A novel hybridization capture method for direct whole genome sequencing of clinical specimens to inform Legionnaires' disease investigations

The unprecedented precision and resolution of whole genome sequencing (WGS) can provide definitive identification of infectious agents for epidemiological outbreak tracking. WGS approaches, however, are frequently impeded by low pathogen DNA recovery from available primary specimens or unculturable samples. A cost-effective hybrid capture assay for Legionella pneumophila WGS analysis directly on primary specimens was developed. DNA from a diverse range of sputum and autopsy specimens PCR-positive for L. pneumophila serogroup 1 (LPSG1) was enriched with this method, and WGS was performed. All tested specimens were determined to be enriched for Legionella reads (up to 209,000-fold), significantly improving the discriminatory power to compare relatedness when no clinical isolate was available. We found the WGS data from some enriched specimens to differ by less than five single-nucleotide polymorphisms (SNPs) when compared to the WGS data of a matched culture isolate. This testing and analysis retrospectively provided previously unconfirmed links to environmental sources for clinical specimens of sputum and autopsy lung tissue. The latter provided the additional information needed to identify the source of these culture-negative cases associated with the South Bronx 2015 Legionnaires' disease (LD) investigation in New York City. This new method provides a proof of concept for future direct clinical specimen hybrid capture enrichment combined with WGS and bioinformatic analysis during outbreak investigations.IMPORTANCELegionnaires' disease (LD) is a severe and potentially fatal type of pneumonia primarily caused by inhalation of Legionella-contaminated aerosols from man-made water or cooling systems. LD remains extremely underdiagnosed as it is an uncommon form of pneumonia and relies on clinicians including it in the differential and requesting specialized testing. Additionally, it is challenging to obtain clinical lower respiratory specimens from cases with LD, and when available, culture requires specialized media and growth conditions, which are not available in all microbiology laboratories. In the current study, a method for Legionella pneumophila using hybrid capture by RNA baiting was developed, which allowed us to generate sufficient genome resolution from L. pneumophila serogroup 1 PCR-positive clinical specimens. This new approach offers an additional tool for surveillance of future LD outbreaks where isolation of Legionella is not possible and may help solve previously unanswered questions from past LD investigations.

Evaluation of three protocols for direct susceptibility testing for Gram-negative rods from flagged positive blood culture bottles

Bloodstream infections are associated with high mortality, which can be reduced by targeted antibiotic therapy in the early stages of infection. Direct antibiotic susceptibility testing (AST) from flagged positive blood cultures may facilitate the administration of early effective antimicrobials much before the routine AST. This study aimed to evaluate three different direct AST protocols for Gram-negative rods from flagged positive blood culture broths. Blood culture broths showing Gram-negative rods only were subjected to direct AST by Clinical and Laboratory Standards Institute-recommended direct disk diffusion (protocol A). Additionally, automated AST (protocol B) and Kirby-Bauer disk diffusion (protocol C) were performed with standard inoculum prepared from bacterial pellets obtained by centrifuging blood culture broths in serum separator vials. For comparison, conventional AST of isolates from solid media subculture was also performed with Kirby-Bauer disk diffusion (reference standard) and the automated method. Overall, categorical agreements of protocols A, B, and C were 97.6%, 95.7%, and 95.9%, respectively. Among Enterobacterales, minor error, major error, and very major error rates of protocol B were 3.5%, 0.36%, and 0.43%, respectively, whereas minor error, major error, and very major error rates of protocol C were 3.4%, 0.72%, and 0.21%, respectively, and among non-fermenters, protocol B had a minor error rate of 6.5%, and protocol C had a minor error rate of 4.1% and major error rate of 1.9%. All three direct AST protocols demonstrated excellent categorical agreements with the reference method. Performance of protocols B and C between Enterobacterales and non-fermenters was not statistically different.

IMPORTANCE

Bloodstream infections are associated with high mortality that can be reduced by targeted antibiotic therapy in the early stages of infection. Direct antibiotic susceptibility testing (AST) from flagged positive blood cultures may facilitate the administration of early effective antimicrobials much before the routine AST. Clinical and Laboratory Standards Institute-recommended direct AST can be performed with a limited number of antibiotic disks only. On the other hand, using an automated system for direct AST will not only allow effective laboratory workflow with reduced turnaround time but also provide the minimum inhibitory concentration values of tested antibiotics. However, using expensive automated systems for direct AST may not be feasible for resource-limited laboratories. Therefore, in this study, we aimed to evaluate the CLSI-recommended method and two other direct AST protocols (one with an automated system and the other with disk diffusion) for Gram-negative rods from flagged positive blood cultures.

Resolution of Radiculopathy Following Indirect Versus Direct Decompression in Single Level Lumbar Fusion

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To evaluate resolution of radiculopathy in one-level lumbar fusion with indirect or direct decompression techniques.

METHODS

Patients ≥18 years of age with preoperative radiculopathy undergoing single-level lumbar fusion with up to 2-year follow-up were grouped by indirect and direct decompression. Direct decompression (DD) group included ALIF and LLIF with posterior DD procedure as well as all TLIF. Indirect decompression (ID) group included ALIF and LLIF without posterior DD procedure. Propensity score matching was used to control for intergroup differences in age. Intergroup outcomes were compared using means comparison tests. Logistic regressions were used to correlate decompression type with symptom resolution over time. Significance set at P < .05.

RESULTS

116 patients were included: 58 direct decompression (DD) (mean 53.9y, 67.2% female) and 58 indirect decompression (ID) (mean 54.6y, 61.4% female). DD patients experienced greater blood loss than ID. Additionally, DD patients were 4.7 times more likely than ID patients to experience full resolution of radiculopathy at 3 months post-op. By 6 months, DD patients demonstrated larger reductions in VAS score. With regard to motor function, DD patients had improved motor score associated with the L5 dermatome at 6 months relative to ID patients.

CONCLUSIONS

Direct decompression was associated with greater resolution of radiculopathy in the near post-operative term, with no differences at long term follow-up when compared with indirect decompression. In particularly debilitated patients, these findings may influence surgeons to perform a direct decompression to achieve more rapid resolution of radiculopathy symptoms.

The conventional diagnosis challenge: Real-time PCR and nested PCR correlation with the scoring system for individuals at high-risk of Pneumocystis jirovecii pneumonia

INTRODUCTION

Pneumocystis jirovecii is an opportunistic fungus that affects mainly people living with HIV (CD4 cell count lower than 200 cells/ml) and other immunosuppressed patients. Since P. jirovecii does not grow on routine mycological media, diagnosis of P. jirovecii pneumonia relies on indirect evidence of its presence in respiratory samples.

OBJECTIVES

To associate the results of direct immunofluorescence and two molecular methods with a score to predict P. jirovecii pneumonia in patients with AIDS.

MATERIALS AND METHODS

A prospective study was conducted with 40 patients. A respiratory sample collected before treatment was subjected to direct immunofluorescence using the Merifluor kit, to nested PCR targeting the mitochondrial large subunit ribosomal RNA, and to the VIASURE real-time PCR kit.

RESULTS

These three techniques revealed P. jirovecii in 6, 12, and 15 samples, respectively. All positive samples by direct immunofluorescence were positive by nested PCR, and all positive samples by nested PCR amplified by real-time PCR. There was a statistically significant association between the P. jirovecii pneumonia score and the molecular methods. Two patients were early diagnosed and responded well to treatment.

CONCLUSION

Molecular methods, especially real-time PCR, are recommended for early diagnosis of P. jirovecii pneumonia in AIDS patients.

Non-Vitamin K Antagonist Oral Anticoagulants in Patients with β-Thalassemia

Background. Patients with β-thalassemia have a high incidence of atrial fibrillation (AF) and other supraventricular arrhythmias. The use of non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prophylaxis in patients with β-thalassemia has not been systematically evaluated. Methods. We enrolled patients with transfusion-dependent β-thalassemia, who were on treatment with NOACs for thromboembolic prophylaxis of supraventricular arrhythmias. Data on thromboembolic and bleeding events were collected. Results. Eighteen patients were enrolled. The patients had a history of AF (sixteen), typical atrial flutter (five), and atypical atrial flutter (four). The patients were treated with dabigatran (seven), apixaban (five), rivaroxaban (four) or edoxaban (two). The mean follow-up duration was 22 ± 15 months. No thromboembolic events were reported. No major bleedings were observed. Three patients had non-major bleeding events. Two patients reported dyspepsia during treatment with dabigatran and were shifted to a different NOAC. Conclusions. Our study suggests the efficacy and safety of NOACs in patients affected by transfusion-dependent β-thalassemia.

Bone Laser Patterning to Decipher Cell Organization

The laser patterning of implant materials for bone tissue engineering purposes has proven to be a promising technique for controlling cell properties such as adhesion or differentiation, resulting in enhanced osteointegration. However, the possibility of patterning the bone tissue side interface to generate microstructure effects has never been investigated. In the present study, three different laser-generated patterns were machined on the bone surface with the aim of identifying the best surface morphology compatible with osteogenic-related cell recolonization. The laser-patterned bone tissue was characterized by scanning electron microscopy and confocal microscopy in order to obtain a comprehensive picture of the bone surface morphology. The cortical bone patterning impact on cell compatibility and cytoskeleton rearrangement on the patterned surfaces was assessed using Stromal Cells from the Apical Papilla (SCAPs). The results indicated that laser machining had no detrimental effect on consecutively seeded cell metabolism. Orientation assays revealed that patterns with larger hatch distances were correlated with higher cell cytoskeletal conformation to the laser-machined patterns. To the best of our knowledge, this study is the first to consider and evaluate bone as a biological interface that can be engineered for improvement. Further investigations should focus on the in vivo implications of this direct patterning.

Comparison of Clinical Characteristics and Predictors of Mortality between Direct and Indirect ARDS

Background and Objectives: Acute Respiratory Distress Syndrome (ARDS) is a heterogeneous syndrome that encompasses lung injury from a direct pulmonary or indirect systemic insult. Studies have shown that direct and indirect ARDS differ in their pathophysiologic process. In this study, we aimed to compare the different clinical characteristics and predictors of 28-day mortality between direct and indirect ARDS. Materials and Methods: The data of 1291 ARDS patients from September 2012 to December 2021 at the Second Affiliated Hospital of Chongqing Medical University were reviewed. We enrolled 451 ARDS patients in our study through inclusion and exclusion criteria. According to the risk factors, each patient was divided into direct (n = 239) or indirect (n = 212) ARDS groups. The primary outcome was 28-day mortality. Results: The patients with direct ARDS were more likely to be older (p < 0.001) and male (p = 0.009) and have more comorbidity (p < 0.05) and higher 28-day mortality (p < 0.001) than those with indirect ARDS. Age and multiple organ dysfunction syndrome (MODS) were predictors of 28-day mortality in the direct ARDS group, while age, MODS, creatinine, prothrombin time (PT), and oxygenation index (OI) were independent predictors of 28-day mortality in the indirect ARDS group. Creatinine, PT, and OI have interactions with ARDS types (all p < 0.01). Conclusions: The patients with direct ARDS were more likely to be older and male and have worse conditions and prognoses than those with indirect ARDS. Creatinine, PT, and OI were predictors of 28-day mortality only in the indirect ARDS group. The differences between direct and indirect ARDS suggest the need for different management strategies of ARDS.

Economic Burden of Diabetes and Hypertension: A Study of Direct and Indirect Cost of Treatment in Southeast Nigeria

The prevalence of diabetes mellitus and hypertension is increasing yearly in many low- and middle-income countries such as Nigeria. The increasing burden of these noncommunicable diseases has led to an increase in the overall cost of health care. This study aimed at determining the direct and indirect health care costs of diabetes mellitus and hypertension occurring both singly and in co-morbidity. The study was undertaken in the Enugu State University Teaching Hospital (a tertiary hospital) in Enugu State, Southeast Nigeria. Data were collected using a pre-tested questionnaire. Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had hypertension, and 28% had both diabetes mellitus and hypertension in co-morbidity. Direct costs of treating diabetes mellitus and hypertension in the month before the survey were $28.40 and $19.35, respectively, while the indirect costs of treatment in the month before the study were $7.36 and $5.51, respectively. Direct and indirect costs for diabetes mellitus and hypertension in co-morbidity were $37.00 and $4.62, respectively. A concentration index showed that diabetes mellitus and hypertension were more evident among the poor than the rich. The economic cost when compared with patients' income revealed that >25% of their income is spent monthly on health care.

Safety and Efficacy of Risankizumab and Infliximab in the Treatment of Plaque Psoriasis: Results From a Direct and Indirect Meta-Analysis

The objective of our study was to compare a potent drug of the anti-TNF class family, infliximab, with a potent drug of the IL-inhibitors family, risankizumab, in terms of efficacy and safety endpoints. Online databases were searched for relevant placebo-controlled, randomized trials. The following efficacy outcomes were included: PASI-75, PASI-90, and sPGA, as well as the incidence of any adverse events and serious adverse events. The risk ratios (RR) with the respective 95% confidence intervals (CIs) of different psoriasis scores were pooled in a meta-analysis model, using the Mantel-Haenszel method.

The combined risk ratios (RR) showed that infliximab and risankizumab are effective in increasing the number of patients with more than 75% improvement in the PASI (RR= 26.68, 95% CI [14.98, 47.51] p<0.001) and (RR= 10.17, 95% CI [7.24, 14.30] p<0.001), respectively. Test for subgroup differences showed that risankizumab is more effective. Regarding PASI-90 outcome, risankizumab and infliximab are more effective than placebo (RR= 26.22, 95% CI [14.20, 48.41], p<0.001), and (RR= 15.18, 95% CI [8.72, 26.45], p<0.001) respectively. The results showed that risankizumab does not cause significant serious adverse events (RR = 0.59, 95% CI [0.31, 1.13], p=0.12) while, on the other hand, infliximab causes significant serious adverse events (RR = 2.30, 95% CI [1.08, 4.88], p=0.03). The test of subgroup difference showed that risankizumab is safer (p<0.001). Analysis of the incidence of any adverse events showed that risankizumab is safer as well (p=0.007). Infection rates were similar among both drugs (p=0.05). In conclusion, risankizumab is preferred for the treatment of psoriasis than infliximab, and is significantly more effective and safe.

Teaching Smartphone Funduscopy with 20 Diopter Lens in Undergraduate Medical Education

Purpose

To assess attitudes of pre-clinical undergraduate medical students toward learning smartphone funduscopy (SF) and its appropriateness as a teaching tool.

Patients and Methods

Second year medical students received instruction on direct ophthalmoscopy (DO) and SF; they were then paired with a peer and randomly assigned to perform DO or SF first. The SF technique involved freehand alignment of the axes of the smartphone camera with a condenser lens. Both techniques were done through a maximally dilated pupil. A questionnaire was completed to acquire data on baseline experience, performance of both examination techniques, attitudes, and appropriateness. Statistical significance testing and Bland-Altman analysis were used to determine differences between DO and SF, and a multivariable mixed regression model was fitted to identify any predictors for positive attitudes toward DO or SF.

Results

One hundred thirty-seven (137) individuals completed the study. A similar proportion of students could identify the optic nerve, macula, and vessels using DO and SF. However, self-reported quality scores were higher for DO for the optic nerve (p = 0.006) and macula (p = 0.08). The mean (standard deviation) attempts to identify these major structures were 2.7 (SD 2.3) for DO and 4.5 (SD 2.9) for SF (p < 0.001). Attitudes of students were consistently more positive toward DO across the five questions assessed. A small subset of students had equally positive attitudes toward DO and SF. Improved quality scores were predictive of positive attitudes for both DO and SF. Ultimately, 24% of students preferred SF over DO.

Conclusion

Among inexperienced examiners of the fundus through a dilated pupil, SF is a non-inferior technique to DO in identifying structures. Despite overall favorable attitudes towards the more familiar DO, those students who quickly learned the SF technique had similar satisfaction scores. Teaching SF should be considered in undergraduate medical education.

Trial of Rivaroxaban in AntiPhospholipid Syndrome (TRAPS): Two-year outcomes after the study closure

BACKGROUND

Trial of Rivaroxaban in AntiPhospholipid Syndrome was a prospective randomized, open-label, noninferiority study conducted in 14 centers in Italy. Rivaroxaban was compared with warfarin for the prevention of thromboembolic events, major bleeding, and vascular death in high-risk, triple-positive patients with antiphospholipid syndrome.

OBJECTIVE

The aim of this paper is to report the events during the 2-year follow-up after the study closure.

METHODS

On January 28, 2018, the trial was prematurely stopped by adjudication and safety committee for an excess of events in the rivaroxaban group. Randomized patients were advised on trial results and those randomized to rivaroxaban were solicited to switch to warfarin. All 14 participating centers were asked and accepted to follow their patients for clinical events. This report describes the rate of events that occurred between January 28, 2018, and January 28, 2020.

RESULTS

Of 120 randomized patients, 115 were available for follow-up. Outcome events were two in six (33.3%) patients who remained on direct oral anticoagulants (DOACs) and six in 109 (5.7%) patients on warfarin (hazard ratio [HR] 6.9; 95% confidence interval [CI] 1.4-34.5, P = .018). The two patients on DOACs (one taking dabigatran and one taking rivaroxaban) suffered from thromboembolic events, whereas of the six patients with composite outcomes on warfarin, three had thromboembolic events (HR for thrombosis 13.3; 95% CI 2.2-79.9, P = .005).

CONCLUSION

These data further support the use of warfarin in high-risk patients with antiphospholipid syndrome.

Single Incision Laparoscopic Surgery: Feasibility of the Direct Fascial Puncture Technique Without Working Trocars

Introduction

As single-incision laparoscopic surgery (SILS) became popular, many access platforms and techniques emerged. When we initially described the direct fascial puncture (DFP) technique, many suggested it was not practical for three reasons: (1) increased hernia formation, (2) inability to complete operations without instrument changes and (3) insurmountable instrument drag. This study sought to determine whether the technique was a feasible approach by evaluating the outcomes with DFP-SILS in a single surgeon unit.

Methods

This was a retrospective audit of all consecutive patients who had unselected SILS operations by a single surgeon. For the DFP-SILS operation, a single optical trocar was used at the umbilicus, a second was rail-roaded beside the optical trocar and a third was directly passed across the fascia at the left-lateral extent of the skin wound. We recorded the number of conversions or failed operations and examined the patients routinely after operation to evaluate for incisional herniae.

Results

There were 50 DFP-SILS operations performed: 37 cholecystectomies, 12 appendectomies and one jejunal resection. The operations were successful in all cases with no conversions or mortality recorded. One patient (2%) developed a superficial surgical site infection after SILS-DFP appendectomy. The therapeutic outcomes were comparable to existing series of multi-port laparoscopy. There were no incisional herniae detected.

Conclusion

Even in the resource-poor setting, SILS operations are feasible and safe using the DFP technique. The theoretic concerns have not been realized in clinical practice.

Performance of a Novel Fluorogenic Assay for Detection of Carbapenemase-Producing Enterobacteriaceae from Bacterial Colonies and Directly from Positive Blood Cultures

Rapid and accurate detection of carbapenemase-producing Enterobacteriaceae (CPE) is critical for appropriate treatment and infection control. We compared a rapid fluorogenic assay using a carbapenem-based fluorogenic probe with other phenotypic assays: modified carbapenem inactivation method (mCIM), Carba NP test (CNP), and carbapenemase inhibition test (CIT). A total of 217 characterized isolates of Enterobacteriaceae were included as follows: 63 CPE; 48 non-carbapenemase-producing carbapenem-resistant Enterobacteriaceae (non-CP-CRE); 53 extended-spectrum β-lactamase producers; and 53 third-generation-cephalosporin-susceptible isolates. The fluorogenic assay using bacterial colonies (Fluore-C) was conducted by lysing the isolates followed by centrifugation and mixing the supernatant with fluorogenic probe. In addition, for the fluorogenic assay using spiked blood culture bottles (Fluore-Direct), pellets were obtained via the saponin preparation method, which can directly identify the pathogens using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). The fluorescence signal was measured over 50 min using a fluorometer. The fluorescent signal of CPE was significantly higher than that of non-CPE in both Fluore-C (median relative fluorescence units [RFU] [range], 5,814 [240 to 32,009] versus 804 [36 to 2,480], respectively; P < 0.0001) and Fluore-Direct (median RFU [range], 10,355 [1,689 to 31,463] versus 1,068 [428 to 2,155], respectively; P < 0.0001) tests. Overall, positive and negative percent agreements of Fluore-C, mCIM, CNP, CIT, and Fluore-Direct were 100% and 98.7%, 98.3% and 97.5%, 88.1% and 100%, 96.4% and 98.7%, and 98.3% and 98.1%, respectively. The relatively lower positive percent agreement (PPA) of CNP was mainly observed in OXA-type CPE. The fluorogenic assay showed excellent performance with bacterial colonies and also directly from positive blood cultures. We included many non-CP-CRE isolates for strict evaluation. The fluorogenic assay will be a useful tool for clinical microbiology laboratories.

A comparison of perceived diagnostic image quality in direct digital panoramic images between standard and advanced external GOP image processing

Objective: The objective of the present study was to study the effect of adaptive image processing (GOP processing) on the visibility of anatomical structures in direct digital panoramic images. Material and methods: The study comprised panoramic images of 50 consecutive adult individuals aged 18-60 years. Nine dentists working with dental radiology compared the structural image quality of all standard-processed and GOP-processed panoramic images for six anatomical structures, using a six-point scale for visual grading characteristics analysis. Results: For all anatomic structures a statistically significant difference in favour of the GOP was found. Conclusions: The present study shows that it is possible to improve perceived diagnostic image quality of direct digital panoramic radiography using GOP technology compared to the manufacturers' standard processing. Manufacturers' image-processing programs can be further developed, as there is a possibility of improving the perceived diagnostic content of an image with external processing.

The Attitudes Towards the Use of Restraint and Restrictive Intervention Amongst Healthcare Staff on Acute Medical and Frailty Wards-A Brief Literature Review

Restraint in modern non-psychiatric-based healthcare is often regarded as a rare occurrence. It is deemed to be used as a last resort to prevent patients from directly harming themselves. However, techniques are used in modern day practice which are considered direct and indirect restraints with the justification of maintaining patient safety, but they are often not classified as “restraints”. Examples of these include the use of bed rails or tables to prevent patients from “wandering” and to reduce the risk of falls and injuries. More indirect techniques would involve passive interactions with patients or leaving mobility aids out of reach. Staff subconsciously restrain patients and reduce their liberties despite agreeing that patient autonomy should be upheld—a necessary evil to maintain a duty of care. Whilst the use of restraints is often justified to ensure patient care and prevent injury, it is not without consequence. There are physical and psychological health risks such as pressure sores from the inability to mobilise, or the brewing of anger and frustration when denied access to everyday actions. The reasons why restraints are used, whilst stemming from maintaining patient safety, are often due to low staffing levels and the inability to constantly watch at-risk patients due to a large workload. Inadequate training is another factor; by improving education in direct and indirect restraint and providing alternative methods, more ethical decisions and positive outcomes can be implemented. Healthcare professionals are reluctant to use restraint but often conduct it without realising it; assessing their understanding of restraint and providing education to raise awareness of the consequences of direct and indirect methods would result in positive steps toward reducing their use at the same time as looking to provide alternatives to uphold patient care whilst maintaining their dignity and liberty.

Blue light-emitting diode technology-operated microscopy is preferable to both short arc mercury lamp-operated microscopy and laser scanning confocal microscopy for direct immunofluorescence images evaluation in routinely diagnosing subepidermal autoimmune blistering diseases

Direct immunofluorescence (DIF) microscopy still is the gold standard in diagnosing and differentiating subepidermal autoimmune blistering diseases (SABDs) from other bullous diseases. New optical systems were developed that aim to facilitate DIF images evaluation. The aim of the study was to evaluate the usefulness of three fluorescence microscopy systems with different light source for routine diagnostics of SABDs with DIF. In total, perilesional tissue samples for DIF from 34 SABD patients were examined under the three commercial microscopy systems (short arc mercury lamp-operated microscopy-MLM, blue light-emitting diode technology-operated microscopy-bLED and laser scanning confocal microscopy-LSCM) for the detection and pattern analysis of IgA, IgG, IgG1, IgG4, C3 immunoreactants along the dermal-epidermal junction (DEJ) by three independent observers simultaneously. MLM, bLED, and LSCM provided comparable quality of disease-characterizing immunoreactants imaging (number of immunoreactant types detected and patterns of their deposition along DEJ were the same) but screening of slides was quicker using bLED than both LSCM and MLM, as statistical analysis indicated. It is concluded that bLED is an efficient and preferable system for routinely diagnosing SABDs cost-effectively. RESEARCH HIGHLIGHTS: New optical systems were developed that aim to facilitate direct immunofluorescence evaluation. Here, we evaluate the usefulness of three fluorescence microscopy systems with different light source for routine diagnostics concluding that that bLED is an efficient and preferable system.

Random PCR-based genotyping by sequencing technology GRAS-Di (genotyping by random amplicon sequencing, direct) reveals genetic structure of mangrove fishes

While various technologies for high-throughput genotyping have been developed for ecological studies, simple methods tolerant to low-quality DNA samples are still limited. In this study, we tested the availability of a random PCR-based genotyping-by-sequencing technology, genotyping by random amplicon sequencing, direct (GRAS-Di). We focused on population genetic analysis of estuarine mangrove fishes, including two resident species, the Amboina cardinalfish (Fibramia amboinensis, Bleeker, 1853) and the Duncker's river garfish (Zenarchopterus dunckeri, Mohr, 1926), and a marine migrant, the blacktail snapper (Lutjanus fulvus, Forster, 1801). Collections were from the Ryukyu Islands, southern Japan. PCR amplicons derived from ~130 individuals were pooled and sequenced in a single lane on a HiSeq2500 platform, and an average of three million reads was obtained per individual. Consensus contigs were assembled for each species and used for genotyping of single nucleotide polymorphisms by mapping trimmed reads onto the contigs. After quality filtering steps, 4,000-9,000 putative single nucleotide polymorphisms were detected for each species. Although DNA fragmentation can diminish genotyping performance when analysed on next-generation sequencing technology, the effect was small. Genetic differentiation and a clear pattern of isolation-by-distance was observed in F. amboinensis and Z. dunckeri by means of principal component analysis, F_ST and the admixture analysis. By contrast, L. fulvus comprised a genetically homogeneous population with directional recent gene flow. These genetic differentiation patterns reflect patterns of estuary use through life history. These results showed the power of GRAS-Di for fine-grained genetic analysis using field samples, including mangrove fishes.

Clinical Outcomes of Patients With Lateral Femoral Cutaneous Nerve Injury After Direct Anterior Total Hip Arthroplasty

BACKGROUND

Direct anterior total hip arthroplasty (THA) is an increasingly utilized and patient-requested approach for arthroplasty carrying a unique set of complications. Injury to the lateral femoral cutaneous nerve (LFCN) can have a wide range of clinical symptoms ranging from hypesthesia to painful paresthesia. Long-term effects of this injury have not been well studied. We describe duration and severity of these symptoms and correlate their relationship with hip functional scores.

METHODS

Between January 2009 and January 2016, 1665 patients with 1871 hips who underwent direct anterior THA by a single surgeon were surveyed for reported outcomes including Douleur Neuropathique 4-Interview (DN4-I), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR), and Patient-Reported Outcomes Measurement Information System Short Form Global Health Assessment. The DN4-I was considered positive if 3 (or more) of 7 neuropathic pain symptoms were affirmed at present in the distribution of the LFCN of the affected leg.

RESULTS

Six hundred eighty patients accounting for 778 hips completed the survey. Overall, 16% of responders had positive DN4-I scores for continued neuropathic symptoms with a mean time since surgery of 3.9 years at assessment. Twenty-four percent of those responding within 2 years of surgery had positive scores compared with 15% from 2 to 4 years, 14% from 4 to 6 years, and 11% positive from 6 to 8 years after surgery. Of those with positive DN4-I scores, the most commonly affirmed neuropathic symptom was "numbness", reported in 37% of patients. The overall average interval HOOS, JR score was 89.8. There were no differences in HOOS, JR or Patient-Reported Outcomes Measurement Information System scores for patients further out from surgery.

CONCLUSION

The most commonly experienced neuropathic symptom in the distribution of the LFCN following direct anterior THA is "numbness" that occurred in 37% of patients with a positive DN4-I score. Neuropathic symptoms improved in patients further out from surgery with pain reported in 11% of patients from 6 to 8 years postoperatively. Neuropathic symptoms significantly improve with time and appear to be independent of hip function scores.

AAV gene delivery to the spinal cord: serotypes, methods, candidate diseases, and clinical trials

INTRODUCTION

Adeno-associated viral (AAV) vector-mediated gene delivery to the spinal cord has finally entered the pathway towards regulatory approval. Phase 1 clinical trials using AAV gene therapy for pediatric disorders - spinal muscular atrophy (SMA) and giant axonal neuropathy (GAN) - are now underway.

AREAS COVERED

This review addresses the latest progress in the field of AAV gene delivery to the spinal cord, particularly focusing on the most prominent AAV serotypes and delivery methodologies to the spinal cord. Candidate diseases and scaling up experiments in large animals are also discussed.

EXPERT OPINION

Intravenous (IV) and intrathecal (IT) deliveries seem to undoubtedly be the preferred routes of administration for diffuse spinal cord delivery of therapeutic AAV vectors that can cross the blood-brain barrier (BBB) and correct inherited genetic disorders. Conversely, intraparenchymal delivery is still an undervalued but very viable approach for segmental therapy in afflictions such as ALS or Pompe Disease as a means to prevent respiratory dysfunction.

Expanding the developmental models of writing: A direct and indirect effects model of developmental writing (DIEW)

We investigated direct and indirect effects of component skills on writing (DIEW) using data from 193 children in Grade 1. In this model, working memory was hypothesized to be a foundational cognitive ability for language and cognitive skills as well as transcription skills, which, in turn, contribute to writing. Foundational oral language skills (vocabulary and grammatical knowledge) and higher-order cognitive skills (inference and theory of mind) were hypothesized to be component skills of text generation (i.e., discourse-level oral language). Results from structural equation modeling largely supported a complete mediation model among four variations of the DIEW model. Discourse-level oral language, spelling, and handwriting fluency completely mediated the relations of higher-order cognitive skills, foundational oral language, and working memory to writing. Moreover, language and cognitive skills had both direct and indirect relations to discourse-level oral language. Total effects, including direct and indirect effects, were substantial for discourse-level oral language (.46), working memory (.43), and spelling (.37), followed by vocabulary (.19), handwriting (.17), theory of mind (.12), inference (.10), and grammatical knowledge (.10). The model explained approximately 67% of variance in writing quality. These results indicate that multiple language and cognitive skills make direct and indirect contributions, and it is important to consider both direct and indirect pathways of influences when considering skills that are important to writing.

Immediate Effects of Proprioceptive Neuromuscular Facilitation Stretching Programs Compared With Passive Stretching Programs for Hamstring Flexibility: A Critically Appraised Topic

Clinical Scenario: Increasing hamstring flexibility through clinical stretching interventions may be an effective means to prevent hamstring injuries. However the most effective method to increase hamstring flexibility has yet to be determined.

CLINICAL QUESTION

For a healthy individual, are proprioceptive neuromuscular facilitation (PNF) stretching programs more effective in immediately improving hamstring flexibility when compared with static stretching programs? Summary of Key Findings: A thorough literature search returned 195 possible studies; 5 studies met the inclusion criteria and were included. Current evidence supports the use of PNF stretching or static stretching programs for increasing hamstring flexibility. However, neither program demonstrated superior effectiveness when examining immediate increases in hamstring flexibility. Clinical Bottom Line: There were consistent findings from multiple low-quality studies that indicate there is no difference in the immediate improvements in hamstring flexibility when comparing PNF stretching programs to static stretching programs in physically active adults. Strength of Recommendation: Grade B evidence exists that PNF and static stretching programs equally increase hamstring flexibility immediately following the stretching program.

Direct versus indirect revascularization procedures for moyamoya disease: a comparative effectiveness study

OBJECTIVE Moyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD. METHODS A comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed. RESULTS A structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization. CONCLUSIONS In the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.

Induction of Direct or Priming Resistance against Botrytis cinerea in Strawberries by β-Aminobutyric Acid and Their Effects on Sucrose Metabolism

The specific forms of disease resistance induced by β-aminobutyric acid (BABA) and their impacts on sucrose metabolism of postharvest strawberries were determined in the present research. Treatment with 10-500 mmol L(-1) BABA inhibited the Botrytis cinerea infection, possibly directly by suppressing the fungus growth and indirectly by triggering disease resistance. Moreover, BABA-induced resistance against B. cinerea infection in strawberries was associated with either one of two mechanisms, depending upon the concentration used: BABA at concentrations higher than 100 mmol L(-1) directly induced the defense response, including a H2O2 burst, modulation of the expression of PR genes, including FaPR1, FaChi3, Faβglu, and FaPAL, and increased activities of chitinase, β-1,3-glucanase, and PAL, whereas BABA at 10 mmol L(-1) activated a priming response because the BABA-treated fruits exhibited an increased capacity to express molecular defense only when the fruits were inoculated with B. cinerea. Activation of the priming defense appeared almost as effective against B. cinerea as inducing direct defense. However, the primed strawberries maintained higher activities of SS synthesis and SPS and SPP enzymes) and lower level of SS cleavage during the incubation; these activities contributed to higher sucrose, fructose, and glucose contents, sweetness index, and sensory scores compared to fruits exhibiting the direct defense. Thus, it is plausible that the priming defense, which can be activated by BABA at relatively low concentrations, represents an optimal strategy for combining the advantages of enhanced disease protection and soluble sugar accumulation.

Direct (presenting primarily to trauma center) versus indirect (referred or transferred) admission of patients to the Trauma Centre of King George Medical University: One-year prospective pilot study

Background:

India does not have a trauma registry. There is lack of base line demographic data of trauma victims that present directly to the trauma center and those that are transferred to the trauma center.

Aim:

To compare the clinical and demographic profile of directly admitted (presenting primarily to the trauma center) and referred (transferred to trauma center) patients at the trauma centre of King George Medical University.

Materials and Methods:

The demographic and clinical profiles of patients admitted on thirty-three consecutive Mondays were collected and compared. In addition, the demographic data of patients admitted on Mondays and eight randomly selected Wednesdays and Saturdays were analyzed to ascertain the representativeness of the studied sample.

Results:

Of the 572 patients in the study, 327 were referred and 245 were directly admitted. There was 27% mortality in the referred group and 22% mortality in the directly admitted group, the difference been statistically insignificant (P value 0.20). Patients referred from peripheral hospitals were more severely injured with a lower GCS and a higher TRISS, and had a higher proportion of multi system major trauma and severe head injury.

Conclusion:

Referred admitted (transferred) patients at the KGMU trauma center are more seriously injured than the patients presenting directly. Yet there is no statistically significant difference in the overall mortality. A future study focusing on certain sub-categories of patients such as those demonstrating subdural hematoma, GCS less than 9 or ISS more than 15 may yield interesting data.

The cost-effectiveness of ustekinumab for moderate-to-severe psoriasis

Given its chronicity and impact on quality of life, psoriasis is a costly disease. As new and better treatments are developed, the cost of treating psoriasis has risen. In this drug profile, the authors discuss ustekinumab, its pharmacokinetics, safety profile, and direct and indirect costs to determine its cost-efficacy. The authors searched PubMed with specific search phrases for clinical trials investigating this issue over 5 years. Eleven articles analyzed cost-effectiveness of ustekinumab, and the references of these articles were included. Studies limited to 12 weeks reported that ustekinumab may not be cost-effective as it has high cost per injection and is costly when loading doses are required. Studies that went beyond 12 weeks documented that, with ustekinumab's infrequent dosing, it is cost-effective during the maintenance period.

Human B-cell isotype switching origins of IgE

BACKGROUND

B cells expressing IgE contribute to immunity against parasites and venoms and are the source of antigen specificity in allergic patients, yet the developmental pathways producing these B cells in human subjects remain a subject of debate. Much of our knowledge of IgE lineage development derives from model studies in mice rather than from human subjects.

OBJECTIVE

We evaluate models for isotype switching to IgE in human subjects using immunoglobulin heavy chain (IGH) mutational lineage data.

METHODS

We analyzed IGH repertoires in 9 allergic and 24 healthy adults using high-throughput DNA sequencing of 15,843,270 IGH rearrangements to identify clonal lineages of B cells containing members expressing IgE. Somatic mutations in IGH inherited from common ancestors within the clonal lineage are used to infer the relationships between B cells.

RESULTS

Data from 613,641 multi-isotype B-cell clonal lineages, of which 592 include an IgE member, are consistent with indirect switching to IgE from IgG- or IgA-expressing lineage members in human subjects. We also find that these inferred isotype switching frequencies are similar in healthy and allergic subjects.

CONCLUSIONS

We found evidence that secondary isotype switching of mutated IgG1-expressing B cells is the primary source of IgE in human subjects, with lesser contributions from precursors expressing other switched isotypes and rarely IgM or IgD, suggesting that IgE is derived from previously antigen-experienced B cells rather than naive B cells that typically express low-affinity unmutated antibodies. These data provide a basis from which to evaluate allergen-specific human antibody repertoires in healthy and diseased subjects.

Partial venom gland transcriptome of a Drosophila parasitoid wasp, Leptopilina heterotoma, reveals novel and shared bioactive profiles with stinging Hymenoptera

Analysis of natural host-parasite relationships reveals the evolutionary forces that shape the delicate and unique specificity characteristic of such interactions. The accessory long gland-reservoir complex of the wasp Leptopilina heterotoma (Figitidae) produces venom with virus-like particles. Upon delivery, venom components delay host larval development and completely block host immune responses. The host range of this Drosophila endoparasitoid notably includes the highly-studied model organism, Drosophila melanogaster. Categorization of 827 unigenes, using similarity as an indicator of putative homology, reveals that approximately 25% are novel or classified as hypothetical proteins. Most of the remaining unigenes are related to processes involved in signaling, cell cycle, and cell physiology including detoxification, protein biogenesis, and hormone production. Analysis of L. heterotoma's predicted venom gland proteins demonstrates conservation among endo- and ectoparasitoids within the Apocrita (e.g., this wasp and the jewel wasp Nasonia vitripennis) and stinging aculeates (e.g., the honey bee and ants). Enzyme and KEGG pathway profiling predicts that kinases, esterases, and hydrolases may contribute to venom activity in this unique wasp. To our knowledge, this investigation is among the first functional genomic studies for a natural parasitic wasp of Drosophila. Our findings will help explain how L. heterotoma shuts down its hosts' immunity and shed light on the molecular basis of a natural arms race between these insects.

Easy way to learn standardization : direct and indirect methods

In direct age-adjustment, a common age-structured population is used as standard. This population may actually exist (e.g., United States population, 1999) or may be fictitious (e.g., two populations may be combined to create a standard). In indirect age-adjustment, a common set of age-specific rates is applied to the populations whose rates are to be standardized. The simplest and most useful form of indirect adjustment is the standardized mortality ratio (SMR) (5).