Optimising a self-assembling peptide hydrogel as a Matrigel alternative for 3-dimensional mammary epithelial cell culture

Three-dimensional (3D) organoid models have been instrumental in understanding molecular mechanisms responsible for many cellular processes and diseases. However, established organic biomaterial scaffolds used for 3D hydrogel cultures, such as Matrigel, are biochemically complex and display significant batch variability, limiting reproducibility in experiments. Recently, there has been significant progress in the development of synthetic hydrogels for in vitro cell culture that are reproducible, mechanically tuneable, and biocompatible. Self-assembling peptide hydrogels (SAPHs) are synthetic biomaterials that can be engineered to be compatible with 3D cell culture. Here we investigate the ability of PeptiGel® SAPHs to model the mammary epithelial cell (MEC) microenvironment in vitro. The positively charged PeptiGel®Alpha4 supported MEC viability, but did not promote formation of polarised acini. Modifying the stiffness of PeptiGel® Alpha4 stimulated changes in MEC viability and changes in protein expression associated with altered MEC function, but did not fully recapitulate the morphologies of MECs grown in Matrigel. To supply the appropriate biochemical signals for MEC organoids, we supplemented PeptiGels® with laminin. Laminin was found to require negatively charged PeptiGel® Alpha7 for functionality, but was then able to provide appropriate signals for correct MEC polarisation and expression of characteristic proteins. Thus, optimisation of SAPH composition and mechanics allows tuning to support tissue-specific organoids.

Alterations in Blood Methylome as Potential Epigenetic Biomarker in Sporadic Parkinson's Disease

OBJECTIVE

To characterize DNA methylation (DNAm) differences between sporadic Parkinson's disease (PD) and healthy control (HC) individuals enrolled in the Parkinson's Progression Markers Initiative (PPMI).

METHODS

Using whole blood, we characterized longitudinal differences in DNAm between sporadic PD patients (n = 196) and HCs (n = 86) enrolled in PPMI. RNA sequencing (RNAseq) was used to conduct gene expression analyses for genes mapped to differentially methylated cytosine-guanine sites (CpGs).

RESULTS

At the time of patient enrollment, 5,178 CpGs were differentially methylated (2,683 hypermethylated and 2,495 hypomethylated) in PD compared to HC. Of these, 579 CpGs underwent significant methylation changes over 3 years. Several differentially methylated CpGs were found near the cytochrome P450 family 2 subfamily E member 1 (CYP2E1) gene. Additionally, multiple hypermethylated CpGs were associated with the N-myc downregulated gene family member 4 (NDRG4) gene. RNA-Seq analyses showed 75 differentially expressed genes in PD patients compared to controls. An integrative analysis of both differentially methylated sites and differentially expressed genes revealed 20 genes that exhibited hypomethylation concomitant with overexpression. Additionally, 1 gene, cathepsin H (CTSH), displayed hypermethylation that was associated with its decreased expression.

INTERPRETATION

We provide initial evidence of alterations in DNAm in blood of PD patients that may serve as potential epigenetic biomarker of disease. To evaluate the significance of these changes throughout the progression of PD, additional profiling at longer intervals and during the prodromal stages of disease will be necessary. ANN NEUROL 2024;95:1162-1172.

Effect of Peptide-Polymer Host-Guest Electrostatic Interactions on Self-Assembling Peptide Hydrogels Structural and Mechanical Properties and Polymer Diffusivity

Peptide-based supramolecular hydrogels are an attractive class of soft materials for biomedical applications when biocompatibility is a key requirement as they exploit the physical self-assembly of short self-assembling peptides avoiding the need for chemical cross-linking. Based on the knowledge developed through our previous work, we designed two novel peptides, E(FKFE)2 and K(FEFK)2, that form transparent hydrogels at pH 7. We characterized the phase behavior of these peptides and showed the clear link that exists between the charge carried by the peptides and the physical state of the samples. We subsequently demonstrate the cytocompatibility of the hydrogel and its suitability for 3D cell culture using 3T3 fibroblasts and human mesenchymal stem cells. We then loaded the hydrogels with two polymers, poly-l-lysine and dextran. When polymer and peptide fibers carry opposite charges, the size of the elemental fibril formed decreases, while the overall level of fiber aggregation and fiber bundle formation increases. This overall network topology change, and increase in cross-link stability and density, leads to an overall increase in the hydrogel mechanical properties and stability, i.e., resistance to swelling when placed in excess media. Finally, we investigate the diffusion of the polymers out of the hydrogels and show how electrostatic interactions can be used to control the release of large molecules. The work clearly shows how polymers can be used to tailor the properties of peptide hydrogels through guided intermolecular interactions and demonstrates the potential of these new soft hydrogels for use in the biomedical field in particular for delivery or large molecular payloads and cells as well as scaffolds for 3D cell culture.

Proactive green innovation and firm climate resilience: the nonlinear interaction effect of climate risk

Based on empirical analysis of 113 climate disasters affecting 3563 listed firms across 31 provinces in China from 2010 to 2022, as documented in the Emergency Events Database (EM-DAT), this study employs event study and multiple regression to explore the impact of proactive green innovation on firm climate resilience. By categorizing proactive green innovation into process and product innovation and climate resilience into short-term and long-term resilience, a proactive green innovation-firm climate resilience 2 × 2 matrix is constructed to provide innovative insights. This study reveals that proactive green innovation enhances firm climate resilience. Specifically, proactive green process innovation both enhances short-term and long-term climate resilience, while proactive green product innovation only enhances long-term rather than short-term climate resilience. Furthermore, climate disaster has inverted U-shaped interaction effect on the relationship between proactive green innovation and short-term climate resilience and U-shaped interaction effect on the relationship between proactive green innovation and long-term climate resilience. Additionally, this study also investigates the heterogeneous mechanisms of proactive green innovation enhancing short-term and long-term climate resilience based on network embeddedness theory and legitimacy theory.

UDP-Glucose/P2Y14 Receptor Signaling Exacerbates Neuronal Apoptosis After Subarachnoid Hemorrhage in Rats

BACKGROUND

Subarachnoid hemorrhage (SAH) is a severe subtype of stroke with poor outcomes. Abnormal glucose metabolism often occurs after SAH, but the strict control of blood glucose levels is not always beneficial. This study aimed to investigate the contribution of uridine diphosphate glucose (UDP-G), an intermediate of glucose/glycogen metabolism, and its receptor P2Y14 (P2Y purinoceptor 14) to SAH pathology and explored the potential targeted treatments in rats.

METHODS

A total of 218 Sprague-Dawley male rats were used. SAH was induced by endovascular perforation. Brain expressions of P2Y14, uridine diphosphate glucose (UDP-G), and its converting enzyme UGP2 (UDP-G pyrophosphorylase-2) were evaluated. Exogenous UDP-G or selective P2Y14 inhibitor was administered intranasally at 1 hour after SAH to explore their potential effects. Intranasal Ugp2 or P2ry14 siRNA was delivered 24 hours before SAH for mechanistic evaluation. Primary neuron culture and hemoglobin stimulation were used as in vitro model of SAH. Post-SAH evaluation included liquid chromatography-mass spectrometry measurement of brain endogenous UDP-G level, neurobehavioral assessments, Western blotting, immunohistochemistry, TUNEL staining, and Nissl staining.

RESULTS

There was an acute elevation of endogenous brain UDP-G and UGP2 after SAH, and P2Y14 was expressed in neurons. Although P2Y14 inhibitor decreased neurological dysfunction, neuronal apoptosis, and proapoptotic molecules, exogenous UDP-G exacerbated these outcomes at 24 hours after SAH. Early inhibition of P2Y14 preserved long-term neuronal survival in the hippocampus, amygdala, and cortex with improved neurocognition and depressive-like behavior. In addition, in vivo knockdown of Ugp2- and P2ry14-reduced neurological deficits and proapoptotic molecules at 24 hours after SAH, and furthermore in vitro knockdown of P2ry14-reduced apoptosis in hemoglobin stimulated primary neuron.

CONCLUSIONS

These findings suggest a detrimental role of brain UDP-G/P2Y14 signaling in SAH, as a part of glucose metabolic pathology at the tissue level. P2Y14 inhibitor 4-[4-(4-piperidinyl)phenyl]-7-[4-(trifluoromethyl)phenyl]-2-naphthalenecarboxylic acid hydrochloride may serve as a potential therapeutic target in treating patients with SAH.

IL-13 and IL-13-induced periostin levels are specifically decreased in patients following endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Type 2 (T2) inflammation plays a pathogenic role in chronic rhinosinusitis (CRS). The effects of endoscopic sinus surgery (ESS) on T2 inflammation are unknown.

OBJECTIVE

The aim of this study was to compare T2 inflammatory biomarkers from middle meatal (MM) mucus for distinguishing patients with CRS from CRS-free patients, identifying major phenotypes (CRS without nasal polyps [CRSsNP] and CRS with nasal polyps [CRSwNP]), assessing endotypic change, and establishing cross-sectional and longitudinal outcomes in patients undergoing ESS.

METHODS

MM mucus samples were collected from patients with CRSsNP and patients with CRSwNP before and 6 to 12 months after ESS and compared with samples from CRS-free control patients. T2 biomarkers were evaluated both continuously and using threshold-based definitions of T2 endotype to identify relationships with patient-reported (based on the 22-Item Sinonasal Outcomes Test and Chronic Rhinosinusitis Patient-Reported Outcomes Measure) and clinician-reported (radiographic and endoscopic) severity. Linear mixed models were developed to analyze clinical variables associated with T2 biomarker levels.

RESULTS

A total of 154 patients with CRS (89 with CRSsNP and 65 with CRSwNP) were enrolled, with a mean interval of 9 months between ESS and follow-up. An analysis of pre-ESS MM mucus samples revealed elevated levels of T2 mediators in patients with CRSwNP versus in patients with CRSsNP and CRS-free controls. Temporally stable correlations between levels of IL-13 and IL-5, levels of periostin and complement 5a, and levels of eosinophil cationic protein (ECP) and eotaxin-3 were observed. On this basis and on the basis of pathologic significance, levels of IL-13, periostin and ECP were further analyzed. After ESS, levels of IL-13 and periostin decreased significantly, whereas ECP levels remained unchanged. Across pre- and post-ESS evaluation, the T2 endotype was associated with radiographic severity but did not predict outcomes. CRSwNP status and African American race were associated with higher levels of IL-13 and periostin, whereas ECP level was higher in patients undergoing extensive surgery.

CONCLUSION

ESS decreased levels of IL-13 and periostin in the middle meatus. T2 inflammation after ESS was correlated with patient- and clinician-reported severity across phenotypes. Pre-ESS T2 inflammation did not predict post-ESS outcomes.

Mitochondrial ferritin upregulation reduced oxidative stress and blood-brain-barrier disruption by maintaining cellular iron homeostasis in a neonatal rat model of germinal matrix hemorrhage

Germinal matrix hemorrhage (GMH) is a devasting neurological disease in premature newborns. After GMH, brain iron overload associated with hemoglobin degradation contributed to oxidative stress, causing disruption of the already vulnerable blood-brain barrier (BBB). Mitochondrial ferritin (FTMT), a novel mitochondrial outer membrane protein, is crucial in maintaining cellular iron homeostasis. We aimed to investigate the effect of FTMT upregulation on oxidative stress and BBB disruption associated with brain iron overload in rats. A total of 222 Sprague-Dawley neonatal rat pups (7 days old) were used to establish a collagenase-induced GMH model and an iron-overload model of intracerebral FeCl2 injection. Deferiprone was administered via gastric lavage 1 h after GMH and given daily until euthanasia. FTMT CRISPR Knockout and adenovirus (Ad)-FTMT were administered intracerebroventricularly 48 h before GMH and FeCl2 injection, respectively. Neurobehavioral tests, immunofluorescence, Western blot, Malondialdehyde measurement, and brain water content were performed to evaluate neurobehavior deficits, oxidative stress, and BBB disruption, respectively. The results demonstrated that brain expressions of iron exporter Ferroportin (FPN) and antioxidant glutathione peroxidase 4 (GPX4) as well as BBB tight junction proteins including Claudin-5 and Zona Occulta (ZO)-1 were found to be decreased at 72 h after GMH. FTMT agonist Deferiprone attenuated oxidative stress and preserved BBB tight junction proteins after GMH. These effects were partially reversed by FTMT CRISPR Knockout. Iron overload by FeCl2 injection resulted in oxidative stress and BBB disruption, which were improved by Ad-FTMT mediated FTMT overexpression. Collectively, FTMT upregulation is neuroprotective against brain injury associated with iron overload. Deferiprone reduced oxidative stress and BBB disruption by maintaining cellular iron homeostasis partially by the upregulating of FTMT after GMH. Deferiprone may be an effective treatment for patients with GMH.

Excessive fluoride induces ovarian function impairment by regulating levels of ferroptosis in fluorosis women and ovarian granulosa cells

The aim of this study was to investigate the role of ferroptosis in fluorosis women and the in vitro molecular mechanisms leading to ovarian dysfunction and abnormal hormone secretion by sodium fluoride (NaF) treatment of KGN cells. Fifty women with fluorosis as Fluorosis group and fifty healthy women as Control group were included in this study. The levels of lipid peroxidation and activities of antioxidant enzyme were assessed by photometric methods. The content of iron and glutathione (GSH) in serum was measured by microplate method. KGN cells were treated by different concentration of NaF (0, 1, 2, 4 and 8 ×10-3 M) for 24 h. The mRNA and protein expression levels of ferroptosis-related molecules, including glutathione peroxidase 4 (GPX4), solute carrier family 7 member (SLC7A11), nuclear factor erythroid 2-related factor 2 (Nrf2), ferritin heavy chain 1 (FTH1) and p53, were assessed by qRT-PCR and western blot analysis. Fluorosis group women had a significant higher levels of iron, Malondialdehyde (MDA), FSH and LH, and a lower levels of E2 and antioxidant enzyme in serum than that in the control group. The representative molecular changes of ferroptosis, such as the decrease in GPX4, Nrf2 and SLC7A11 expression (mRNA and protein expression), the increase in protein expression of p53, and a reduced level of E2 were observed in KGN cells treated by excessive NaF.It is concluded therefore that NaF increases the expression of p53 and inhibits ovarian granulosa cell ferroptosis preventive protein expression, resulting in abnormal hormone secretion and the ovarian dysfunction.

Fabrication and Application of Ag@SiO2/Au Core-Shell SERS Composite in Detecting Cu2+ in Water Environment

A sensitive and simple method for detecting Cu2+ in the water source was proposed by using surface-enhanced Raman scattering spectroscopy (SERS) based on the Ag@SiO2/Au core-shell composite. The Ag@SiO2 SERS tag was synthesized by a simple approach, in which Ag nanoparticles were first embedded with Raman reporter PATP and next coated with a SiO2 shell. The Ag@SiO2 nanoparticles had strong stability even in a high-concentration salty solution, and there were no changes to their properties and appearance within one month. The Ag@SiO2/Au composite was fabricated through a controllable self-assemble process. L-cysteine was decorated on the surface of a functionalized Ag@SiO2/Au composite, as the amino and carboxyl groups of it can form coordinate covalent bond with Cu2+, which shows that the Ag@SiO2/Au composite labelled with L-cysteine has excellent performance for the detection of Cu2+ in aqueous media. In this study, the SERS detection of Cu2+ was carried out using Ag@SiO2 nanoparticles, and the limit of detection (LOD) as low as 0.1 mg/L was achieved.

[Progress in complex network theory-based studies on the associations between health-related behaviors and chronic non-communicable diseases]

In recent years, the research focus on health-related behavior and chronic non-communicable diseases has shifted from the analysis on independent effects of multiple causes on a single outcome to the evaluation the complex relationships between multiple causes and multiple effects. Complex network theory, an important branch of system science, considers the relationships among factors in a network and can reveal how health-related behaviors interact with chronic diseases through a series of complex network models and indicators. This paper summarizes the definition and development of complex network theory and its commonly used models, indicators, and case studies in the field of health-related behavior and chronic disease to promote the application of complex network theory in the field of health and provide reference and tools for future research of the relationship between health-related behavior and chronic disease.

[Mediating effects of body mass index and lipid levels on the association between alcohol consumption and hypertension in occupational population]

Objective: To investigate the association between alcohol consumption and hypertension and SBP, DBP and the mediating effects of body mass index (BMI) and lipid level in occupational population, and provide reference for the intervention and prevention of hypertension. Methods: Based on the data of Southwest Occupational Population Cohort from China Railway Chengdu Group Co., Ltd., the information about the demographic characteristics, behavior and lifestyle, blood pressure and lipids level of the participants were collected through questionnaire survey, physical examination and blood biochemical test. Logistic/linear regression was used to analyze the association between alcohol consumption and hypertension, SBP and DBP. The individual and joint mediating effects of BMI, HDL-C, LDL-C, TG, and TC were explored through causal mediating analysis. A network analysis was used to explore the correlation between alcohol consumption, BMI and lipid levels, and hypertension. Results: A total of 22 887 participants were included, in whom 1 825 had newly detected hypertension. Logistic regression analysis found that current/former drinkers had a 33% increase of risk for hypertension compared with never-drinkers (OR=1.33, 95%CI:1.19-1.48). Similarly, alcohol consumption could increase SBP (β=1.05, 95%CI:0.69-1.40) and DBP (β=1.10, 95%CI:0.83-1.38). Overall, BMI and lipid levels could mediate the associations between alcohol consumption and hypertension, SBP and DBP by 21.91%, 28.40% and 22.64%, respectively. BMI and TG were the main mediators, and they were also the two nodes with the highest edge weight and bridge strength centrality in the network of alcohol consumption, BMI, lipid levels and hypertension. Conclusions: Alcohol consumption was associated with increased risk for hypertension, and BMI and TG were important mediators and key nodes in the network. It is suggested that paying attention to the alcohol consumption, BMI and TG might help prevent hypertension in occupational population.

[Association between work environment noise perception and cardiovascular diseases, depressive symptoms, and their comorbidity in occupational population]

Objective: To explore the association between occupational noise perception and cardiovascular disease (CVD), depression symptoms, as well as their comorbidity in occupational population and provide evidence for the prevention and control of physical and mental illnesses. Methods: A cross-sectional survey design was adopted, based on baseline data in population in 28 prefectures in Sichuan Province and Guizhou Province, and 33 districts (counties) in Chongqing municipality from Southwest Occupational Population Cohort from China Railway Chengdu Group Co., Ltd. during October to December 2021. A questionnaire survey was conducted to collect information about noise perception, depressive symptoms, and the history of CVD. Latent profile analysis model was used to determine identify noise perception type, and multinomial logistic regression analysis was conducted to explore the relationship between different occupational noise perception types and CVD, depression symptoms and their comorbidity. Results: A total of 30 509 participants were included, the mean age was (36.6±10.5) years, and men accounted for 82.0%. The direct perception of occupational noise, psychological effects and hearing/sleep impact of occupational noise increased the risk for CVD, depressive symptoms, and their comorbidity. By using latent profile analysis, occupational noise perception was classified into four levels: low, medium, high, and very high. As the level of noise perception increased, the association with CVD, depressive symptoms, and their comorbidity increased. In fact, very high level occupational noise perception were found to increase the risk for CVD, depressive symptoms, and their comorbidity by 2.14 (95%CI: 1.73-2.65) times, 8.80 (95%CI: 7.91-9.78) times, and 17.02 (95%CI: 12.78-22.66) times respectively compared with low-level occupational noise perception. Conclusions: Different types of occupational noise perception are associated with CVD and depression symptom, especially in the form of CVD complicated with depression symptom. Furthermore, the intensity of occupational noise in the work environment should be reduced to lower the risk for physical and mental health.

Use of the Assessment of Caregiver Experience with Neuromuscular Disease (ACEND) in Spinal Muscular Atrophy

Background: Spinal muscular atrophy (SMA) has a remarkable impact on function and participation. Subsequently, the caregivers of individuals with SMA are impacted as well. Providers and the SMA community should be aware of the presence of and likely expectations for the existence of caregiver burden. Methods: The Assessment of Caregiver Experience with Neuromuscular Disease (ACEND) quantifies caregivers' perceptions of function and quality of life pertaining to time, finance and emotion. Analyses were conducted among SMA types and ambulatory and ventilatory status. Participants with SMA had varying ranges of function and were on pharmaceutical treatment. Total ACEND score, longitudinal change in total ACEND score, total quality of life (QOL) score, change in total QOL score and subdomains for QOL, including time, emotion and finance, were all explored. Results: Overall, the ACEND demonstrated discriminant validity and some observed trends. Total ACEND scores improved for caregivers of those with SMA 2, remained stable longitudinally for caregivers of those with SMA 1 and 3 and were not influenced by ventilation status. The caregivers of individuals with SMA 1 had the lowest total quality of life (QOL) score, as did the caregivers of non-ambulatory individuals and those requiring assisted ventilation. Longitudinally, there were no changes in total QOL between caregivers of individuals with different SMA types or ambulatory or ventilation status. There were some differences in emotional needs, but no differences in financial impact between the caregivers of individuals with different types of SMA or ambulatory and ventilatory status. Conclusions: With this information enlightening the presence of caregiver burden and expected changes in burden with pharmaceutical treatment, providers, third party payors and the SMA community at large can better assist, equip and empower those providing the necessary assistance to enable the lives of those with SMA.

Exploring Diagnostic Precision and Triage Proficiency: A Comparative Study of GPT-4 and Bard in Addressing Common Ophthalmic Complaints

In the modern era, patients often resort to the internet for answers to their health-related concerns, and clinics face challenges to providing timely response to patient concerns. This has led to a need to investigate the capabilities of AI chatbots for ophthalmic diagnosis and triage. In this in silico study, 80 simulated patient complaints in ophthalmology with varying urgency levels and clinical descriptors were entered into both ChatGPT and Bard in a systematic 3-step submission process asking chatbots to triage, diagnose, and evaluate urgency. Three ophthalmologists graded chatbot responses. Chatbots were significantly better at ophthalmic triage than diagnosis (90.0% appropriate triage vs. 48.8% correct leading diagnosis; p < 0.001), and GPT-4 performed better than Bard for appropriate triage recommendations (96.3% vs. 83.8%; p = 0.008), grader satisfaction for patient use (81.3% vs. 55.0%; p < 0.001), and lower potential harm rates (6.3% vs. 20.0%; p = 0.010). More descriptors improved the accuracy of diagnosis for both GPT-4 and Bard. These results indicate that chatbots may not need to recognize the correct diagnosis to provide appropriate ophthalmic triage, and there is a potential utility of these tools in aiding patients or triage staff; however, they are not a replacement for professional ophthalmic evaluation or advice.

Exploratory mixed methods study on care-seeking behaviors of Asian Americans with pelvic floor symptoms

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate whether younger age was associated with noncare-seeking behavior among Asian Americans with pelvic floor symptoms, and secondarily, to explore multilevel factors that may contribute to noncare-seeking behavior in this population.

METHODS

We performed a concurrent mixed methods study and heterogeneously sampled Asian Americans with urinary incontinence, urgency-frequency, vaginal bulge, or anal incontinence. We stratified the participants into two groups, care seekers vs noncare seekers. Using Anderson's model as the main framework, we administered validated questionnaires and conducted semi-structured interviews to explore factors associated with care-seeking behaviors.

RESULTS

Seventy-eight surveys and 20 interviews were completed and analyzed. Most participants reported urinary leakage (67%), followed by urinary urgency-frequency (50%), anal incontinence (18%), and vaginal bulge (17%). The mean age of the study cohort was 46.1 ± 16.2 years. We found noncare seekers to be younger and with an increased proportion of lifetime spent in the USA than care seekers. When controlling for age, proportion of lifetime spent in the USA, symptom severity, and individual-level resources, both younger age and increased proportion of lifetime spent in USA remained independently associated with noncare-seeking behavior. From qualitative data, we found that noncare seekers often experienced anti-Asian racism across workplace, neighborhoods, and health care settings. Additionally, noncare seekers also reported symptom minimization and decreased self-efficacy when coping with their pelvic floor symptoms.

CONCLUSIONS

We found that one's age and proportion of lifetime spent in the USA may affect the extent of exposure to anti-Asian racism that is associated with symptom minimization, increased perceived barrier, and noncare-seeking behavior.

Surgical versus nonsurgical treatment selection patterns among Asian American patients with pelvic floor disorders: a matched cohort study

INTRODUCTION AND HYPOTHESIS

The objective was to determine if Asian racial identity was associated with the selection of surgical versus nonsurgical treatments for pelvic floor disorders (PFDs). Secondarily, we aimed to determine if there were other demographic or clinical characteristics associated with treatment selection patterns.

METHODS

This was a retrospective matched cohort study that examined new patient visits (NPVs) of Asian patients at an academic urogynecology practice in Chicago, IL, USA. We included NPVs with primary diagnoses of anal incontinence, mixed urinary incontinence, stress urinary incontinence, overactive bladder, or pelvic organ prolapse. We identified Asian patients with self-identified racial identity recorded in the electronic medical records. Every Asian patient was age matched to white patients in a 1:3 ratio. The primary outcome was surgical versus nonsurgical treatment selection for their primary PFD diagnosis. Comparison of demographic and clinical variables between the two groups and multivariate logistic regression models were performed.

RESULTS

A total of 53 Asian patients and 159 white patients were included in this analysis. Asian patients were less likely to be English speaking (92% vs 100%, p=0.004), endorse history of anxiety (17% vs 43%, p<0.001), and report history of any pelvic surgery (15% vs 34%, p=0.009) than white patients. When controlling for race, age, history of anxiety, depression, prior pelvic surgery, sexual activity, Pelvic Organ Prolapse Distress Inventory, Colorectal-Anal Distress Inventory, and Urinary Distress Inventory scores, Asian racial identity (adjusted odds ratio 0.36 [95% CI 0.14-0.85]) was independently associated with decreased likelihood of choosing surgical treatments for PFDs.

CONCLUSIONS

Asian patients with PFDs were less likely than white patients to undergo surgical treatment for their PFDs despite similar demographic and clinical characteristics.

Preserved Edge Convolutional Neural Network for Sensitivity Enhancement of Deuterium Metabolic Imaging (DMI)

PURPOSE

Common to most MRSI techniques, the spatial resolution and the minimal scan duration of Deuterium Metabolic Imaging (DMI) are limited by the achievable SNR. This work presents a deep learning method for sensitivity enhancement of DMI.

METHODS

A convolutional neural network (CNN) was designed to estimate the 2H-labeled metabolite concentrations from low SNR and distorted DMI FIDs. The CNN was trained with synthetic data that represent a range of SNR levels typically encountered in vivo. The estimation precision was further improved by fine-tuning the CNN with MRI-based edge-preserving regularization for each DMI dataset. The proposed processing method, PReserved Edge ConvolutIonal neural network for Sensitivity Enhanced DMI (PRECISE-DMI), was applied to simulation studies and in vivo experiments to evaluate the anticipated improvements in SNR and investigate the potential for inaccuracies.

RESULTS

PRECISE-DMI visually improved the metabolic maps of low SNR datasets, and quantitatively provided higher precision than the standard Fourier reconstruction. Processing of DMI data acquired in rat brain tumor models resulted in more precise determination of 2H-labeled lactate and glutamate + glutamine levels, at increased spatial resolution (from >8 to 2 $\mu$L) or shortened scan time (from 32 to 4 min) compared to standard acquisitions. However, rigorous SD-bias analyses showed that overuse of the edge-preserving regularization can compromise the accuracy of the results.

CONCLUSION

PRECISE-DMI allows a flexible trade-off between enhancing the sensitivity of DMI and minimizing the inaccuracies. With typical settings, the DMI sensitivity can be improved by 3-fold while retaining the capability to detect local signal variations.

Fractalkine Enhances Hematoma Resolution and Improves Neurological Function via CX3CR1/AMPK/PPARγ Pathway After GMH

BACKGROUND

Hematoma clearance has been a proposed therapeutic strategy for hemorrhagic stroke. This study investigated the impact of CX3CR1 (CX3C chemokine receptor 1) activation mediated by r-FKN (recombinant fractalkine) on hematoma resolution, neuroinflammation, and the underlying mechanisms involving AMPK (AMP-activated protein kinase)/PPARγ (peroxisome proliferator-activated receptor gamma) pathway after experimental germinal matrix hemorrhage (GMH).

METHODS

A total of 313 postnatal day 7 Sprague Dawley rat pups were used. GMH was induced using bacterial collagenase by a stereotactically guided infusion. r-FKN was administered intranasally at 1, 25, and 49 hours after GMH for short-term neurological evaluation. Long-term neurobehavioral tests (water maze, rotarod, and foot-fault test) were performed 24 to 28 days after GMH with the treatment of r-FKN once daily for 7 days. To elucidate the underlying mechanism, CX3CR1 CRISPR, or selective CX3CR1 inhibitor AZD8797, was administered intracerebroventricularly 24 hours preinduction of GMH. Selective inhibition of AMPK/PPARγ signaling in microglia via intracerebroventricularly delivery of liposome-encapsulated specific AMPK (Lipo-Dorsomorphin), PPARγ (Lipo-GW9662) inhibitor. Western blot, Immunofluorescence staining, Nissl staining, Hemoglobin assay, and ELISA assay were performed.

RESULTS

The brain expression of FKN and CX3CR1 were elevated after GMH. FKN was expressed on both neurons and microglia, whereas CX3CR1 was mainly expressed on microglia after GMH. Intranasal administration of r-FKN improved the short- and long-term neurobehavioral deficits and promoted M2 microglia polarization, thereby attenuating neuroinflammation and enhancing hematoma clearance, which was accompanied by an increased ratio of p-AMPK (phosphorylation of AMPK)/AMPK, Nrf2 (nuclear factor erythroid 2-related factor 2), PPARγ, CD36 (cluster of differentiation 36), CD163 (hemoglobin scavenger receptor), CD206 (the mannose receptor), and IL (interleukin)-10 expression, and decreased CD68 (cluster of differentiation 68), IL-1β, and TNF (tumor necrosis factor) α expression. The administration of CX3CR1 CRISPR or CX3CR1 inhibitor (AZD8797) abolished the protective effect of FKN. Furthermore, selective inhibition of microglial AMPK/PPARγ signaling abrogated the anti-inflammation effects of r-FKN after GMH.

CONCLUSIONS

CX3CR1 activation by r-FKN promoted hematoma resolution, attenuated neuroinflammation, and neurological deficits partially through the AMPK/PPARγ signaling pathway, which promoted M1/M2 microglial polarization. Activating CX3CR1 by r-FKN may provide a promising therapeutic approach for treating patients with GMH.

[Effects of tibial second toe free flap bridged with blood flow and nerve in the treatment of severe flexion contracture of the proximal interphalangeal joint]

Objective: To investigate the effects of tibial second toe free flap bridged with blood flow and nerve in the treatment of severe flexion contracture of the proximal interphalangeal joint. Methods: A retrospective observational study was conducted. From March 2013 to October 2019, 9 patients with severe flexion contracture (type Ⅲ) of the proximal interphalangeal joint after trauma operation, conforming to the inclusion criteria, were hospitalized in Suzhou Ruihua Orthopaedic Hospital, including 5 males and 4 females, aged from 17 to 62 years. After the contracture tissue affecting the extension of the proximal interphalangeal joint was cut off, and the scar tissue was resected, the size of the volar wound near the proximal interphalangeal joint in extended position was 2.0 cm×1.0 cm-2.5 cm×1.5 cm, with the length of proper digital artery and nerve defect being 1.0-1.5 cm. A free flap of the same size as the wound was cut from the tibial side of the second toe and transplanted to repair the wound, and the defective proper digital artery and nerve was repaired by bridging with the tibial proper plantar digital artery and nerve of about 1.5 cm in length. The full-thickness skin graft was taken from the proximal tibial side of the lower leg to repair the wound at flap donor site. The wound at skin graft donor site was sutured directly. The survival of flap and skin graft was observed after operation. The patients were followed up, and at the last follow-up, the recovery of the affected finger and the second toe, including the donor and recipient areas were observed, the two-point discrimination distances of the flap repaired site and the pulp of the affected finger were observed and measured at the same time, the blood flow patency of bridged vessel of the affected finger was examined by Allen test, and the function of the proximal interphalangeal joint of the affected finger was evaluated according to Chinese Medical Association's standard for the range of motion of proximal interphalangeal joint. Results: The flaps and skin grafts survived smoothly after operation. The follow-up after operation lasted for 5 to 22 months, with a mean of 10 months. At the last follow-up, the flap repaired site had good shape, good color and texture, with the two-point discrimination distance being 9-12 mm, and the two-point discrimination distance of the pulp of the affected finger was 6-10 mm; the Allen test results of the affected fingers were all negative (i.e., the bridged vessels had good blood flow patency), with no recurrence of flexion contracture, and the function of the proximal interphalangeal joint was evaluated as excellent; the skin graft area of the second toe was not ruptured but was a little pigmented, and the flexion and extension activities of toe were good. Conclusions: The tibial second toe free flap bridged with blood flow and nerve has reliable therapeutic effect in the treatment of severe flexion contracture of the proximal interphalangeal joint, and the color and texture of the flap repaired area are good. Bridging to repair the severely contracted proper digital artery and nerve is beneficial to improve the blood supply of the finger body and rebuild the sensation.

Combined exposure to multiple metals on hypertension in NHANES under four statistical models

Metals exposure has gained increasing attention in the hypertension prevention. However, previous studies have focused on the impacts of single or separated metals on hypertension, and the critical metals contributing to the prevalence of hypertension are still under discussion. We collected data from 5092 participants across three consecutive National Health and Nutrition Examination Survey (NHANES) circles (2011-2016). Weighted logistic regression, weighted quantile sum (WQS) regression, quantile-based g-computation (QGC), and Bayesian kernel machine regression (BKMR) analyses were conducted to evaluate the combined and individual effects of 15 urinary metals, as well as to identify the critical metals on the development of hypertension. In our study, the weighted prevalence of hypertension was 37.9%, and the average age was 47.42 years. Manganese, uranium and tin were found as the independent risk factors for hypertension, while barium, lead, and thallium were found to have protective effects against hypertension. Lead, barium, tungsten, uranium, and tin were determined as critical elements for the prediction of hypertension. No significant interaction relationship was detected between multiple metals. There might be potential positive combined effects of urinary metal mixture on hypertension. Tungsten, uranium, and tin were positively associated with hypertension while lead and barium were negatively associated with hypertension. The underlying mechanisms of urinary metal exposure on the risk of hypertension deserve further investigations.

Blood inflammatory biomarkers predict in-hospital pneumonia after endovascular treatment of aneurysm in patients with aneurysmal subarachoid hemorrhage

The systemic inflammatory response index (SIRI) is a well-known marker of systemic inflammation reflecting the body's inflammatory/immune state. The study aimed to evaluate the relationship between the SIRI on admission and aneurysmal subarachnoid hemorrhage (aSAH)-associated pneumonia and compare with other currently used bio-markers. We reviewed 562 successive patients with aneurysmal SAH who underwent endovascular treatment between January 2019 and September 2021. ASAH-associated pneumonia was diagnosed using the modified Centers for Disease Control and Prevention criteria. The SIRI on admission was calculated as monocyte count × neutrophil count / lymphocyte count. Multiple logistic regression models were used for data analysis. A total of 158 (28.11%) patients developed aSAH-associated pneumonia. Using the Multiple logistic regression analysis, a notable dose-response association was found between the elevated SIRI (fourth quartile) and aSAH-associated pneumonia (adjusted odds ratio = 6.759; 95% confidence interval [CI], 3.280-13.930; p < 0.001 [p for trend < 0.001]). The SIRI (0.701, 95% CI: 0.653-0.749) presented a higher area under the curve (AUC) than systemic immune- inflammation index (SII) (0.669, 95% CI: 0.620-0.718) (p = 0.089); neutrophil-to-lymphocyte ratio (NLR) (0.665, 95% CI: 0.616-0.714) (p = 0.035) and platelet-lymphocyte ratio (PLR) (0.587, 95% CI: 0.534-0.641) (p < 0.001). A higher SIRI on admission was associated with aSAH-associated pneumonia, which may guide further clinical trials of prophylactic antibiotic therapy.

Self-assembled peptide nanoparticles for photodynamic therapy: morphological and mechanical effects on hepatocellular carcinoma cells

Self-assembling peptides, offering favorable biocompatibility, high stability, and easy incorporation of various functionalities, have demonstrated enormous potential for the precise design of next-generation nanodrugs for non-invasive tumor therapy. Peptide-based supramolecular photodynamic therapy (PDT) has shown great promise as an emerging modality for cancer treatment, achieving substantially-enhanced photosensitizer delivery selectivity and treatment efficacy, based on peptide biological activity and self-assembly potential. Although considerable research has been conducted toward fabricating self-assembling peptide-based smart nanodrugs for PDT, few studies have investigated cellular biophysical responses as indicators of tumor function and metabolic state. Here, via atomic force microscopy (AFM)-based morphological and mechanical measurements, including optical microscopy and scanning electron microscopy, we observed, for the first time, variation in membrane stiffness of human liver (HepG2) cancer cells treated with self-assembling peptides serving as a PDT nanodrug. This biophysical information will help to establish a comprehensive understanding of the anticancer effect of peptide-based smart nanodrugs, and highlight the exceptional ability of AFM in determining cell-surface properties.

Association between higher systemic immune inflammation index (SII) and deep vein thrombosis (DVT) in patients with aneurysmal subarachnoid hemorrhage (aSAH) after endovascular treatment

Inflammation contributes to deep vein thrombosis (DVT) formation in patients with aSAH after endovascular treatment. The relationship between systemic immune-inflammatory index (SII) as an inflammatory marker and DVT formation remains unclear. Thus, this study aims to evaluate the association between SII and aSAH-associated DVT following endovascular treatment. We enrolled 562 consecutive patients with aSAH after endovascular treatment at three centers from January 2019 to September 2021. The endovascular treatments included simple coil embolization and stent-assisted coil embolization. Deep venous thrombosis (DVT) was assessed by Color Doppler ultrasonography (CDUS). Multivariate logistic regression analysis was used to establish the model. We assessed the association of the SII, neutrophil-to-lymphocyte ratio (NLR), the systemic inflammatory response index (SIRI), platelet-lymphocyte ratio (PLR), and DVT by using restricted cubic spline (RCS). ASAH-associated DVT was found in 136 (24.20%) patients. Based on the multiple logistic regression analysis, the correlation was found between aSAH-associated DVT and elevated SII (fourth quartile) (adjusted odds ratio = 8.20 [95% confidence interval, 3.76-17.92]; p < 0.001 [p for trend < 0.001]), elevated NLR (fourth quartile) (adjusted odds ratio = 6.94 [95% confidence interval, 3.24-14.89]; p < 0.001 [p for trend < 0.001]), elevated SIRI (fourth quartile) (adjusted odds ratio = 4.82 [95% confidence interval, 2.36-9.84]; p < 0.001 [p for trend < 0.001]), and elevated PLR (fourth quartile) (adjusted odds ratio = 5.49 [95% confidence interval, 2.61-11.57]; p < 0.001 [p for trend < 0.001]). The increased SII was correlated with the formation of aSAH-associated DVT after endovascular treatment.

Application of an effective marker-less augmented reality image guidance method in dental implant surgery

BACKGROUND

The existing augmented reality (AR) dental implant surgery navigation system usually uses markers to complete image guidance. However, markers often affect dentists' operations and make patients uncomfortable.

METHODS

To solve the problems caused by markers, this paper proposes an effective marker-less image guidance method. After initialisation is completed by contour matching, the corresponding relationship is obtained by matching the feature points between the current frame and the preloaded initial frame. The camera pose is estimated by solving the Perspective-n-Point problem.

RESULTS

The registration error of AR images is 0.731 ± 0.144 mm. The planting errors are 1.174 ± 0.241 mm at the neck, 1.433 ± 0.389 mm at the apex and 5.566 ± 2.102° for the angle. The maximum error and standard deviation meet the clinical requirements.

CONCLUSIONS

We demonstrate that the proposed method can accurately guide dentists to perform dental implant surgery.

Implementation of a culturally competent APOL1 genetic testing programme into living donor evaluation: A two-site, non-randomised, pre-post trial design

INTRODUCTION

While living donor (LD) kidney transplantation is the optimal treatment for patients with kidney failure, LDs assume a higher risk of future kidney failure themselves. LDs of African ancestry have an even greater risk of kidney failure post-donation than White LDs. Because evidence suggests that Apolipoprotein L1 (APOL1) risk variants contribute to this greater risk, transplant nephrologists are increasingly using APOL1 genetic testing to evaluate LD candidates of African ancestry. However, nephrologists do not consistently perform genetic counselling with LD candidates about APOL1 due to a lack of knowledge and skill in counselling. Without proper counselling, APOL1 testing will magnify LD candidates' decisional conflict about donating, jeopardising their informed consent. Given cultural concerns about genetic testing among people of African ancestry, protecting LD candidates' safety is essential to improve informed decisions about donating. Clinical 'chatbots', mobile apps that provide genetic information to patients, can improve informed treatment decisions. No chatbot on APOL1 is available and no nephrologist training programmes are available to provide culturally competent counselling to LDs about APOL1. Given the shortage of genetic counsellors, increasing nephrologists' genetic literacy is critical to integrating genetic testing into practice.

METHODS AND ANALYSIS

Using a non-randomised, pre-post trial design in two transplant centres (Chicago, IL, and Washington, DC), we will evaluate the effectiveness of culturally competent APOL1 testing, chatbot and counselling on LD candidates' decisional conflict about donating, preparedness for decision-making, willingness to donate and satisfaction with informed consent and longitudinally evaluate the implementation of this intervention into clinical practice using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

ETHICS AND DISSEMINATION

This study will create a model for APOL1 testing of LDs of African ancestry, which can be implemented nationally via implementation science approaches. APOL1 will serve as a model for integrating culturally competent genetic testing into transplant and other practices to improve informed consent. This study involves human participants and was approved by Northwestern University IRB (STU00214038). Participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04910867. Registered 8 May 2021, https://register.

CLINICALTRIALS

gov/prs/app/action/SelectProtocol?sid=S000AWZ6&selectaction=Edit&uid=U0001PPF&ts=7&cx=-8jv7m2 ClinicalTrials.gov Identifier: NCT04999436. Registered 5 November 2021, https://register.

CLINICALTRIALS

gov/prs/app/action/SelectProtocol?sid=S000AYWW&selectaction=Edit&uid=U0001PPF&ts=11&cx=9tny7v.

Effect of Sodium Fluoride on Reproductive Function Through Regulating Reproductive Hormone Level and Circulating SIRT1 in Female Rats

Fluorosis causes female reproductive dysfunction with reduced fertility without established pathogenesis. To clarify the mechanism, Sprague-Dawley female rats were selected with drinking water containing 0, 50 (low), 100 (moderate), and 150 mg/L (high) sodium fluoride (NaF) for a short (2 months), medium (4 months), and long term (6 months). The water consumption and body weight of female rats were recorded daily. The effect of NaF on the estrous cycle was examined by vaginal smears and recorded in different term treatments. Female and male rats were mated in a 2:1 ratio for 1 week at 2-, 4-, and 6-month treatment time for mating performance and fertility rate. Selected female rats were executed for tissue and blood collection at different treatment terms. Twenty-four-hour urine sample from each female rat was collected using the metabolic cage. The levels of steroid hormones and silent information regulator 2 homolog 1 (SIRT1) in serum were measured by appropriate ELISA kits. Body weight of the high NaF group was significantly less during short-term treatment than that of other treatment groups or control group. Urinary fluoride concentration was increased linearly with treatment time. Treatment of NaF significantly decreased steroid hormone level while increased SIRT1 level in the serum. In addition, NaF treatment significantly decreased pregnancy rate. It is concluded that NaF inhibits the secretion of hormone and estradiol (E₂) release from the ovary, thereby reducing the rate of pregnant. SIRT1 may be involved in this NaF-induced reproductive dysfunction in female rats through regulating reproductive hormone, FSH, and LH secretion.

The Extra-Islet Pancreas Supports Autoimmunity in Human Type 1 Diabetes

In autoimmune Type 1 diabetes (T1D), immune cells progressively infiltrate and destroy the islets of Langerhans - islands of endocrine tissue dispersed throughout the pancreas. However, it is unclear how this process, called 'insulitis', develops and progresses within this organ. Here, using highly multiplexed CO-Detection by indEXing (CODEX) tissue imaging and cadaveric pancreas samples from pre-T1D, T1D, and non-T1D donors, we examine pseudotemporal-spatial patterns of insulitis and exocrine inflammation within large pancreatic tissue sections. We identify four sub-states of insulitis characterized by CD8 ⁺ T cells at different stages of activation. We further find that exocrine compartments of pancreatic lobules affected by insulitis have distinct cellularity, suggesting that extra-islet factors may make particular lobules permissive to disease. Finally, we identify "staging areas" - immature tertiary lymphoid structures away from islets where CD8 ⁺ T cells appear to assemble before they navigate to islets. Together, these data implicate the extra-islet pancreas in autoimmune insulitis, greatly expanding the boundaries of T1D pathogenesis.

Inflammation index SIRI is associated with increased all-cause and cardiovascular mortality among patients with hypertension

Background

Inflammation plays an essential role in the pathogenesis of hypertension. A novel inflammatory biomarker systemic inflammatory response index (SIRI) is related with all-cause and cardiovascular (CVD) mortality, while the role of SIRI in hypertension patients is unclear.

Methods

A total of 21,506 participants with hypertension were recruited in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018. SIRI was calculated as the neutrophil count ^* monocyte count/lymphocyte count. Hypertension was defined according to the examination of blood pressure, prescription, and self-reported physician diagnosis. Survival status was followed through 31 December 2019. The non-linear relationship was assessed using restricted cubic spline analysis. The association of all-cause mortality with SIRI was evaluated using the Kaplan-Meier curve and the weighted Cox regression analysis. The predictive abilities were assessed with Receiver operating curve.

Results

During 189,063 person-years of follow-up, 5,680 (26.41%) death events were documented, including 1,967 (9.15%) CVD related deaths. A J-shaped association was observed between SIRI and all-cause and CVD mortality. The Kaplan-Meier curve indicated the all-cause and CVD mortality risks were higher in high SIRI quartiles compared with lower SIRI quartiles. After adjusting for all covariates, the SIRI was positively associated with the all-mortality risk with HR = 1.19 (1.15, 1.22), and CVD mortality with HR = 1.19 (1.15, 1.24). The result was robust in subgroup analysis and sensitivity analysis.

Conclusion

Elevated SIRI level is associated with increased all-cause and CVD mortality among patients with hypertension. SIRI is considered as a potential inflammatory biomarker in the clinical practice. Further large-scale cohort studies are required to confirm our findings.

MicroRNA-140-5p shuttled by microglia-derived extracellular vesicles attenuates subarachnoid hemorrhage-induced microglia activation and inflammatory response via MMD downregulation

BACKGROUND

It is documented that microglia-secreted extracellular vesicles (microglia-EVs) exert neuroprotection which is important following subarachnoid hemorrhage (SAH). Herein, we focused on the mechanism of microglia-EVs harboring microRNA-140-5p (miR-140-5p) in SAH development.

METHODS

After the successful establishment of SAH rats, neurological function was evaluated, and behaviors were observed. Serum inflammatory factors (IL-1β and TNF-α) were quantified by ELISA, followed by the detection of microglial polarization by immunofluorescence. The relationship between miR-140-5p and monocyte to macrophage differentiation-associated (MMD) was evaluated using luciferase assay. Following the extraction of microglia and microglia-EVs, the transferring of miR-140-5p by microglia-EVs was assessed by co-culture experiments. SAH rats were treated with the EVs sourced from microglia overexpressing miR-140-5p (microglia-EVs-miR-140-5p) or EVs sourced from miR-140-5p-deficient microglia (microglia-EVs-miR-140-5p inhibitor) for in vivo effect assessment.

RESULTS

Microglia-EVs inhibited microglia activation and secretion of TNF-α and IL-1β by delivering miR-140-5p. Microglia-EVs could transmit miR-140-5p into microglia. Furthermore, microglia-EVs-miR-140-5p reduced the expression of its target MMD, resulting in blocked inflammatory response and activation of microglia in SAH rats by disrupting the PI3K/AKT and Erk1/2 signaling.

CONCLUSION

In summary, microglia-EVs transmitted miR-140-5p into microglia to downregulate MMD and finally contributed to neuroprotection in SAH rats.

Class-Aware Adversarial Transformers for Medical Image Segmentation

Transformers have made remarkable progress towards modeling long-range dependencies within the medical image analysis domain. However, current transformer-based models suffer from several disadvantages: (1) existing methods fail to capture the important features of the images due to the naive tokenization scheme; (2) the models suffer from information loss because they only consider single-scale feature representations; and (3) the segmentation label maps generated by the models are not accurate enough without considering rich semantic contexts and anatomical textures. In this work, we present CASTformer, a novel type of adversarial transformers, for 2D medical image segmentation. First, we take advantage of the pyramid structure to construct multi-scale representations and handle multi-scale variations. We then design a novel class-aware transformer module to better learn the discriminative regions of objects with semantic structures. Lastly, we utilize an adversarial training strategy that boosts segmentation accuracy and correspondingly allows a transformer-based discriminator to capture high-level semantically correlated contents and low-level anatomical features. Our experiments demonstrate that CASTformer dramatically outperforms previous state-of-the-art transformer-based approaches on three benchmarks, obtaining 2.54%-5.88% absolute improvements in Dice over previous models. Further qualitative experiments provide a more detailed picture of the model's inner workings, shed light on the challenges in improved transparency, and demonstrate that transfer learning can greatly improve performance and reduce the size of medical image datasets in training, making CASTformer a strong starting point for downstream medical image analysis tasks.

DNA Methylation Profiles of Ovarian Granular Cells from Fluorosis Female Patients Suffering Reproductive Dysfunctions

Fluorosis often causes female reproductive dysfunction. A rapid turnover of DNA methylation is a pathological change in many human diseases, including female reproductive dysfunction. The role of DNA methylation in fluorosis was unknown and investigated in this experiment. Fifty fluorosis women patients were selected as High F group and forty-six healthy women were recruited as Control group were enrolled. In addition, ovarian granulosa cells were obtained from five women in High F group and five women in Control group. All ten women went through in vitro fertilization (IVF) process with DNA methylation sequencing. KGN cells (human granulosa cell line) were cultured with different concentrations of sodium fluoride (0-8 mM NaF) for 24 h for the in vitro study. The level of DNA methylation in blood samples was significantly higher in High F group than that in Control group. The level of serum estradiol (E₂) was significantly lower in women from High F group, while the levels of serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in High F group were significantly higher than that in Control group. The methylation sequences of KGN cells relating to autophagy were significantly changed by NaF treatment dose-dependently. Based on these results, it is concluded that DNA methylation and autophagy may play a significant role in the pathophysiology of reproductive dysfunction caused by fluorosis.

Analysis of Clinical Features and Risk Factors in Pregnant Women With Miliary Pulmonary Tuberculosis After In Vitro Fertilization Embryo Transfer

Purpose

Miliary pulmonary tuberculosis (TB) among pregnant women after in vitro fertilization embryo transfer (IVF-ET) causes poor outcomes but is rarely reported. This study analyzed the clinical characteristics and risk factors of these patients to provide hints for further studies.

Method

The demographic characteristics, clinical manifestations, radiologic features, treatment, and outcomes of six patients diagnosed from May 2012 to August 2021 in Xiangya Hospital and 69 patients that were reported in English or Chinese literature from January 1980 to August 2021 were retrospectively analyzed. Continuous variables were compared between groups by t-test or Mann–Whitney U test, and categorical variables were compared between groups by chi-square test or Fisher exact test. Univariate and multiple logistic regression analyses were used to determine the predictors of respiratory failure.

Results

A total of 75 patients were included. The average age of patients was about 30 years. All patients had tubal obstruction; 5 of them were diagnosed with pelvic TB before. Thirteen cases had a history of pulmonary or extrapulmonary TB, six out of them without any antituberculosis treatment history. All patients were in their first or second trimester during the onset of symptoms. The average interval between onset of symptoms and radiologic examination was about 21 days. The most common abnormalities on chest computed tomography scan were multiple nodules, pulmonary infiltrate, and consolidation. Merely 10 patients obtained bacteriological diagnosis by Mycobacterium tuberculosis culture or polymerase chain reaction test. The other patients were clinically diagnosed. All the patients received antituberculosis treatment. Although 44% of patients had fatal complications, all cases were cured or improved after antituberculosis treatment. Unfortunately, only eight fetuses survived (10.6%). The most frequent and severe complication was type I respiratory failure (20%). Patients with expectoration, dyspnea, coarse breath sounds, ground-glass opacity, and pulmonary infiltrate or consolidation were more likely to have respiratory failure (P < 0.05). Ground-glass opacity (OR = 48.545, 95% CI = 2.366–995.974, P = 0.012) and pulmonary infiltrate or consolidation (OR = 19.943, 95% CI = 2.159–184.213, P = 0.008) were independent predictors for respiratory failure.

Conclusion

Tube infertility with underscreened or untreated TB is a risk factor for miliary TB during pregnancy after IVF-ET. Ground-glass opacity and pulmonary infiltrate or consolidation are predictors of respiratory failure. We demonstrate risk factors for incidence and complications to supply clues for future intervention and improve patient prognosis.

Effects of blood lipids and lipid-modifying drugs on intracranial aneurysms

OBJECTIVES

We used 2-sample Mendelian randomization (MR) to examine the effects of blood lipids and lipid-modifying drugs on intracranial aneurysm (IA).

METHODS

Genetic variants for the effects of high-density lipoprotein cholesterol (HDL-C), apolipoprotein A1 (apo-A1), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (apo-B), and triglycerides and targets for lipid-modifying drugs were selected from the genome-wide discovery analyses of the UK Biobank. Summary-level data on IAs were obtained from the International Stroke Genetics Consortium (ISGC). Univariate and multivariate MR analyses were performed.

RESULTS

Univariate MR analyses showed that the HDL-C was negatively correlated with IA (OR, 0.816; 95% CI, 0.715-0.932; P=0.003) and ruptured IA (rIA) (OR, 0.775, 0.663-0.906; P=0.001). The MVMR-IVW analysis showed that the HDL-C was negatively correlated with IA (OR, 0.655; 95% CI, 0.434-0.988; P=0.043) and rIA (OR, 0.563, 0.347-0.913; P=0.02), and the LDL-C was negatively correlated with IA (OR, 0.402; 95% CI, 0.191-0.848; P=0.017) and rIA (OR, 0.376, 0.160-0.883; P=0.025). Using genetic proxies of known lipid-modifying drugs, we found that the increased HDL-C with CETP proxies was associated with a decreased risk of rIA (OR, 0.852, 0.747-0.973; P=0.018), and the decreased LDL-C with HMGCR proxies were associated with increased risk of IA (OR, 1.772; 95% CI, 1.080-2.908; P=0.024) and rIA (OR, 1.856; 95% CI, 1.022-3.371; P = 0.042).

CONCLUSIONS

Genetically determined HDL-C and LDL-C reduce the risk of IA and rIA. The effects of different lipid-modifying drugs on IA need to be further investigated.

The identification of treatment-resistant depression patients in electronic health records, a retrospective cohort study in China

Introduction

Previous Electronic Health Records (EHR) based studies adopted various definitions in identifying Treatment-Resistant Depression (TRD) patients. There is a lack of similar attempts among Chinese population which limits the understanding of TRD in China.

Objectives

Assess TRD identification using EHR from a major psychiatric hospital in China.

Methods

This study utilized a retrospective Major Depressive Disorder (MDD) cohort of patients who newly initiated pharmaceutical treatment (2010-2018); follow-up was ended upon 1-year or treatment discontinuation (≥120d without treatment). TRD was first identified based on common clinical definition of two prior regimen failures (change of regimen) with 4-week as regimen adequacy threshold (Def1). Alternative adequacy thresholds of 2-week and 6-week were applied. Based on Def1 (4-week), at least 3 distinctive regimens were additionally required in TRD identification (Def2). Further, a data-driven definition (Def3) based on drug count as having ≥3 antidepressants or ≥1 antipsychotic within 1 year was considered (Cepeda et al., 2018).

Results

From 12257 MDD patients included in the cohort, Def1 identified 633 (5.2%) TRD cases, whereas regimen adequacy thresholds of 2-week and 6-week identified 1772 (14.5%) and 61 (0.5%) cases, respectively. Further, Def2 identified 261 (2.4%) TRD cases. Finally, Def3 yielded 2449 (20.0%) TRD cases, including 1966 exclusive cases that were not identified by Def1.

Conclusions

This study showed different definitions for TRD identification had considerable impact on the number of patients identified among Chinese population, obscuring the comparability among EHR-based TRD studies. As first step, we found the criteria of regimen adequacy as major contributor to the observed variability in China.

Disclosure

No significant relationships.

Sex and Race Differences in the Evaluation and Treatment of Young Adults Presenting to the Emergency Department With Chest Pain

Background Acute myocardial infarctions are increasingly common among young adults. We investigated sex and racial differences in the evaluation of chest pain (CP) among young adults presenting to the emergency department. Methods and Results Emergency department visits for adults aged 18 to 55 years presenting with CP were identified in the National Hospital Ambulatory Medical Care Survey 2014 to 2018, which uses stratified sampling to produce national estimates. We evaluated associations between sex, race, and CP management before and after multivariable adjustment. We identified 4152 records representing 29 730 145 visits for CP among young adults. Women were less likely than men to be triaged as emergent (19.1% versus 23.3%, respectively, P<0.001), to undergo electrocardiography (74.2% versus 78.8%, respectively, P=0.024), or to be admitted to the hospital or observation unit (12.4% versus 17.9%, respectively, P<0.001), but ordering of cardiac biomarkers was similar. After multivariable adjustment, men were seen more quickly (hazard ratio [HR], 1.15 [95% CI, 1.05-1.26]) and were more likely to be admitted (adjusted odds ratio, 1.40 [95% CI, 1.08-1.81]; P=0.011). People of color waited longer for physician evaluation (HR, 0.82 [95% CI, 0.73-0.93]; P<0.001) than White adults after multivariable adjustment, but there were no racial differences in hospital admission, triage level, electrocardiography, or cardiac biomarker testing. Acute myocardial infarction was diagnosed in 1.4% of adults in the emergency department and 6.5% of admitted adults. Conclusions Women and people of color with CP waited longer to be seen by physicians, independent of clinical features. Women were independently less likely to be admitted when presenting with CP. These differences could impact downstream treatment and outcomes.

Integrated proteome and lipidome analysis of naturally aged safflower seeds varying in vitality

Seed ageing has an important effect on germination and productivity. During natural ageing, seed vigour decreases rapidly but, to date, the molecular mechanisms underlying this decrease have not been fully elucidated. Using omics, some of the details regarding seed vigour decline during natural ageing might be elucidated through integrated analysis. Safflower seed germination and physio-biochemical changes during natural ageing (stored for 4, 16 and 28 months) were determined. Proteome and lipidome profiling during natural seed ageing was performed, and the differentially expressed proteins and lipid metabolite species analysed. The surface and internal structures of cotyledons were observed. An integrating analysis of the proteome and lipidome was also carried out. Natural seed ageing significantly decreased safflower seed germination and vigour. 4,184 proteins and 1,193 lipids were quantified, both of which show huge differences among the different naturally aged seeds. The surface of the cotyledons collapsed and cracked, and the oil bodies become looser during natural ageing. The total content of DAG and PA increased, while the content of TAG and PL (PC, PE, PS, PI and PL) significantly decreased during seeds ageing. Two lipase genes (HH-026818-RA and HH-025320) likely participated in this degradation of lipids. We conclude that the enzymes that participate in glycerolipid metabolism and fatty acid degradation probably lead to the degradation of oil bodies (TAG) and membrane lipids (PC, PE, PS, PI, PG) and, ultimately, destroy the structure, causing a decline in seed vigour during natural seed ageing.

First Report of Neofusicoccum parvum Causing Leaf Spot on coral trees (Viburnum odoratissimum) in China

Coral trees (Viburnum odoratissimum), as a class of evergreen shrubs, are mainly planted in landscapes in numerous cities in China. During September 2020, the author investigated four major parks in Hefei (Bao Park, Hefei Botanical Garden, Luzhou Park and Peninsula Park) and the campus of Anhui Agricultural University (approximately 0.5 ha) (31°49'21.30″N, 117°13'18.25″E). The results showed that the incidence rate of leaf spot disease reached 60% among approximately 100,000 coral trees planted in these areas. Coral trees begin to show leaf spots in August. In early stages of coral trees infection, the symptoms appeared as small brown spots ranged in length from 2 to 3 millimeters on the leaves. After the disease patches expand and darken, the coral leaves eventually wither and fall, which seriously affects its viewing and admiring value. To identify the fungal pathogen, the five-point sampling method was used to take typical similar leaf samples from 5 regions, and 6 samples were taken from each site, so a total of 150 samples were obtained. Fragments of sample leaves were surface-sterilized with 1% NaClO, plated on potato dextrose agar, and incubated at 25 °C in the dark. A total of 275 strains were obtained from 150 samples. According to the morphological characteristics, 275 strains were purified and divided into four types. Four representative strains (MI1, K1, F1, D1) were selected from four types for further pathogenicity testing and identification. The pathogenicity test was conducted in triplicate by inoculating wounded leaves of 1-year-old potted V. odoratissimum with 20μL of a conidial suspension (106 conidia/mL). The control was inoculated with sterile water. The specimens were placed in a growth chamber while maintaining 90% relative humidity and 28℃. After five days, the characteristic lesions were observed only on inoculated MI1 spore suspension leaves. The same fungus was reisolated from the lesions, thus fulfilling Koch's postulates. The pathogenic fungi accounted for 60% of all strains. Fungal colonies were circular and had abundant white aerial mycelium, and colonies changed from white to pure black after maturity. Conidia were fusiform (16-17×5-6 μm), thin-walled, transparent, and without diaphragms. Molecular identification was performed by partially sequencing the internal transcribed spacer (ITS) gene, the translation elongation Factor 1-alpha(EF1-alpha) gene, and the β-tubulin (TUB2) gene by using the primers ITS1/ITS4 (White et al. 1990), EF1-728F (Alves et al. 2008)/EF1-986R (Carbone & Kohn 1999), and Bt2a/Bt2b (Glass & Donaldson 1995), respectively. The obtained ITS sequence (MW767713) showed 99% identity with N. parvum CMW28429 (KU997429.1), the EF1-alpha sequence (MZ398261) showed 99% identity with N. parvum isolate A4 (FJ528597.1), and the TUB2 sequence (MZ398260) showed 99% identity with N. parvum isolate BO52 (KU554657.1). By combining the sequences of individual fragments of each fungus in the order ITS, EF1-alpha and TUB2, MEGA 6.0 was used to analyze the sequence of kinship by using the maximum likelihood method, and the repeat value of bootstraps was 1000. A polygenic phylogenetic tree analysis based on multilocus alignment (ITS, EF1-alpha and TUB2) was constructed with some strains of Botryosphaeriaceae species. The results of the phylogenetic tree showed that MI1 and N. parvum clustered into a branch. To our knowledge, this is the first report of N. parvum causing leaf spot on V. odoratissimum in China.

Layer-by-layer coated hybrid nanoparticles with pH-sensitivity for drug delivery to treat acute lung infection

Bacteria-induced acute lung infection (ALI) is a severe burden to human health, which could cause acute respiratory distress syndrome (ARDS) and kill the patient rapidly. Therefore, it is of great significance to develop effective nanomedicine and therapeutic approach to eliminate the invading bacteria in the lung and manage ALI. In this study, we design a layer-by-layer (LbL) liposome-polymer hybrid nanoparticle (HNP) with a pH-triggered drug release profile to deliver antibiotics for the eradication of bacteria to treat ALI. The liposome is prepared by the lipid film hydration method with a homogenous hydrodynamic diameter and low polydispersity index (PDI). The antibiotic spectinomycin is efficiently loaded into the liposomal core through the pH-gradient method. The pH-sensitive polycationic polymer poly(β-amino ester) (PBAE) and polyanionic sodium alginate (NaAIg) layers are decorated on the surface of liposome in sequence via electrostatic interaction, resulting in spectinomycin-loaded layer-by-layer hybrid nanoparticles (denoted as Spe@HNPs) which have reasonable particle size, high stability, prolonged circulation time, and pH-triggered drug release profile. The in vitro results demonstrate that Spe@HNPs can efficiently induce the death of bacteria with low minimum inhibitory concentration (MIC) against Staphylococcus aureus (S. aureus) and drug-resistant MRSA BAA40 strains. The in vivo results reveal that Spe@HNPs can eradicate the invading MRSA BAA40 with improved antimicrobial efficacy and low side-effect for ALI treatment. This study not only reports a promising nanomedicine but also provides an effective method to prepare nanoplatforms for drug delivery and controlled release.

High-Resolution Magnetic Resonance Spectroscopic Imaging using a Multi-Encoder Attention U-Net with Structural and Adversarial Loss

Common to most medical imaging techniques, the spatial resolution of Magnetic Resonance Spectroscopic Imaging (MRSI) is ultimately limited by the achievable SNR. This work presents a deep learning method for 1H-MRSI spatial resolution enhancement, based on the observation that multi-parametric MRI images provide relevant spatial priors for MRSI enhancement. A Multi-encoder Attention U-Net (MAU-Net) architecture was constructed to process a MRSI metabolic map and three different MRI modalities through separate encoding paths. Spatial attention modules were incorporated to automatically learn spatial weights that highlight salient features for each MRI modality. MAU-Net was trained based on in vivo brain imaging data from patients with high-grade gliomas, using a combined loss function consisting of pixel, structural and adversarial loss. Experimental results showed that the proposed method is able to reconstruct high-quality metabolic maps with a high-resolution of 64×64 from a low-resolution of 16 × 16, with better performance compared to several baseline methods.

What is an appropriate caesarean delivery rate for China: a multicentre survey

Objective

To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction.

Design

A multicentre cross‐sectional study.

Setting

A total of 94 hospitals across 23 provinces in China.

Population

A total of 73 977 randomly selected deliveries.

Methods

We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates.

Main outcome measures

CD rates in China.

Results

In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs.

Conclusions

Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD.

Tweetable abstract

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953.

[The prevention and management of approach-specific complications of abdominal aortic balloon occlusion in pelvic and sacral surgery]

Objective: To investigate the causes,prevention and treatment of femoral artery puncture related complications caused by the application of resuscitative endovascular balloon occlusion of the aorta (REBOA) in the resection of pelvic and sacral tumors. Methods: Clinical data of 23 patients with femoral artery puncture related complications who received REBOA in the resection of pelvic and sacral tumors from August 2010 to August 2018 at the Musculoskeletal Tumor Center,Peking University People's Hospital were retrospectively analyzed.There were 8 males and 15 females,with the an age of (37.0±16.2) years (range:15 to 65 years).Arterial access via the Seldinger technique for REBOA was obtained in the right common femoral artery of 18 cases,and in the left of 6 cases.An arterial sheath with a diameter of 11 to 12 F(1 F≈0.33 mm) was used for the patient.The occurrence and treatment of postoperative complications were analyzed. Results: Acute femoral arterial thrombosis occurred in 18 patients,which was managed by open repair 48 hours postoperatively.Among the 349 patients admitted before 2015 who received hemostasis by compression after femoral artery sheath removal,12 patients (3.4%) developed acute femoral artery thrombosis.While the 476 patients admitted after 2015 who used a vascular stapler to close the femoral artery wound,6 patients (1.3%) developed acute femoral artery thrombosis.One case of retroperitoneal hematoma and 1 case of femoral pseudoaneurysm were found and surgically fixed.Postoperative follow-up was (40±18) months (range:13 to 108 months).Three cases with chronic lower extremity ischemia were confirmed by Doppler ultrasonography during 1 to 5 years follow-up.Two of them had minimal symptoms and denied further treatment,while the other one received femoral-femoral artery bypass surgery to restore distal flow for pain and numbness relief. Conclusions: Acute femoral arterial thrombosis was the most common femoral artery puncture.Technique refinement of REBOA,the use of percutaneous suture device and close follow-up can reduce the approach-specific complications,and help to detect and treat the complications timely,which may popularize the clinical application of REBOA.

Cable manipulation with a tactile-reactive gripper

Cables are complex, high-dimensional, and dynamic objects. Standard approaches to manipulate them often rely on conservative strategies that involve long series of very slow and incremental deformations, or various mechanical fixtures such as clamps, pins, or rings. We are interested in manipulating freely moving cables, in real time, with a pair of robotic grippers, and with no added mechanical constraints. The main contribution of this paper is a perception and control framework that moves in that direction, and uses real-time tactile feedback to accomplish the task of following a dangling cable. The approach relies on a vision-based tactile sensor, GelSight, that estimates the pose of the cable in the grip, and the friction forces during cable sliding. We achieve the behavior by combining two tactile-based controllers: (1) cable grip controller, where a PD controller combined with a leaky integrator regulates the gripping force to maintain the frictional sliding forces close to a suitable value; and (2) cable pose controller, where an linear–quadratic regulator controller based on a learned linear model of the cable sliding dynamics keeps the cable centered and aligned on the fingertips to prevent the cable from falling from the grip. This behavior is possible with the use of reactive gripper fitted with GelSight-based high-resolution tactile sensors. The robot can follow 1 m of cable in random configurations within two to three hand regrasps, adapting to cables of different materials and thicknesses. We demonstrate a robot grasping a headphone cable, sliding the fingers to the jack connector, and inserting it. To the best of the authors’ knowledge, this is the first implementation of real-time cable following without the aid of mechanical fixtures. Videos are available at http://gelsight.csail.mit.edu/cable/

[Incidence and trend of severe postpartum hemorrhage between 2016 and 2019 in China]

Objective: To investigate the incidence and trend of severe postpartum hemorrhage (sPPH) in China, and to provide basic data for the development and evaluation of sPPH prevention and control strategy. Methods: Obstetric data was extracted from annual national representative sampling surveys based on the National Clinical Improvement System. From 2016 to 2019, 2 978, 3 400, 4 576 and 4 594 maternity hospitals with sPPH cases were included for statistics. The annual incidence of sPPH was calculated according to province and type of medical institutions and generalized linear model was emplyed to identify the determinants affecting sPPH incidence. Results: In China, sPPH incidence increased from 0.62% in 2016 to 0.93% in 2018, and was 0.92% in 2019. Eighteen provinces had an inverted U-shaped trend of sPPH over time and most of them had the highest incidence in 2018; ten provinces had an upward trend of sPPH and 3 provinces had a U-shaped trend. In 2019, the top five provinces with the highest sPPH incidence were Yunnan (1.88%), Beijing (1.45%), Jiangsu (1.31%), Guizhou (1.26%), and Ningxia Hui Autonomous Region (1.22%); the top five provinces with the lowest incidence were Henan (0.55%), Jiangxi (0.60%), Inner Mongolia Autonomous Region (0.64%), Liaoning (0.64%) and Gansu (0.69%). In 2019, the sPPH incidence in different types of medical institutions were as follows: tertiary public general hospital (1.15%), tertiary public specialized hospital (1.02%), secondary public general hospital (0.81%), private hospital (0.61%) and secondary public specialized hospital (0.58%). sPPH incidence was positively associated with proportion of twin pregnancies, macrosomia, primipara, and puerpera aged ≥35 years in maternity hospitals (P<0.05). Conclusions: sPPH incidence generally showes an increasing trend from 2016 and is stable at a high level in recent two years in China. It is warranted to further strengthen the monitoring of postpartum hemorrhage, and improve the capability of hierarchical management and treatment in maternity institutions and regions, in order to reduce sPPH incidence and maternal mortality.

Prospects and Pitfalls: Next-Generation Tools to Control Mosquito-Transmitted Disease

Mosquito-transmitted diseases, including malaria and dengue, are a major threat to human health around the globe, affecting millions each year. A diverse array of next-generation tools has been designed to eliminate mosquito populations or to replace them with mosquitoes that are less capable of transmitting key pathogens. Many of these new approaches have been built on recent advances in CRISPR/Cas9-based genome editing. These initiatives have driven the development of pathogen-resistant lines, new genetics-based sexing methods, and new methods of driving desirable genetic traits into mosquito populations. Many other emerging tools involve microorganisms, including two strategies involving Wolbachia that are achieving great success in the field. At the same time, other mosquito-associated bacteria, fungi, and even viruses represent untapped sources of new mosquitocidal or antipathogen compounds. Although there are still hurdles to be overcome, the prospect that such approaches will reduce the impact of these diseases is highly encouraging.