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A 55-year-old man with acute myeloid leukemia began to have shortness of breath, cough with blood-tinged sputum, and hypoxemia 17 days after receiving a myeloablative allogeneic stem-cell transplant from a haploidentical donor.

BackgroundHuman immunodeficiency virus type 1 (HIV-1) elite controllers are able to control virus replication to levels below the limits of detection by commercial assays, but the actual level of viremia in these individuals is not well defined. Here, we quantify plasma HIV-1 RNA in elite controllers and correlate this with specific immunologic parameters MethodsPlasma HIV-1 RNA levels were quantified in 90 elite controllers with use of a real time reverse-transcriptase polymerase chain reaction assay with a sensitivity of 0.2 copies/mL. HIV-1–specific immune responses and longitudinal CD4+ T cell counts were examined ResultsThe median plasma HIV-1 RNA level was 2 copies/mL (interquartile range, 0.2–14 copies/mL). A longitudinal analysis of 31 elite controllers demonstrated 2–5–fold fluctuations in viremia in the majority of individuals; 6 had persistent levels below 1 copy/mL. Viremia correlated directly with HIV-1–specific neutralizing antibodies and Western blot reactivity but not with CD8+ T cell responses. Absolute CD4+ T cell decrease was more common among individuals with detectable viremia (P=.04) ConclusionsLow-level viremia is present in the majority of elite controllers and is associated with higher HIV-1–specific antibody responses. Absolute CD4+ T cell loss is more common among viremic individuals, suggesting that even very low-level viremia has negative consequences over time

Introduction: Vertically integrating physiology into patient care has the potential to improve clinical reasoning. Clinical Physiology Grand Rounds (CPGR) is a case-based teaching method that brings together students from all years of medical school to focus on linking clinical presentations to core basic science concepts including anatomy, physiology, and pathophysiology. In this study, we describe the implementation of CPGR at two different institutions in the United States and assess student-reported outcomes. Methods: We survey students who participated in CPGR at Columbia University College of Physicians & Surgeons (P&S) and Medical University of South Carolina (MUSC). Subjects were queried across three domains: the benefits of attending, the impact of concept maps, and the impact of the mixed-learner environment. Results: Despite differences in session leadership and the underlying medical school curricula, conference attendees reported similar benefits at the two schools included in this study. Students overwhelmingly (92.9%) reported that remembering clinical presentations was easier when they understood the underlying physiology. They also reported gaining a true understanding of concepts that were previously memorized (87.5%). Both clinical (92.5%) and preclinical students (93.1%) valued the mixed-learner environment as a component of the conference. Discussion: By assuring a mixed-learner environment with near-peer interactions, using concept maps as a teaching tool, and rigorously linking clinical presentation and management to physiological concepts, we found that the key benefits of CPGR were replicable across different institutions, despite several local differences in how CPGR was implemented, led, and conducted.

The authors of this work have assembled the background to a selection of leading cases in English Law. From the Mareva case (synonymous with a type of injunction) to Lord Denning's classic ruling in the High Trees House case (the turning point for equitable estoppel).

Pneumocystis jirovecii pneumonia (PCP) typically presents as an interstitial and alveolar process with ground glass opacities on chest computed tomography (CT). The absence of ground glass opacities on chest CT is thought to have a high negative predictive value for PCP in individuals with AIDS. Here, we report a case of PCP in a man with AIDS who presented to our hospital with subacute shortness of breath and a nonproductive cough. While his chest CT revealed diffuse nodular rather than ground glass opacities, bronchoscopy with bronchoalveolar lavage and transbronchial biopsies confirmed the diagnosis of PCP and did not identify additional pathogens. PCP was not the expected diagnosis based on chest CT, but it otherwise fit well with the patient’s clinical and laboratory presentation. In the era of combination antiretroviral therapy, routine prophylaxis for PCP, and increased use of computed tomography, it may be that PCP will increasingly present with nonclassical chest radiographic patterns. Clinicians should be aware of this presentation when selecting diagnostic and management strategies.

\"Hanging in the Balance\" traces the History of capital punishment in the United Kingdom from ancient times to the modern day - through periods of reform until hanging for murder was finally abolished by Parliament in 1969. It describes in detail the Parliamentary and public debates, and notes the stance taken by organizations and individuals (including the tenacious and persistent Sydney Silverman MP). The book collates data and references not previously brought together in one place-and in exploring the underlying issues and the recurring arguments about deterrence, retribution and expediency it provides an invaluable resource vis-a-vis the same debate in the many countries where capital punishment still exists.Lord Callaghan was home secretary at the time of abolition. His 'Foreword' conveys how strong his personal feelings were concerning the death penalty from the time he entered Parliament in 1945. The book's closing chapters record how his insistence that abolition should become permanent ultimately overcame the still considerable opposition. Capital punishment was finally abolished in 1999 throughout the UK. For all practical purposes this had already happened in 1969 when the Murder (Abolition of Death Penalty) Act 1965 was made fully effective into following a trial period.

One promising method for reducing fuel consumption and emissions, particularly in heavy duty trucks, is platooning. As the distance between vehicles decreases, the following vehicles will experience less aerodynamic drag on the front of the vehicle. However, reducing the velocity of the air contacting the front of the vehicle could have adverse effects on the temperature of the engine. To compensate for this effect, the energy consumption of the engine cooling system might increase, ultimately limiting the overall improvements obtained with platooning. Understanding the coupling between drag reduction and engine cooling load requirement is key for successfully implementing platooning strategies. Additionally, in a Connected and Automated Vehicle (CAV) environment, where information of the future engine load becomes available, the operation of the cooling system can be optimized in order to achieve the maximum fuel consumption reduction. In this paper, a control-oriented physics-based model for the engine cooling loop of a Volvo engine is developed and validated against road data. Starting from the validated model, an optimal control problem for the coolant system is formulated considering the tradeoff between the tracking of the engine temperature setpoint and the corresponding fuel consumption under different trailing distances. To compare the coolant system performance, Dynamic Programming (DP) is used to determine the global optimal solution for the coolant system actuator. The coupling between optimal cooling system operation and reduction in ram air are evaluated by comparing the results obtained from the DP under different platooning conditions against the unrestricted scenario. In addition, the paper analyzes the changes in the tradeoff between fuel consumption and setpoint tracking for different vehicle distances. This analysis will provide useful insight on the sensitivity of the coolant system controller calibration to the platoon distance.