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Activating signal co-integrator complex 1 (ASCC1) acts with ASCC-ALKBH3 complex in alkylation damage responses. ASCC1 uniquely combines two evolutionarily ancient domains: nucleotide-binding K-Homology (KH) (associated with regulating splicing, transcriptional, and translation) and two-histidine phosphodiesterase (PDE; associated with hydrolysis of cyclic nucleotide phosphate bonds). Germline mutations link loss of ASCC1 function to spinal muscular atrophy with congenital bone fractures 2 (SMABF2). Herein analysis of The Cancer Genome Atlas (TCGA) suggests ASCC1 RNA overexpression in certain tumors correlates with poor survival, Signatures 29 and 3 mutations, and genetic instability markers. We determined crystal structures of Alvinella pompejana (Ap) ASCC1 and Human (Hs) PDE domain revealing high-resolution details and features conserved over 500 million years of evolution. Extending our understanding of the KH domain Gly-X-X-Gly sequence motif, we define a novel structural Helix-Clasp-Helix (HCH) nucleotide binding motif and show ASCC1 sequence-specific binding to CGCG-containing RNA. The V-shaped PDE nucleotide binding channel has two His-Φ-Ser/Thr-Φ (HXT) motifs (Φ being hydrophobic) positioned to initiate cyclic phosphate bond hydrolysis. A conserved atypical active-site histidine torsion angle implies a novel PDE substrate. Flexible active site loop and arginine-rich domain linker appear regulatory. Small-angle X-ray scattering (SAXS) revealed aligned KH-PDE RNA binding sites with limited flexibility in solution. Quantitative evolutionary bioinformatic analyses of disease and cancer-associated mutations support implied functional roles for RNA binding, phosphodiesterase activity, and regulation. Collective results inform ASCC1's roles in transactivation and alkylation damage responses, its targeting by structure-based inhibitors, and how ASCC1 mutations may impact inherited disease and cancer.

BACKGROUND: Obstructive sleep apnea (OSA) increases risk for cognitive decline and Alzheimers disease (AD). While the underlying mechanisms remain unclear, hypoxemia during OSA has been implicated in cognitive impairment. OSA during rapid eye movement (REM) sleep is usually more severe than in non-rapid eye movement (NREM) sleep, but the relative effect of oxyhemoglobin desaturation during REM versus NREM sleep on memory is not completely characterized. Here, we examined the impact of OSA, as well as the moderating effects of AD risk factors, on verbal memory in a sample of middle-aged and older adults with heightened AD risk. METHODS: Eighty-one adults (mean age:61.7 ± 6.0 years, 62% females, 32% apolipoprotein E ε4 allele (APOE4) carriers, and 70% with parental history of AD) underwent clinical polysomnography including assessment of OSA. OSA features were derived in total, NREM, and REM sleep. REM-NREM ratios of OSA features were also calculated. Verbal memory was assessed with the Rey Auditory Verbal Learning Test (RAVLT). Multiple regression models evaluated the relationships between OSA features and RAVLT scores while adjusting for sex, age, time between assessments, education years, body mass index (BMI), and APOE4 status or parental history of AD. The significant main effects of OSA features on RAVLT performance and the moderating effects of AD risk factors (i.e., sex, age, APOE4 status, and parental history of AD) were examined. RESULTS: Apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxyhemoglobin desaturation index (ODI) during REM sleep were negatively associated with RAVLT total learning and long-delay recall. Further, greater REM-NREM ratios of AHI, RDI, and ODI (i.e., more events in REM than NREM) were related to worse total learning and recall. We found specifically that the negative association between REM ODI and total learning was driven by adults 60 + years old. In addition, the negative relationships between REM-NREM ODI ratio and total learning, and REM-NREM RDI ratio and long-delay recall were driven by APOE4 carriers. CONCLUSION: Greater OSA severity, particularly during REM sleep, negatively affects verbal memory, especially for people with greater AD risk. These findings underscore the potential importance of proactive screening and treatment of REM OSA even if overall AHI appears low.

IntroductionLate-onset Alzheimer's disease (LOAD) has a strong genetic component. Participants in Long-Life Family Study (LLFS) exhibit delayed onset of dementia, offering a unique opportunity to investigate LOAD genetics.MethodsWe conducted a whole genome sequence analysis of 3475 LLFS members. Genetic associations were examined in six independent studies (N = 14,260) with a wide range of LOAD risk. Association analysis in a sub-sample of the LLFS cohort (N = 1739) evaluated the association of LOAD variants with beta amyloid (Aβ) levels.ResultsWe identified several single nucleotide polymorphisms (SNPs) in tight linkage disequilibrium within the MTUS2 gene associated with LOAD (rs73154407, p = 7.6 × 10-9). Association of MTUS2 variants with LOAD was observed in the five independent studies and was significantly stronger within high levels of Aβ42/40 ratio compared to lower amyloid.DiscussionMTUS2 encodes a microtubule associated protein implicated in the development and function of the nervous system, making it a plausible candidate to investigate LOAD biology.HighlightsLong-Life Family Study (LLFS) families may harbor late onset Alzheimer's dementia (LOAD) variants. LLFS whole genome sequence analysis identified MTUS2 gene variants associated with LOAD. The observed LLFS variants generalized to cohorts with wide range of LOAD risk. The association of MTUS2 with LOAD was stronger within high levels of beta amyloid. Our results provide evidence for MTUS2 gene as a novel LOAD candidate locus.

In this study, we aimed to understand the potential role of the gut microbiome in the development of Alzheimers disease (AD). We took a multi-faceted approach to investigate this relationship. Urine metabolomics were examined in individuals with AD and controls, revealing decreased formate and fumarate concentrations in AD. Additionally, we utilised whole-genome sequencing (WGS) data obtained from a separate group of individuals with AD and controls. This information allowed us to create and investigate host-microbiome personalised whole-body metabolic models. Notably, AD individuals displayed diminished formate microbial secretion in these models. Additionally, we identified specific reactions responsible for the production of formate in the host, and interestingly, these reactions were linked to genes that have correlations with AD. This study suggests formate as a possible early AD marker and highlights genetic and microbiome contributions to its production. The reduced formate secretion and its genetic associations point to a complex connection between gut microbiota and AD. This holistic understanding might pave the way for novel diagnostic and therapeutic avenues in AD management.

Chitin is an abundant biopolymer and pathogen-associated molecular pattern that stimulates a host innate immune response. Mammals express chitin-binding and chitin-degrading proteins to remove chitin from the body. One of these proteins, Acidic Mammalian Chitinase (AMCase), is an enzyme known for its ability to function under acidic conditions in the stomach but is also active in tissues with more neutral pHs, such as the lung. Here, we used a combination of biochemical, structural, and computational modeling approaches to examine how the mouse homolog (mAMCase) can act in both acidic and neutral environments. We measured kinetic properties of mAMCase activity across a broad pH range, quantifying its unusual dual activity optima at pH 2 and 7. We also solved high-resolution crystal structures of mAMCase in complex with oligomeric GlcNAcn, the building block of chitin, where we identified extensive conformational ligand heterogeneity. Leveraging these data, we conducted molecular dynamics simulations that suggest how a key catalytic residue could be protonated via distinct mechanisms in each of the two environmental pH ranges. These results integrate structural, biochemical, and computational approaches to deliver a more complete understanding of the catalytic mechanism governing mAMCase activity at different pH. Engineering proteins with tunable pH optima may provide new opportunities to develop improved enzyme variants, including AMCase, for therapeutic purposes in chitin degradation.

Abstract There are a limited number of effective vaccines against dengue virus (DENV) and significant efforts are being made to develop potent anti-virals. Previously, we described that platelet-chemokine CXCL4 negatively regulates interferon (IFN)-α/β synthesis and promotes DENV2 replication. An antagonist to CXCR3 (CXCL4 receptor) reversed it and inhibited viral replication. In a concurrent search, we identified CXCR3-antagonist from our compound library, namely 7D, which inhibited all serotypes of DENV in vitro. With a half-life of ~2.85 h in plasma and no significant toxicity, 7D supplementation (8 mg/kg-body-weight) to DENV2-infected IFNα/β/γR−/−AG129 or wild-type C57BL6 mice increased synthesis of IFN-α/β and IFN-λ, and rescued disease symptoms like thrombocytopenia, leukopenia and vascular-leakage, with improved survival. 7D, having the property to inhibit Sirt-1 deacetylase, promoted acetylation and phosphorylation of STAT3, which in-turn increased plasmablast proliferation, germinal-center maturation and synthesis of neutralizing-antibodies against DENV2 in mice. A STAT3-inhibitor successfully inhibited these effects of 7D. Together, these observations identify compound 7D as a stimulator of IFN-α/β/λ synthesis via CXCL4:CXCR3:p38:IRF3 signaling, and a booster for neutralizing-antibody generation by promoting STAT3-acetylation in plasmablasts, capable of protecting dengue infection.

Organ donation after circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries, most commonly being category III-controlled donations. This document, prepared by a multidisciplinary group of experts, describes the feasibility of category III DCDD in India, in view of the January 2023 Supreme Court (SC) judgment simplifying the process of withdrawal of life-sustaining treatment (WLST). The paper discusses the concept and types of futility of care, how to elicit patients values and wishes, outlines its determination in several clinical situations and the process of WLST in such cases, in accordance with the SC judgement. The judgement mandates evaluation for futility of care by the primary and secondary medical boards before intimation to the judicial magistrate and WLST. The paper also discusses the use of new and upcoming organ preservation techniques and technologies in various organ transplants and outcomes of such transplants. We have also reviewed international best practices in cDCDD, discuss the ethical, medical, legal, economic, procedural, and logistic challenges in India and outline a path for DCDD in India. The manuscript discusses and compares the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. Further clarifications of aspects such as ante-mortem measures and do-not attempt resuscitation (DNAR) may be required during implementation of the judgement in some situations.

Abstract Background Obstructive sleep apnea (OSA) increases risk for cognitive decline and Alzheimer’s disease (AD). While the underlying mechanisms remain unclear, hypoxemia during OSA has been implicated in cognitive impairment. OSA during rapid eye movement (REM) sleep is usually more severe than in non-rapid eye movement (NREM) sleep, but the relative effect of oxyhemoglobin desaturation during REM versus NREM sleep on memory is not completely characterized. Here, we examined the impact of OSA, as well as the moderating effects of AD risk factors, on verbal memory in a sample of middle-aged and older adults with heightened AD risk. Methods Eighty-one adults (mean age:61.7 ± 6.0 years, 62% females, 32% apolipoprotein E ε4 allele (APOE4) carriers, and 70% with parental history of AD) underwent clinical polysomnography including assessment of OSA. OSA features were derived in total, NREM, and REM sleep. REM-NREM ratios of OSA features were also calculated. Verbal memory was assessed with the Rey Auditory Verbal Learning Test (RAVLT). Multiple regression models evaluated the relationships between OSA features and RAVLT scores while adjusting for sex, age, time between assessments, education years, body mass index (BMI), and APOE4 status or parental history of AD. The significant main effects of OSA features on RAVLT performance and the moderating effects of AD risk factors (i.e., sex, age, APOE4 status, and parental history of AD) were examined. Results Apnea–hypopnea index (AHI), respiratory disturbance index (RDI), and oxyhemoglobin desaturation index (ODI) during REM sleep were negatively associated with RAVLT total learning and long-delay recall. Further, greater REM-NREM ratios of AHI, RDI, and ODI (i.e., more events in REM than NREM) were related to worse total learning and recall. We found specifically that the negative association between REM ODI and total learning was driven by adults 60 + years old. In addition, the negative relationships between REM-NREM ODI ratio and total learning, and REM-NREM RDI ratio and long-delay recall were driven by APOE4 carriers. Conclusion Greater OSA severity, particularly during REM sleep, negatively affects verbal memory, especially for people with greater AD risk. These findings underscore the potential importance of proactive screening and treatment of REM OSA even if overall AHI appears low.

Background As a matter of policy, voluntary, community and social enterprises contribute substantially to the English health and care system. Few studies explain how the National Health Service and local authorities commission them, what outputs result, what contexts influence these outcomes and what differentiates this kind of commissioning. Objectives To explain how voluntary, community and social enterprises are commissioned, the consequences, what barriers both parties face and what absorptive capacities they need. Design Observational mixed-methods realist analysis: exploratory scoping, cross-sectional analysis of National Health Service Clinical Commissioning Group spending on voluntary, community and social enterprises, systematic comparison of case studies, action learning. Social prescribing, learning disability support and end-of-life care were tracers. Setting Maximum-variety sample of six English local health and care economies, 2019–23. Participants Commissioning staff; voluntary, community and social enterprise members. Interventions None; observational study. Main outcome measures How the consequences of commissioning compared with the original aims of the commissioners and the voluntary, community and social enterprises: predominantly qualitative (non-measurable) outcomes. Data sources Data sources were: 189 interviews, 58 policy and position papers, 37 items of rapportage, 692,659 Clinical Commissioning Group invoices, 102 Freedom of Information enquiries, 131 survey responses, 18 local project group meetings, 4 national action learning set meetings. Data collected in England during 2019–23. Results Two modes of commissioning operated in parallel. Commodified commissioning relied on creating a principal–agent relationship between commissioner and the voluntary, community and social enterprises, on formal competitive selection (‘procurement’) of providers. Collaborative commissioning relied on ‘embedded’ interorganisational relationships, mutual recognition of resource dependencies, a negotiated division of labour between organisations, and control through persuasion. Commissioners and voluntary, community and social enterprises often worked around the procurement regulations. Both modes were present everywhere but the balance depended inter alia on the number and size of voluntary, community and social enterprises in each locality, their past commissioning experience, the character of the tracer activity, and the level of deprivation and the geographic dispersal of the populations served. The COVID-19 pandemic produced a shift towards collaborative commissioning. Voluntary, community and social enterprises were not always funded at the full cost of their activity. Integrated Care System formation temporarily disrupted local co-commissioning networks but offered a longer-term prospect of greater voluntary, community and social enterprise influence on co-commissioning. To develop absorptive capacity, commissioners needed stronger managerial and communication capabilities, and voluntary, community and social enterprises needed greater capability to evidence what outcomes their proposals would deliver. Limitations Published data quality limited the spending profile accuracy, which did not include local authority commissioning. Case studies did not cover London, and focused on three tracer activities. Absorptive capacity survey was not a random sample. Conclusions The two modes of commissioning sometimes conflicted. Workarounds arose from organisations’ embeddedness and collaboration, which the procurement regulations often disrupted. Commissioning activity at below its full cost appears unsustainable. Future work Spending profiles of local authority commissioning; analysis of commissioning in London and of activities besides the present tracers. Analysis of absorptive capacity and its consequences, adjusting the concept for application to voluntary, community and social enterprises. Comparison with other health systems’ commissioning of voluntary, community and social enterprises. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128107) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 39. See the NIHR Funding and Awards website for further award information. Plain language summary National Health Service commissioners and local councils often buy health and care services from voluntary, community and social enterprises. This study aimed to explore how commissioners and voluntary, community and social enterprises worked together and where improvements could be made. We talked to commissioners and voluntary, community and social enterprises in six areas across England and focused on services for learning disabilities, social prescribing and end-of-life care. We analysed National Health Service financial accounts to see how much the National Health Service was spending on services provided by voluntary, community and social enterprises. We surveyed how commissioners and voluntary, community and social enterprises were using information and knowledge to make decisions. We organised events bringing together commissioners and voluntary, community and social enterprises to share knowledge and experience. We found there were two ways commissioners bought services from voluntary, community and social enterprises. One was commodified (a buying-and-selling model), the other collaborative (based on working together). Both were happening at the same time in all the areas of the study, but usually one of them was more present than the other. We saw a general move towards collaboration, but some areas were further along with this than others. Various things helped commissioners and voluntary, community and social enterprises collaborate, such as: paying voluntary, community and social enterprises enough for their services; having people and networks that encouraged others to work with voluntary, community and social enterprises; and including voluntary, community and social enterprises in making decisions about health and care. Commissioners and voluntary, community and social enterprises might therefore lean further towards working together to see how collaborative commissioning can be further developed; how to make contract prices cover voluntary, community and social enterprises’ costs; how to enable longer-term contracts; and how to enable less hurried, more considered ways of renewing contracts (e.g. by putting draft contract specifications out to pre-tender consultation). The new Integrated Care Systems in local areas could encourage all this to happen, but pressures elsewhere in the health and care sector might make it more difficult. Scientific summary Background This study examines how the NHS and local authorities commissioned voluntary, community and social enterprises (VCSEs); some outcomes for commissioners, VCSEs and the health system; and which contexts affected these outcomes. Existing studies describe how the public funding of independent providers occurs through a commissioning cycle of service specification, provider selection, contract-letting and monitoring of the activities actually delivered. The original policy (and theoretical) formulations of this cycle presupposed a clear separation of commissioners from providers. In practice, however, the cycle is partly implemented, and attenuated, by co-commissioning activities, collaborations in which potential providers, citizens and the public contribute at each stage. Commissioning has been explained as, inter alia, a means by which governments continued to exercise governance (not direct control) over independent providers of public-funded services through six main media of power: managerial techniques, negotiated order, discursive control, resource dependencies, provider competition, and juridical control. Each particular combination constitutes a ‘mode of commissioning’. Previous studies have examined the modes of commissioning applied elsewhere, but not to VCSEs, and then usually from the standpoint of policy-makers’ aims and intended service outcomes of commissioning. Fewer studies have explored commissioning from the VCSE standpoint. Some that did reported largely negative consequences for the commissioned VCSEs: a loss of freedom to criticise policy and a ‘degeneration’ of the VCSEs’ democratic internal regimes. Still fewer studies have closely examined the interactions between commissioners and VCSEs as they engage in the commissioning cycle and in co-commissioning. The practical import of these questions is whether the commissioning of health-related VCSEs enables them to supplement the reach of NHS activities and strengthen users’ voice in the health system, or whether it undermines the characteristics of VCSEs which first motivated the commissioning of them. Because commissioning involves two main groups of agents, their interactions involve not just one but two context–mechanism–outcome configurations (CMOCs). In one, the commissioners are the focal actor (as in most realist evaluations); in the other, VCSEs are. The two configurations intersect at the commissioning mechanisms, where the parties interact. Earlier studies suggested that the parties’ absorptive capacity (ACAP) to acquire, assimilate, transform and exploit externally sourced knowledge was an important context affecting what interactions occurred, and to what effect. Objectives This study aimed to produce knowledge about which factors strengthen (or weaken) collaboration between healthcare commissioners and VSCEs, and make commissioning relationships between the commissioners and VCSEs more productive for all. Research questions were: RQ1. How do healthcare commissioners address the task of commissioning VCSEs as service providers, and what barriers do they face? RQ2. What are the consequences for VCSEs of the public bodies commissioning services from them? RQ3. How are VCSEs involved in Clinical Commissioning Group (CCG), local authority and other [e.g. Integrated Care System (ICS), NHS England] commissioning decisions? RQ4. What ACAPs do healthcare commissioners and VCSEs respectively need for enabling VCSEs to be commissioned, and for co-commissioning? Methods This study was a mixed-methods realist analysis of the mechanisms by which English health-related VCSEs are commissioned. To investigate the intersecting CMOCs, we used five main methods: Preliminary scoping work with national-level NHS and VCSE organisations to identify important current developments in this domain and likely data sources, based on interviews and content analysis of policy documents. A cross-sectional profile of CCG spending on VCSEs, which provided data about patterns of VCSE commissioning and was a sampling frame for the three following work packages. We content-analysed 226,138 CCG invoices (for sums over £25k) from 2018 to 2019 to discover the distribution of CCG spending on VCSEs and how it compared with CCG spending on non-VCSE providers. Using findings from the preceding work packages, we drew a sample of six places contrasted by their proportion of spending on VCSEs. We systematically compared case studies of VCSE–commissioner collaboration in formulating local commissioning strategies (‘co-commissioning’) in them (2020–2). Commissioners’ and VCSEs’ aims when engaging in commissioning were examined separately for either side, as were the outcomes relevant to each, but not the structures and activities through which they interacted. A systematic comparison of case studies of the commissioning of VCSEs, using the same study sites, methods and unit of analysis as the preceding work package (late 2020 to summer 2022). Action learning activities (2020–3) in the same sites: Local project reference groups supported the project in each study site and combined as: national action learning workshops a preliminary, exploratory (not randomised sample) survey of ACAP in the study sites local co-researchers who conducted local research projects into the commissioning of VCSEs and whom the research team mentored As tracer studies we examined social prescribing, end-of-life care and support for learning disabilities, on the assumption that this selection gave variety in the scale and number of VCSEs involved, and type of activity (clinical vs. preventive). Framework analyses were used to synthesise the five sets of findings and map them onto the research questions. Results Two modes of commissioning VCSEs existed in parallel: A commodified mode centred on the commissioning cycle, financial dependencies, formalised procurement [a regulatory (i.e. juridically based) practice] and provider competition. Consulted VCSEs were often excluded at either service specification or provider selection stage in the cycle. The financial dependency of VCSEs was a central medium of power for commissioners. Juridical power was in the background but seldom used in practice. The paradigm form of this mechanism was a direct bilateral principal–agent relationship between one commissioner and one VCSE, with the latter wielding less power. This was a commodified mode of commissioning. To reduce their transaction work (costs), commissioners were introducing larger contracts (e.g. with one large ‘lead’ provider subcontracting many smaller VCSEs). Networks for negotiating what activities were commissioned and how they were implemented. Commissioners and VCSEs were both embedded in these networks, which constituted an interorganisational negotiated order among commissioners, among VCSEs, and between commissioners and VCSEs. Persuasion and legitimation were the main discursive media of power, supplemented by relationality (mutual trust) and mutual ‘real-side’ (as opposed to financial) resource dependency. Workarounds such as alliance and lead provider commissioning were important media of managerial power, adopted in order to diminish the expected, and in some cases observed, adverse consequences of commodified commissioning. VCSEs’ commissioning and co-commissioning activities overlapped considerably. The networking mechanisms supplemented and attenuated the quasi-market mechanisms, and indeed were partly intended to. This was a collaborative mode of commissioning. It was not that where one mode of commissioning existed, the other did not; both coexisted and interacted everywhere but the balance between them varied. Certain contexts affected how these mechanisms worked in practice: Local health and care system characteristics: Fiscal constraints upon commissioners constrained how much VCSE activity could be commissioned, compelled commissioners to prioritise VCSE activities that appeared to offer immediate cost savings elsewhere in the health system, and destabilised VCSE income. Diverse ownership mix of provider organisations (e.g. in learning disability services) motivated more cautious, commodified commissioning insofar as commissioners anticipated challenges to their decisions from unsuccessful bidders. Having a small number of stable VCSEs (e.g. in end-of-life care) enabled and necessitated collaborative commissioning. Geographical and historical characteristics: Population deprivation motivated commissioners and VCSEs to respond through collaborative commissioning. Spatial dispersion increased the practical difficulty and costs of, and the number of networks involved in, collaborative commissioning. Co-terminosity of commissioners minimised the number of interorganisational interfaces that the networks had to span. Local policies, ethos and history strongly influenced whether collaboration and trust between commissioners and VCSEs was long-established, and thus how collaborative commissioning could be. The presence and nature of networking spaces, in particular which VCSEs participated, and how much voice they had when they did participate, affected how collaborative co-commissioning could be. Organisational characteristics: ACAP affected commissioners’ ability to know what resources VCSEs could offer, and what VCSEs were aiming for, in becoming involved in commissioning, and vice versa. Commissioners relied on formal sources of information and evidence more than VCSEs tended to. Discursive (translation) gaps between VCSEs and commissioners were widespread. Organisational systems, culture and bureaucracy: the more narrowly procurement regulations were interpreted and implemented, the more commissioning was commodified rather than collaborative. Individuals’ role, discretion and influence: individuals who lobbied for VCSEs to engage, or be engaged, in commissioning and who were boundary-spanners with knowledge of both commissioning and VCSEs facilitated the development of collaborative commissioning, as did ‘maverick’ individuals who devised workarounds when procurement regulations appeared to obstruct the commissioning of VCSEs, especially collaborative commissioning. The nature of VCSE activity: Statutory or non-statutory status: statutory requirements for service provision exposed commissioners’ resource dependence on VCSEs, which led to more collaborative, flexible commissioning. Tracer group characteristics: tracer groups’ characteristics affected commissioning partly through the above contexts; that is, whether VCSEs were few and large (e.g. hospices) or the opposite (social prescribing); undertaking statutorily mandated activity (e.g. hospices, some learning disability support). The degree of specialisation of VCSE work affected the number and mix of providers. Stability of demand for a VCSE’s activity favoured more collaborative commissioning. A temporal context: the COVID-19 pandemic shifted the commissioning of VCSEs substantially towards a more collaborative mode, and this change had not fully reverted. The outcomes of these mechanisms included some that approximated to commissioners’ and VCSEs’ respective aims in using the above commissioning mechanisms. For commissioners the main outcomes were to obtain the use of VCSE resources, sometimes at below the full cost of provision. It was often claimed that VCSE activities had relieved, or would relieve, pressure on NHS services, but firm evidence was scarce. Commissioning VCSEs also offered a way for commissioners to pilot test possible innovations (e.g. for self-help in maintaining health) and a ready-made route to access patient, carer and public opinions. For VCSEs the main outcome was income, although the income flow was often unstable, which made it hard to retain paid staff, and below the cost of their activities. Some VCSEs also increased their voice in the local health system, but we also found a large periphery of VCSEs that did not participate in the networks described above and were not commissioned. We found a more nuanced picture than previous studies’ account of the internal ‘degeneration’ of VCSEs as a result of being commissioned. Most VCSEs reported little change to their aims or ‘mission’, and some had increased the professionalism of their management. We also found emergent, unforeseen outcomes. There was a general shift towards collaborative commissioning away from commodified commissioning, but it made the discursive gap between commissioners and VCSEs more apparent. The undercosting of some VCSE activities amounted to a hidden subsidy to commissioners from VCSEs. VCSE activities added a new category of public health activities, those of preventive self-care at a personal and family level, to the longer-established models of clinical prevention (vaccination, etc.) and the ‘new’ public health (legislative and policy changes, e.g. food labelling controls). ICS formation tended to disrupt co-commissioning networks in the short term, but offered a longer-term prospect of greater VCSE input into co-commissioning. Conclusions By research question: RQ1. Commissioners used two commissioning mechanisms in parallel. Each embodied a different kind of governance structure and a different mode of commissioning. Centred on the commissioning cycle, the quasi-market mechanisms implemented a heavily commodified mode of commissioning whose paradigm was a principal–agent relationship between commissioner and VCSE. The networking mechanisms of collaborative commissioning consisted of a triple negotiated order: networking among commissioners, networking among VCSEs and networking between commissioners and VCSEs. A barrier to using this hybrid mechanism was that at certain points in the commissioning cycle, especially provider selection, the mechanisms conflicted. Unfavourable contexts were other barriers: more specialised VCSE activities, dependence on a few individuals, non-coterminous commissioners, possible competition from corporate and public providers, population dispersal and fiscal austerity. RQ2. For VCSEs, consequences of being commissioned depended on the mode of commissioning but were mainly some extension of VCSE activities, including advocacy; marginal adjustments (not drift) in mission; and additional funding, but often unstable and below the full cost of these activities. RQ3. VCSE involvement in co-commissioning occurred through networking rather than quasi-market mechanisms. VCSEs with long-established working relationships with commissioners were often the ones involved, and were often larger VCSEs. Small local VCSEs were involved vicariously through their participation in VCSE infrastructure bodies or networks which were more directly involved, but a large periphery of small VCSEs remained outside these networks. RQ4. The ACAPs that commissioners needed were a combination of managerial and communication skills: to routinise ‘acquiring’ and ‘assimilating’ information from VCSEs; to specify calls for practical proposals or bids from VCSEs so as to elicit responses from suitable VCSEs; and then to apply (‘exploit’) information and ideas from VCSEs in ways that did not then penalise the VCSEs which provided them (e.g. by excluding them from tendering). VCSEs needed to develop the capacities to supply evidence, both hard and soft intelligence, about why they wished to supplement or amend commissioners’ assumptions and proposals, and to express what outcomes their proposals would offer, what metrics could be used to verify that, and more generally how the VCSE’s proposals would add social value. In ACAP terms, the commissioners appeared to need to develop their knowledge acquisition and exploitation capacities especially, while VCSEs needed to develop their knowledge acquisition and transformation capacities. Implications for health and care Below-cost funding for VCSE activity is not sustainable in the long term because VCSE activities require paid-for inputs, even when volunteer labour is used. The instability of VCSE income from commissioners contributed to VCSE staff turnover. If it continues, commissioners’ move towards longer contracts implies that a stratification and concentration of the VCSE side of the quasi-market may occur. Research recommendations are, in descending priority order, for research to: Quantify the impacts of VCSE activity on demand on NHS services. Extend our analysis of NHS commissioner spending on health-related VCSE activity to include local authority spending, and longitudinally. Test whether our findings apply to the commissioning of large (cross-England) VCSEs engaged in health-related activity. Assess the nature, effects and development of ACAP in commissioners and VCSEs by means that combine representative sample surveys (e.g. using the survey instrument developed for this study) and deeper analysis of the specific mechanisms by which ACAP affects commissioning practice. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128107) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 39. See the NIHR Funding and Awards website for further award information.

ABSTRACT Background Modeling outcomes, such as onset of heart failure (HF) or mortality, in patients following ST elevation myocardial infarction (STEMI) is challenging but clinically very useful. The acute insult following a myocardial infarction and chronic degeneration seen in HF involve a similar process where a loss of cardiomyocytes and abnormal remodeling lead to pump failure. This process may alter the strength and direction of the heart's net depolarization signal. We hypothesize that changes over time in unique parameters extracted using vectorcardiography (VCG) have the potential to predict outcomes in patients post‐STEMI and could eventually be used as a noninvasive and cost‐effective surveillance tool for characterizing the severity and progression of HF to guide evidence‐based therapies. Methods We identified 162 patients discharged from Michigan Medicine between 2016 and 2021 with a diagnosis of acute STEMI. For each patient, a single 12‐lead ECG > 1 week pre‐STEMI and > 1 week post‐STEMI were collected. A set of unique VCG parameters were derived by analyzing features of the QRS complex. We used LASSO regression analysis incorporating clinical variables and VCG parameters to create a predictive model for HF, mortality, or the composite at 90, 180, and 365 days post‐STEMI. Results The VCG model is most predictive for HF onset at 90 days with a robust AUC. Variables from the HF model mitigating or driving risk, at a p

Summary: Background: Decision-making during health crises differs from routine decision-making and is constrained by ambiguity about evolving epidemiological situations, urgency of response, lack of evidence, and fear. Recent analyses of governance and decision-making during COVID-19, focusing on leadership qualities, involvement of specific stakeholders, and effective resource management, do not adequately address a persisting gap in understanding the determinants of decision-making during health crises at the national level. Methods: We undertook a study to understand the processes and characteristics of decision-making during the COVID-19 pandemic in Singapore. We used a case study approach and collected empirical evidence about public health decision-making, using a combination of key informant interviews and focus group discussions with stakeholders from government, academia and civil society organizations. Findings: We argue that administrative centralization and political legitimacy played important roles in agile governance and decision-making during the pandemic in Singapore. We demonstrate the role of the Singapore government's centralization in creating a unified and coherent governance model for emergency response and the People's Action Party's (PAP) legitimacy in facilitating people's trust in the government. Health system resilience and financial reserves further facilitated an agile response, yet community participation and prioritization of vulnerable migrant populations were insufficient in the governance processes. Interpretation: Our analysis contributes to the theory and practice of crisis decision-making by highlighting the role of political and administrative determinants in agile crisis decision-making. Funding: This study is funded by the U.S. Centers for Disease Control and Prevention through a Cooperative Research Agreement (NU2HGH2020000037).

Abstract Quinoa (Chenopodium quinoa Willd.), an Andean crop, is a facultative halophyte food crop recognized globally for its high nutritional value and plasticity to adapt to harsh conditions. We conducted a genome-wide association study on a diverse set of quinoa germplasm accessions. These accessions were evaluated for the following agronomic and biochemical traits: days to 50% flowering (DTF), plant height (PH), panicle length (PL), stem diameter (SD), seed yield (SY), grain diameter (GD), and thousand-grain weight (TGW). These accessions underwent genotyping-by-sequencing using the DNBSeq-G400R platform. Among all evaluated traits, TGW represented maximum broad-sense heritability. Our study revealed average SNP density of ≈ 3.11 SNPs/10 kb for the whole genome, with the lowest and highest on chromosomes Cq1B and Cq9A, respectively. Principal component analysis clustered the quinoa population in three main clusters, one clearly representing lowland Chilean accessions, whereas the other two groups corresponded to germplasm from the highlands of Peru and Bolivia. In our germplasm set, we estimated linkage disequilibrium decay to be ≈ 118.5 kb. Marker-trait analyses revealed major and consistent effect associations for DTF on chromosomes 3A, 4B, 5B, 6A, 7A, 7B and 8B, with phenotypic variance explained (PVE) as high as 19.15%. Nine associations across eight chromosomes were also found for saponin content with 20% PVE by qSPN5A.1. More QTLs were identified for PL and TGW on multiple chromosomal locations. We identified putative candidate genes in the genomic regions associated with DTF and saponin content. The consistent and major-effect genomic associations can be used in fast-tracking quinoa breeding for wider adaptation across marginal environments.

Introduction: Due to the lack of cadavers, anatomists across the nation are facing trouble in teaching. Plastinated specimens can be used to get around this deficiency and reliance. Aim: To assess the change in weight during plastination using melamine. Materials and Methods: A cross-sectional cadaveric study was conducted in the Department of Anatomy at GMC Kota, Rajasthan, India, using nine specimens from cadavers obtained between June 2016 and June 2017. Freshly dissected specimens from a fresh cadaver were used for plastination. The weight reduction after dehydration using acetone (three changes of seven days each), degreasing using xylene (three changes of seven days each), impregnation with a melamine-xylene mixture (10 days in a vacuum), and curing was recorded. Weight was measured using a digital weighing balance and recorded after each step. All statistical analyses were performed using Analysis of Variance (ANOVA) in MedCalc software version 22.009. Results: There was a gradual weight loss after each step except for impregnation. The percentage of mean weight after dehydration was 58.59±4.03%, after degreasing was 56.21±2.55%, after impregnation was 66.06±4.69%, and after curing was 48.26±5.39% and p-value was highly significant (

Abstract In this study, we aimed to understand the potential role of the gut microbiome in the development of Alzheimer's disease (AD). We took a multi-faceted approach to investigate this relationship. Urine metabolomics were examined in individuals with AD and controls, revealing decreased formate and fumarate concentrations in AD. Additionally, we utilised whole-genome sequencing (WGS) data obtained from a separate group of individuals with AD and controls. This information allowed us to create and investigate host-microbiome personalised whole-body metabolic models. Notably, AD individuals displayed diminished formate microbial secretion in these models. Additionally, we identified specific reactions responsible for the production of formate in the host, and interestingly, these reactions were linked to genes that have correlations with AD. This study suggests formate as a possible early AD marker and highlights genetic and microbiome contributions to its production. The reduced formate secretion and its genetic associations point to a complex connection between gut microbiota and AD. This holistic understanding might pave the way for novel diagnostic and therapeutic avenues in AD management.

Abstract In recent times, secure quantum communication in layered networks has emerged as an important area of study. The authors harness the potential offered by multidimensional states in secure quantum communication with only one quantum participant and all the other classical participants. Three protocols are proposed for—(i) entanglement‐based layered semi‐quantum key distribution, (ii) layered semi‐quantum secret sharing, and (iii) integrated layered semi‐quantum key distribution and secret sharing to share secret information in arbitrarily layered networks. These protocols integrate the features of semi‐quantum communication in layered networks. All three protocols allow for simultaneous distribution of secure information in all the layers of a network, thanks to the employment of multidimensional states. These protocols are presented for a small network of at most five participants and three layers and show the robustness of the same against various eavesdropping strategies. Finally, a detailed procedure is provided for generalisations of the proposed protocols to distribute keys/secrets in any arbitrarily structured quantum network.

Abstract This paper explores the scope of services and challenges in implementing Time Bank in India. This community-based initiative allows people to exchange skills and services without the involvement of money. A qualitative study was conducted using semi-structured telephone interviews with 20 participants aged 18 to 35. Thematic analysis revealed four major themes: Services, Challenges, and Limitations of Time Bank, Factors Affecting Help-Seeking Behavior, and Community and Gender Dynamics. Participants expressed interest in offering a wide range of services, from household tasks to professional services. However, challenges and limitations were also identified, such as a lack of awareness and understanding of the concept, social stigma, and concerns about trust, privacy, and safety issues. The study underscores the need to consider cultural and social factors while implementing community-based initiatives. Despite these challenges, participants believed Time Bank could be a valuable platform for building social connections and community support. The study’s implications highlight the need for further research on the impact of Time Bank on social capital and the sustainability of the initiative in different cultural contexts.

Abstract Obesity, a global health challenge, is a major risk factor for multiple life-threatening diseases, including diabetes, fatty liver, and cancer. There is an ongoing need to identify safe and tolerable therapeutics for obesity management. Herein, we show that treatment with artesunate, an artemisinin derivative approved by the FDA for the treatment of severe malaria, effectively reduces body weight and improves metabolic profiles in preclinical models of obesity, including male mice with overnutrition-induced obesity and male cynomolgus macaques with spontaneous obesity, without inducing nausea and malaise. Artesunate promotes weight loss and reduces food intake in obese mice and cynomolgus macaques by increasing circulating levels of Growth Differentiation Factor 15 (GDF15), an appetite-regulating hormone with a brainstem-restricted receptor, the GDNF family receptor α-like (GFRAL). Mechanistically, artesunate induces the expression of GDF15 in multiple organs, especially the liver, in mice through a C/EBP homologous protein (CHOP)-directed integrated stress response. Inhibition of GDF15/GFRAL signalling by genetic ablation of GFRAL or tissue-specific knockdown of GDF15 abrogates the anti-obesity effect of artesunate in mice with diet-induced obesity, suggesting that artesunate controls bodyweight and appetite in a GDF15/GFRAL signalling-dependent manner. These data highlight the therapeutic benefits of artesunate in the treatment of obesity and related comorbidities.

Abstract Renal proximal tubule epithelial cells have considerable intrinsic repair capacity following injury. However, a fraction of injured proximal tubule cells fails to undergo normal repair and assumes a proinflammatory and profibrotic phenotype that may promote fibrosis and chronic kidney disease. The healthy to failed repair change is marked by cell state-specific transcriptomic and epigenomic changes. Single nucleus joint RNA- and ATAC-seq sequencing offers an opportunity to study the gene regulatory networks underpinning these changes in order to identify key regulatory drivers. We develop a regularized regression approach to construct genome-wide parametric gene regulatory networks using multiomic datasets. We generate a single nucleus multiomic dataset from seven adult human kidney samples and apply our method to study drivers of a failed injury response associated with kidney disease. We demonstrate that our approach is a highly effective tool for predicting key cis- and trans-regulatory elements underpinning the healthy to failed repair transition and use it to identify NFAT5 as a driver of the maladaptive proximal tubule state.

Introduction Hepatic artery complications (HACs), such as a thrombosis or stenosis, are serious causes of morbidity and mortality after paediatric liver transplantation (LT). This study will investigate the incidence, current management practices and outcomes in paediatric patients with HAC after LT, including early and late complications.Methods and analysis The HEPatic Artery stenosis and Thrombosis after liver transplantation In Children (HEPATIC) Registry is an international, retrospective, multicentre, observational study. Any paediatric patient diagnosed with HAC and treated for HAC (at age

Amongst the range of bioprinting technologies currently available, bioprinting by material extrusion is gaining increasing popularity due to accessibility, low cost, and the absence of energy sources, such as lasers, which may significantly damage the cells. New applications of extrusion-based bioprinting are systematically emerging in the biomedical field in relation to tissue and organ fabrication. Extrusion-based bioprinting presents a series of specific challenges in relation to achievable resolutions, accuracy and speed. Resolution and accuracy in particular are of paramount importance for the realization of microstructures (for example, vascularization) within tissues and organs. Another major theme of research is cell survival and functional preservation, as extruded bioinks have cells subjected to considerable shear stresses as they travel through the extrusion apparatus. Here, an overview of the main available extrusion-based printing technologies and related families of bioprinting materials (bioinks) is provided. The main challenges related to achieving resolution and accuracy whilst assuring cell viability and function are discussed in relation to specific application contexts in the field of tissue and organ fabrication.

Chitin is an abundant biopolymer and pathogen-associated molecular pattern that stimulates a host innate immune response. Mammals express chitin-binding and chitin-degrading proteins to remove chitin from the body. One of these proteins, Acidic Mammalian Chitinase (AMCase), is an enzyme known for its ability to function under acidic conditions in the stomach but is also active in tissues with more neutral pHs, such as the lung. Here, we used a combination of biochemical, structural, and computational modeling approaches to examine how the mouse homolog (mAMCase) can act in both acidic and neutral environments. We measured kinetic properties of mAMCase activity across a broad pH range, quantifying its unusual dual activity optima at pH 2 and 7. We also solved high-resolution crystal structures of mAMCase in complex with oligomeric GlcNAcn, the building block of chitin, where we identified extensive conformational ligand heterogeneity. Leveraging these data, we conducted molecular dynamics simulations that suggest how a key catalytic residue could be protonated via distinct mechanisms in each of the two environmental pH ranges. These results integrate structural, biochemical, and computational approaches to deliver a more complete understanding of the catalytic mechanism governing mAMCase activity at different pH. Engineering proteins with tunable pH optima may provide new opportunities to develop improved enzyme variants, including AMCase, for therapeutic purposes in chitin degradation.

Abstract Breakdown of the neurovascular unit is associated with blood-brain barrier (BBB) leakiness contributing to cognitive decline and disease pathology in the early stages of Alzheimer’s disease (AD). Vascular stability depends on angiopoietin-1 (ANGPT-1) signalling, antagonised by angiopoietin-2 (ANGPT-2) expressed upon endothelial injury. We examined the relationship between CSF ANGPT-2 and CSF markers of BBB leakiness and core AD biomarkers across three independent cohorts: (i) 31 AD patients and 33 healthy controls grouped according to their biomarker profile (i.e., AD cases t-tau > 400 pg/mL, p-tau > 60 pg/mL and Aβ42