives that are relevant to patients with CHD. Studies carried out across Europe, the United States, and Canada have investigated the efficacy of Web-based interventions for those with heart disease. The largest was reported recently in the British Medical Journal ; howeverThere may also be benefits to the service, releasing capacity for CR specialists to manage more complex patients in conventional CR, as well as providing additional choice for those unwilling to do standard CR .Over the last few years, we have developed and refined an online comprehensive CR program, Activate Your Heart (AYH). The aim of this study was to observe the impact on exercise performance and health-related quality of life on patients who completed AYH.This was a prospective observational study. Patients were recruited from those referred to CR at the University Hospitals of Leicester NHS Trust. Assessments by a CR specialist were conducted at baseline and after 8 weeks of following AYH. We recruited patients with CHD having one or more of the following: percutaneous coronary intervention (PCI) in the last 3 months, undergone coronary artery bypass graft (CABG) in the last 3 months, or were medically managed for their CHD. To identify low-risk patients, a prospective threshold of at least level 7 (420 meters) of the Incremental Shuttle Walking Test (ISWT)  was agreAYH  is an inThe AYH program had been structured so as to guide the user through four stages that each have specific tasks the user needs to achieve before progressing to the next stage . Tasks iIn Stage 1, participants were asked to do a multiple choice questionnaire to establish their knowledge regarding the principles of exercising safely. A score of 80% was set as a threshold to ensure understanding of these principles. In Stages 2-4, participants were required to record all their exercises in an exercise diary. During Stage 2, participants were advised to record a cumulative total of 30 minutes of exercise 5 days out of 7. The intensity of the exercise was based on their performance on the baseline exercise tests and prescribed at 60-80% of baseline performance. In Stage 3, this was amended to 30 minutes of continuous exercise. Finally, in Stage 4, participants were required to record at least 30 minutes of at least moderate exercise 5 days out of 7, in order to fulfill the national requirements for exercise. There is also interactivity around diet and weight management, stress management, and smoking cessation, if appropriate. For smokers, a cost calculator was developed that would calculate how much the user had spent or saved since starting the program. This was delivered along with advice and support to stop smoking.Other features embedded within the AYH program included a forum where patients were also able to share views and experiences with other program users, a blog, and a frequently asked questions section. The forum was monitored and moderated, as necessary, by CR specialists. In addition patients were able to communicate privately with a CR specialist via the Ask the Expert messaging facility. All queries were answered by a CR specialist within 48 hours of being posted.The CR team members were provided with individual passwords to access the administration section of the program; this allowed them to view and monitor individual patients’ progress and view patient login data. If a patient had not logged in for more than 7 days, or were logging in but not progressing, they would be contacted via email or telephone by the CR specialists. All participants attended a follow-up assessment on completion of the AYH program by a CR specialist.All data captured on the program were encrypted to safeguard patient confidentiality.The outcome measures employed were the Hospital Anxiety and Depression Scale (HADS), the MacNew Quality of Life (QOL) questionnaire , the ISWThe HADS is a validated measure of anxiety and depression . It consThe MacNew comprises 27 questions, which are divided into 3 domains: emotional, physical, and social. Each question is based on a score between 1 and 7, with lower scores corresponding to impaired QOL. This questionnaire has been reported to be both a valid and reliable measure for this population .The ISWT is a standardized field exercise test, which has shown to be both a valid and reliable test for assessing exercise capacity and has been previously reported in trials of CR ,35. Partt test. Changes in proportions after using the AYH program  were assessed using the non-parametric, paired samples McNemar’s test, as the data were categorical/binary. A P value of P≤.05 was reported as significant. Effect size was calculated as a mean change (pre-post) divided by the standard deviation of the change. The magnitude of change can be assessed against the following criteria: small, 0.2 to 0.5; moderate, 0.5 to 0.8; and large, >0.8 [All data were analyzed using PASW Statistics for Windows, Version 18.0. For normally distributed data, parametric tests were carried out. Within-group changes after the AYH program in HADS scores, ISWT distance and MacNew scores, BMI and weight were analyzed using a paired ge, >0.8 . No formThe study was approved by Leicestershire, Northamptonshire and Rutland Research Ethics Committee 2  (ID No. UHL 10322). All subjects for the study provided written informed consent.P<.001), despite relatively high levels of performance at baseline. Statistically significant improvements were also reported for the MacNew QOL questionnaire . We also observed statistically significant improvements in the proportion of participants consuming 5 portions of fruit and vegetables each day: 22 (71%) to 29 (94%), P=.01. The proportion of those consuming at least 2 portions of oily fish each week rose from 14 (45%) to 21(68%), P=.01. Anxiety and depression did not change significantly. There were no significant changes to the number of patients exercising for at least 30 minutes, 5 days per week: 27 (82%) pre and 26 (79%) post. No significant changes to smoking habits or BMI were observed in the study period.We recruited 41 patients to the AYH program . PatientFeedback from this cohort, indicated that 22 (54%) of the 41 recruited would not have attended a traditional out-patient CR program. Participants logged on to the program between 5 and 42 times, with an average of 10 times per participant.This observational study demonstrates the potential benefits of using AYH as a form of CR to improve exercise capacity, quality of life, and dietary behavior in a low-risk population presenting for CR. The baseline exercise performance of this group was high, as expected in this cohort and their scope to increase their performance would be limited compared to those with lower baseline levels. The level of anxiety and depression were low at baseline, reflecting our selection criteria, again limiting the scope of improvement.AYH may give patients a real choice of alternatives to supervised CR. Studies have shown that most patients with CHD who were still working preferred to follow a home-based rehab program to the conventional supervised CR program . AlternaPatients require a CR program that is flexible to suit their lifestyle . Using tAdherence to Web-based programs can be a potential issue as highlighted in previous studies . ReasonsIn order for any Web-based program to be successful, it must suit the working practices of the health care professional (HCP) . This waP<.001) in exercise capacity, QOL (P<.001), and in a larger group, improvements in the number of patients exercising for at least 30 minutes, 5 days per week . Statistically signifcant improvements were also noted for anxiety (P=.01) and depression (P=.03) and for those eating at least 2 portions of oily fish per week (P=.02). However, no changes were reported for consumption of fruit and vegetables or smoking habits. Feedback from this cohort indicated that over two-thirds of the participants  would not have attended a traditional out-patient CR program.Following the pilot study, AYH has been incorporated into the CR service and made available to patients referred to the CR department. The criteria for inclusion were amended to allow for moderate risk patients to take part, that is, patients who completed at least level 5 (250 meters) of the ISWT and who had normal to moderate left ventricular dysfunction. We have collected data from 106 participants, using the outcomes employed in this study, which showed that after following AYH, there were statistically significant changes (mean change 47.16 m, The data reported are our initial findings from the AYH program; we now need to proceed to a clinical effectiveness trial incorporating a control group. Furthermore, the program was not offered to high-risk patients. Participants recorded low anxiety and depression scores and relatively high ISWT at baseline; nevertheless, statistically significant improvements were still observed.In order to make AYH more accessible, a mobile version of AYH has also been developed. This allows users to access the program on their mobile device, such as smartphones and tablets  and 5. UAYH has been designed to support individuals with CHD, promoting an alternative form of CR and provides a viable alternative option for patients, as well as providing a timely and patient-centered approach to CR. AYH enables patients to choose a program that best suits their lifestyle. The convenience of using AYH means that many of the barriers associated with conventional CR programs are removed. To our knowledge, AYH is the first online comprehensive CR program to be introduced into a clinical service. This paper demonstrates that AYH can positively influence exercise capacity, QOL, and dietary behavior in a low-risk group and can be integrated into an existing CR service.