Consistently Exploring Nurse Staffing and Neurocritical Care Unit Turnover

ABSTRACT

BACKGROUND: Staffing models within nursing units have long been a hot topic of discussion. The COVID-19 pandemic exacerbated this discussion by straining the national nursing environment and workforce. Before the pandemic, the neuroscience intensive care unit (NSICU) primarily used an acuity-adjusted staffing model and aimed for a nurse-to-patient ratio of 1:1.5. During and after the pandemic, the NSICU was forced to primarily use a centralized staffing model because of the increased turnover in the hospital at large and a rise in patient census. METHODS : Unit census data in an NSICU were tracked before, during, and after the pandemic alongside utilization of a centralized staffing model in the hospital at large. RESULTS : During this time, the NSICU saw a statistically significant increase in average nurse-to-patient ratio and incidences of both floating and tripled assignments. The NSICU simultaneously saw a 180% increase in nursing turnover. CONCLUSION : Although we cannot prove that a centralized staffing model is directly responsible for higher nursing turnover, its utilization led to greater incidence of poor staffing-reflected in deviation from the nurse-to-patient ratio goal of the unit. Nurse staffing concerns play a large role in nurse satisfaction in the workforce: staffing shortages have been described both as a precursor to and as a consequence of increased nursing turnover.

Signalling between the sexes during pollen tube reception

Plant reproduction is a complex, highly-coordinated process in which a single, male germ cell grows through the maternal reproductive tissues to reach and fertilise the egg cell. Focussing on Arabidopsis thaliana, we review signalling between male and female partners which is important throughout the pollen tube journey, especially during pollen tube reception at the ovule. Numerous receptor kinases and their coreceptors are implicated in signal perception in both the pollen tube and synergid cells at the ovule entrance, and several specific peptide and carbohydrate ligands for these receptors have recently been identified. Clarifying the interplay between these signals and the downstream responses they instigate presents a challenge for future research and may help to illuminate broader principles of plant cell-cell communication.

Dosimetric Implications of Prostate Bed Deformability: An Analysis of the SCIMITAR Clinical Trial

PURPOSE/OBJECTIVE(S)

The post-operative prostate bed is a dynamic target volume due to the deformable nature of the bladder and rectum. These changes can lead to incorrect dosing of the prostate bed and organs at risk (OARs). Our objective was to quantify the dosimetric impact of prostate bed and OAR deformation.

MATERIALS/METHODS

SCIMITAR (NCT03541850) is a prospective phase II clinical trial evaluating stereotactic body radiotherapy (SBRT) in the post-prostatectomy setting. This analysis included a subset of patients who received 5 fractions of 6-6.8 Gy to the prostate bed under CT-based image guidance. The clinical target volume (CTV) and OARs were contoured on fractional CBCT images. Changes in volume, shape (via the dice similarity coefficient [DSC]), and dosimetry were quantified. Student's t-test was used to analyze the differences between planning and daily treatment outcomes.

RESULTS

A total of 29 patients (145 fractional images) were analyzed. We found the CTV volume remained stable (median change 1.1%; IQR: -15.1% - 16.1%), whereas the CTV shape was deformable (DSC of 0.76 [IQR: 0.71 - 0.79]). The bladder and rectum exhibited changes with median volume change of 5.7% (IQR: -24.3% - 51.0%) and 5.5% (IQR: -8.7% - 21.9%), respectively and median DSC of 0.77 (IQR: 0.68 - 0.84) and 0.74 (IQR: 0.69 - 0.80) respectively. The CTV received less radiation dose than planned (volume receiving 95%: 93.2% actual vs 99.6% planned, p < 0.01). 39% (56/145) of total fractions and 52% (15/29) of patients met criteria for CTV under-coverage (volume receiving 95% of the prescription dose < 93%). The rectum received higher dose than planned on several parameters (e.g., V27.5 Gy increased from 15.4% to 21.0% [p = 0.009] and V32.5 Gy increased from 6.0% to 10.9% [p = 0.006]) (Table 1).

CONCLUSION

We found underdosing of the prostate CTV and overdosing of the rectum in patients receiving CT-guided postoperative SBRT. While future work will correlate these dosimetric consequences with toxicity, these data suggest that approaches such as adaptive radiotherapy may be beneficial.

Fixed-Field IMRT for Cervix Carcinoma Patients on an MR-LINAC Platform: Dosimetric Feasibility and Challenges

PURPOSE/OBJECTIVE(S)

To investigate the impact of MR-LINAC performance characteristics and inverse planning implementation on the feasibility of fixed-field IMRT for cervix carcinoma patients by benchmarking MR-LINAC plans against clinically used VMAT plans in a single institution study and multi-institutional treatment planning challenge.

MATERIALS/METHODS

For 10 cervix cancer patients who had previously received Linac-based VMAT, new treatment plans were optimized for MR-LINAC IMRT using 6X FFF fixed fields with maximum available field size of 27.4 x 24.1 cm2. Dose optimization was performed on the clinically used planning CT and structure set. Prescribed dose was 48.6 Gy in 27 fractions for all patients with 6 patients receiving an additional integrated boost for a total of 58.05 Gy to involved nodes. Constraints were based on our institutional protocol as per Table 1. IMRT delivery time was limited to 20 min. Original clinically used VMAT plans were generated on Eclipse (Varian Medical System) using 3 to 4 arcs. For the multi-institutional planning challenge, the data set from a single patient was anonymized and shared to participants. Participants used a single MR-based Linac planning platform to generate a plan based on our institutional constraints, with maximum treatment time limited to 20 min. For all analyses, a paired samples t-test was used to compare the significance defined at p < 0.05.

RESULTS

For MR-LINAC plans, the mean number of fields used was 23, mean number of segments 229, and the average estimated treatment delivery time was 17.3 minutes. MR-LINAC plans showed a significantly higher heterogeneity and dose to organs at risk compared to VMAT plans (Table 1). For the planning challenge, a total of 30 participants registered interest. Of this, seven plans were submitted to the challenge. On average, participants generated a plan that would be acceptable based on our institutional constraints (Table 1). However, the volumetric dose to bowel and pelvic bones were higher on MR-LINAC plans compared to the reference VMAT plan.

CONCLUSION

MR-LINAC fixed-field IMRT for cervix cancer patients is feasible but system constraints and optimization implementation result in greater dose heterogeneity and worse organ-at-risk sparing compared to Linac based VMAT. Further research is needed to determine if potential reduction of treatment margins, allowed by better MRI soft-tissue visualization, will result in MR-LINAC IMRT superior to Linac VMAT.

Methods for a composite ecological suitability measure to inform cumulative restoration assessments in Gulf of Mexico estuaries

Ecosystem management requires a systematic, holistic approach that considers ecological and social outcomes. Effective restoration practices promote a balance of ecological and social goals by addressing ecological integrity, efficiently maximizing benefits while minimizing investment, and encompassing collaborative stakeholder engagement. Socio-ecological assessments can inform adaptive management and be utilized to prioritize restoration activities and monitor restoration effectiveness. In estuarine systems, socio-ecological assessments should evaluate the ability of habitats to support both ecologically and locally important species. The composite measure presented utilizes a combination of ecological and social measures to characterize ecological suitability for individual and multiple Gulf of Mexico estuarine species. The ecological suitability value (ES) for a given spatial unit is based on a suite of biophysical measures of the quality and extent of suitable habitat for each species, the species' trophic importance in a food web context, and the importance of each species in relation to stakeholder values and benefits. ES values for individual spatial units can be aggregated to estimate the distribution of ecological suitability at the estuarine scale. The ES values are calculated using examples for each step in the process. The information provided by ecological suitability characterizations can support restoration prioritization decisions for Gulf of Mexico estuaries and can provide a baseline measure to gauge restoration effectiveness over time to inform cumulative restoration assessments.

An evolutionary epigenetic clock in plants

Molecular clocks are the basis for dating the divergence between lineages over macroevolutionary timescales (~105 to 108 years). However, classical DNA-based clocks tick too slowly to inform us about the recent past. Here, we demonstrate that stochastic DNA methylation changes at a subset of cytosines in plant genomes display a clocklike behavior. This "epimutation clock" is orders of magnitude faster than DNA-based clocks and enables phylogenetic explorations on a scale of years to centuries. We show experimentally that epimutation clocks recapitulate known topologies and branching times of intraspecies phylogenetic trees in the self-fertilizing plant Arabidopsis thaliana and the clonal seagrass Zostera marina, which represent two major modes of plant reproduction. This discovery will open new possibilities for high-resolution temporal studies of plant biodiversity.

The incidence and characteristics of giant cell arteritis in Hispanics and the associated outcomes of ischemic ocular events and stroke

Giant cell arteritis (GCA) is a large vessel vasculitis whereby up to half of all patients show ocular involvement, highlighting the importance of treating GCA before it leads to irreversible blindness. Most of the research published for GCA and associated adverse ocular events are based on majority Caucasian populations establishing the current belief that Hispanics have a much lower incident of GCA. We sought to investigate the incidence of GCA in Hispanics and characterize associated ocular events, stroke rates, and comorbid diseases. We conducted a retrospective cohort study of GCA-coded medical records in self-identified Hispanics assessed at the University Medical Center Hospital in El Paso, Texas. From 2000 to 2019, there were 68 new cases of GCA in the Hispanics which represents an average incidence of 0.062% with a 95% confidence interval of [0.05, 0.09] of Hispanics over the age of 50 admitted to University Medical Center hospital. Of the subjects diagnosed with GCA, the majority had ocular involvement such as blurry vision (47.06%), ocular pain (26.47%), and blindness (14.71%). We did not observe a history of stroke had a statistically significant difference associated with GCA with ophthalmic disease compared to GCA without ophthalmic disease. Polymyalgia rheumatica (PMR) was identified in only 2.94% of the Hispanic subjects with GCA. Major conclusions in our study advocate Hispanics with GCA are prevalent and unique in its associations with other comorbid diseases. Unlike non-Hispanic White populations, Hispanic subjects with GCA do not show an association with PMR nor an increased association with stroke.

An evolutionary epigenetic clock in plants

Molecular clocks are the basis for dating the divergence between lineages over macro-evolutionary timescales (~10 5 -10 8 years). However, classical DNA-based clocks tick too slowly to inform us about the recent past. Here, we demonstrate that stochastic DNA methylation changes at a subset of cytosines in plant genomes possess a clock-like behavior. This 'epimutation-clock' is orders of magnitude faster than DNA-based clocks and enables phylogenetic explorations on a scale of years to centuries. We show experimentally that epimutation-clocks recapitulate known topologies and branching times of intra-species phylogenetic trees in the selfing plant A. thaliana and the clonal seagrass Z. marina , which represent two major modes of plant reproduction. This discovery will open new possibilities for high-resolution temporal studies of plant biodiversity.

Attention and Memory in Depersonalization-Spectrum Dissociative Disorders: Impact of Selective-Divided Attentional Condition, Stimulus Emotionality, and Stress

We investigated cognition in depersonalization-spectrum dissociative disorders without comorbid posttraumatic stress disorder to explore evidence for emotionally avoidant information processing. Forty-eight participants with DSM-IV dissociative disorder (DD) (Depersonalization Disorder - 37, Dissociative Disorder NOS -11), 36 participants with Posttraumatic Stress Disorder (PTSD), and 56 healthy controls (HC) were administered the Weschler Adult Intelligence Scale-III (WAIS); the Weschler Memory Scale-III (WMS); and three Stroop tasks: the Standard Stroop, a selective-attention Emotional Stroop using neutral, dissociation, and trauma-related word categories, and a divided-attention Emotional Stroop using comparable words. Participants were also administered a paired-associates explicit and implicit memory test using emotionally neutral and negative words, before and after the Trier Social Stress Test. The DD and HC groups had comparable general intelligence and memory scores, though dissociation severity was inversely related to verbal comprehension and working memory. In the selective-attention condition, DD participants showed greater incidental recall across word categories with comparable interference. However in the divided-attention condition, DD participants significantly favored lesser attentional interference at the expense of remembering words. Across attentional conditions, DD participants had better recall for disorder-related than neutral words. Pre-stress, the DD group demonstrated better explicit memory for neutral versus negative words with reversal after stress, whereas the HC group demonstrated the opposite pattern; implicit memory did not differ. Cognition in the PTSD control group was generally dissimilar to the DD group. The findings in toto provide substantial evidence for emotionally avoidant information processing in DD, vulnerable to the impact of stress, at the level of both attention and memory.

Tricolored bats at a southern range edge exhibit partial migration northward in autumn

BACKGROUND

Animal migration is a widespread global adaptation by which individuals move in response to environmental conditions to reach more favorable conditions. For bats in temperate climates, migration and hibernation are often associated with each other when these bats must migrate to reach suitable overwintering sites. However, differences in movement across the geographical range of a species and the degree to which hibernation drives migratory behavior of bats in subtropical climates, where conditions may remain warm with available prey year-round, remains incomplete. Understanding the migratory strategies of subtropical bats during winter is of increasing importance as they are threatened by stressors such as disease and environmental change.

METHODS

We evaluated migration patterns of tricolored bats (Perimyotis subflavus) in Florida, USA, through analysis of stable hydrogen isotope ratios of the fur. We inferred the summer geographic origins of the fur samples and estimated the minimum distance and likely direction traveled by hibernating individuals. We used linear models to examine whether hibernation region, colony size, and an individual's sex affected the distance traveled.

RESULTS

We sampled 111 bats hibernating at 40 sites and found that more than half (54.1%) of individuals were residents of the area in which they hibernated. We found that almost half of the sampled bats (43.2%) traveled from southern Florida to overwinter in North Florida. We also documented three individuals that traveled > 100 km from northerly origins, one of which had traveled an estimated minimum distance of 1382 km. We also found that tricolored bats moved farther to reach hibernacula in Northwest Florida and hibernacula with more populous colonies, with no difference in movement between sexes.

CONCLUSIONS

Our results indicate a pattern of northward autumnal movements of tricolored bats in the subtropical southeastern portion of their range. We suggest that bats are differentially constrained at the edge of their geographical range, resulting in movement contrary to what is expected. Even though we found that few (2.7%) bats moved into Florida from farther north, those migrants can potentially transfer the fungus that causes the deadly white-nose syndrome, which does not currently occur in the state. Our results support the characterization of tricolored bats as flexible partial migrators, with a rarely exercised capacity for long-distance movements.

A conceptual approach to characterizing ecological suitability: Informing socio-ecological measures for restoration effectiveness

A combination of ecological and socio-economic outcome indicators is essential for understanding and assessing the effectiveness of the remediation and restoration of degraded ecosystems and revitalizing communities that could benefit from these ecosystem management activities. In this paper, we propose and develop a conceptual approach to characterize ecological suitability that incorporates ecological attributes that support ecosystem structural diversity and functionality, stakeholder values and perceptions, and the benefits derived from ecosystem goods and services. A structured literature review was used to identify existing restoration frameworks and indicators to inform the conceptual foundation for characterizing ecological suitability. The structure of the conceptual approach primarily builds from ecological and social attributes in the International Principles and Standards for the Practice of Ecological Restoration (Gann et al., 2019). We provide a conceptual example of the ecological suitability approach in estuaries. This example is based on habitat suitability and food web characterizations in combination with the provisioning of ecosystem services and desired social benefits to prioritize and evaluate restoration effectiveness. This foundational work sets the stage for developing a composite measure of ecological suitability. The holistic conceptual approach presented complements existing information regarding restoration effectiveness evaluations. Characterizing ecological suitability is a novel way to incorporate ecological and social information and communicate potential restoration outcomes to ecosystem managers and stakeholders.

A. thaliana Hybrids Develop Growth Abnormalities through Integration of Stress, Hormone and Growth Signaling

Hybrids between Arabidopsis thaliana accessions are important in revealing the consequences of epistatic interactions in plants. F1 hybrids between the A. thaliana accessions displaying either defense or developmental phenotypes have been revealing the roles of the underlying epistatic genes. The interaction of two naturally occurring alleles of the OUTGROWTH-ASSOCIATED KINASE (OAK) gene in Sha and Lag2-2, previously shown to cause a similar phenotype in a different allelic combination in A. thaliana, was required for the hybrid phenotype. Outgrowth formation in the hybrids was associated with reduced levels of salicylic acid, jasmonic acid and abscisic acid in petioles and the application of these hormones mitigated the formation of the outgrowths. Moreover, different abiotic stresses were found to mitigate the outgrowth phenotype. The involvement of stress and hormone signaling in outgrowth formation was supported by a global transcriptome analysis, which additionally revealed that TCP1, a transcription factor known to regulate leaf growth and symmetry, was downregulated in the outgrowth tissue. These results demonstrate that a combination of natural alleles of OAK regulates growth and development through the integration of hormone and stress signals and highlight the importance of natural variation as a resource to discover the function of gene variants that are not present in the most studied accessions of A. thaliana.

Review: Smart agri-systems for the pig industry

The projected rise in the global human population and the anticipated increase in demand for meat and animal products, albeit with a greatly reduced environmental footprint, offers a difficult set of challenges to the livestock sector. Primarily, how do we produce more, but in a way that is healthier for the animals, public, and the environment? Implementing a smart agri-systems approach, utilising multiplatform precision technologies, internet of things, data analytics, machine learning, digital twinning and other emerging technologies can support a more informed decision-making and forecasting position that will allow us to move towards greater sustainability in future. If we look to precision agronomy, there are a wide range of technologies available and examples of how digitalisation and integration of platform outputs can lead to advances in understanding the agricultural system and forecasting upcoming events and performance that have hitherto been impossible to achieve. There is much for the livestock sector and animal scientists to learn from the developments of precision technologies and smart agri-system approaches in the arable and horticultural contexts. However, there are several barriers the livestock sector must overcome: (i) the development and implementation of precision livestock farming technologies that can be easily integrated and analysed without the support of a dedicated data analyst in house; (ii) the lack of extensive validation of many developed and available precision livestock farming technologies means that reliability and accuracy are likely to be compromised when applied in commercial practice; (iii) the best smart agri-systems approaches are reliant on large quantities of data from across a wide variety of conditions, but at present the complications of data sharing, commercial sensitivities, data ownership, and permissions make it challenging to obtain or knit together data from different parts of the system into a comprehensive picture; and (iv) the high level of investment needed to develop and scale these technologies is substantial and represents significant risk for companies when a technology is emerging. Using a case study of the National Pig Centre (a flagship pig research facility in the UK) we discuss how a smart agri-systems approach can be applied in practice to investigate alternative future systems for production, and enable monitoring of these systems as a commercial demonstrator site for future pork production.

Activity-based protein profiling reveals deubiquitinase and aldehyde dehydrogenase targets of a cyanopyrrolidine probe

Ubiquitin carboxy-terminal hydrolase L1 (UCHL1), a deubiquitinating enzyme (DUB), is a potential drug target in various cancers, and liver and lung fibrosis. However, bona fide functions and substrates of UCHL1 remain poorly understood. Herein, we report the characterization of UCHL1 covalent inhibitor MT16-001 based on a thiazole cyanopyrrolidine scaffold. In combination with chemical proteomics, a closely related activity-based probe (MT16-205) was used to generate a comprehensive quantitative profile for on- and off-targets at endogenous cellular abundance. Both compounds are selective for UCHL1 over other DUBs in intact cells but also engage a range of other targets with good selectivity over the wider proteome, including aldehyde dehydrogenases, redox-sensitive Parkinson's disease related protein PARK7, and glutamine amidotransferase. Taken together, these results underline the importance of robust profiling of activity-based probes as chemical tools and highlight the cyanopyrrolidine warhead as a versatile platform for liganding diverse classes of protein with reactive cysteine residues which can be used for further inhibitor screening, and as a starting point for inhibitor development.

The genetic and epigenetic landscape of the Arabidopsis centromeres

Centromeres attach chromosomes to spindle microtubules during cell division and, despite this conserved role, show paradoxically rapid evolution and are typified by complex repeats. We used long-read sequencing to generate the Col-CEN Arabidopsis thaliana genome assembly that resolves all five centromeres. The centromeres consist of megabase-scale tandemly repeated satellite arrays, which support CENTROMERE SPECIFIC HISTONE H3 (CENH3) occupancy and are densely DNA methylated, with satellite variants private to each chromosome. CENH3 preferentially occupies satellites that show the least amount of divergence and occur in higher-order repeats. The centromeres are invaded by ATHILA retrotransposons, which disrupt genetic and epigenetic organization. Centromeric crossover recombination is suppressed, yet low levels of meiotic DNA double-strand breaks occur that are regulated by DNA methylation. We propose that Arabidopsis centromeres are evolving through cycles of satellite homogenization and retrotransposon-driven diversification.

Multiplexed Simian Immunodeficiency Virus-Specific Paired RNA-Guided Cas9 Nickases Inactivate Proviral DNA

Human and simian immunodeficiency virus (HIV and SIV) infections establish lifelong reservoirs of cells harboring an integrated proviral genome. Genome editing CRISPR-associated Cas9 nucleases, combined with SIV-specific guiding RNA (gRNA) molecules, inactivate integrated provirus DNA in vitro and in animal models. We generated RNA-guided Cas9 nucleases (RGNu) and nickases (RGNi) targeting conserved SIV regions with no homology in the human or rhesus macaque genome. Assays in cells cotransfected with SIV provirus and plasmids coding for RGNus identified SIV long terminal repeat (LTR), trans-activation response (TAR) element, and ribosome slip site (RSS) regions as the most effective at virus suppression; RGNi targeting these regions inhibited virus production significantly. Multiplex plasmids that coexpressed these three RGNu (Nu3), or six (three pairs) RGNi (Ni6), were more efficient at virus suppression than any combination of individual RGNu and RGNi plasmids. Both Nu3 and Ni6 plasmids were tested in lymphoid cells chronically infected with SIVmac239, and whole-genome sequencing was used to determine on- and off-target mutations. Treatment with these all-in-one plasmids resulted in similar levels of mutations of viral sequences from the cellular genome; Nu3 induced indels at the 3 SIV-specific sites, whereas for Ni6 indels were present at the LTR and TAR sites. Levels of off-target effects detected by two different algorithms were indistinguishable from background mutations. In summary, we demonstrate that Cas9 nickase in association with gRNA pairs can specifically eliminate parts of the integrated provirus DNA; also, we show that careful design of an all-in-one plasmid coding for 3 gRNAs and Cas9 nuclease inhibits SIV production with undetectable off-target mutations, making these tools a desirable prospect for moving into animal studies. IMPORTANCE Our approach to HIV cure, utilizing the translatable SIV/rhesus macaque model system, aims at provirus inactivation and its removal with the least possible off-target side effects. We developed single molecules that delivered either three truncated SIV-specific gRNAs along with Cas9 nuclease or three pairs of SIV-specific gRNAs (six individual gRNAs) along with Cas9 nickase to enhance efficacy of on-target mutagenesis. Whole-genome sequencing demonstrated effective SIV sequence mutation and inactivation and the absence of demonstrable off-target mutations. These results open the possibility to employ Cas9 variants that introduce single-strand DNA breaks to eliminate integrated proviral DNA.

Novel allele elh of the UBP14 gene affects plant organ size via cell expansion in Arabidopsis thaliana

Plant organ size control is an essential process of plant growth and development. The regulation of plant organ size involves a complicated network of genetic, molecular interactions, as well as the interplay of environmental factors. Here, we report a temperature-sensitive hypocotyl elongation EMS-generated mutant, hereby referred to as elongated hypocotyl under high-temperature (elh). The elongated hypocotyl phenotype was prominent when the elh seedlings were grown at high temperature, 28^°C, but not under the growth temperature of 21^°C. We observed significantly larger organ sizes in elh plants, including cotyledons, petals and seeds. In elh plants, the cell sizes in cotyledons and petals were significantly larger than wild type. By measuring the cell density and organ area of cotyledons, petals and mature dissected embryos, we found no differences in total cell numbers in any organ indicating that cell expansion rather than cell proliferation was perturbed in elh. elh plants produced leaves at a slower rate than wild type plants, suggesting that perturbing the balance between cell division and cell expansion is linked to the developmental rate at which leaves are produced.

Reference range for 24-h urine calcium, calcium/creatinine ratio, and correlations with calcium absorption and serum vitamin D metabolites in normal women

A study of 959 black and white women shows that the normal range for 24-h urine calcium excretion in white women is 30-300 mg and 10-285 mg in black women. Clinical laboratories use a normal range for 24-h urine calcium excretion of 100-300 mg; there is a need for them to update their age- and race-specific ranges.

INTRODUCTION

Recommendations for a normal range for 24-h urine calcium vary from a low of 50 mg to a high of 400 mg; most "laboratory normal ranges" based on older literature are incorrect. The objective of this analysis is to define a normal range for young women age 25-45 years and older women age 55-90 years, white and black, for 24-h urine calcium and calcium/creatinine ratio, and to examine the relationship between 24-h urine calcium, calcium absorption, and vitamin D metabolites.

METHODS

Data from 3 studies was collected on 959 normal black and white women, ages 25-87 years, for 24-h urine calcium, creatinine, calcium intake, serum 25-hydroxyvitamin D (25OHD),1,25 dihydroxyvitamin D (1,25(OH)₂D), and calcium absorption. Urine calcium and creatinine were measured on an auto-analyzer. Calcium absorption was measured by a single isotope method. Serum 25OHD and 1,25(OH)₂D were measured by competitive protein binding assay or radioimmunoassay. Because 24-h urine calcium did not fit a normal distribution, non-parametric methods were used to determine the 95% reference interval (RI) and 90% non-parametric confidence intervals (CI) calculated for groups.

RESULTS

The 95% reference intervals for 24-h urine calcium for women were as follows: black older 7-225 mg, black younger 8-285 mg; white older 37-275 mg, and white younger 23-287 mg. In older white women, 24-h urine calcium was significantly correlated with serum 1,25(OH)₂ D, r = 0.23, p < 0.001, calcium intake r = 0.12, p = 0.001, and calcium absorption r = 0.18, p = 0.003, but not serum 25OHD r = 0.07, p = 0.06.

CONCLUSIONS

The normal reference interval for 24-h urine calcium for black women is lower than white women. Twenty-four-hour urine calcium was correlated with serum 1,25(OH)₂ D calcium intake and calcium absorption, but not serum 25OHD. This range will be useful clinically for defining hypercalciuria and for following patients on vitamin D and calcium treatment.

Investigating the relationship between environmental quality, socio-spatial segregation and the social dimension of sustainability in US urban areas

This work is intended to assess the relationship between the three dimensions of sustainability (environmental, economic, and social) and residential segregation broadly across US urban areas. Multivariate indices of segregation and sustainability are created using data aggregated to 933 US Census Core-Based Statistical Areas (CBSAs). The relationship between segregation and sustainability (and dimensions, independently) is analyzed across the CBSAs using correlation and spatial analyses. Results show an inverse relationship between segregation and sustainability, where increasing urban segregation corresponds to decreases in sustainability. Social and economic dimensions of sustainability are negatively correlated with segregation while the environmental dimension is positively correlated. Spatial analysis reveals regional associations between the measures with most of the lower sustainability scores and higher segregation scores occuring mainly in the South. The findings demonstrate an inverse relationship between segregation and sustainability as well as between the environmental and social dimensions. These correlations indicate a need to consider inequalities, and the social dimension of sustainability more broadly, when planning urban revitalization efforts. Spatial scale is also imperative to understanding and improving the social outcomes for all members of the community.

Projecting effects of land use change on human well-being through changes in ecosystem services

Changing patterns of land use, temperature, and precipitation are expected to impact ecosystem services, including water quality and quantity, buffering of extreme events, soil quality, and biodiversity. Scenario analyses that link such impacts on ecosystem services to human well-being may be valuable in anticipating potential consequences of change that are meaningful to people living in a community. Ecosystem services provide numerous benefits to community well-being, including living standards, health, cultural fulfillment, education, and connection to nature. Yet assessments of impacts of ecosystem services on human well-being have largely focused on human health or monetary benefits (e.g. market values). This study applies a human well-being modelling framework to demonstrate the potential impacts of alternative land use scenarios on multi-faceted components of human well-being through changes in ecosystem services (i.e., ecological benefits functions). The modelling framework quantitatively defines these relationships in a way that can be used to project the influence of ecosystem service flows on indicators of human well-being, alongside social service flows and economic service flows. Land use changes are linked to changing indicators of ecosystem services through the application of ecological production functions. The approach is demonstrated for two future land use scenarios in a Florida watershed, representing different degrees of population growth and environmental resource protection. Increasing rates of land development were almost universally associated with declines in ecosystem services indicators and associated indicators of well-being, as natural ecosystems were replaced by impervious surfaces that depleted the ability of ecosystems to buffer air pollutants, provide habitat for biodiversity, and retain rainwater. Scenarios with increases in indicators of ecosystem services, however, did not necessarily translate into increases in indicators of well-being, due to covarying changes in social and economic services indicators. The approach is broadly transferable to other communities or decision scenarios and serves to illustrate the potential impacts of changing land use on ecosystem services and human well-being.

Silencing integrated SIV proviral DNA with TAR-specific CRISPR tools

BACKGROUND

One approach for a functional HIV cure is to prevent transcription from integrated proviral DNA. A critical step in HIV transcription is the Tat protein interaction with the TAR element viral RNA. We tested the strategy of blocking this Tat-TAR interaction in the SIVmac model.

METHODS

We designed five CRISPR short guiding RNAs (sgRNAs) targeting the SIVmac TAR element, along with inactive versions of Cas9 (dCas9). These sgRNA constructs were delivered as ribonucleoproteins or plasmid DNA, along with SIV DNA. The constructs were also tested in integrated viral DNA in a cell line chronically infected by SIV.

RESULTS

The sgRNAs targeting the coding strand of the TAR element inhibited SIV RNA transcription in association with dCas9-KRAB, but not with dCas9.

CONCLUSIONS

Induction of epigenetic modifications may be more effective in inactivating provirus than transcriptional interference and thus may be a better strategy to achieve a functional cure in vivo.

Discovery of a Potent and Selective Covalent Inhibitor and Activity-Based Probe for the Deubiquitylating Enzyme UCHL1, with Antifibrotic Activity

Ubiquitin carboxy-terminal hydrolase L1 (UCHL1) is a deubiquitylating enzyme that is proposed as a potential therapeutic target in neurodegeneration, cancer, and liver and lung fibrosis. Herein we report the discovery of the most potent and selective UCHL1 probe (IMP-1710) to date based on a covalent inhibitor scaffold and apply this probe to identify and quantify target proteins in intact human cells. IMP-1710 stereoselectively labels the catalytic cysteine of UCHL1 at low nanomolar concentration in cells. We further demonstrate that potent and selective UCHL1 inhibitors block pro-fibrotic responses in a cellular model of idiopathic pulmonary fibrosis, supporting the potential of UCHL1 as a potential therapeutic target in fibrotic diseases.

A malectin domain kinesin functions in pollen and seed development in Arabidopsis

The kinesin family is greatly expanded in plants compared with animals and, with more than a third up-regulated in expression during cell division, it has been suggested that this expansion facilitated complex plant-specific cytoskeletal rearrangements. The cell cycle-regulated kinesins include two with an N-terminal malectin domain, a protein domain that has been shown to bind polysaccharides and peptides when found extracellularly in receptor-like kinases. Although malectin domain kinesins are evolutionarily deep rooted, their function in plants remains unclear. Here we show that loss of MALECTIN DOMAIN KINESIN 2 (MDKIN2) results in stochastic developmental defects in pollen, embryo, and endosperm. High rates of seed abnormalities and abortion occur in mdkin2 mutants through a partial maternal effect. No additive effect or additional developmental defects were noted in mdkin1 mdkin2 double mutants. MDKIN2 is expressed in regions of cell division throughout the plant. Subcellular localization of MDKIN2 indicates a role in cell division, with a possible secondary function in the nuclei. Our results reveal a non-essential but important role for a malectin domain kinesin during development in plants.

CrRLK1L receptor-like kinases HERK1 and ANJEA are female determinants of pollen tube reception

Communication between the gametophytes is vital for angiosperm fertilisation. Multiple CrRLK1L-type receptor kinases prevent premature pollen tube burst, while another CrRLK1L protein, FERONIA (FER), is required for pollen tube reception in the female gametophyte. We report here the identification of two additional CrRLK1L homologues, HERCULES RECEPTOR KINASE 1 (HERK1) and ANJEA (ANJ), which act redundantly to promote pollen tube growth arrest at the synergid cells. HERK1 and ANJ localise to the filiform apparatus of the synergid cells in unfertilised ovules, and in herk1 anj mutants, a majority of ovules remain unfertilised due to pollen tube overgrowth, together indicating that HERK1 and ANJ act as female determinants for fertilisation. As in fer mutants, the synergid cell-specific, endomembrane protein NORTIA (NTA) is not relocalised after pollen tube reception; however, unlike fer mutants, reactive oxygen species levels are unaffected in herk1 anj double mutants. Both ANJ and HERK1 associate with FER and its proposed co-receptor LORELEI (LRE) in planta. Together, our data indicate that HERK1 and ANJ act with FER to mediate female-male gametophyte interactions during plant fertilisation.

Effect of vitamin D supplementation on total and free 25 hydroxyvitamin D and parathyroid hormone. An analysis of two randomized controlled trials

BACKGROUND

It is questionable as to whether total serum 25 hydroxyvitamin D (T25D) levels are lower in African Americans. We measured serum T25D, free 25hydroxyvitamin D (F25D) and serum parathyroid hormone (PTH) in African American and Caucasian women and studied the effect of vitamin D dosing to determine if differences by race or age occur.

METHODS

Healthy young and older Caucasian and African American women who were vitamin D insufficient were randomized in two clinical trials to escalating daily doses of vitamin D from 400 to 4800 IU and placebo for 12 months.

RESULTS

Baseline F25D and T25D were significantly lower in young but not older African American compared to Caucasian women. At baseline, the rate of change, or slope, in F25D with T25D was significantly greater in younger women than in older women, but difference in the rate of change in F25D with T25D is similar in African American and Caucasian women. After vitamin D supplementation, there was an increase in F25D, and the dose response was not significantly different by age or race. The ratio of F25D/T25D decreased in all groups once T25D exceeded ~60 nmol L^-1 . There was a progressive decrease in serum PTH with increasing vitamin D doses and the per cent change was similar for F25D and T25D.

CONCLUSION

Serum F25D and T25D are lower in younger African American women, and since dietary vitamin D is similar in the groups, it is likely that the cause of low serum 25OHD in African American women is due to reduced UV exposure and reduced skin production of vitamin D.

Surviving in a Hostile World: Plant Strategies to Resist Pests and Diseases

As primary producers, plants are under constant pressure to defend themselves against potentially deadly pathogens and herbivores. In this review, we describe short- and long-term strategies that enable plants to cope with these stresses. Apart from internal immunological strategies that involve physiological and (epi)genetic modifications at the cellular level, plants also employ external strategies that rely on recruitment of beneficial organisms. We discuss these strategies along a gradient of increasing timescales, ranging from rapid immune responses that are initiated within seconds to (epi)genetic adaptations that occur over multiple plant generations. We cover the latest insights into the mechanistic and evolutionary underpinnings of these strategies and present explanatory models. Finally, we discuss how knowledge from short-lived model species can be translated to economically and ecologically important perennials to exploit adaptive plant strategies and mitigate future impacts of pests and diseases in an increasingly interconnected and changing world.

Using Re-scaled Resilience Screening Index Results and Location Quotients for Socio-Ecological Characterizations in U.S. Coastal Regions

In terms of natural hazard events, resilience characterizations provide a means of identifying risk profiles, degrees of preparedness, and the ability of communities to respond and recover. While nationally consistent measures of community resilience to natural hazards are needed to address widespread socio-ecological impacts from a broad policy perspective, geographically specific resilience characterizations are needed to target local resources to increase community resilience. The Climate Resilience index (CRSI) was developed to characterize the resilience of socio-ecological systems in the context of governance and risk to natural hazard events for all U.S. counties for the years 2000-2015. Those resilience characterizations were based on the full range of nationwide county domain scores. This paper presents a re-scaled application of CRSI, where county domain scores are limited to the range of scores within a specific set of U.S. coastal and shoreline counties within each of eight coastal regions. The re-scaled CRSI values for selected counties/parishes in the Gulf of Mexico (GOM) region are also presented in conjunction with calculated Location Quotients (LQ) values >1.0, which represent a high employment dependence on ocean economy sectors. Using a combination of re-scaled CRSI and LQ values provides a more holistic picture of vulnerability and resilience in these U.S. coastal shoreline counties. The relative resilience assessments presented for coastal regions are useful in identifying potential strengths and weaknesses in resilience aspects given similar hazard profiles, a signature otherwise diluted in nation-wide county-level assessments. The unique approach of combining CRSI and LQ for characterizing natural hazard resilience described could be transferred to other specific geographies as defined by population groups, hazard profiles and economic dependence.

Development of a Multi-Hazard Landscape for Exposure and Risk Interpretation: The PRISM Approach

Methods:

Exposures are assessed as a proportion of land-area, allowing for multiple hazards to be combined in a single calculation. Risk calculations are weighted by land-use types (built, dual-benefit, natural) in each county. This allows for a more detailed analysis of land impacts and removes some of the bias introduced by monetary losses in heavily urbanized counties.

Results:

The results of the quantitative analysis show a landscape where the risk to natural systems is high and the western United States is exposed to a bulk of the risk. Land-use and temporal profiles exemplify a dynamic risk-scape.

Conclusion:

The calculation of risk is meant to inform community decisions based on the unique set of hazards in that area over time.

SHH pathway inhibition is protumourigenic in adamantinomatous craniopharyngioma

Pharmacological inhibition of the sonic hedgehog (SHH) pathway can be beneficial against certain cancers but detrimental in others. Adamantinomatous craniopharyngioma (ACP) is a relevant pituitary tumour, affecting children and adults, that is associated with high morbidity and increased mortality in long-term follow-up. We have previously demonstrated overactivation of the SHH pathway in both human and mouse ACP. Here, we show that this activation is ligand dependent and induced by the expression of SHH protein in a small proportion of tumour cells. We investigate the functional relevance of SHH signalling in ACP through MRI-guided preclinical studies using an ACP mouse model. Treatment with vismodegib, a clinically approved SHH pathway inhibitor, results in a significant reduction in median survival due to premature development of highly proliferative and vascularised undifferentiated tumours. Reinforcing the mouse data, SHH pathway inhibition in human ACP leads to a significant increase in tumour cell proliferation both ex vivo, in explant cultures, and in vivo, in a patient-derived xenograft model. Together, our results demonstrate a protumourigenic effect of vismodegib-mediated SHH pathway inhibition in ACP.

Effect of increasing doses of vitamin D on bone mineral density and serum N-terminal telopeptide in elderly women: a randomized controlled trial

BACKGROUND

There are few controlled studies of the effect of different doses of vitamin D3 on bone mineral density (BMD).

OBJECTIVES

We conducted a randomized placebo-controlled trial of increasing doses of vitamin D3 in 163 Caucasian and 31 African American women with serum 25-hydroxyvitamin D (25OHD) ≤50 nmol/L. This is an analysis of secondary outcome BMD to see if there is an association between percent change in BMD and dose of vitamin D3.

METHODS

Participants were randomly assigned to placebo, vitamin D3 400, 800, 1600, 2400, 3200, 4000, or 4800 IU/day; calcium supplements, average 600mg, were given to provide a total calcium intake of 1200 mg/d. The primary outcome was 12-month serum 25OHD level. Analysis methods include ANOVA and Pearson correlations.

RESULTS

The mean percent increase (±SD) in BMD at 12 months for all women was small; total body, 0.62% (± 2.72), femoral neck 0.59% (±3.58) and spine 0.43% (±2.80). There was no difference in BMD or serum N-telopeptide in response to vitamin D by dose or race. The increase in total body, spine and hip BMD in elderly women given vitamin D doses between 400 and 4800 IU daily and calcium supplementation is small, unrelated to dose or 12-month serum 25OHD, free 25OHD or 1,25(OH)2D. There was no evidence of a threshold change in BMD with increasing serum 25OHD or free 25OHD in this population.

CONCLUSIONS

We found no significant effect of daily vitamin D dose ranging from 400 to 4800 IU/day on BMD or serum N-terminal telopeptides in elderly women with initially low serum 25OHD.

The meaning of work for young adults diagnosed with serious mental health conditions

OBJECTIVE

Despite the increased recognition of the importance of work for social and psychological well-being, the meaning of work for young adults with serious mental health conditions is understudied. This study uses a participatory action research approach to explore the economic, social and psychological significance of work for young adults diagnosed with psychiatric disabilities.

METHOD

We conducted 57 one-hour semistructured interviews with young adults between the ages of 18 to 30 enrolled in 3 well established vocational support programs. NVivo 8 software was used to sort and systematically organize the interview data.

RESULTS

Young adults with psychiatric disabilities work in part for financial independence from their family but also for additional reasons. Work provides the opportunity for social engagement and feelings of contributing to society as a whole. For some young adults, work provides the opportunity to enhance their self-esteem, self-confidence, and a positive self-image. For Latino young adults, work provides a way to cope with their mental illness.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our findings provide pertinent information for vocational rehabilitation services, recovery programs, and even parents on the importance of connecting young adults to jobs that enhance self-esteem and self-efficacy and are in line with their personal interests. Future research is needed to understand potential cultural and age differences in the meaning of work. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Measuring Community Resilience to Natural Hazards: The Natural Hazard Resilience Screening Index (NaHRSI)-Development and Application to the United States

Natural disasters often impose significant and long-lasting stress on financial, social, and ecological systems. From Atlantic hurricanes to Midwest tornadoes to Western wildfires, no corner of the United States is immune from the threat of a devastating natural hazard event. Across the nation, there is a recognition that the benefits of creating environments resilient to adverse natural hazard events help promote and sustain county and community success over time. The challenge for communities is in finding ways to balance the need to preserve the socioecological systems on which they depend in the face of constantly changing natural hazard threats. The Natural Hazard Resilience Screening Index (NaHRSI; previously entitled Climate Resilience Screening Index) has been developed as an endpoint for characterizing county resilience outcomes that are based on risk profiles and responsive to changes in governance, societal, built, and natural system characteristics. The NaHRSI framework serves as a conceptual roadmap showing how natural hazard events impact resilience after factoring in county characteristics. By evaluating the factors that influence vulnerability and recoverability, an estimation of resilience can quantify how changes in these characteristics will impact resilience given specific hazard profiles. Ultimately, this knowledge will help communities identify potential areas to target for increasing resilience to natural hazard events.

The relationship between transgenerational acquired resistance and global DNA methylation in Arabidopsis

Progeny of heavily diseased plants develop transgenerational acquired resistance (TAR). In Arabidopsis, TAR can be transmitted over one stress-free generation. Although DNA methylation has been implicated in the regulation of TAR, the relationship between TAR and global DNA methylation remains unknown. Here, we characterised the methylome of TAR-expressing Arabidopsis at different generations after disease exposure. Global clustering of cytosine methylation revealed TAR-related patterns in the F3 generation, but not in the F1 generation. The majority of differentially methylated positions (DMPs) occurred at CG context in gene bodies. TAR in F3 progeny after one initial generation of disease, followed by two stress-free generations, was lower than TAR in F3 progeny after three successive generations of disease. This difference in TAR effectiveness was proportional to the intensity of differential methylation at a sub-set of cytosine positions. Comparison of TAR-related DMPs with previously characterised cytosine methylation in mutation accumulation lines revealed that ancestral disease stress preferentially acts on methylation-labile cytosine positions, but also extends to methylation-stable positions. Thus, the TAR-related impact of ancestral disease extends beyond stochastic variation in DNA methylation. Our study has shown that the Arabidopsis epigenome responds globally to disease in previous generations and we discuss its contribution to TAR.

Application of the Human Well-Being Index to Sensitive Population Divisions: A Children's Well-Being Index Development

The assessment of community well-being is critical as an end-point measure that will facilitate decision support and assist in the identification of sustainable solutions to address persistent problems. While the overall measure is important, it is equally vital to distinguish variations among groups within the population who may be impacted in a different manner. The U.S. Environmental Protection Agency (US EPA) developed the Human Well-Being Index (HWBI), as a way of measuring these outcomes and assessing community characteristics. The HWBI approach produces a suite of indicators, domains and a final composite index appropriate for characterizing well-being of a population. While generalized approaches are needed, it is important to also recognize variations in well-being across community enclaves. This paper presents an adaption of the HWBI for child populations to test the applicability of the index framework to specific community enclaves. First, an extensive literature review was completed to ensure the theoretical integrity of metric and indicator substitutions from the original HWBI framework. Metric data were then collected, refined, imputed where necessary and evaluated to confirm temporal and spatial availability. A Children's Well-Being Index (CWBI) value, representing the same indicators and domains of well-being as the original HWBI, was calculated for the population under age 18 across all US counties for 2011. Implications of this research point to an effective, holistic end-point measure that can be tracked over time. Similarly, there is great potential for the application of the original HWBI method to other statistical population segments within the greater US population. These adaptations could help identify and close gaps in equity of resource distribution among these groups.

An Approach to Assigning In Vitro Potency to Unfractionated and Low Molecular Weight Heparins Based on the Inhibition of Prothrombin Activation and Catalysis of Thrombin Inhibition

Unfractionated and low molecular weight (LMW) heparins with good antithrombotic activity invariably catalyze thrombin inhibition and inhibit the appearance of thrombin activity in contact-activated plasma. Conversely, the antithrombotic efficacy of LMW heparins decreases as their ability to catalyze thrombin inhibition and to inhibit the appearance of thrombin activity in plasma decrease. The activated partial thromboplastin time (APTT) has proven a reliable test for assaying unfractionated heparin. We therefore compared 2 unfractionated and 3 LMW heparins on the basis of the minimum concentrations required to double the APTT of normal plasma and by then determined how this anticoagulant effect was achieved. The amount of unfractionated and LMW heparin which doubled the APTT was found to be equivalent to —0.25 antithrombin units. This concentration of each glycosaminoglycan completely inhibited prothrombin activation for 45 s after CaCl2 was added to contact-activated plasma; accelerated thrombin inhibition by purified antithrombin III by approximately 50-fold; and accelerated thrombin inhibition equally by anti thrombin III in undiluted plasma. This concentration of the three LMW heparins increased, by approximately 70fold, the rate of factor Xa inhibition by purified antithrombin III compared to the 50-fold increase seen with the two unfractionated heparins. These results thus suggest that tests based on the inhibition of prothrombin activation and/or on the catalysis of thrombin inhibition provide a useful basis for assigning in vitro potency to both unfractionated and LMW heparins.

Tear Histamine and Histaminase during the Early (Epr) and Late (Lpr) Phases of the Allergic Reaction and the Effects of Lodoxamide

The objectives of this study were two-fold: to identify tear histamine content and its relationship to changes in tear histaminase activity during the early (EPR) and late phases (LPR) of the allergic reaction induced by a conjunctival provocation test (CPT) and to evaluate the effects of lodoxamide on histamine release and allergic signs and symptoms during EPR and LPR. A baseline CPT was administered to 20 allergic patients with no baseline signs or symptoms of allergy. Clinical signs and symptoms were evaluated after 20 minutes and 6 hours. Tear samples were taken after 5-10 minutes and after 6 hours for subsequent analyses of cytology and histamine content (ELISA). Patients were then randomly assigned to receive lodoxamide or placebo four times daily for one week in a double-masked fashion. A second CPT was done after this therapy and the same parameters were re-evaluated. During EPR, tear histamine increased significantly with respect to baseline values (p < 0.05). During LPR, tear histamine increased significantly (p < 0.05) only in histamine inactivated samples. Histaminase enzymes were also significantly less active during the EPR (5.5 +/- 0.7) than the LPR (9.9 +/- 2.3) and at baseline. Histamine levels significantly correlated with allergic signs and symptoms (p < 0.05) only during the EPR. Lodoxamide significantly reduced histamine release during EPR (p < 0.05), allergic signs and symptoms during both EPR (p < 0.001) and LPR (p < 0.005), and tear cytology counts during LPR. In conclusion, greater histaminase activity may account for the smaller amount of tear histamine generally found during LPR, while these enzymes seem to play less of a role during the surge of histamine release and activity in the EPR. Lodoxamide was shown to ideally inhibit various aspects of the allergic reaction: clinical signs and symptoms in both the early and late phases, the primarily EPR-related peak of histamine release, and the primarily LPR-related changes in tear cytology.

Blink: Characteristics, Controls, and Relation to Dry Eyes

Blink is a complex phenomenon that is profoundly affected by diverse endogenous and exogenous stimuli. It has been studied in the context of cognition, emotional, and psychological states, as an indicator of fatigue and sleepiness, particularly in the automobile and transportation industry, in visual tasking, and finally, as it relates to tear film stability and ocular surface health. The fact that it is highly variable and has input from so many sources makes it very difficult to study. In the present review, the behavior of blink in many of these systems is discussed, ultimately returning in each instance to a discussion of how these factors affect blink in the context of dry eyes. Blink is important to ocular surface health and to an individual's optimal functioning and quality of life. Disturbances in blink, as cause or effect, result in a breakdown of tear film stability, optical clarity, and visual function.

Use of the Controlled Adverse Environment (CAE) in Clinical Research: A Review

The many internal and external factors that contribute to the pathophysiology of dry eye disease (DED) create a difficult milieu for its study and complicate its clinical diagnosis and treatment. The controlled adverse environment (CAE^®) model has been developed to minimize the variability that arises from exogenous factors and to exacerbate the signs and symptoms of DED by stressing the ocular surface in a safe, standardized, controlled, and reproducible manner. By integrating sensitive, specific, and clinically relevant endpoints, the CAE has proven to be a unique and adaptable model for both identifying study-specific patient populations with modifiable signs and symptoms, and for tailoring the evaluation of interventions in clinical research studies.