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Purpose: The Audiovisual-Assisted Therapeutic Ambience in Radiotherapy (AVATAR) trial was a prospective multicenter study (NCT03991156) examining the combination of video immersion with radiation therapy and was successfully conducted through the collaboration of pediatric radiation oncology teams at 10 institutions independent of any pre-existing consortium. We sought to analyze and report the methodology of trial conception and development, process map, and cost. Methods and Materials: The study enrolled patients aged 3 to 10 years preparing to undergo radiation therapy, integrated the combination of AVATAR-based video immersion with radiation therapy at each institution, and offered AVATAR use as an alternative to anesthesia, with rates of anesthesia use and outcomes of serial standardized anxiety and quality-of-life assessments assessed among the 81 children enrolled. A process map was created based on the trial timeline with the following components: study development time (time from conception of the trial to the accrual of the first patient, including design phase, agreement and approval phase, and site preparation phase), and accrual duration time (time from the first to last accrual). Costs and institutional success rates were calculated. Results: Time from inception of study to last accrual was 3.6 years (1313 days). The study development time was 417 days (31.7%), and accrual duration time was 896 days (68.3%), with the final 50% of accrual occurring in

Reconstructing the evolutionary origins of Mycobacterium tuberculosis, the causative agent of human tuberculosis, has helped identify bacterial factors that have led to the tubercle bacillus becoming such a formidable human pathogen. Here we report the discovery and detailed characterization of an exceedingly slow growing mycobacterium that is closely related to M. tuberculosis for which we have proposed the species name Mycobacterium spongiae sp. nov., (strain ID: FSD4b-SM). The bacterium was isolated from a marine sponge, taken from the waters of the Great Barrier Reef in Queensland, Australia. Comparative genomics revealed that, after the opportunistic human pathogen Mycobacterium decipiens, M. spongiae is the most closely related species to the M. tuberculosis complex reported to date, with 80% shared average nucleotide identity and extensive conservation of key M. tuberculosis virulence factors, including intact ESX secretion systems and associated effectors. Proteomic and lipidomic analyses showed that these conserved systems are functional in FSD4b-SM, but that it also produces cell wall lipids not previously reported in mycobacteria. We investigated the virulence potential of FSD4b-SM in mice and found that, while the bacteria persist in lungs for 56 days after intranasal infection, no overt pathology was detected. The similarities with M. tuberculosis, together with its lack of virulence, motivated us to investigate the potential of FSD4b-SM as a vaccine strain and as a genetic donor of the ESX-1 genetic locus to improve BCG immunogenicity. However, neither of these approaches resulted in superior protection against M. tuberculosis challenge compared to BCG vaccination alone. The discovery of M. spongiae adds to our understanding of the emergence of the M. tuberculosis complex and it will be another useful resource to refine our understanding of the factors that shaped the evolution and pathogenesis of M. tuberculosis.

Abstract The unique properties of solid acid electrolytes, in particular CsH2PO4, are in many ways ideal for fuel cell operation. However, the technology is constrained by high cathode overpotentials. Here a simplified cathode geometry is employed to obtain the fundamental electrochemical parameters (exchange current density and charge transfer coefficient) describing the oxygen reduction reaction (ORR) at the CsH2PO4‐Pt‐gas interface. The parameters are incorporated into a 1D model of the voltage–current characteristics of realistic SAFC cathodes, which reproduced the measured polarization behavior of such cathodes without recourse to fitting adjustable parameters. Following this validation, the model is utilized to evaluate the impact of changes to cathode properties, microstructure, and operating conditions. Of these, the charge transfer coefficient, measured to have a value of ≈0.6 for ORR on Pt in the SAFC cathode environment, is found to have the greatest impact on power output. Nevertheless, even without material modifications, a combination of microstructural and operational modifications are identified with projected performance metrics meeting Department of Energy targets (0.8 V at 300 mA cm−2, and peak power density of 1 W cm−2), albeit at high Pt loadings. However, the analysis indicates that truly meaningful advances will likely necessitate the discovery of alternative ORR catalysts.

Abstract Hundreds of studies have explored student evolution acceptance because evolution is a core concept of biology that many undergraduate biology students struggle to accept. However, this construct of “evolution acceptance” has been defined and measured in various ways, which has led to inconsistencies across studies and difficulties in comparing results from different studies. Many studies and essays have offered evaluations and perspectives of evolution acceptance instruments, but publications with a focus on consensus building across research teams is still needed. Further, little attention has been paid to how evolution acceptance instruments may be interpreted differently by students with varied religious backgrounds. Funded by a Research Coordination Network in Undergraduate Biology Education grant from the National Science Foundation, we gathered 16 experts from different disciplinary and religious backgrounds to review current evolution acceptance instruments and create a guide to the strengths and weaknesses of these instruments, including appropriate contexts for using these instruments and their potential weaknesses with different religious populations. Finally, in an attempt to move the field forward, we articulated a consensus definition of evolution acceptance that can be used to guide future instrument development.

Background: In 2021, South Africa introduced a new 6-month internship in family medicine and primary care. This study aimed to assess the new rotation at district health facilities in the Western Cape. Methods: A descriptive survey of interns and supervisors, as phase-two of an exploratory sequential mixed methods study. Questionnaires were developed from a descriptive exploratory qualitative study. Data were analysed with the Statistical Package for Social Sciences. Results: Questionnaires were completed by 72 interns (response rate 21%) and 36 supervisors (response rate 90%), across 10 training programmes. Interns felt more independent (97.2%), confident (90.3%) and resilient (91.6%). They learnt to manage undifferentiated and chronic conditions (91.6%), to refer patients (94.3%) and conduct procedures (77.8%). Most interns were not exposed to community-based services (68.0%) and continuity of care (54.1%). Supervision was mostly adequate during the day (79.1%) and afterhours (80.6%). Many interns reported no structured teaching programme (41.7% – 55.6%). Most supervision was from medical officers and registrars. Supervisors saw interns as valuable members of the clinical team (100.0%), who required extra support and administration (42.5%). The majority of interns (75.0%) and supervisors (72.7%) thought the rotation was the right length and the best preparation for community service (67.6%). Conclusion: The rotation met most expectations of the Health Professions Council of South Africa. Programmes need to improve exposure to community-orientated primary care, public health medicine, palliative and ongoing care. Supervision and orientation of interns needs improvement. Contribution: This is the first evaluation of the new family medicine internship programme in South Africa.

Background: Learning portfolios (LPs) provide evidence of workplace-based assessments (WPBAs) in clinical settings. The educational impact of LPs has been explored in high-income countries, but the use of portfolios and the types of assessments used for and of learning have not been adequately researched in sub-Saharan Africa. This study investigated the evidence of learning in registrars’ LPs and the influence of the training district and year of training on assessments. Methods: A cross-sectional study evaluated 18 Family Medicine registrars’ portfolios from study years 1–3 across five decentralised training sites affiliated with the University of the Witwatersrand. Descriptive statistics were calculated for the portfolio and quarterly assessment (QA) scores and self-reported clinical skills competence levels. The competence levels obtained from the portfolios and university records served as proxy measures for registrars’ knowledge and skills. Results: The total LP median scores ranged from 59.9 to 81.0, and QAs median scores from 61.4 to 67.3 across training years. The total LP median scores ranged from 62.1 to 83.5 and 62.0 to 67.5, respectively in QAs across training districts. Registrars’ competence levels across skill sets did not meet the required standards. Higher skills competence levels were reported in the women’s health, child health, emergency care, clinical administration and teaching and learning domains. Conclusion: The training district and training year influence workplace-based assessment (WPBA) effectiveness. Ongoing faculty development and registrar support are essential for WPBA. Contribution: This study contributes to the ongoing discussion of how to utilise WPBA in resource-constrained sub-Saharan settings.

Healthcare practitioners are regularly faced with treating patients at the end of their life, and this can be very daunting. This article hopes to help the practitioner have an approach to managing end-of-life care that makes it less distressing. The symptoms at the end-of-life include delirium and/or agitation, breathing changes, skin changes, sleeping more, decrease in need for food and drink, incontinence, and increased secretions. These symptoms are discussed and practical ways of management are given. The article further discusses how to approach the difficult conversation with the family and gives guidance as to what needs to be discussed. A number of tips are discussed on how to prepare the family to handle a death at home. It is essential to look at coping mechanisms and selfcare for practitioners dealing with end-of-life care as the death of a patient not only affects the family but also the practitioner.

Summary: Childhood, adolescent, and young adult (CAYA) cancer survivors are at risk of pulmonary dysfunction. Current follow-up care guidelines are discordant. Therefore, the International Late Effects of Childhood Cancer Guideline Harmonization Group established and convened a panel of 33 experts to develop evidence-based surveillance guidelines. We critically reviewed available evidence regarding risk factors for pulmonary dysfunction, types of pulmonary function testing, and timings of surveillance, then we formulated our recommendations. We recommend that CAYA cancer survivors and healthcare providers are aware of reduced pulmonary function risks and pay vigilant attention to potential symptoms of pulmonary dysfunction, especially among survivors treated with allogeneic haematopoietic stem cell transplantation, thoracic radiotherapy, and thoracic surgery. Based on existing limited evidence and current lack of interventions, our panel recommends pulmonary function testing only for symptomatic survivors. Since scarce existing evidence informs our recommendation, we highlight the need for prospective collaborative studies to address pulmonary function knowledge gaps among CAYA cancer survivors.

Abstract Microgravity-induced bone loss results in a 1% bone mineral density loss monthly and can be a mission critical factor in long-duration spaceflight. Biomolecular therapies with dual osteogenic and anti-resorptive functions are promising for treating extreme osteoporosis. We previously confirmed that NELL-like molecule-1 (NELL-1) is crucial for bone density maintenance. We further PEGylated NELL-1 (NELL-polyethylene glycol, or NELL-PEG) to increase systemic delivery half-life from 5.5 to 15.5 h. In this study, we used a bio-inert bisphosphonate (BP) moiety to chemically engineer NELL-PEG into BP-NELL-PEG and specifically target bone tissues. We found conjugation with BP improved hydroxyapatite (HA) binding and protein stability of NELL-PEG while preserving NELL-1’s osteogenicity in vitro. Furthermore, BP-NELL-PEG showed superior in vivo bone specificity without observable pathology in liver, spleen, lungs, brain, heart, muscles, or ovaries of mice. Finally, we tested BP-NELL-PEG through spaceflight exposure onboard the International Space Station (ISS) at maximal animal capacity (n = 40) in a long-term (9 week) osteoporosis therapeutic study and found that BP-NELL-PEG significantly increased bone formation in flight and ground control mice without obvious adverse health effects. Our results highlight BP-NELL-PEG as a promising therapeutic to mitigate extreme bone loss from long-duration microgravity exposure and musculoskeletal degeneration on Earth, especially when resistance training is not possible due to incapacity (e.g., bone fracture, stroke).

Abstract Introduction Treatments for type 2 diabetes vary widely in their complexity. The simplicity or complexity of a treatment regimen may have an impact on patient preference, treatment adherence, and health outcomes. The purpose of this qualitative study was to develop two draft patient-reported outcome instruments focusing on patients’ experience with simplicity and complexity of treatment for type 2 diabetes. Methods The instruments were developed in a series of steps: gather information to support development of a concept elicitation interview guide (literature review and expert interviews), concept elicitation interviews with patients (N = 30), cognitive interviews with patients (N = 20), and a translatability assessment. Results In concept elicitation interviews, patients with type 2 diabetes reported a range of treatment attributes that influence their perceptions of treatment simplicity and complexity, such as injection devices, medication preparation, dose timing, dose frequency, ease of taking the correct dose, flexibility of dose schedule, remembering to take medication, and food requirements. Two draft questionnaires were developed based on the literature review, expert interviews, and concept elicitation interviews with patients. Revisions were made to these draft instruments based on qualitative interviews with patients and translatability assessment. Discussion The qualitative research conducted in this study supports the content validity of two newly developed instruments, the Simplicity of Diabetes Treatment Questionnaire (Sim-Q) and the Simplicity of Diabetes Treatment Questionnaire-Comparison (Sim-Q-Comp), designed to assess the simplicity and complexity of diabetes treatment from the patient’s perspective.

The plethora of genome sequences produced in the postgenomic age has not resolved many of our most pressing biological questions. Correlating gene expression with an interrogatable and easily observable characteristic such as the surrogate phenotype conferred by a reporter gene is a valuable approach to gaining insight into gene function. Many reporters including lacZ, amdS, and the fluorescent proteins mRuby3 and mNeonGreen have been used across all manners of organisms. Described here is an investigation into the creation of a robust, synthetic, fusion reporter system for Cryptococcus neoformans that combines some of the most useful fluorophores available in this system with the versatility of the counter-selectable nature of amdS. The reporters generated include multiple composition and orientation variants, all of which were investigated for differences in expression. Evaluation of known promoters from the TEF1 and GAL7 genes was undertaken, elucidating novel expression tendencies of these biologically relevant C. neoformans regulators of transcription. Smaller than lacZ but providing multiple useful surrogate phenotypes for interrogation, the fusion ORF serves as a superior whole-cell assay compared to traditional systems. Ultimately, the work described here bolsters the array of relevant genetic tools that may be employed in furthering manipulation and understanding of the WHO fungal priority group pathogen C. neoformans.

Abstract Objective Rare genetic diseases of obesity typically present with hyperphagia, a pathologic desire to consume food. Cost‐utility models assessing the value of treatments for these rare diseases will require health state utilities representing hyperphagia. This study estimated utilities associated with various hyperphagia severity levels. Methods Four health state vignettes were developed using published literature and clinician input to represent various severity levels of hyperphagia. Utilities were estimated for these health states in a time trade‐off elicitation study in a UK general population sample. Results In total, 215 participants completed interviews (39.5% male; mean age 39.1 years). Mean (SD) utilities were 0.98 (0.02) for no hyperphagia, 0.91 (0.10) for mild hyperphagia, 0.70 (0.30) for moderate hyperphagia, and 0.22 (0.59) for severe hyperphagia. Mean (SD) disutilities were −0.08 (0.10) for mild, −0.28 (0.30) for moderate, and −0.77 (0.58) for severe hyperphagia. Conclusions These data show increasing severity of hyperphagia is associated with decreased utility. Utilities associated with severe hyperphagia are similar to those of other health conditions severely impacting quality of life (QoL). These findings highlight that treatments addressing substantial QoL impacts of severe hyperphagia are needed. Utilities estimated here may be useful in cost‐utility models of treatments for rare genetic diseases of obesity.

Background: Palliative care (PC) is a priority in South Africa, focussing on integrating PC into primary health care. Few examples exist showing how this is done. In 2018, a rural PC project was implemented, which subsequently evolved into an integrated service between the hospital and the community. Aim: The aim was to review the PC project over 4 years. Setting: The setting was the George subdistrict of the Garden Route district in South Africa. Community-based services were offered to all patients with PC needs by three non-governmental organisations who deliver home community-based care via community health workers. They were supplemented by primary health care clinics, an intermediate care facility and two hospitals. Methods: This was a retrospective descriptive study. Inpatient ward round data and patient referrals between 2018 and 2022 were analysed using descriptive statistics. Variables included patient demographics, diagnosis, home visits and place of death. Results: A total of 819 patients were referred. Inpatients were reviewed on weekly ward rounds by a multidisciplinary team. The most common diagnosis was cancer (57%). Home visits enabled patient follow-ups, of which 152 were recorded. Conclusion: The programme has become sustainable and integrated in the public healthcare system. Contributing factors included dedicated staff, using simple tools and continuous training. The findings may be useful to PC programmes in similar contexts elsewhere. Contribution: This work adds new knowledge to the field of PC in an underresourced rural healthcare environment in sub-Saharan Africa, by describing how system-wide integration of a new service was navigated to become sustainable.

Background: Workplace-based learning (WBL) provides authentic learning opportunities to develop fit-for-practice healthcare workers. Different types of WBL opportunities have been described in high-income countries, but the opportunities in the district health systems of sub-Saharan Africa have not been characterised. Aim: This study explored family physicians’ (FPs) and registrars’ perceptions of WBL opportunities in a decentralised postgraduate family medicine registrar training programme. Setting: The study was conducted at five decentralised training sites across two provinces affiliated with the University of the Witwatersrand in South Africa. Methods: This instrumental case study involved semi-structured qualitative interviews with 11 FPs and 11 registrars purposively sampled across the training sites. The verbatim transcripts were thematically analysed using Braun and Clark’s six-step approach. Results: Workplace-based learning opportunities were grouped into four themes: Learning from interpersonal interactions, learning from district activities, self-directed learning and contextual influences on learning opportunities. Registrars learnt from patients, peers, FPs and other professionals. Feedback, self-reflection, portfolio use, involvement in various district events, such as student and staff teaching, and continuous medical education augmented learning. Contextual influences originated from health facilities, resource availability, district management and university support, excessive workload and a need for standardised district learning opportunities. Conclusion: Registrars are exposed to several types of WBL opportunities in district health systems. Effective engagement with available opportunities and addressing contextual challenges could enhance registrar learning. Contribution: Maximising learning opportunities to promote registrars’ acquisition of required skills and competencies to efficiently address community needs in a middle-income country such as South Africa.

Plain English summary This study focused on the ACTIV-2 COVID-19 Symptom Diary (ACSD), a questionnaire that assesses symptom severity of COVID-19. The ACSD begins with global items assessing overall symptom severity, followed by a symptom checklist focusing on individual symptoms. Interviews were conducted with 30 adults who had tested positive for COVID-19. The patients reported their experiences with COVID-19, completed the ACSD, and provided their opinions about the ACSD. Based on input from these patients, the ACSD appears to be clear and easy to complete, and it includes the most common and important symptoms of COVID-19. The ACSD was edited for clarity, and “brain fog” and dizziness were recommended additions for future research. This study suggests that the ACSD is a useful questionnaire for assessment of COVID-19 symptoms in clinical studies. Studies like this are important for ensuring that symptoms are measured appropriately and accurately in clinical trials. Future research with larger samples will be needed to further examine the questionnaire.

Abstract Field trips are steadily declining due to limited funding, time constraints, safety concerns, and other logistical issues. Many schools are resorting to a virtual field trip (VFT), especially when education is disrupted due to public health concerns, natural disasters, or other unforeseen significant events. Virtual reality as a common form of VFT is likely not an option for many schools due to cost and other barriers. The purpose of our study was to explore the potential of going in a VFT using 360-degree (360°) videos as an alternative to a physical field trip in primary education. We recruited third-grade pupils (aged 8–9) from two private elementary schools to experience VFTs using 360° videos (360V) and regular videos (REGV). Using a switching-replications experimental design, we compared their content recall (assessment tests) and VFT experience (attitude, perceived usefulness, involvement, inquiry, video engagement, and virtual guide) across four-time points. Our results show that the increase in content recall scores of 360V groups after VFTs was consistently higher compared to REGV groups at all time points, although it was only significant in one quarter. We also found pupils’ video engagement, involvement, and attitude as significant factors in their VFT experience. These results call attention to a possible implementation of VFTs and continue the long-standing tradition that has been acknowledged as a student-centered, interactive instructional method.

Abstract Novel treatments for muscle wasting are of significant value to patients with disease states that result in muscle weakness, injury recovery after immobilization and bed rest, and for astronauts participating in long-duration spaceflight. We utilized an anti-myostatin peptibody to evaluate how myostatin signaling contributes to muscle loss in hindlimb suspension. Male C57BL/6 mice were left non-suspended (NS) or were hindlimb suspended (HS) for 14 days and treated with a placebo vehicle (P) or anti-myostatin peptibody (D). Hindlimb suspension (HS-P) resulted in rapid and significantly decreased body mass (−5.6% by day 13) with hindlimb skeletal muscle mass losses between −11.2% and −22.5% and treatment with myostatin inhibitor (HS-D) partially attenuated these losses. Myostatin inhibition increased hindlimb strength with no effect on soleus tetanic strength. Soleus mass and fiber CSA were reduced with suspension and did not increase with myostatin inhibition. In contrast, the gastrocnemius showed histological evidence of wasting with suspension that was partially mitigated with myostatin inhibition. While expression of genes related to protein degradation (Atrogin-1 and Murf-1) in the tibialis anterior increased with suspension, these atrogenes were not significantly reduced by myostatin inhibition despite a modest activation of the Akt/mTOR pathway. Taken together, these findings suggest that myostatin is important in hindlimb suspension but also motivates the study of other factors that contribute to disuse muscle wasting. Myostatin inhibition benefitted skeletal muscle size and function, which suggests therapeutic potential for both spaceflight and terrestrial applications.

Several bumble bee species (Bombus Latreille) are declining and efforts to conserve populations will be strengthened by an improved knowledge of their geographic distribution. Knowledge gaps exist, however, especially in central portions of North America. Here we report 29 species of bumble bees from South Dakota in the north-central USA, based on 130 years of records from 1891 to 2021. Specimens or observations were available for >90% of the 66 counties, though they were not distributed evenly as most records came from Pennington, Lawrence, Custer, Brookings, and Day Counties. The five most commonly collected or reported bumble bee species were B. griseocollis (54 counties), B. pensylvanicus (41 counties), B. fervidus (39 counties), B. huntii (27 counties), and B. bimaculatus (25 counties). Twenty species were recorded from 10 or fewer counties. Despite differences in occurrence, 66% of the Bombus species in South Dakota were collected or observed since 2020, including six of the nine species of conservation concern (B. fraternus, B. pensylvanicus, B. fervidus, B. occidentalis, B. terricola, and B. morrisoni). However, the critically endangered B. affinis, B. variabilis, and B. suckleyi have not been collected or observed for over 50 years. While this checklist is the first for South Dakota bumble bees in nearly 100 years, data are still lacking as ~55% of counties had fewer than five species reported. We suggest future efforts should focus on these under-sampled areas to fill in baseline knowledge of the wild bee fauna towards completing a more holistic view of bumble bee distributions across the Great Plains.

A new long-legged fly species, Chrysotus soya sp. nov. (Diptera: Dolichopodidae), is described and illustrated from specimens collected in soybean fields near Brookings, South Dakota, USA. The abundance of this species in soybeans suggests it plays an important role as a beneficial predator.

It is unclear why hemorrhagic myocardial infarctions (hMI) are destined for adverse outcomes. Here, the authors show that hMI drives fatty degeneration of infarct territories and contributes to adverse remodeling of the heart, which can be mitigated via timely depletion of iron within the hMI zone.

Phosphorus (P) limitation is pervasive in tropical forests. Here the authors analyse the dependence of photosynthesis on leaf N and P in tropical forests, and show that incorporating leaf P constraints in a terrestrial biosphere model enhances its predictive power.

Background: Family planning (FP) is a key component of primary health care (PHC). Nurses are the first source of FP information to women outside their social context. There is a paucity of research regarding clients’ lived experiences of FP, particularly understanding both the client’s and the healthcare worker’s experiences in the same clinical context and community. Aim: This study aims to explore the lived experiences of nurses and female clients regarding FP services at PHC clinics. Setting: Two PHC clinics in a rural sub-district in South Africa. Methods: A descriptive qualitative study using semi-structured interviews was conducted. Clients and nurses were selected using criterion-based purposive sampling and interviewed by female research assistants in a home language in a private setting. Transcription and translation of audio recordings were done. Data were analysed inductively using the framework method. Results: Ten clients and eight nurses were interviewed, with an equal number from each clinic. The median age of clients was 28.5 years and of nurses was 47.5 years. Four themes emerged: (1) Stigma, culture and the teenage girl; (2) Bad effects – the Big Five, clustered around weight changes, blood blockages and abnormal bleeding, pain, fertility and cancer; (3) FP social dynamics; and (4) FP and the health system. Conclusion: Family planning is highly moralised and stigmatised. Negative effects of FP were not adequately recognised by the health system. Family planning outreach into the community and dedicated FP resources at clinics were suggestions to improve the service. Contribution: This work helps to better understand patients’ experiences of family planning services.

IntroductionIn dryland systems, biological soil crusts (biocrusts) can occupy large areas of plant interspaces, where they fix carbon following rain. Although distinct biocrust types contain different dominant photoautotrophs, few studies to date have documented carbon exchange over time from various biocrust types. This is especially true for gypsum soils. Our objective was to assess the carbon exchange of biocrust types established at the world’s largest gypsum dune field at White Sands National Park.MethodsWe sampled five different biocrust types from a sand sheet location in three different years and seasons (summer 2020, fall 2021, and winter 2022) for carbon exchange measurements in controlled lab conditions. Biocrusts were rehydrated to full saturation and light incubated for 30 min, 2, 6, 12, 24, and 36 h. Samples were then subject to a 12-point light regime with a LI-6400XT photosynthesis system to determine carbon exchange.ResultsBiocrust carbon exchange values differed by biocrust type, by incubation time since wetting, and by date of field sampling. Lichens and mosses had higher gross and net carbon fixation rates than dark and light cyanobacterial crusts. High respiration rates were found after 0.5 h and 2 h incubation times as communities recovered from desiccation, leveling off after 6 h incubation. Net carbon fixation of all types increased with longer incubation time, primarily as a result of decreasing respiration, which suggests rapid recovery of biocrust photosynthesis across types. However, net carbon fixation rates varied from year to year, likely as a product of time since the last rain event and environmental conditions preceding collection, with moss crusts being most sensitive to environmental stress at our study sites.DiscussionGiven the complexity of patterns discovered in our study, it is especially important to consider a multitude of factors when comparing biocrust carbon exchange rates across studies. Understanding the dynamics of biocrust carbon fixation in distinct crust types will enable greater precision of carbon cycling models and improved forecasting of impacts of global climate change on dryland carbon cycling and ecosystem functioning.

Summary: Tissue boundaries and interfaces are engines of morphogenesis in vivo. However, despite a wealth of micropatterning approaches available to control tissue size, shape, and mechanical environment in vitro, fine-scale spatial control of cell positioning within tissue constructs remains an engineering challenge. To address this, we augment DNA “velcro” technology for selective patterning of ssDNA-labeled cells on mechanically defined photoactive polyacrylamide hydrogels. Hydrogels bearing photopatterned single-stranded DNA (ssDNA) features for cell capture are then co-functionalized with extracellular matrix (ECM) proteins to support subsequent adhesion of patterned tissues. ECM protein co-functionalization does not alter ssDNA pattern fidelity, cell capture, or hydrogel elastic stiffness. This approach enables mechanobiology studies and measurements of signaling activity at dynamic cell interfaces with precise initial patterning. Combining DNA velcro patterning and ECM functionalization provides independent control of initial cell placement, adhesion, and mechanics, constituting a new tool for studying biological interfaces and for programming multicellular interactions in engineered tissues.

Background Interferon (IFN)-β induction via activation of the stimulator of interferon genes (STING) pathway has shown promising results in tumor models. STING is activated by cyclic dinucleotides such as cyclic GMP–AMP dinucleotides with phosphodiester linkages 2′–5′ and 3′–5′ (cGAMPs), that are produced by cyclic GMP–AMP synthetase (cGAS). However, delivery of STING pathway agonists to the tumor site is a challenge. Bacterial vaccine strains have the ability to specifically colonize hypoxic tumor tissues and could therefore be modified to overcome this challenge. Combining high STING-mediated IFN-β levels with the immunostimulatory properties of Salmonella typhimurium could have potential to overcome the immune suppressive tumor microenvironment.Methods We have engineered S. typhimurium to produce cGAMP by expression of cGAS. The ability of cGAMP to induce IFN-β and its IFN-stimulating genes was addressed in infection assays of THP-I macrophages and human primary dendritic cells (DCs). Expression of catalytically inactive cGAS is used as a control. DC maturation and cytotoxic T-cell cytokine and cytotoxicity assays were conducted to assess the potential antitumor response in vitro. Finally, by making use of different S. typhimurium type III secretion (T3S) mutants, the mode of cGAMP transport was elucidated.Results Expression of cGAS in S. typhimurium results in a 87-fold stronger IFN-β response in THP-I macrophages. This effect was mediated by cGAMP production and is STING dependent. Interestingly, the needle-like structure of the T3S system was necessary for IFN-β induction in epithelial cells. DC activation included upregulation of maturation markers and induction of type I IFN response. Coculture of challenged DCs with cytotoxic T cells revealed an improved cGAMP-mediated IFN-γ response. In addition, coculture of cytotoxic T cells with challenged DCs led to improved immune-mediated tumor B-cell killing.Conclusion S. typhimurium can be engineered to produce cGAMPs that activate the STING pathway in vitro. Furthermore, they enhanced the cytotoxic T-cell response by improving IFN-γ release and tumor cell killing. Thus, the immune response triggered by S. typhimurium can be enhanced by ectopic cGAS expression. These data show the potential of S. typhimurium–cGAS in vitro and provides rationale for further research in vivo.

Abstract Purpose Various parameters of mechanical dyssynchrony have been proposed to improve patient selection criteria for cardiac resynchronization therapy, but sensitivity and specificity are lacking. However, echocardiographic parameters are consistently investigated at rest, whereas heart failure (HF) symptoms predominately manifest during submaximal exertion. Although strain-based predictors of response are promising, feasibility and reproducibility during exercise has yet to be demonstrated. Methods Speckle-tracking echocardiography was performed in patients with HF at two separate visits. Echocardiography was performed at rest, during various exercise intensity levels, and during recovery from exercise. Systolic rebound stretch of the septum (SRSsept), systolic shortening, and septal discoordination index (SDI) were calculated. Results Echocardiography was feasible in about 70–80% of all examinations performed during exercise. Of these acquired views, 84% of the cine-loops were suitable for analysis of strain-based mechanical dyssynchrony. Test–retest variability and intra- and inter-operator reproducibility at 30% and 60% of the ventilatory threshold (VT) were about 2.5%. SDI improved in the majority of patients at 30% and 60% of the VT, with moderate to good agreement between both intensity levels. Conclusion Although various challenges remain, exercise echocardiography with strain analysis appears to be feasible in the majority of patients with dyssynchronous heart failure. Inter- and intra-observer agreement of SRSsept and SDI up to 60% of the VT were comparable to resting values. During exercise, the extent of SDI was variable, suggesting a heterogeneous response to exercise. Further research is warranted to establish its clinical significance.

Workplace-based assessment (WPBA) is becoming part of high-stake assessments in specialist training. Entrustable professional activities (EPAs) are a recent addition to WPBA. This is the first South African publication on developing EPAs for postgraduate family medicine training. An EPA is a unit of practice, observable in the workplace, constituting several tasks with underlying knowledge, skills and professional behaviours. Entrustable professional activities allow for entrustable decisions regarding competence in a described work context. A national workgroup representing all nine postgraduate training programmes in South Africa has developed 19 EPAs. This new concept needs change management to understand the theory and practice of EPAs. Family medicine departments with large clinical workloads are small, necessitating navigating logistical issues to develop EPAs. It has unmasked existing workplace learning and assessment challenges. Contribution: This article contributes new thinking to developing EPAs for family medicine in an effort to understand more authentic WPBA nationally.

Background: A major disparity exists in access to specialised healthcare between rural and urban areas. Specialist outreach programmes are one of the ways in which rural specialist healthcare inequality is being addressed. A number of rural district hospitals (RDH) employ local, private specialists (LPS) to supplement public specialist outreach. Limited research exists on private specialist outreach and support (PSOS) in sub-Saharan Africa or South Africa. Methods: This was a descriptive, exploratory, qualitative study using thematic analysis of semi-structured interviews. Non-probability, purposive sampling was used to obtain a sample size of 16 participants. The audio recordings were transcribed verbatim and analysed with the framework method and ATLAS.ti version 8© software. Results: Four major themes emerged, namely roles of LPS, effects, sustainability and feasibility of PSOS. Overall PSOS was considered sustainable, feasible and had positive effects in and beyond the sub-districts. The value of PSOS was supported by improved access and timeliness of services, improved competency of RDH medical practitioners, improved coordination, comprehensiveness and continuity of care. Private specialist outreach and support was, however, associated with increased burden on the RDH resources and required a basic level of RDH infrastructure to function effectively. Conclusion: The perceived contribution of private specialist outreach services was positive overall. Implementation in RDHs is feasible, but should involve consideration of factors in the hospital, town, sub-district and district prior to implementation. Contribution: This paper provides evidence that private specialist outreach and support services are feasible in the state health sector, provided that certain considerations are taken into account.

Background: Clinical training is one of the roles of family physicians (FPs) in decentralised postgraduate training. Effective training requires skilled trainers and sufficient resources. Little is known about the resources available for decentralised clinical training in district health systems in low- to middle-income countries, especially in sub-Saharan Africa. Aim: To explore FPs’ and registrars’ perceptions of the available resources in a decentralised postgraduate family medicine (FM) training programme. Setting: Five decentralised training sites affiliated with the University of the Witwatersrand across two provinces in South Africa. Methods: This qualitative study forms part of a broader project evaluating a FM registrar training programme using the logic model. Semistructured interviews were conducted with a purposive sample of 11 FPs and 11 registrars. The interviews were transcribed verbatim and analysed thematically. Results: Three themes were identified: ‘Impact of resource constraints’, ‘Family physicians’ skills and knowledge could be further improved’ and ‘Family physicians need additional support to optimise their training role’. The additional resources needed include more FPs, equipment, infrastructure and funding. Knowledge and skills of FPs were reported variable and needed further improvement. Additional support was required from peers, the district management and the university. Conclusion: Well-resourced decentralised training environments with sufficient skilled trainers and adequate resources are needed to positively influence FP training and supervision, especially in middle-income countries like South Africa. Contribution: Clinical trainers need adequate resources and support from peers, district management and the university for effective decentralised clinical training.

Background: Postgraduate supervision forms a vital component of decentralised family medicine training. While the components of effective supervisory feedback have been explored in high-income countries, how this construct is delivered in resource-constrained low- to middle-income countries has not been investigated adequately. Aim: This article evaluated supervisory feedback in family medicine registrars’ learning portfolios (LPs) as captured in their learning plans and mini-Clinical Evaluation Exercise (mini-CEX) forms and whether the training district or the year of training affected the nature of the feedback. Setting: Registrars’ LPs from 2020 across five decentralised sites affiliated with the University of the Witwatersrand in South Africa were analysed. Methods: Two modified tools were used to evaluate the quantity of the written feedback in 38 learning plans and 57 mini-CEX forms. Descriptive statistics, Fisher’s exact and Wilcoxon rank-sum tests were used for analysis. Content analysis was used to derive counts of areas of feedback. Results: Most learning plans (61.2%) did not refer to registrars’ clinical knowledge or offer an improvement strategy (86.1%). The ‘extent of supervisors’ feedback’ was rated as ‘poor’ (63.2%), with only 14.0% rated as ‘good.’ The ‘some’ and ‘no’ feedback categories in the mini-CEX competencies (p 0.001 to p = 0.014) and the ‘extent of supervisors’ feedback’ (p 0.001) were significantly associated with training district. Feedback focused less on clinical reasoning and negotiation skills. Conclusion: Supervisors should provide specific and constructive narrative feedback and an action plan to improve registrars’ future performance. Contribution: Supervisory feedback in postgraduate family medicine training needs overall improvement to develop skilled family physicians.

Background: Effective palliative care is an urgent humanitarian need, particularly in less developed countries, including South Africa (SA). People can be palliated within their communities, motivating the integration of palliative care into primary healthcare systems. While community health workers (CHWs) play a vital role in health coverage at the primary care level, literature on their roles in palliation is limited. Aim: To explore the roles of CHWs in palliative care delivery in a rural subdistrict in SA. Setting: This study was conducted in the George subdistrict of the Western Cape province, SA. Methods: A descriptive qualitative study explored the perceptions of a wide range of stakeholders (n = 39) of CHWs’ roles in palliative care. Data were collected via semistructured interviews and focus group discussions and analysed thematically. Results: Patients experienced severe biopsychosocial symptoms and needed home-based palliation. While CHWs identified and referred patients, their main responsibilities were health promotion and disease prevention. Palliation was primarily a registered nurse’s function. Community health workers were conflicted by their limited ability to deliver basic palliative care to patients. Conclusion: While there is a definite need for community-based palliative care, the optimal structure of such a service and the roles of CHWs therein are uncertain. Future research should explore the home-based palliation needs of patients in similar contexts and the service design best suited to address these needs within the primary healthcare domain. Contribution: This study illustrates the influence of individual and system-related factors on CHWs’ roles in palliative care. It can inform service design to optimise CHWs’ contribution to palliation within primary health care.

The actinorhizal plant, Coriaria myrtifolia, is a neurotoxic plant species endemic to the western Mediterranean area, which forms a nitrogen-fixing symbiosis with members of Frankia cluster 2. Contrarily to other Frankia clusters, the occurrence and mode of dispersal for infective cluster 2 units outside of the host plant rhizosphere remains controversial. The present study was designed to investigate the structure of the microbiomes of C. myrtifolia phytosphere, rhizosphere, and soil samples extending outward linearly up to 1 km. Results showed that the epiphyte and endophyte communities were not significantly different from each other for most of the plant tissues. The communities associated with the below-ground tissues (nodule and root) were significantly different from those found on the above-ground tissues (fruit, leaves, and stems) and had a higher community richness. Coriaria myrtifolia phytomicrobiomes were dominated by Cyanobacteria for leaf, stem, and fruit while Actinobacteria and Proteobacteria were dominant in the root and nodule organelles. The nodule, a special niche for nitrogen fixation, was mainly inhabited by Frankia but contained several non-Frankia bacteria. Beside Frankia cluster 2, the presence of clusters 1, 4, and large numbers of cluster 3 strains have been detected in nodules, roots, and rhizospheres of C. myrtifolia. Despite Frankia being found in all plots using plant trapping bioassays with C. myrtifolia seedlings, Frankia cluster 2 was not detected in soil metagenomes showing the limits of detection by this approach. This result also suggests that in the absence of appropriate host plant species, Frankia cluster 2 has a reduced number of infective units present in the soil outward from the rhizosphere.

Purpose The International Consortium for Pooled Studies on Subsequent Malignancies after Childhood and Adolescent Cancer was established in 2018 to address gaps in knowledge of risk and risk factors for breast cancer subsequent to childhood/adolescent cancer by pooling individual patient data from seven cohorts. Initially, the pooled cohort will focus on three clinically relevant questions regarding treatment-related subsequent breast cancer risk in female survivors, which are the risk related to low-dose radiotherapy exposure to the chest, specific chemotherapy agents and attained age.Participants The consortium database includes pooled data on 21 892 female survivors from seven cohorts in North America and Europe with a primary cancer diagnosis at

African American (AA) men have increased risk of prostate cancer diagnosis and mortality, but the cause remains unknown. MRI fusion improves diagnosis of localized prostate cancer, particularly in anterior lesions; however, cost and access are limited in a community practice setting. By utilizing a diverse cohort of veterans with equal access to care in a single payer system, we describe prostate cancer detection. We queried a prospectively maintained institutional review board-approved database of men undergoing prostate biopsy for untreated prostate cancer. We included all consecutive patients from October 2017 to February 2020. Statistical analysis including Kaplan–Meier Curves, Fisher’s exact test, and Forest plot was performed. From 246 consecutive patients, 166 were AA and 80 were non-AA. There were similar distributions of PSA, PSAD, and number of targetable lesions between the AA and non-AA cohort (p > 0.05 for all). We found no difference in location on MRI between race groups. There was similar cancer detection, focusing on anterior lesions and rate of positive Gleason grade (≥GG1) and clinically significant (≥GG2) cancer between cohorts. In a predominant AA cohort of veterans, we found similar distribution of location for MRI-targeted lesions, along with rates of tumor detection and aggressiveness of disease. In this single payer veteran population, we did not identify specific biologic differences inherent to tumor detection between AA and non-AA patients.

We explored secondary school principals' knowledge of suicide prevention programs, their perceptions of the logistical and cultural barriers associated with suicide prevention program adoption, and their justification for adopting (or not adopting) suicide prevention programs in their schools. Principals, as positional leaders of schools, can lead the adoption and support of school-based suicide prevention programs for their students. Using a phenomenology framework, we conducted semi-structured interviews of eight secondary school principals working in public schools in the south-central United States. The principals readily identified the importance of supporting students' mental health to enhance their learning as a justification for implementing suicide prevention programs for their students. They shared how limited staffing, time, perception of school responsibility for student mental health, and lack of knowledge of available suicide prevention resources were logistical, cultural, and knowledge barriers to adopting suicide prevention programs for students. Our research has profound implications for practice.

Abstract Renal Cell Carcinoma (RCC) is the most common form of kidney cancer, with clear cell RCC (ccRCC) representing about 85% of all RCC tumors. There are limited curable treatments available for metastatic ccRCC because this disease is unresponsive to conventional targeted systemic pharmacotherapy. Exosomes (Exo) are small extracellular vesicles (EVs) secreted from cancer cells with marked roles in tumoral signaling and pharmacological resistance. Ketoconazole (KTZ) is an FDA approved anti-fungal medication which has been shown to suppress exosome biogenesis and secretion, yet its role in ccRCC has not been identified. A time-course, dose-dependent analysis revealed that KTZ selectively decreased secreted Exo in tumoral cell lines. Augmented Exo secretion was further evident by decreased expression of Exo biogenesis (Alix and nSMase) and secretion (Rab27a) markers. Interestingly, KTZ-mediated inhibition of Exo biogenesis was coupled with inhibition of ERK1/2 activation. Next, selective inhibitors were employed and showed ERK signaling had a direct role in mediating KTZ’s inhibition of exosomes. In sunitinib resistant 786-O cells lines, the addition of KTZ potentiates the efficacy of sunitinib by causing Exo inhibition, decreased tumor proliferation, and diminished clonogenic ability of RCC cells. Our findings suggest that KTZ should be explored as an adjunct to current RCC therapies.

Abstract Reduced knee weight-bearing from prescription or sedentary lifestyles are associated with cartilage degradation; effects on the meniscus are unclear. Rodents exposed to spaceflight or hind limb unloading (HLU) represent unique opportunities to evaluate this question. This study evaluated arthritic changes in the medial knee compartment that bears the highest loads across the knee after actual and simulated spaceflight, and recovery with subsequent full weight-bearing. Cartilage and meniscal degradation in mice were measured via microCT, histology, and proteomics and/or biochemically after: (1) ~ 35 days on the International Space Station (ISS); (2) 13-days aboard the Space Shuttle Atlantis; or (3) 30 days of HLU, followed by a 49-day weight-bearing readaptation with/without exercise. Cartilage degradation post-ISS and HLU occurred at similar spatial locations, the tibial-femoral cartilage-cartilage contact point, with meniscal volume decline. Cartilage and meniscal glycosaminoglycan content were decreased in unloaded mice, with elevated catabolic enzymes (e.g., matrix metalloproteinases), and elevated oxidative stress and catabolic molecular pathway responses in menisci. After the 13-day Shuttle flight, meniscal degradation was observed. During readaptation, recovery of cartilage volume and thickness occurred with exercise. Reduced weight-bearing from either spaceflight or HLU induced an arthritic phenotype in cartilage and menisci, and exercise promoted recovery.

Abstract Introduction T‐cell antigen receptor (TCR) interaction with cognate peptide:MHC complexes trigger clustering of TCR:CD3 complexes and signal transduction. Triggered TCR:CD3 complexes are rapidly internalized and degraded in a process called ligand‐induced TCR downregulation. Classic studies in immortalized T‐cell lines have revealed a major role for the Src family kinase Lck in TCR downregulation. However, to what extent a similar mechanism operates in primary human T cells remains unclear. Methods Here, we developed an anti‐CD3‐mediated TCR downregulation assay, in which T‐cell gene expression in primary human T cells can be knocked down by microRNA constructs. In parallel, we used CRISPR/Cas9‐mediated knockout in Jurkat cells for validation experiments. Results We efficiently knocked down the expression of tyrosine kinases Lck, Fyn, and ZAP70, and found that, whereas this impaired T cell activation and effector function, TCR downregulation was not affected. Although TCR downregulation was marginally inhibited by the simultaneous knockdown of Lck and Fyn, its full abrogation required broad‐acting tyrosine kinase inhibitors. Conclusions These data suggest that there is substantial redundancy in the contribution of individual tyrosine kinases to TCR downregulation in primary human T cells. Our results highlight that TCR downregulation and T cell activation are controlled by different signaling events and illustrate the need for further research to untangle these processes.

ABSTRACT Background Radiation‐related screening guidelines for survivors of childhood cancer currently use irradiated regions (IR) to determine risk for late effects. However, contemporary radiotherapy techniques utilize volumetric dosimetry (VD) to determine organ‐specific exposures, which could inform need for late effect surveillance. Methods This cross‐sectional cohort study involved patients treated for cancer using computerized tomography‐planned irradiation at Children's Hospital Los Angeles from 2000–2016. Organs at risk were identified using both VD and IR. Under each method, Children's Oncology Group Long‐Term Follow‐Up Guidelines were applied to determine radiation‐related potential late effects and their correlative recommended screening practices. Patients served as their own controls. Mean number of potential late effects per patient and recommended screening practices per patient per decade of follow‐up were compared using paired t‐tests; comparisons were adjusted for diagnosis and gender using random effects, repeated measure linear regression. Results In this cohort (n = 132), median age at end of treatment was 10.6 years (range, 1.4–20.4). Brain tumor was the most common diagnosis (45%) and head/brain the most common irradiated region (61%). Under IR and VD, the mean number of potential late effects flagged was 24.4 and 21.7, respectively (−11.3%, p

Abstract Introduction The Diabetes Injection Device Preference Questionnaire (DID-PQ) was designed to assess patient preference between two non-insulin injection devices. In a recent crossover study, people with type 2 diabetes (T2D) completed the DID-PQ after performing mock injections with two non-insulin injection devices. The purpose of the current analysis was to use these data to assess construct validity of the DID-PQ and demonstrate one way to test whether there is a significant preference for one injection device over another. Methods Data were from an open-label, multicenter, randomized, crossover study assessing preference between the dulaglutide and semaglutide injection pens. In addition to the 10-item DID-PQ, people with T2D completed a global item assessing overall preference. DID-PQ responses were compared to the global preference item (percent agreement, Gwet’s AC1, prevalence-adjusted and bias-adjusted Kappa [PABAK]). For each item of the DID-PQ, a two-sided binomial test assessed whether the difference in preference was statistically significant. Results The sample included 310 participants (48.4% female; mean age = 60.0). The DID-PQ had minimal missing data. There was strong concordance (percent agreement > 78%) between the global preference item and all DID-PQ items except item 6, which assesses preference related to needle size (59.7%). The Gwet AC1 and PABAK statistics also indicated strong agreement between the global preference item and all DID-PQ items except item 6. There was a statistically significant difference (p

Background: Specialist training in family medicine (FM) is growing rapidly in sub-Saharan Africa. The strong emphasis on workplace-based learning for speciality training makes it vital to gain in-depth insights into registrar supervision. Previous studies have explored aspects of supervision at decentralised sites in high-income countries, however, little is known about the benefits and constraints of decentralised postgraduate supervision in low- to middle-income countries, especially in Africa. Aim: This study aimed to explore family physicians’ and registrars’ perceptions of the strengths and challenges of clinical and educational supervision across decentralised training sites. Setting: The study was conducted across two provinces at five decentralised training sites affiliated with the University of the Witwatersrand, Johannesburg. Methods: This qualitative study involved semi-structured interviews with a purposive sample of 11 FPs and 11 registrars. The data were thematically analysed. Results: Two of the four themes identified, ‘supervision is context-specific and supervisor-dependent’, and ‘the nature of engagement matters’, involved strengths and challenges. The other two, ‘supervision is not ideal’ and ‘the training environment is challenging’, focussed on challenges. Conclusion: Supervisors and registrars described the postgraduate FM supervision as context-specific and supervisor-dependent. Supervisors displayed good clinical-teacher characteristics and supervisory relationships. However, several challenges, including registrars’ workload, resource shortages and a lack of standardisation across training sites, need to be addressed. Regular faculty development is essential for supervisors to be aware of relevant aspects of, and current trends in, postgraduate training.

Purpose: Pulmonary dysfunction is a prevalent and potentially debilitating late effect of pediatric cancer treatment. We postulated that age, as a surrogate for respiratory developmental status, might be associated with vulnerability to pulmonary injury. Materials and Methods: Sixty-one children treated with lung radiation at our institution who had undergone a pulmonary function test (PFT) between 1995 and 2016 were analyzed. Data collection included age at diagnosis and treatment, radiation dose and location, spirometry, and plethysmography results. PFTs were normalized according to age, sex, height, and ethnicity, and transformed into standardized z-scores. Obstructive disease was defined as forced expiratory volume in 1 second z score/forced vital capacity z score < −1.645, restrictive as total lung capacity z score 13. Compared with patients >13 years, those .05). Conclusions: PFT abnormalities were common among our cohort of childhood cancer survivors treated with lung radiation. Younger age at treatment is associated with an increased risk of developing pulmonary dysfunction, presumably owing to developmental immaturity.

Abstract Background Exercise stress echocardiography is clinically used to assess cardiovascular diseases. For accurate cardiac evaluation, a stable field-of-view is required. However, transducer orientation and position are difficult to preserve. Hands-free acquisitions might provide more consistent and reproducible results. In this study, the field-of-view stability and variability of hands-free acquisitions are objectively quantified in a comparison with manually obtained images, based on image structural and feature similarities. In addition, the feasibility and consistency of hands-free strain imaging is assessed. Methods In twelve healthy males, apical and parasternal images were acquired hands-free, using a fixation device, and manually, during semi-supine exercise sessions. In the final ten seconds of every exercise period, the image structural similarity and cardiac feature consistency were computed using a steerable pyramid employing complex, oriented wavelets. An algorithm discarding images displaying lung artifacts was created. Hands-free strain consistency was analyzed. Results Hands-free acquisitions were possible in 9 of the 12 subjects, whereas manually 10 out of 12 could be imaged. The image structural similarity was significantly improved in the hands-free apical window acquisitions (0.91 versus 0.82), and at least equally good in the parasternal window (0.90 versus 0.82). The change in curvature and orientation of the interventricular septum also appeared to be lower in the hands-free acquisitions. The variability in field-of-view was similar in both acquisitions. Longitudinal, septal strain was shown to be at least as consistent when obtained hands-free compared to manual acquisitions. Conclusions The field-of-view was shown to be more or equally stable and consistent in the hands-free data in comparison to manually obtained images. The variability was similar, thus respiration- and exercise-induced motions were comparable for manual and hands-free acquisitions. Additionally, the feasibility of hands-free strain has been demonstrated. Furthermore, the results suggest the hands-free measurements to be more reproducible, though further analysis is required.

Genetic manipulation of primary lymphocytes is crucial for both clinical purposes and fundamental research. Despite their broad use, we encountered a paucity of data on systematic comparison and optimization of retroviral vectors, the workhorses of genetic modification of primary lymphocytes. Here, we report the construction and validation of a versatile range of retroviral expression vectors. These vectors can be used for the knockdown or overexpression of genes of interest in primary human and murine lymphocytes, in combination with a wide choice of selection and reporter strategies. By streamlining the vector backbone and insert design, these publicly available vectors allow easy interchangeability of the independent building blocks, such as different promoters, fluorescent proteins, surface markers and antibiotic resistance cassettes. We validated these vectors and tested the optimal promoters for in vitro and in vivo overexpression and knockdown of the murine T cell antigen receptor. By publicly sharing these vectors and the data on their optimization, we aim to facilitate genetic modification of primary lymphocytes for researchers entering this field.

South Africa recently experienced the third wave of the coronavirus disease 2019 (COVID-19)pandemic. Social media is flooded with polarised conversations, with opinions for and against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. Many people are hesitant, and some are strongly opposed to vaccination. Vaccine hesitancy must be understood in historical, political and socio-cultural contexts. The aim of this study was to offer a values-driven approach to vaccine hesitancy conversations. It focusses on ethical dilemmas forthcoming from values violations, interrogating the personal and institutional scripts and rationalisations that prevent resolution, and offering ways of re-scripting these. Values-driven conversations provide safe spaces for vaccine-hesitant individuals to voice their reservations. The manner in which conversations are conducted is as important as the contents being discussed. Healthcare professionals are trusted by the public and should use ways of conversing that do not erode this trust. Creating respectful, compassionate platforms of engagement and incentivising vaccination are important measures for change in vaccine perspectives.

Purpose: : Cancer patients experience significant distress and burden of decision-making throughout treatment and beyond. These stressors can interfere with their ability to make reasoned and timely decisions about their care and lead to low physical and social functioning and poor survival. This pilot study examined the impact of offering Problem-Solving Skills Training (PSST) to adult cancer survivors to help them and their caregivers cope more successfully with post-treatment decision-making burden and distress. Patients and Methods: : Fifty patients who completed their definitive treatment for colorectal, breast or prostate cancer within the last 6 months and reported distress (level > 2 on the National Comprehensive Cancer Network distress thermometer) were randomly assigned to either care as usual (CAU) or 8 weekly PSST sessions. Patients were invited to include a supportive other (n = 17). Patient and caregiver assessments at baseline (T1), end of intervention or 3 months (T2), and at 6 months (T3) focused on problem-solving skills, anxiety/depression, quality of life and healthcare utilization. We compared outcomes by study arm and interviewed participants about PSST burden and skill maintenance. Results: : Trial participation rate was 60%; 76% of the participants successfully completed PSST training. PSST patients reported reduction in anxiety/depression, improvement in QoL (p