A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus

BACKGROUND

Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes.

METHODS

Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

RESULTS AND DISCUSSION

Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events.

CONCLUSIONS

This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Essential role of obscurin kinase-1 in cardiomyocyte coupling via N-cadherin phosphorylation

Obscurins are giant cytoskeletal proteins with structural and regulatory roles. Obscurin-B (~870 kDa), the largest known isoform, contains 2 enzymatically active Ser/Thr kinase (kin) domains, kin1 and kin2, which belong to the myosin light chain kinase family. Kin1 binds to and phosphorylates N-cadherin, a major component of the intercalated disc, the unique sarcolemmal microdomain that mediates the mechanochemical coupling of adjacent cardiomyocytes. Obscurin-B containing kin1 and N-cadherin colocalize at cell junctions in embryonic rat ventricular myocytes (ERVMs), and their codistribution is regulated by Ca2+. Phosphoproteomics analysis revealed that obscurin-kin1 phosphorylates N-cadherin at Ser-788 located within the juxtamembrane region of its cytoplasmic domain, with an apparent Kcat of approximately 5.05 min-1. Overexpression of obscurin-kin1 or phosphomimic-Ser-788-Glu N-cadherin in ERVMs markedly increases cell adhesion and chemical coupling. Importantly, phosphomimic Ser-788-Glu N-cadherin exhibits significantly reduced binding to p120-catenin, while overexpression of phosphoablated Ser-788-Ala N-cadherin increases RhoA activity. Consistent with an essential role of the obscurin-kin1/N-cadherin axis in cardiomyocyte coupling, it is deregulated in end-stage human heart failure. Given the nearly ubiquitous expression of obscurin and N-cadherin, our findings may have broad applicability in deciphering the obscurin-kin1/N-cadherin axis that likely mediates cell coupling in diverse tissues and organs.

COVID-19 pandemic impact on adolescent mental health: a reassessment accounting for development

Current prospective reports suggest a pandemic-related increase in adolescent mental health problems. We examine whether age-related change over 11-14 years accounts for this increase. Mothers and adolescents in a UK-based birth cohort (Wirral Child Health and Development Study; WCHADS; N = 737) reported on adolescent depression and behavioural problems pre-pandemic (December 2019-March 2020), mid-pandemic (June 2020-March 2021) and late pandemic (July 2021-March 2022). Analysis used repeated measures models for over-dispersed Poisson counts with an adolescent-specific intercept with age as a time-varying covariate. Maturational curves for girls, but not for boys, showed a significant increase in self-reported depression symptoms over ages 11-14 years. Behavioural problems decreased for both. After adjusting for age-related change, girls' depression increased by only 13% at mid-pandemic and returned to near pre-pandemic level at late pandemic (mid versus late - 12%), whereas boys' depression increased by 31% and remained elevated (mid versus late 1%). Age-adjusted behavioural problems increased for both (girls 40%, boys 41%) and worsened from mid- to late pandemic (girls 33%, boys 18%). Initial reports of a pandemic-related increase in depression in young adolescent girls could be explained by a natural maturational rise. In contrast, maturational decreases in boys' depression and both boys' and girls' behavioural problems may mask an effect of the pandemic.

A longitudinal comparison of emotional, behavioral and attention problems in autistic and typically developing children

BACKGROUND

Mental health problems are elevated in autistic individuals but there is limited evidence on the developmental course of problems across childhood. We compare the level and growth of anxious-depressed, behavioral and attention problems in an autistic and typically developing (TD) cohort.

METHODS

Latent growth curve models were applied to repeated parent-report Child Behavior Checklist data from age 2-10 years in an inception cohort of autistic children (Pathways, N = 397; 84% boys) and a general population TD cohort (Wirral Child Health and Development Study; WCHADS; N = 884, 49% boys). Percentile plots were generated to quantify the differences between autistic and TD children.

RESULTS

Autistic children showed elevated levels of mental health problems, but this was substantially reduced by accounting for IQ and sex differences between the autistic and TD samples. There was small differences in growth patterns; anxious-depressed problems were particularly elevated at preschool and attention problems at late childhood. Higher family income predicted lower base-level on all three dimensions, but steeper increase of anxious-depressed problems. Higher IQ predicted lower level of attention problems and faster decline over childhood. Female sex predicted higher level of anxious-depressed and faster decline in behavioral problems. Social-affect autism symptom severity predicted elevated level of attention problems. Autistic girls' problems were particularly elevated relative to their same-sex non-autistic peers.

CONCLUSIONS

Autistic children, and especially girls, show elevated mental health problems compared to TD children and there are some differences in predictors. Assessment of mental health should be integrated into clinical practice for autistic children.

Photo elicitation, an approach to better understanding the patient experience with OAAs: pilot study and future implications

PURPOSE

Oral anti-cancer agents (OAAs) represent a new frontier in cancer treatment, but we do not know how well patients incorporate the strategies that they are taught for managing the side effects of OAAs into their daily lives. The purpose of this study was to understand how OAA side effects influenced patients' lives and what strategies patients used to manage them.

METHODS

The study used an interpretive descriptive design utilizing photo elicitation interviews (PEI). Two pharmacists employed at the study ambulatory oncology clinic assisted with recruitment. Participants took photos and subsequent interviews focused on talking to participants about each photo, eliciting participant perspectives describing side effects of OAAs and management strategies. A directed content analysis approach was used to analyze the transcribed interviews.

RESULTS

A total of nine participants were included in the study. Three themes and associated sub-themes emerged: making changes to nutritional habits due to OAA side effects (hydration and food), strategies to alleviate OAA side effects (medication and non-medication related), and methods of coping with OAA effects (intra- and interpersonal). Changing nutritional habits was an important strategy to manage OAA side effects. Medication-related strategies to alleviate OAA side effects could be nuanced and, additionally, there was wide variability in coping methods used.

CONCLUSION

Patient education on OAAs and side effects is not always tailored to each unique patient and their circumstances. This study uncovered how participants devised their own distinct strategies to prevent or manage OAA side effects in an effort to help improve patients' experiences when taking OAAs.

First Double-Differential Measurement of Kinematic Imbalance in Neutrino Interactions with the MicroBooNE Detector

We report the first measurement of flux-integrated double-differential quasielasticlike neutrino-argon cross sections, which have been made using the Booster Neutrino Beam and the MicroBooNE detector at Fermi National Accelerator Laboratory. The data are presented as a function of kinematic imbalance variables which are sensitive to nuclear ground-state distributions and hadronic reinteraction processes. We find that the measured cross sections in different phase-space regions are sensitive to different nuclear effects. Therefore, they enable the impact of specific nuclear effects on the neutrino-nucleus interaction to be isolated more completely than was possible using previous single-differential cross section measurements. Our results provide precision data to help test and improve neutrino-nucleus interaction models. They further support ongoing neutrino-oscillation studies by establishing phase-space regions where precise reaction modeling has already been achieved.

Renal Embolization-Induced Uremic Swine Model for Assessment of Next-Generation Implantable Hemodialyzers

Reliable models of renal failure in large animals are critical to the successful translation of the next generation of renal replacement therapies (RRT) into humans. While models exist for the induction of renal failure, none are optimized for the implantation of devices to the retroperitoneal vasculature. We successfully piloted an embolization-to-implantation protocol enabling the first implant of a silicon nanopore membrane hemodialyzer (SNMHD) in a swine renal failure model. Renal arterial embolization is a non-invasive approach to near-total nephrectomy that preserves retroperitoneal anatomy for device implants. Silicon nanopore membranes (SNM) are efficient blood-compatible membranes that enable novel approaches to RRT. Yucatan minipigs underwent staged bilateral renal arterial embolization to induce renal failure, managed by intermittent hemodialysis. A small-scale arteriovenous SNMHD prototype was implanted into the retroperitoneum. Dialysate catheters were tunneled externally for connection to a dialysate recirculation pump. SNMHD clearance was determined by intermittent sampling of recirculating dialysate. Creatinine and urea clearance through the SNMHD were 76-105 mL/min/m2 and 140-165 mL/min/m2, respectively, without albumin leakage. Normalized creatinine and urea clearance measured in the SNMHD may translate to a fully implantable clinical-scale device. This pilot study establishes a path toward therapeutic testing of the clinical-scale SNMHD and other implantable RRT devices.

Feasibility of an implantable bioreactor for renal cell therapy using silicon nanopore membranes

The definitive treatment for end-stage renal disease is kidney transplantation, which remains limited by organ availability and post-transplant complications. Alternatively, an implantable bioartificial kidney could address both problems while enhancing the quality and length of patient life. An implantable bioartificial kidney requires a bioreactor containing renal cells to replicate key native cell functions, such as water and solute reabsorption, and metabolic and endocrinologic functions. Here, we report a proof-of-concept implantable bioreactor containing silicon nanopore membranes to offer a level of immunoprotection to human renal epithelial cells. After implantation into pigs without systemic anticoagulation or immunosuppression therapy for 7 days, we show that cells maintain >90% viability and functionality, with normal or elevated transporter gene expression and vitamin D activation. Despite implantation into a xenograft model, we find that cells exhibit minimal damage, and recipient cytokine levels are not suggestive of hyperacute rejection. These initial data confirm the potential feasibility of an implantable bioreactor for renal cell therapy utilizing silicon nanopore membranes.

A descriptive study of policy and system-level interventions to address cancer survivorship issues across six United States health systems

PURPOSE

To describe policy and system-level interventions with potential to improve cancer care at six sites.

METHODS

In 2016, six institutions received foundation support to develop unique multi-component interventions aimed at improving cancer care for underserved populations. These organizations, located across the United States, participated in a cross-site evaluation to assess the overall initiative impact and to identify potentially promising policy and system-level solutions for dissemination and broader implementation. A health system and policy tracking tool was developed to collect data from each site and included a description of their efforts, strategies employed, and changes achieved (e.g., new policies, clinical protocols). Tracking tool data were analyzed using rapid qualitative analyses and a matrix approach. Semi-structured interviews were conducted with site leaders (N = 65) and were analyzed by thematic analysis.

RESULTS

Sites reported 20 system and policy efforts, which resulted in improvements to electronic health records and telehealth strategies, changes to hospital/health system policies, and standardized clinical protocols/guidelines, among others. Efforts were aimed at: (1) coordinating care across multiple providers, supported by patient navigators; (2) expanding psychosocial and supportive care; (3) improving patient-provider communication; and (4) addressing barriers to accessing care. Interview analyses provided insights into successful strategies, challenges, and implications of the COVID-19 pandemic on cancer care.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

Despite advances in diagnosis and treatment, cancer care remains inequitable. System-level improvements aimed at eliminating common barriers faced by underserved populations offer opportunities to improve the delivery of equitable, effective, and efficient care.

First Measurement of Quasielastic Λ Baryon Production in Muon Antineutrino Interactions in the MicroBooNE Detector

We present the first measurement of the cross section of Cabibbo-suppressed Λ baryon production, using data collected with the MicroBooNE detector when exposed to the neutrinos from the main injector beam at the Fermi National Accelerator Laboratory. The data analyzed correspond to 2.2×10^{20} protons on target running in neutrino mode, and 4.9×10^{20} protons on target running in anti-neutrino mode. An automated selection is combined with hand scanning, with the former identifying five candidate Λ production events when the signal was unblinded, consistent with the GENIE prediction of 5.3±1.1 events. Several scanners were employed, selecting between three and five events, compared with a prediction from a blinded Monte Carlo simulation study of 3.7±1.0 events. Restricting the phase space to only include Λ baryons that decay above MicroBooNE's detection thresholds, we obtain a flux averaged cross section of 2.0_{-1.7}^{+2.2}×10^{-40}  cm^{2}/Ar, where statistical and systematic uncertainties are combined.

Characterization of human islet function in a convection-driven intravascular bioartificial pancreas

Clinical islet transplantation for treatment of type 1 diabetes (T1D) is limited by the shortage of pancreas donors and need for lifelong immunosuppressive therapy. A convection-driven intravascular bioartificial pancreas (iBAP) based on highly permeable, yet immunologically protective, silicon nanopore membranes (SNM) holds promise to sustain islet function without the need for immunosuppressants. Here, we investigate short-term functionality of encapsulated human islets in an iBAP prototype. Using the finite element method (FEM), we calculated predicted oxygen profiles within islet scaffolds at normalized perifusion rates of 14-200 nl/min/IEQ. The modeling showed the need for minimum in vitro and in vivo islet perifusion rates of 28 and 100 nl/min/IEQ, respectively to support metabolic insulin production requirements in the iBAP. In vitro glucose-stimulated insulin secretion (GSIS) profiles revealed a first-phase response time of <15 min and comparable insulin production rates to standard perifusion systems (~10 pg/min/IEQ) for perifusion rates of 100-200 nl/min/IEQ. An intravenous glucose tolerance test (IVGTT), performed at a perifusion rate of 100-170 nl/min/IEQ in a non-diabetic pig, demonstrated a clinically relevant C-peptide production rate (1.0-2.8 pg/min/IEQ) with a response time of <5 min.

First Constraints on Light Sterile Neutrino Oscillations from Combined Appearance and Disappearance Searches with the MicroBooNE Detector

We present a search for eV-scale sterile neutrino oscillations in the MicroBooNE liquid argon detector, simultaneously considering all possible appearance and disappearance effects within the 3+1 active-to-sterile neutrino oscillation framework. We analyze the neutrino candidate events for the recent measurements of charged-current ν_{e} and ν_{μ} interactions in the MicroBooNE detector, using data corresponding to an exposure of 6.37×10^{20} protons on target from the Fermilab booster neutrino beam. We observe no evidence of light sterile neutrino oscillations and derive exclusion contours at the 95% confidence level in the plane of the mass-squared splitting Δm_{41}^{2} and the sterile neutrino mixing angles θ_{μe} and θ_{ee}, excluding part of the parameter space allowed by experimental anomalies. Cancellation of ν_{e} appearance and ν_{e} disappearance effects due to the full 3+1 treatment of the analysis leads to a degeneracy when determining the oscillation parameters, which is discussed in this Letter and will be addressed by future analyses.

Activity patterns and reproductive behavior of the Critically Endangered Bermuda skink (Plestiodon longirostris)

The study of rare or cryptic species in zoos can provide insights into natural history and behavior that would be difficult to obtain in the field. Such information can then be used to refine population assessment protocols and conservation management. The Bermuda skink (Plestiodon longirostris) is an endemic Critically Endangered lizard. Chester Zoo's successful conservation breeding program is working to safeguard, increase and reinforce skink populations in the wild. A key aim of this program is to develop our understanding of the behavior of this species. In this study, using 24 h video recordings, we examined the daily activity patterns, basking behavior and food preferences of four pairs of Bermuda skinks. The skinks displayed a bimodal pattern of activity and basking, which may have evolved to avoid the strength of the midday sun in exposed habitats in Bermuda. Captive Bermuda skinks appear to prefer a fruit-based diet to orthopteran prey. We also documented their reproductive behavior and compared it against two closely related species. Although there were many similarities between the courtship and mating behaviors of the three species, there was a significantly shorter period of cloacal contact in the Bermuda skink. Oophagia was also documented for the first time in this species. This knowledge has enabled the evaluation of the current ex-situ management practices of this species, filled gaps in knowledge that would be challenging to obtain in the field, and enabled the enhancement of both animal husbandry and reproductive success for the conservation breeding program.

Synergy between callous-unemotional traits and aggression in preschool children: Cross-informant and cross-cultural replication in the UK Wirral Child Health and Development Study, and the Colombian La Sabana Parent-Child Study

Incremental prediction of aggression from callous-unemotional (CU) traits is well established, but cross-cultural replication and studies of young children are needed. Little is understood about the contribution of CU traits in children who are already aggressive. We addressed these issues in prospective studies in the United Kingdom and Colombia. In a UK epidemiological cohort, CU traits and aggression were assessed at age 3.5 years, and aggression at 5.0 years by mothers (N = 687) and partners (N = 397). In a Colombian general population sample, CU traits were assessed at age 3.5 years and aggression at 3.5 and 5.0 years by mother report (N = 220). Analyses consistently showed prediction of age-5.0 aggression by age-3.5 CU traits controlling for age-3.5 aggression. Associations between age-3.5 CU traits and age-5.0 aggression were moderated by aggression at 3.5 years, with UK interaction terms, same informant, β = .07 p = .014 cross-informant, β = .14 p = .002, and in Colombia, β = .09 p = .128. The interactions arose from stronger associations between CU traits and later aggression in those already aggressive. Our findings with preschoolers replicated across culturally diverse settings imply a major role for CU traits in the maintenance and amplification of already established aggression, and cast doubt on their contribution to its origins.

Search for an Excess of Electron Neutrino Interactions in MicroBooNE Using Multiple Final-State Topologies

We present a measurement of ν_{e} interactions from the Fermilab Booster Neutrino Beam using the MicroBooNE liquid argon time projection chamber to address the nature of the excess of low energy interactions observed by the MiniBooNE Collaboration. Three independent ν_{e} searches are performed across multiple single electron final states, including an exclusive search for two-body scattering events with a single proton, a semi-inclusive search for pionless events, and a fully inclusive search for events containing all hadronic final states. With differing signal topologies, statistics, backgrounds, reconstruction algorithms, and analysis approaches, the results are found to be either consistent with or modestly lower than the nominal ν_{e} rate expectations from the Booster Neutrino Beam and no excess of ν_{e} events is observed.

Exposure to community violence and Callous-Unemotional traits in young children: the role of positive parenting

Introduction

Studies regarding environmental contributions on callous-unemotional (CU) traits in children have informed about the protective role of positive parenting. However, it has not been explored whether findings from these studies -mostly conducted in High-Income Countries- can be generalised to Low-Middle-Income Countries (LMICs). Exposure to community violence is common in LMICs and is associated with emotional and behavioural problems in children. Therefore, it may represent an environmental risk factor for CU traits.

Objectives

This prospective study explores whether positive parenting has a protective role in relation to CU traits in young Colombian children whose families have been exposed to community violence.

Methods

We assessed 235 families with children at age 3.5 years, from three contrasting regions of Colombia, using observations of mother-child interactions and maternal reports of community violence at ages 3.5 and 5.0 years.

Results

Hierarchical multiple linear regression models indicated that maternal positivity at 3.5 years was associated with lower CU traits at age 5.0 years only in children of families exposed to community violence (interaction term p= .001). In the exposed group maternal positivity explained 10% of the variance (β= -.34, p= .001) with low positivity associated with elevated CU traits and high positivity with low CU traits. Maternal praise was not associated with CU traits. However, maternal negativity during play was associated with elevated CU traits as a main effect.

Conclusions

Based on these findings, whether or not exposure to community violence is associated with elevated CU traits depends on maternal positivity, with low positivity creating vulnerability, and high positivity, resilience.

Disclosure

No significant relationships.

Multisite Clinical Utilization of Antibiotics among Hospitalized Patients with COVID‐19

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has infected over 212,000,000 individuals worldwide with a mortality rate of 2.1% as of August 2021. A concerning trend in the treatment of COVID‐19 has emerged wherein hospitalized patients are administered broad spectrum antibiotics to stave off secondary bacterial infection. However, the clinical justification for the use of broad‐spectrum antibiotics for viral respiratory infection remains tenuous. Over administration of these therapies contributes to the growing frequency of antimicrobial resistance, which prior to the pandemic contributed to nearly 700,000 death per year.

Objective

To describe the clinical utilization and efficacy of broad‐spectrum antibiotics among hospitalized patients with SARS‐CoV‐2 within 3 hospital systems in the American southwest.

Methods

A multisite retrospective chart review of patients admitted to inpatient care due SARS‐CoV‐2 infection from March 1^st, 2020 through January 31^st, 2021 was conducted. Abstracted data included patient demographics, laboratory culture results, administered antibiotics, and patient outcomes. Analysis was conducted using descriptive statistics, the Pearson chi‐square for categorical data, and the Mann‐Whitney U test for continuous data.

Results

A total of 489 patients with confirmed SARS‐CoV‐2 infection via nasopharyngeal sample were included in the analysis with 19.2% (94/489) diagnosed with a concurrent bacterial infection. Patients with concurrent bacterial infections were more likely to require critical care (50.0% vs 20.7%; p<0.001) and expire (28.7% vs 14.4%; p<0.001) while hospitalized. Though the rates of secondary bacterial infection were low, 83.4% of all patients were administered at least one broad spectrum antibiotic, with the most common being Azithromycin (60%; 297/489) followed by Ceftriaxone (46.6%; 228/489). Antibiotics were not preferentially administered to patients with concurrent bacterial infection (p=0.1619), nor did it show clinical efficacy for reducing mortality among the entire sample (p=0.190) or those with secondary infection (p=0.191).

Conclusion

The COVID‐19 pandemic has contributed to non‐specific over administration of broad‐spectrum antibiotics, which failed to improve the rate of patient mortality even when afflicted with secondary infection. Over‐administration of these drugs will continue to exacerbate the growing rates of antimicrobial resistance. Clinicians are recommended to apply early empirical approaches when selecting to employ antibiotic therapies.

First Measurement of Energy-Dependent Inclusive Muon Neutrino Charged-Current Cross Sections on Argon with the MicroBooNE Detector

We report a measurement of the energy-dependent total charged-current cross section σ(E_{ν}) for inclusive muon neutrinos scattering on argon, as well as measurements of flux-averaged differential cross sections as a function of muon energy and hadronic energy transfer (ν). Data corresponding to 5.3×10^{19} protons on target of exposure were collected using the MicroBooNE liquid argon time projection chamber located in the Fermilab booster neutrino beam with a mean neutrino energy of approximately 0.8 GeV. The mapping between the true neutrino energy E_{ν} and reconstructed neutrino energy E_{ν}^{rec} and between the energy transfer ν and reconstructed hadronic energy E_{had}^{rec} are validated by comparing the data and Monte Carlo (MC) predictions. In particular, the modeling of the missing hadronic energy and its associated uncertainties are verified by a new method that compares the E_{had}^{rec} distributions between data and a MC prediction after constraining the reconstructed muon kinematic distributions, energy, and polar angle to those of data. The success of this validation gives confidence that the missing energy in the MicroBooNE detector is well modeled and underpins first-time measurements of both the total cross section σ(E_{ν}) and the differential cross section dσ/dν on argon.

Search for Neutrino-Induced Neutral-Current Δ Radiative Decay in MicroBooNE and a First Test of the MiniBooNE Low Energy Excess under a Single-Photon Hypothesis

We report results from a search for neutrino-induced neutral current (NC) resonant Δ(1232) baryon production followed by Δ radiative decay, with a ⟨0.8⟩  GeV neutrino beam. Data corresponding to MicroBooNE's first three years of operations (6.80×10^{20} protons on target) are used to select single-photon events with one or zero protons and without charged leptons in the final state (1γ1p and 1γ0p, respectively). The background is constrained via an in situ high-purity measurement of NC π^{0} events, made possible via dedicated 2γ1p and 2γ0p selections. A total of 16 and 153 events are observed for the 1γ1p and 1γ0p selections, respectively, compared to a constrained background prediction of 20.5±3.65(syst) and 145.1±13.8(syst) events. The data lead to a bound on an anomalous enhancement of the normalization of NC Δ radiative decay of less than 2.3 times the predicted nominal rate for this process at the 90% confidence level (C.L.). The measurement disfavors a candidate photon interpretation of the MiniBooNE low-energy excess as a factor of 3.18 times the nominal NC Δ radiative decay rate at the 94.8% C.L., in favor of the nominal prediction, and represents a greater than 50-fold improvement over the world's best limit on single-photon production in NC interactions in the sub-GeV neutrino energy range.

A practical approach to continuous glucose monitoring (rtCGM) and FreeStyle Libre systems (isCGM) in children and young people with Type 1 diabetes

Real-time continuous glucose monitoring (rtCGM) and FreeStyle Libre glucose monitoring systems (isCGM) are new evolving technologies used in the management of Type 1 diabetes. They offer potential to improve diabetes control and reduce hypoglycaemia. rtCGM can be linked to insulin pump providing hybrid closed loop therapy. Families of children and young people are keen to have the benefit from these technologies. These are relatively expensive so it is important that health care professionals, families of children and young people (CYP) with diabetes are adequately trained in the use of these devices. Health care professionals need to be able to make patient selection based on individual needs and preferences to achieve maximum benefit. Association of Children's Diabetes Clinicians (ACDC) developed a comprehensive guideline in 2017 to help identify which patients may be most likely to benefit and how these technologies may be practically implemented. Since then new technologies have been introduced and the use of GCM has expanded in routine clinical practice. This article, aims to provide a practical approach and help identify which patients may be most likely to benefit and how the technology may be implemented in order to maximise the clinical benefits.

Exploring the process of information sharing in an adult intensive care unit: an ethnographic study

Information sharing, a component of patient and family engagement (PFE), is an important process that may contribute to intensive care unit (ICU) quality of care. Yet, virtually no studies explore how the process of information sharing unfolds in the ICU from the interprofessional team and family member perspectives. To better understand the process of information sharing, we conducted ethnographic fieldwork in a 20-bed medical ICU, focusing on behaviors and interactions of the interprofessional team and family members (May 2016 - October 2016). We completed 17.5 observation hours, 6 shadowing sessions, and 12 semi-structured interviews with 17 total participants. We used thematic content analysis and iterative inductive coding to identify three themes about the information sharing process: 1) family factors (health literacy and past experience with the ICU environment) influence information sharing; 2) clinicians strategies can support engagement in the process of information sharing (assessing families' need for information, understanding a families' hope, using rounds as an opportunity for information sharing); 3) the process of information sharing allows for trust building between families and the ICU team. Our findings suggest that information sharing is a crucial process that may serve as a catalyst for effective patient and family engagement in the ICU.

SARS-CoV-2 infects the human kidney and drives fibrosis in kidney organoids

Kidney failure is frequently observed during and after COVID-19, but it remains elusive whether this is a direct effect of the virus. Here, we report that SARS-CoV-2 directly infects kidney cells and is associated with increased tubule-interstitial kidney fibrosis in patient autopsy samples. To study direct effects of the virus on the kidney independent of systemic effects of COVID-19, we infected human-induced pluripotent stem-cell-derived kidney organoids with SARS-CoV-2. Single-cell RNA sequencing indicated injury and dedifferentiation of infected cells with activation of profibrotic signaling pathways. Importantly, SARS-CoV-2 infection also led to increased collagen 1 protein expression in organoids. A SARS-CoV-2 protease inhibitor was able to ameliorate the infection of kidney cells by SARS-CoV-2. Our results suggest that SARS-CoV-2 can directly infect kidney cells and induce cell injury with subsequent fibrosis. These data could explain both acute kidney injury in COVID-19 patients and the development of chronic kidney disease in long COVID.

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COVID-19 patients present tubulo-interstitial kidney fibrosis compared with controls

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SARS-CoV-2 infection stimulates profibrotic signaling in human kidney organoids

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SARS-CoV-2 infection can be inhibited by a protease blocker in human kidney organoids

Rural Michigan Farmers' Health Concerns and Experiences: A Focus Group Study

Objectives:

Rural residents comprise approximately 15% of the United States population. They face challenges in accessing and using a health care system that is not structured to meet their unique needs. It is important to understand rural residents’ perceptions of health and experiences interacting with the health care system to identify gaps in care.

Methods:

Our team conducted focus groups with members of the Michigan Farm Bureau during their 2019 Annual Meeting. Topics explored included resources to manage health, barriers to virtual health care services, and desired changes to localized healthcare delivery. Surveys were used to capture demographic and internet access information.

Conclusion:

Analysis included data from 2 focus groups (n = 14). Participants represented a wide age range and a variety of Michigan counties. The majority were full-time farm owners with most—93% (n = 13)—reporting they had access to the internet in their homes and 86% (n = 12) reporting that their cellphones had internet capabilities. Participants identified challenges and opportunities in 4 categories: formal health care; health and well-being supports; health insurance experiences; and virtual health care.

Conclusion:

The findings from this study provide a useful framework for developing interventions to address the specific needs of rural farming residents. Despite the expressed challenges in access and use of health care services and resources, participants remained hopeful that innovative approaches, such as virtual health platforms, can address existing gaps in care. The study findings should inform the design and evaluation of interventions to address rural health disparities.

Search for a Higgs Portal Scalar Decaying to Electron-Positron Pairs in the MicroBooNE Detector

We present a search for the decays of a neutral scalar boson produced by kaons decaying at rest, in the context of the Higgs portal model, using the MicroBooNE detector. We analyze data triggered in time with the Fermilab NuMI neutrino beam spill, with an exposure of 1.93×10^{20} protons on target. We look for monoenergetic scalars that come from the direction of the NuMI hadron absorber, at a distance of 100 m from the detector, and decay to electron-positron pairs. We observe one candidate event, with a standard model background prediction of 1.9±0.8. We set an upper limit on the scalar-Higgs mixing angle of θ<(3.3-4.6)×10^{-4} at the 95% confidence level for scalar boson masses in the range (100-200)  MeV/c^{2}. We exclude, at the 95% confidence level, the remaining model parameters required to explain the central value of a possible excess of K_{L}^{0}→π^{0}νν[over ¯] decays reported by the KOTO collaboration. We also provide a model-independent limit on a new boson X produced in K→πX decays and decaying to e^{+}e^{-}.

Clinicians Report Barriers and Facilitators to High-Quality Ambulatory Oncology Care

BACKGROUND

Ambulatory oncology practices treat thousands of Americans on a daily basis with high-risk and high-cost antineoplastic agents. However, we know relatively little about these diverse practices and the organizational structures influencing care delivery.

OBJECTIVE

The aim of this study was to examine clinician-reported factors within ambulatory oncology practices that affect care delivery processes and outcomes for patients and clinicians.

METHODS

Survey data were collected in 2017 from 298 clinicians (nurses, physicians, nurse practitioners, and physician assistants) across 29 ambulatory practices in Michigan. Clinicians provided written comments about favorable and unfavorable aspects of their work environments that affected their ability to deliver high-quality care. We conducted inductive content analysis and used the Systems Engineering Initiative for Patient Safety work system model to organize and explain our findings.

RESULTS

Clinicians reported factors within all 5 work-system components of the Systems Engineering Initiative for Patient Safety model that affected care delivery and outcomes. Common themes surfaced, such as unfavorable aspects including staffing inadequacy and high patient volume, limited physical space, electronic health record usability issues, and order entry. Frequent favorable aspects focused on the skills of colleagues, collaboration, and teamwork. Some clinicians explicitly reported how work system factors were relational and influenced patient, clinician, and organizational outcomes.

CONCLUSIONS

These findings show how work-system components are interactive and relational reflecting the complex nature of care delivery.

IMPLICATIONS FOR NURSING PRACTICE

Data obtained from frontline clinicians can support leaders in making organizational changes that are congruent with clinician observations of practices' strengths and opportunities for improvement.

Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation

OBJECTIVE

To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication.

BACKGROUND

Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes.

METHODS

This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis.

RESULTS

Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients.

CONCLUSIONS

Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

Independent relevance of left ventricular hypertrophy for risk of ischaemic heart disease in 25,000 Chinese adults

Background

The prevalence of left ventricular hypertrophy (LVH) is strongly related with established cardiovascular disease (CVD) risk factors and, hence, there has been some uncertainty about its independent relevance for ischaemic heart disease (IHD) after taking account of such risk factors.

Purpose

To examine the associations of LVH with prevalent and incident cases of IHD after adjustment for established risk factors for CVD in a population-based study of Chinese adults.

Methods

The prospective China Kadoorie Biobank cohort study was conducted in the general population of 5 urban and 5 rural areas in China, with a baseline survey in 2004–2008. A random sample of 24,786 participants had a 12-lead electrocardiogram (ECG) recorded at the second resurvey in 2013–2014. Electronic records of ECG tracings were used to estimate LVH using 5 different criteria (Sokolov, Cornell, Romhilt-Estes, Gubner and Mortara). IHD cases were recorded by linkage to electronic records of hospitalisation, death and disease registries. Cox regression was used to estimate the associations of LVH with prevalent (n=1325) and incident (n=900) cases of IHD after adjustment for age, sex, region, prior vascular disease, smoking, alcohol, SBP, diabetes, lipids and body mass index (BMI).

Results

The overall prevalence of LVH in the population varied depending on the criteria used for detection (Mortara [10%], Sokolov [14%], Cornell [6%], Romhilt-Estes [4%] and Gubner [1%]). The prevalence of LVH (using Sokolov) increased with age and was higher in men than women (20% vs 10%) and linearly with levels of SBP, but also by ∼10-fold between the 10 regions in China. Irrespective of which criteria were used for detection (Table), LVH was strongly associated with both prevalent and incident cases of IHD after adjustment for age, sex, region and established CVD risk factors. Any one measure of LVH was associated with an adjusted OR (95% CI) of 1.30 (1.10, 1.53) for prevalent IHD and 1.40 (1.20, 1.64) for incident IHD, respectively.

Conclusions

Overall, 1 in 10 Chinese adults had LVH, and LVH was associated with 30% higher risk of prevalent IHD and 40% higher risk of IHD independent of established CVD risk factors.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): UK Wellcome Trust

Causes and Consequences of Chemotherapy Delays in Ambulatory Oncology Practices: A Multisite Qualitative Study

PURPOSE

In oncology, chemotherapy treatment delays potentially jeopardize patient safety and impede progress toward disease remission. The purpose of this study was to examine the causes and consequences of chemotherapy treatment delays and possible solutions to improve quality of care.

PARTICIPANTS & SETTING

The current authors selected a purposive sample of eight ambulatory oncology practices for ethnographic site visits, which lasted five days each.

METHODOLOGIC APPROACH

The authors conducted 290 observation hours, including clinician shadowing, and 46 semistructured interviews with clinicians (oncology nurses, physicians, and advanced practice providers). Deductive and inductive thematic analysis was performed on all data.

FINDINGS

The authors identified four primary themes from the analysis that affect delays.

IMPLICATIONS FOR NURSING

Future investigations should examine nurses' communication practices in the context of timely chemotherapy administration because communication and documentation technologies within healthcare settings continuously evolve.

Trimethoprim-Sulfamethoxazole Pharmacokinetics during Continuous Ambulatory Peritoneal Dialysis (CAPD)

Ten adult patients on continuous ambulatory peritoneal dialysis (CAPO) received one dose of trimethoprim320 mg (TMP) and sulfamethoxazole 1600 mg (SMX) orally (p.o.), intravenously (i.v.), and intraperitoneally (i.p.) on three separate occasions to characterize the pharmacokinetics of both drugs. Concentrations of both TMP and SMX were measured in serum and dialysate by HPLC to 48 h. Half-life, total body clearance (TBC), and peritoneal clearance (PCI) were determined. The mean half-life of TMP was 28 h, while for SMX it was 12.5 h. Relative to the i.v. dose, the bioavailability following oral administration for TMP was 98% and 87% for SMX. Intraperitoneal bioavailability was 73% for TMP and 65% for SMX after a 4-h dwell.

After 24 h, regardless of the route of administration, less than 3% of TMP and less than 6% of SMX appeared in dialysate.

We conclude that peritoneal losses contribute insignificantly to TMPISMX elimination during CAPO.

P2777Natural history and long-term prognosis of stroke types in urban and rural China: a 9-year prospective study of 0.5 million adults

Background

Stroke is a major cause of premature death and disability worldwide. However, relatively little is known about the natural history and long-term prognosis following stroke in many low and middle income countries, including China.

Methods

The prospective China Kadoorie Biobank recruited 512,000 adults (59% women, mean age 51 years) from 10 (5 urban, 5 rural) areas in China during 2004–08. Information about death and hospitalisation for specific causes was collected by linkage with mortality registries and nationwide health insurance systems. During a 9-year follow-up, 45,732 incident cases of stroke (∼92% confirmed by neuroimaging) were recorded among individuals without prior vascular disease at baseline. The adjusted 28-day case-fatality rates and long-term cumulative risks of recurrent stroke, major vascular events, and mortality following first-ever stroke were estimated by stroke types.

Results

Of the 45,732 first-ever stroke cases reported, 80% (36,588) had IS, 17% (7440) had intracerebral haemorrhage (ICH), 2% (702) had subarachnoid haemorrhage (SAH), and only 1002 (1%) had an unspecified stroke type. The overall 28-day case-fatality following first stroke was 11%, but increased with age and was higher in those in rural than in urban areas (16% vs 6%) and in men than in women (13% vs 10%). The 28-day case-fatality was highest for ICH (47%), lowest for IS (3%) and intermediate for SAH (19%) and unspecified strokes (24%). Among those who survived beyond 28 days, 17% died (28% for ICH, 16% for IS) and 41% had a recurrent stroke (44% for ICH, 41% for IS) at 5 years. For those with first-ever IS, 91% of the subsequent recurrent strokes involved same pathological type, while for ICH, 41% of the recurrent strokes were IS.

Stroke prognosis

Conclusions

Among Chinese adults, the short- and long-term prognosis following first-ever stroke were poor, highlighting the urgent need to implement more effective treatment and secondary prevention strategies for stroke cases.

Acknowledgement/Funding

UK MRC, UK Wellcome Trust, British Heart Foundation, Cancer Research UK, The Chinese Ministry of Science and Technology, the Chinese National Science

Archaeological assessment reveals Earth’s early transformation through land use

Environmentally transformative human use of land accelerated with the emergence of agriculture, but the extent, trajectory, and implications of these early changes are not well understood. An empirical global assessment of land use from 10,000 years before the present (yr B.P.) to 1850 CE reveals a planet largely transformed by hunter-gatherers, farmers, and pastoralists by 3000 years ago, considerably earlier than the dates in the land-use reconstructions commonly used by Earth scientists. Synthesis of knowledge contributed by more than 250 archaeologists highlighted gaps in archaeological expertise and data quality, which peaked for 2000 yr B.P. and in traditionally studied and wealthier regions. Archaeological reconstruction of global land-use history illuminates the deep roots of Earth’s transformation and challenges the emerging Anthropocene paradigm that large-scale anthropogenic global environmental change is mostly a recent phenomenon.

Patient mutations linked to arrhythmogenic cardiomyopathy enhance calpain-mediated desmoplakin degradation

Arrhythmogenic cardiomyopathy (ACM) is an inherited disorder with variable genetic etiologies. Here we focused on understanding the precise molecular pathology of a single clinical variant in DSP, the gene encoding desmoplakin. We initially identified a novel missense desmoplakin variant (p.R451G) in a patient diagnosed with biventricular ACM. An extensive single-family ACM cohort was assembled, revealing a pattern of coinheritance for R451G desmoplakin and the ACM phenotype. An in vitro model system using patient-derived induced pluripotent stem cell lines showed depressed levels of desmoplakin in the absence of abnormal electrical propagation. Molecular dynamics simulations of desmoplakin R451G revealed no overt structural changes, but a significant loss of intramolecular interactions surrounding a putative calpain target site was observed. Protein degradation assays of recombinant desmoplakin R451G confirmed increased calpain vulnerability. In silico screening identified a subset of 3 additional ACM-linked desmoplakin missense mutations with apparent enhanced calpain susceptibility, predictions that were confirmed experimentally. Like R451G, these mutations are found in families with biventricular ACM. We conclude that augmented calpain-mediated degradation of desmoplakin represents a shared pathological mechanism for select ACM-linked missense variants. This approach for identifying variants with shared molecular pathologies may represent a powerful new strategy for understanding and treating inherited cardiomyopathies.

Severe hypokalaemia in diabetic ketoacidosis: a contributor to central pontine myelinolysis?

Hypokalaemia at presentation of diabetic ketoacidosis is uncommon as insulin deficiency and metabolic acidosis shifts potassium extracellularly. However, hypokalaemia is a recognised complication of the management of diabetic ketoacidosis as insulin administration and correction of metabolic acidosis shifts potassium intracellularly. We describe the case of a 9-year-old girl with newly diagnosed type 1 diabetes mellitus presenting in diabetic ketoacidosis, with severe hypokalaemia at presentation due to severe and prolonged emesis. After commencing management for her diabetic ketoacidosis, her serum sodium and osmolality increased rapidly. However, despite maximal potassium concentrations running through peripheral access, and multiple intravenous potassium ‘corrections’, her hypokalaemia persisted. Seventy two hours after presentation, she became drowsy and confused, with imaging demonstrating central pontine myelinolysis – a rare entity seldom seen in diabetic ketoacidosis management in children despite rapid shifts in serum sodium and osmolality. We review the literature associating central pontine myelinolysis with hypokalaemia and hypothesise as to how the hypokalaemia may have contributed to the development of central pontine myelinolysis. We also recommend an approach to the management of a child in diabetic ketoacidosis with hypokalaemia at presentation.

Offering HCV treatment to prisoners is an important opportunity: key principles based on policy and practice assessment in Europe

Background

Prisoners have a high prevalence of hepatitis C virus (HCV) infection but may find it difficult to access healthcare services. This may be related to risk behaviour including history of injecting drugs and marginalisation related to problem drug use/ opioid use disorder (OUD). Direct-acting antiviral products with superior efficacy and safety compared to interferon-based regimens offer HCV cure. Many citizens in Europe have been treated, although few received therapy in prisons.

Methods

Analysis of prisoner HCV treatment need and policy determinants of clinical practice was completed for 5 EU countries. Evidence was collected from national statistical sources and peer-reviewed publications to describe prison populations and HCV prevalence, to map national prison/ HCV health policy or guidance. A consensus of important principles for prisoner HCV care was developed.

Results

Data from published sources describing prisoner HCV prevalence is limited. Prisoner population requiring HCV treatment is not known; estimated numbers based on analysis of evidence: England and Wales, 9000, France, 8000, Spain, 6000, Italy, 6000, Germany, 6000. Treatment access: national law defines right to equivalent care in all countries implying access to HCV therapy in prison similar to community; useful prisoner HCV guidance facilitating treatment decisions present in: 4 of 5 national/ regional HCV policy documents, 4 of 5 national prison healthcare policies. Four of five had practical prison HCV clinical guidelines. Despite existence of policy, implementation of guidance, and so HCV treatment, is suboptimal in many locations.

Conclusions

Prison is an important location to detect, address and treat HCV infection in people who may be underserved for healthcare and find it difficult to navigate community treatment pathways. This is often related to problems with OUD and resulting social inequity. HCV management in prisons must be improved. Policy and clinical practice guidance must be set to promote treatment, and practical steps to make treatment easy should be followed including education to promote engagement, set-up of optimal screening and work up processes with modern tools to reduce time needed/ achieve efficiency; programs to make it easier to get specialists’ input include remote working and nurse-led services.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Abstract 375: Defining a Unifying Mechanism for Select Cardiomyopathy-Linked Variants of Desmoplakin

Arrhythmogenic cardiomyopathy (AC) is a disease that affects 1 in 2000 Americans every year and segregates with sudden cardiac death (SCD). AC is linked to genetic variants in desmosomal genes, however the molecular mechanisms underlying AC remain unclear. To probe the mechanisms of an AC-linked desmosomal mutation, we identified a candidate family with a history of SCD and an unknown variant (R451G) in the desmoplakin (DSP) gene. Statistically significant linkage between the R451G-variant and symptomatic family members (LOD score = 3.4) was established and heart autopsy tissue from a genotype-phenotype positive family member revealed pronounced fibrofatty scarring and a significant loss of DSP protein at the intercalated disc (ID). Notably, the R451G-variant sits in a pocket containing several clinical DSP variants and we show that endogenous DSP is cleaved via a calpain-dependent mechanism. Together this led us to hypothesize that mutant DSP is more susceptible to calpain cleavage, resulting in cellular haploinsufficiency. To define a unifying mechanism for AC-linked variants, we assessed the biomolecular properties of DSP variants. While these variants do not significantly perturb the global structure of DSP, there are significant changes to local stabilizing intramolecular interactions of select variants, which correlates with augmented calpain degradation due to increased exposure of an auto-inhibited calpain-cleavage site. Taken together we have identified a unifying mechanism for select AC-linked variants of DSP grounded in increased susceptibility to calpain-cleavage leading to decreased functional DSP. To test the hypothesis that DSP haploinsufficiency results in poor ID organization and reduced electrical conduction of the myocardium we created engineered heart tissues (EHTs) from induced pluripotent stem cells generated from a symptomatic R451G-positive family member. Surprisingly, we found that conduction velocities were unchanged however, mutant tissues had a significantly slower rate of contraction despite unchanged peak contractile force. This biomechanical deficiency in DSP haploinsuffient cells may indicate poor coupling between the sarcomere lattice and the ID as a fundamental disease mechanism in AC.

Folliculotropic Metastatic Melanoma: A Case Report and Review of the Literature

Folliculotropic metastasis of cutaneous melanoma is rare, with only 5 published case reports in the English language literature since it was first described in 2009. We report a 41-year-old man with a primary cutaneous melanoma of the right upper preauricular region with metastatic spread to the parotid gland and pulmonary lymph nodes. Excision of the primary lesion was performed and immunotherapy was initiated. Sixteen months later, the patient presented with 2 new lesions of the left forehead and left neck. Histopathological examination was consistent with folliculotropic dermal deposits of metastatic melanoma. Deeper sectioning into the blocks revealed only sparse perifollicular pigment deposition and rare dermal melanocytes-a potential diagnostic pitfall had this been seen in the initial sections. This case represents the sixth and youngest patient to date with folliculotropic metastatic melanoma. This entity often presents in patients with advanced disease, including increased Breslow thickness and/or multiple metastases to lymph nodes, internal organs, or both. The folliculotropic metastases tend to be small and are often multiple. The precise relationship between folliculotropic primary melanoma and folliculotropic metastasis is unclear. In one reported case and in our patient, the primary tumor was noted to have a "folliculocentric" pattern. Because of the latter finding, the differential diagnosis includes multiple primary folliculotropic melanomas. Thus, clinical correlation and knowledge concerning the evolution of disease in the patient are critical. This case highlights a rare and unusual pattern of metastatic melanoma and potential problems in differential diagnosis.

Silicon Micropore-Based Parallel Plate Membrane Oxygenator

Extracorporeal membrane oxygenation (ECMO) is a life support system that circulates the blood through an oxygenating system to temporarily (days to months) support heart or lung function during cardiopulmonary failure until organ recovery or replacement. Currently, the need for high levels of systemic anticoagulation and the risk for bleeding are main drawbacks of ECMO that can be addressed with a redesigned ECMO system. Our lab has developed an approach using microelectromechanical systems (MEMS) fabrication techniques to create novel gas exchange membranes consisting of a rigid silicon micropore membrane (SμM) support structure bonded to a thin film of gas-permeable polydimethylsiloxane (PDMS). This study details the fabrication process to create silicon membranes with highly uniform micropores that have a high level of pattern fidelity. The oxygen transport across these membranes was tested in a simple water-based bench-top set-up as well in a porcine in vivo model. It was determined that the mass transfer coefficient for the system using SµM-PDMS membranes was 3.03 ± 0.42 mL O₂ min^-1 m^-2 cm Hg^-1 with pure water and 1.71 ± 1.03 mL O₂ min^-1 m^-2 cm Hg^-1 with blood. An analytic model to predict gas transport was developed using data from the bench-top experiments and validated with in vivo testing. This was a proof of concept study showing adequate oxygen transport across a parallel plate SµM-PDMS membrane when used as a membrane oxygenator. This work establishes the tools and the equipoise to develop future generations of silicon micropore membrane oxygenators.

Correction: An intravascular bioartificial pancreas device (iBAP) with silicon nanopore membranes (SNM) for islet encapsulation under convective mass transport

Correction for 'An intravascular bioartificial pancreas device (iBAP) with silicon nanopore membranes (SNM) for islet encapsulation under convective mass transport' by Shang Song et al., Lab Chip, 2017, 17, 1778-1792.

An intravascular bioartificial pancreas device (iBAP) with silicon nanopore membranes (SNM) for islet encapsulation under convective mass transport

Diffusion-based bioartificial pancreas (BAP) devices are limited by poor islet viability and functionality due to inadequate mass transfer resulting in islet hypoxia and delayed glucose-insulin kinetics. While intravascular ultrafiltration-based BAP devices possess enhanced glucose-insulin kinetics, the polymer membranes used in these devices provide inadequate ultrafiltrate flow rates and result in excessive thrombosis. Here, we report the silicon nanopore membrane (SNM), which exhibits a greater hydraulic permeability and a superior pore size selectivity compared to polymer membranes for use in BAP applications. Specifically, we demonstrate that the SNM-based intravascular BAP with ∼10 and ∼40 nm pore sized membranes support high islet viability (>60%) and functionality (<15 minute insulin response to glucose stimulation) at clinically relevant islet densities (5700 and 11 400 IE per cm²) under convection in vitro. In vivo studies with ∼10 nm pore sized SNM in a porcine model showed high islet viability (>85%) at clinically relevant islet density (5700 IE per cm²), c-peptide concentration of 144 pM in the outflow ultrafiltrate, and hemocompatibility under convection. These promising findings offer insights on the development of next generation of full-scale intravascular devices to treat T1D patients in the future.

Gentle, fast and effective crystal soaking by acoustic dispensing

A high-throughput method is described for crystal soaking using acoustic droplet ejection, and its effectiveness is demonstrated.

The steady expansion in the capacity of modern beamlines for high-throughput data collection, enabled by increasing X-ray brightness, capacity of robotics and detector speeds, has pushed the bottleneck upstream towards sample preparation. Even in ligand-binding studies using crystal soaking, the experiment best able to exploit beamline capacity, a primary limitation is the need for gentle and nontrivial soaking regimens such as stepwise concentration increases, even for robust and well characterized crystals. Here, the use of acoustic droplet ejection for the soaking of protein crystals with small molecules is described, and it is shown that it is both gentle on crystals and allows very high throughput, with 1000 unique soaks easily performed in under 10 min. In addition to having very low compound consumption (tens of nanolitres per sample), the positional precision of acoustic droplet ejection enables the targeted placement of the compound/solvent away from crystals and towards drop edges, allowing gradual diffusion of solvent across the drop. This ensures both an improvement in the reproducibility of X-ray diffraction and increased solvent tolerance of the crystals, thus enabling higher effective compound-soaking concentrations. The technique is detailed here with examples from the protein target JMJD2D, a histone lysine demethylase with roles in cancer and the focus of active structure-based drug-design efforts.

Diffusive Silicon Nanopore Membranes for Hemodialysis Applications

Hemodialysis using hollow-fiber membranes provides life-sustaining treatment for nearly 2 million patients worldwide with end stage renal disease (ESRD). However, patients on hemodialysis have worse long-term outcomes compared to kidney transplant or other chronic illnesses. Additionally, the underlying membrane technology of polymer hollow-fiber membranes has not fundamentally changed in over four decades. Therefore, we have proposed a fundamentally different approach using microelectromechanical systems (MEMS) fabrication techniques to create thin-flat sheets of silicon-based membranes for implantable or portable hemodialysis applications. The silicon nanopore membranes (SNM) have biomimetic slit-pore geometry and uniform pores size distribution that allow for exceptional permeability and selectivity. A quantitative diffusion model identified structural limits to diffusive solute transport and motivated a new microfabrication technique to create SNM with enhanced diffusive transport. We performed in vitro testing and extracorporeal testing in pigs on prototype membranes with an effective surface area of 2.52 cm² and 2.02 cm², respectively. The diffusive clearance was a two-fold improvement in with the new microfabrication technique and was consistent with our mathematical model. These results establish the feasibility of using SNM for hemodialysis applications with additional scale-up.

A large family of anti-activators accompanying XylS/AraC family regulatory proteins

AraC Negative Regulators (ANR) suppress virulence genes by directly down‐regulating AraC/XylS members in Gram‐negative bacteria. In this study, we sought to investigate the distribution and molecular mechanisms of regulatory function for ANRs among different bacterial pathogens. We identified more than 200 ANRs distributed in diverse clinically important gram negative pathogens, including Vibrio spp., Salmonella spp., Shigella spp., Yersinia spp., Citrobacter spp., enterotoxigenic (ETEC) and enteroaggregative E. coli (EAEC), and members of the Pasteurellaceae. By employing a bacterial two hybrid system, pull down assays and surface plasmon resonance (SPR) analysis, we demonstrate that Aar (AggR‐activated regulator), a prototype member of the ANR family in EAEC, binds with high affinity to the central linker domain of AraC‐like member AggR. ANR‐AggR binding disrupted AggR dimerization and prevented AggR‐DNA binding. ANR homologs of Vibrio cholerae, Citrobacter rodentium, Salmonella enterica and ETEC were capable of complementing Aar activity by repressing aggR expression in EAEC strain 042. ANR homologs of ETEC and Vibrio cholerae bound to AggR as well as to other members of the AraC family, including Rns and ToxT. The predicted proteins of all ANR members exhibit three highly conserved predicted α‐helices. Site‐directed mutagenesis studies suggest that at least predicted α‐helices 2 and 3 are required for Aar activity. In sum, our data strongly suggest that members of the novel ANR family act by directly binding to their cognate AraC partners.