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ABSTRACT Multidrug-resistant Staphylococcus aureus is one of the most clinically important pathogens in the world, with infections leading to high rates of morbidity and mortality in both humans and animals. The ability of S. aureus to form biofilms protects cells from antibiotics and promotes the transfer of antibiotic resistance genes; therefore, new strategies aimed at inhibiting biofilm growth are urgently needed. Probiotic species, including Bacillus subtilis, are gaining interest as potential therapies against S. aureus for their ability to reduce S. aureus colonization and virulence. Here, we search for strains and microbially derived compounds with strong antibiofilm activity against multidrug-resistant S. aureus by isolating and screening Bacillus strains from a variety of agricultural environments. From a total of 1,123 environmental isolates, we identify a single strain B. subtilis 6D1, with a potent ability to inhibit biofilm growth, disassemble mature biofilm, and improve antibiotic sensitivity of S. aureus biofilms through an Agr quorum sensing interference mechanism. Biochemical and molecular networking analysis of an active organic fraction revealed multiple surfactin isoforms, and an uncharacterized peptide was driving this antibiofilm activity. Compared with commercial high-performance liquid chromatography grade surfactin obtained from B. subtilis, we show these B. subtilis 6D1 peptides are significantly better at inhibiting biofilm formation in all four S. aureus Agr backgrounds and preventing S. aureus-induced cytotoxicity when applied to HT29 human intestinal cells. Our study illustrates the potential of exploring microbial strain diversity to discover novel antibiofilm agents that may help combat multidrug-resistant S. aureus infections and enhance antibiotic efficacy in clinical and veterinary settings.IMPORTANCEThe formation of biofilms by multidrug-resistant bacterial pathogens, such as Staphylococcus aureus, increases these microorganisms’ virulence and decreases the efficacy of common antibiotic regimens. Probiotics possess a variety of strain-specific strategies to reduce biofilm formation in competing organisms; however, the mechanisms and compounds responsible for these phenomena often go uncharacterized. In this study, we identified a mixture of small probiotic-derived peptides capable of Agr quorum sensing interference as one of the mechanisms driving antibiofilm activity against S. aureus. This collection of peptides also improved antibiotic killing and protected human gut epithelial cells from S. aureus-induced toxicity by stimulating an adaptive cytokine response. We conclude that purposeful strain screening and selection efforts can be used to identify unique probiotic strains that possess specially desired mechanisms of action. This information can be used to further improve our understanding of the ways in which probiotic and probiotic-derived compounds can be applied to prevent bacterial infections or improve bacterial sensitivity to antibiotics in clinical and agricultural settings.

Purpose: To characterize the early postoperative complications following outpatient tibial tubercle osteotomy (TTO) to determine its safety in this setting. Methods: Patients undergoing TTO by a single surgeon between July 2017 and August 2022 for patellar instability or patellofemoral chondromalacia and achieving a minimum of 3 months of clinical and radiographic follow-up were evaluated for inclusion. Although an inclusion criterion was a minimum follow-up of 3 months, if evidence of a healed osteotomy was observed sooner, final follow-up was accepted at 2 months. Patient demographics, perioperative risk factors, and incidence of complications were collected retrospectively. Categorical data were analyzed using χ2 and Fisher exact tests. Continuous data were analyzed using 2-tailed t tests and Mann-Whitney U data for parametric and nonparametric data, respectively. Results: A total of 195 knees in 167 patients met inclusion criteria, with a mean age of 24.7 ± 9.2 years and mean follow-up time of 10.9 months (range, 2-69 months). Fifty-one early postoperative complications occurred in 47 (24.1%) knees in 42 (25.1%) patients. Ten major and 41 minor complications occurred. Major complications were associated with older age (P = .015), smoking (P = .038), and smaller preoperative patellar tendon–lateral trochlear ridge distance (P = .012). Forty-four reoperations occurred in 42 (21.5%) knees in 37 (22.2%) patients. The most common reasons for reoperation included removal of symptomatic hardware (31 knees; 15.9%) and arthrofibrosis requiring lysis of adhesions and manipulation under anesthesia (8 knees; 4.1%). The mean time to reoperation was 13.0 months (range, 1-42 months). Smaller body mass index was associated with increased risk of reoperation (P = .002). Conclusions: Outpatient TTO is safe when performed with the described technique, but the later development of minor complications is not infrequent following surgery. Patients should be counseled regarding a relatively high incidence of hardware irritation, arthrofibrosis, and eventual reoperation. Level of Evidence: Level IV, case series.

Background Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible. Objective(s) (1) Identify configurations being considered, (2) understand service users’ views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users’ preference and being National Health Service-feasible. Design Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users’ care preferences for different seizure scenarios. Objective 4 was addressed by completing ‘knowledge exchange’ workshops. At these, stakeholders considered the findings on users’ stated preferences and judged different pathway configurations against Michie’s ‘acceptability, practicability, effectiveness, affordability, side-effects and equity’ feasibility criteria. Setting This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks. Participants Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders. Results The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5–10 years, with some elements being immediately deployable. Limitations The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented. Conclusions Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy. Study registration The study is registered as researchregistry4723. 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: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information. Plain language summary Ambulances often attend to people with epilepsy. Most of them are taken to the hospital’s accident and emergency department. This typically has little benefit since most patients are already diagnosed and visit the accident and emergency department with non-emergency states. To change things, National Health Service organisations want an ‘alternative care pathway’ for paramedics to use. It could mean the person is not taken to the accident and emergency department but cared for elsewhere. Our project brought stakeholders together to develop an alternative care pathway that includes things important to patients and carers but is also National Health Service-feasible. Seventy National Health Service organisations first told us via a survey and a workshop which pathways they were considering and which might be feasible. Thirty people with epilepsy and their family members and friends were then interviewed. They explained what is wanted after a seizure and problems with current care. One problem was that going to the accident and emergency department does not lead to them getting a follow-up appointment with an epilepsy specialist to check their treatment is right. Using ‘discrete choice experiments’, around 430 people with epilepsy who recently contacted the ambulance service and 170 of their family and friends were asked to make a choice between alternative packages of care, to say which pathway they would prefer in different seizure situations. The results were clear. People wanted care different from what National Health Service organisations told us was available. The choice experiment showed everyone prefers pathways where paramedics have access to their medical records, an epilepsy specialist is available to advise the paramedic, the general practitioner gets a report and they get an appointment with an epilepsy specialist in the future. Everyone wants to avoid long episodes of care (6 hours) and after a typical seizure people with epilepsy want to stay at home. Three workshops were run with paramedics, epilepsy specialists and managers. They said the alternative care pathway wanted by users could be National Health Service-feasible. There is a need to implement and evaluate it now. Scientific summary Background Emergency department (ED) visits for epilepsy are common, costly, often clinically unnecessary and typically lead to little benefit for epilepsy management. An alternative care pathway (CP), which diverts people with epilepsy (PWE) away from ED when ‘999’ is called and leads to care elsewhere, could potentially generate savings and instigate improvements in the person’s ambulatory care. This project sought to identify the optimal configuration, ensuring the CP is both acceptable to service users and NHS-feasible. A key method used was discrete choice experiments (DCEs). They involved users being presented with hypothetical seizure scenarios and making a number of choices to say which CP configuration, described according to a fixed set of characteristics (attributes), they would prefer. The project’s aims were as follows. Aims and objectives Work Package 1 Systematically identify alternative CPs being considered by NHS services and describe extent to which service users have been involved in their design. Understand decision-making processes of PWE and their significant others (SOs) for seeking ED care and their concerns and expectations regarding alternative CPs. Identify attributes of postseizure care that PWE and their SOs (close family and friends) consider important. Work Package 2 Determine users’ and SOs’ preferences for postseizure care using DCEs and identify subgroup differences. Estimate utility of different CP configurations to service users and subgroup differences. Work Package 3 Hold expert workshops at which stakeholders, informed of the DCE evidence, would identify the optimal alternative CP/s for seizures that could be recommended for implementation and evaluation. Methods Work Package 1 Work Package 1a. Survey of service providers England’s ambulance services, epilepsy services and a random sample of its EDs were surveyed (April–June 2019). They were asked what alternative CPs they were considering and the extent to which they had consulted users. Work Package 1b. Interviews with service users Semistructured interviews were conducted in Southeast England with a purposive sample of PWE (April–September 2019). They also completed a ranking exercise to identify the characteristics (attributes) of postseizure care they considered most important. Participants were recruited from third-sector user groups and via a research newsletter. To be eligible, the person needed to be (1) aged ≥ 18, (2) have been diagnosed with epilepsy for ≥ 1 year, (3) had contacted the emergency services in the previous 12 months and (4) be able to provide informed consent and complete an interview in English. People with epilepsy were invited to be interviewed along with a SO. Work Package 1c. Knowledge exchange event Work Package (WP) 1b and 1c findings were used to select a set of candidate attributes that could be used to describe CPs within the DCE. To ensure attributes were features of alternative CPs and the levels likely NHS-feasible, a 1-day ‘knowledge exchange’ event was run (October 2019). Participants were representatives from ambulance and epilepsy services. They were identified for participation via WP1a. Work Package 2 Work Package 2a. Discrete choice experiment design panel and pilot A DCE design panel used evidence from WPs 1a–c to generate the DCE survey, using a D-efficient experimental design (Ngene 1.2.1, ChoiceMetrics, Sydney, Australia). The survey’s purpose was to obtain data of users’ care preferences for three separate scenarios, namely, a ‘typical seizure at home’, a ‘typical seizure in public’ and an ‘atypical seizure’. It, and vignettes describing the different seizure scenarios, was iteratively refined and finalised based on piloting. Work Package 2b. Formal discrete choice experiment A sample of n = 348 adults with epilepsy (and their SOs) from the target population was sought to complete the DCE. They filled in the DCE via an online platform. Participants were recruited via two routes between July and November 2020: (1) from the Merseyside area via the North West Ambulance Service and (2) nationally via public advert. PWE needed to (1) be aged ≥ 18 years, have a diagnosis of epilepsy, (2) have been seen by the ambulance service in prior 12 months and (3) be able to provide informed consent and independently complete the survey in English. Significant others needed to be aged ≥ 16. Data were analysed using a random-effects logit model. Preference weights were estimated for each attribute. Data from PWE and SOs were analysed separately, thus creating six seizure contexts for which preferences were modelled (three seizure scenarios × two participant types). Work Package 3 To identify which CP configuration(s) represented the optimal balance between user preference and NHS feasibility, three online ‘knowledge exchange’ workshops were run. Attendees were representatives from the ambulance service, from epilepsy services and commissioning. Service user representatives were also present. Commissioning and managerial representation was secured via national professional bodies. The DCE findings from WP2 were disseminated, and attendees were introduced to Michie et al.’s affordability, practicability, effectiveness, acceptability, side-effects and equity (APEASE) feasibility criteria. Nominal group techniques were then utilised, with stakeholders sharing views on the extent to which they considered the attribute levels favoured by users to be NHS-feasible. The groups then specified the levels for each attribute they believed represented the optimal balance. Results Work Package 1 Work Package 1a. Survey of service providers Clinical leads and managers from 72 (82.8%) of the invited services responded. Sixty per cent were considering or using an alternative CP change; only 21.2% had consulted service users on it. A range of CP configurations were reported. Some involved caring for PWE at home, ‘on scene’ or in some instances conveying them to an urgent treatment centre. The potential of configurations to improve ambulatory care varied. Work Package 1b. Semistructured interviews with service users Thirty service users (25 PWE and 5 SOs) were interviewed. The average age of PWE was 37 years; mean years was diagnosed 21. Participants provided insights into the challenges service users experience and disruptions they experience due to inadequate information transfer and co-ordination between ambulatory and urgent and emergency care services. Interviews highlighted some initial concerns users had with some possible CP configurations. The ranking exercise provided an approximation of the factors contributing to the ‘decision calculus’ users use when considering postseizure care options. Six attributes appeared most important: (1) whether the ambulance crew would have access to their medical records or care plan, (2) where the CP would take them, (3) how long it would take for them to be assessed, monitored and treated during the emergency episode, (4) extent to which the emergency care provider could request advice from an epilepsy specialist (e.g. epilepsy nurse, neurologist), (5) whether the CP would mean their usual care provider/s would be informed of the incident and, finally, (6) whether any follow-up from the epilepsy specialist would be instigated. Work Package 1c. Knowledge exchange event Thirteen representatives attended the workshop (n = 6 paramedics, n = 4 neurologists, n = 2 epilepsy nurse specialists and n = 1 user group representative). Participants agreed the six attributes identified by WP1b were all characteristics of an alternative CP, plausible and could be ‘traded’. Much of the event focused on identifying attribute levels that were considered feasible. Work Package 2 Work Package 2a. Discrete choice experiment design panel and pilot The panel decided that the six attributes identified in the formative work should be used to describe the CP options within the DCEs. Accordingly, DCEs for the three seizure scenarios were developed with the intention that participants would be randomised to each complete DCEs for two of three seizure scenarios, achieving a 1 : 1 : 1 allocation ratio. The six attributes and their associated levels (between 2 and 4) had the potential to generate 288 possible CP configurations. Use of an efficient experimental design meant that for each of the seizure scenarios a person would consider 24 CPs that were paired into 12 binary choices. The presentation of the DCE was finalised following pilot interviews. The final labels used for the attributes were as follows: (1) ‘The paramedic has access to medical records or a care plan’; (2) ‘What happens next’; (3) ‘Time’; (4) ‘Epilepsy specialists today’; (5) ‘GP told’; (6) ‘Additional contact with an epilepsy specialist’. Work Package 2b. Formal discrete choice experiment Useable submissions to the DCE survey were secured from n = 594 participants (n = 427 PWE; n = 167 SOs). Most (81.1%) were recruited via the public advertisement route. When participants from the two recruitment routes were merged to form a single sample, it was broadly representative of the target population. Two exceptions were its younger age and higher proportion reporting recent contact with an epilepsy specialist. The main ways that the SO participants knew someone with epilepsy was that they were the patient’s parents. The characteristics of the PWE known by SOs differed from those of the PWE taking part themselves (e.g. more learning disability). Across the three seizure scenarios, both PWE and SOs preferred CP configurations that differed from the way care is currently provided. Using coefficients from the random-effects logit models, the expected utility to service users for all possible CP configurations was calculated for the six seizure contexts. Care pathways were then ranked: rank 1 = most preferred; 288 = least preferred. The highest rank that the CP configuration approximating current care achieved was 220/288. There was similarity across the seizure contexts in terms of which attribute levels featured in the top-ranked configurations. In fact, three of the six contexts shared the same top-ranked configuration. For all six contexts, the highest-ranked CP configurations included (1) the paramedic having access to medical records or a care plan, (2) an epilepsy specialist (e.g. epilepsy nurse, neurologist) being available to advise the attending paramedic, (3) the patient’s GP being notified of the incident and (4) an appointment with an epilepsy specialist within 2–3 weeks being booked for the patient. The only attributes that varied within the top-ranked configurations were ‘What happens next’ and ‘Time’. For five of them, the top configuration involved the patient staying ‘where they were’. For the remaining ones – namely, for an ‘atypical seizure’ when considered by a SO – it involved the patient being conveyed to an urgent treatment centre. Different attributes had different levels of effect on preference. Providing crews with access to the medical records or care plan of the patient being attended to and having a specialist able to advise the paramedics had the strongest and consistent positive effect. Not all intended subgroup analyses could be completed due to insufficient cases. Those which could, showed social deprivation, recruitment route, presence of an intellectual impairment, contact with an epilepsy specialist in the prior 12 months, familiarity with the seizure scenario and whether the person with epilepsy had a care plan were not significantly related to preference. Work Package 3 Twenty-seven stakeholders attended a workshop. They included 10 ambulance clinicians, 8 epilepsy specialists, 5 commissioners and 4 patient and public involvement (PPI) representatives. Stakeholders believed the attribute levels preferred by service users were broadly feasible in the next 5–10 years. They identified those where most investment/work was required for them to be deliverable. Stakeholders were of the view that there was sufficient commonality in users’ preferences across the six seizure contexts for a single CP to be deployed. The groups were of the same position as to which configurations represented the optimum. They comprised of the following: (1) ambulance clinicians having access to medical records, (2) the person typically staying where they were, (3) the time taken being < 6 hours (be it 1, 2 or 3 hours), (4) crews being able to be advised by a specialist (an epilepsy nurse or neurologist) on the day, (5) for the person’s GP to be notified and, finally, for the incident to result in an appointment being made for the patient to have a follow-up appointment with an epilepsy specialist (be it within 1 week or 2–3 weeks). When attribute levels were restricted to these, the number of CP configurations for consideration reduced from 288 to 18. Evidence from WP2b showed these 18 included the configurations most preferred by service users for each scenario. Moreover, the evidence indicated that all 18 would be expected to hold more utility to users than the configuration representing current care. Conclusions By working collaboratively with service users from the target population, clinicians and commissioners, this project has provided clear answers to a pressing service delivery question. It provides evidence indicating that for common seizure scenarios, users appear open to paramedics not conveying them to ED and how poorly current care aligns with their preferences. Our project has also shown what postseizure care service users appear to want and that limited differences exist for different seizure scenarios. This appears to support the deployment of a single CP configuration. The study also provided evidence on the estimated improvement in utility that would result from individual attribute changes. This could be used to prioritise CP changes. Importantly, service providers and commissioners were found to be of the view that the CP configuration favoured by users could be NHS-feasible within 5–10 years, and they identified which attribute levels require the most work. It is important to now take the evidence this project has captured on people’s stated preferences and views and seek to implement one of the possible 18 CP configurations and evaluate it to determine its actual feasibility and efficacy in practice. Implications for NHS service commissioning, policy and practice The project identified a refined set of CP configurations that are considered optimal and the most promising candidates for formal evaluation. Pressures on acute services have intensified since our project was completed. This may incentivise ambulance services to use our findings and implement some form of alternative CP before an evaluation has occurred. Not all ambulance services would have the infrastructure and/or relationships with partner organisations to immediately implement the entire CP configuration considered optimal. Commissioners, policy-makers and service providers could support the development of the systems – such as shared record initiatives – to permit it to be offered. Identifying eligible people for the DCE survey via the NHS ambulance service was time-consuming compared to using public adverts. This could be made for efficient by embedding processes within NHS records systems to temporarily ‘strip’ them, including free-text fields, of confidential data. This would enable trained individuals not involved in a person’s care to screen anonymised records. Recommendations for research Using the attribute levels specified by stakeholders as representing the optimum, one of the possible 18 CP configurations should be evaluated for its efficacy. Any evaluation should consider short- (e.g. rates of recontact, death) and long-term outcomes (e.g. proportion of PWE ‘unknown’ to specialists brought to their attention). A cluster-randomised controlled trial would likely provide the most rigorous evidence. However, an alternative, faster evaluation approach may be needed to ensure evidence is generated in an acceptable time frame. Other ways to reduce unnecessary ED attendance warrant research attention. One is how to address ambulance crews’ requests for support in identifying persons suitable for non-conveyance. Attention is also needed on users’ seizure first aid confidence and knowledge. Study registration This study is registered as researchregistry4723. 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: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Abstract Decades of human activities and fire suppression have adversely affected longleaf pine (Pinus palustris) ecosystems, which are home to high levels of diversity and endemism. These iconic ecosystems also now face challenges from urbanization and climate change, which will alter conservation outcomes over the remainder of the 21st century. To explore how long‐term, large‐scale human influences could affect the spatial and functional persistence of extant longleaf pine ecosystems in the Florida Flatwoods Pyrome, we extracted a set of 2400 longleaf pine patches ≥40 ha in size from the Florida Longleaf Pine Ecosystem Geodatabase. Projections from the FUTURES urban growth model and the Florida 2070 project indicate that development will lead to losses of existing longleaf pine habitat, reductions in longleaf pine patch size, and patches that are predominantly located in close proximity to developed areas. Finer‐scale patterns of longleaf pine loss in three focal landscapes highlighted differences in land protection, ecological setting, and development pressure and the value of using of multiple urbanization iterations. The occurrence of suitable conditions to conduct prescribed fires, a crucial tool for maintaining, improving, and restoring longleaf pine ecosystems, is projected to decrease seasonally throughout the study area. As a result, the functional persistence of ecosystems is at risk due to climate changes that increase barriers to the safe and reliable application of intentional fire. The long‐term viability of this critical ecosystem will warrant the evaluation of adaptive strategies that explicitly account for the individual and compounding effects of urban development and changing fire management conditions when considering options for ecosystem protection, management, and restoration.

Total femur replacement is a well-recognized salvage procedure and an alternative to hip disarticulation in patients with massive femoral bone loss. Compared to conventional total femur replacement, intramedullary total femur (IMTF) requires less soft tissue dissection and preserves femoral bone stock and soft-tissue attachments. Despite these advantages, patients can still anticipate compromised functional outcomes and high complication rates following IMTF. Prior studies describe IMTF with the patient positioned laterally and utilizing posterior or anterolateral approaches to the hip. We describe our IMTF technique performed via the direct anterior approach in the supine position. In our experience, this is an effective method, with potential benefits including intraoperative limb length and rotational assessment, use of fluoroscopy, more convenient exposure of the knee, and potential lower rates of hip instability.

# Background There are 2.8 million youth competitive swimmers in the United States (US), and shoulder pain is the most common complaint among swimmers. # Purpose To determine prevalence of shoulder pain, disability, and dissatisfaction in youth competitive swimmers. A secondary purpose was to determine influence of age, competitive swimming experience, and previous history of shoulder pain or injury on shoulder pain, disability, and dissatisfaction, and finally to determine if sex, geographic area, and participation in a second sport relate to shoulder pain, disability, and dissatisfaction. # Study Design Multi-site cross-sectional design # Methods Six-hundred and seventy-one swimmers aged 9–17 years from six states in the US completed surveys which included demographics, the Penn Shoulder Score (PSS), and the Disability of Arm Shoulder Hand (DASH) Sports. Independent t-tests were used to compare pain, disability, dissatisfaction, the influence of age, sex, participation in second sport, geographic region, and history of shoulder pain. Linear regression analyses were performed to determine the interaction of these variables with reported pain and disability. # Results Forty-nine percent of swimmers had shoulder symptoms. Greater shoulder pain and disability were reported in 15 to 17-year-olds compared to 9 to 10-year-olds (pain and disability: p

Introduction: Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions. Methods: The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020–2023). Using the Center for Medicare and Medicaid Services’ chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force–recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years. Results: Within a final cohort of n=11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force–recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; p=0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force–recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; p=0.0014 and 95% CI=1.2, 1.8; p=0.0003). Conclusions: Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force–recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.

Abstract Purpose To determine whether scapular morphology could predict isolated supraspinatus tendon tear propagation after exercise therapy. We hypothesised that a larger critical shoulder angle (CSA) and type III acromial morphology predict a positive change in tear size. Methods Fifty‐nine individuals aged 40–70 years with isolated symptomatic high‐grade partial or full‐thickness supraspinatus tendon tears were included. Individuals participated in a structured, individualised 12‐week exercise therapy programme and underwent ultrasound to measure tear size at baseline and 12 months following therapy. Computed tomography images were segmented to create three‐dimensional subject‐specific bone models and reviewed by three trained clinicians to measure CSA and to determine acromion morphology based on the Bigliani classification. A binary logistic regression was performed to determine the predictive value of CSA and acromion morphology on tear propagation. Results The CSA was 30.0 ± 5.4°. Thirty‐one individuals (52.5%) had type II acromial morphology, followed by type III and type I morphologies (25.4% and 22.0%, respectively); 81.4% experienced no change in tear size, four (6.8%) individuals experienced tear propagation and seven (11.9%) individuals had a negative change in tear size. No significant difference in tear propagation rates based on CSA or acromion morphology (not significant [NS]) was observed. The model predicted tear size status in 81.4% of cases but only predicted tear propagation 8.3% of the time. Overall, CSA and acromion morphology only predicted 24.3% (R2 = 0.243) of variance in tear propagation (NS). Conclusions CSA and acromion morphology were NS predictors of tear propagation of the supraspinatus tendon 12 months following an individualised exercise therapy programme. Level of Evidence II.

Abstract Various erythropoietic abnormalities are highly prevalent among patients with pulmonary arterial hypertension (PAH) and associated with worse disease severity. Given the poorly understood yet important roles of dysregulated erythropoiesis and iron metabolism in PAH, we sought to further characterize the hematologic and iron profiles in PAH and their relationship to PAH severity. We recruited 67 patients with PAH and 13 healthy controls. Hemodynamics attained within 1 year of blood sample collection were available for 36 patients. Multiple hematologic, iron, and inflammatory parameters were evaluated for their association with hemodynamics. The subset with hemodynamic data consisted of 29 females (81%). The most common etiologies were idiopathic PAH (47%) and connective tissue disease‐related PAH (33%). 19 (53%) had functional class 3 or 4 symptomatology, and 12 (33%) were on triple pulmonary vasodilator therapy. Immature reticulocyte fraction (IRF) had significant positive correlations with mean pulmonary artery (PA) pressure (mPAP) (0.59, p

Introduction Many individuals receiving outpatient physical therapy have musculoskeletal pain and up to one-third use prescription opioids. The impact of physical therapist-led mindfulness-based interventions integrated with evidence-based physical therapy (I-EPT) to manage patients with chronic musculoskeletal pain and long-term opioid treatment has not been elucidated. This project evaluates the feasibility of conducting a cluster randomised trial to test the effectiveness of I-EPT.Methods and analysis Study 1 aim: Refine and manualise the I-EPT treatment protocol. Our approach will use semistructured interviews of patients and physical therapists to refine an I-EPT training manual. Study 2 aim: Evaluate different intensities of physical therapist training programmes for the refined I-EPT treatment protocol. Physical therapists will be randomised 1:1:1 to high-intensity training (HighIT), low-IT (LowIT) training and no training arms. Following training, competency in the provision of I-EPT (LowIT and HighIT groups) will be assessed using standardised patient simulations. Study 3 aim: Evaluate the feasibility of the I-EPT intervention across domains of the Reach, Effectiveness, Adoption, Implementation, Maintenance implementation framework. The refined I-EPT treatment protocol will be tested in two different health systems with 90 patients managed by the randomised physical therapists. The coprimary endpoints for study 3 are the proportions of the Pain, Enjoyment of Life and General Activity Scale and the Timeline Followback for opioid use/dose collected at 12 weeks.Ethics and dissemination Ethics approval for the study was obtained from the University of Utah, University of Florida and Florida State University Institutional Review Boards. Informed consent is required for participant enrolment in all phases of this project. On completion, study data will be made available in compliance with NIH data sharing policies.Trial registration number NCT05875207.

Previous studies indicate that CNS administration of oxytocin (OT) reduces body weight in high fat diet-induced obese (DIO) rodents by reducing food intake and increasing energy expenditure (EE). We recently demonstrated that hindbrain (fourth ventricular [4V]) administration of OT elicits weight loss and elevates interscapular brown adipose tissue temperature (TIBAT, a surrogate measure of increased EE) in DIO mice. What remains unclear is whether OT-elicited weight loss requires increased sympathetic nervous system (SNS) outflow to IBAT. We hypothesized that OT-induced stimulation of SNS outflow to IBAT contributes to its ability to activate BAT and elicit weight loss in DIO mice. To test this hypothesis, we determined the effect of disrupting SNS activation of IBAT on the ability of 4V OT administration to increase TIBAT and elicit weight loss in DIO mice. We first determined whether bilateral surgical SNS denervation to IBAT was successful as noted by ≥ 60% reduction in IBAT norepinephrine (NE) content in DIO mice. NE content was selectively reduced in IBAT at 1-, 6- and 7-weeks post-denervation by 95.9 ± 2.0, 77.4 ± 12.7 and 93.6 ± 4.6% (P

PurposeTo examine the impact of an acute high-intensity sprint exercise protocol (HISEP) for eliciting post-exercise cognitive dysfunction in psychomotor, attentional, executive, and memory tasks.MethodsTwenty-four recreationally active adults (22 ± 4 yrs, 169.39 ± 10.07 cm, 75.80 ± 14.73 kg, 27.03 ± 9.55 BF%) performed a HISEP on a cycle ergometer. Average psychomotor reaction time (avgRT; Dynavision D2 Mode A & Mode B), mood (Profile of Mood States Questionnaire; POMS), and cognition (Automated Neuropsychological Assessment Metrics; ANAM) were assessed pre- (PRE), post- (POST) and 60-min post (60POST) HISEP. One-way repeated measures ANOVAs were used to assess changes across time.ResultsFatigue (main effect: p < 0.001, ηp2 = 0.309) was significantly higher at POST compared to PRE (p = 0.007). Tension (main effect: p = 0.021, ηp2 = 0.154) was significantly lower at 60POST compared to PRE (p = 0.029). Mode A avgRT (main effect: p = 0.022, ηp2 = 0.153) was significantly slower at POST compared to PRE (p = 0.026). Throughput (TP) scores for ANAM code substitution-delayed (CSD) task (main effect: p < 0.001, ηp2 = 0.284) and matching to sample (M2S) tasks (main effect: p = 0.014, ηp2 = 0.169) were significantly lower at POST compared to PRE (p = 0.001 and p = 0.025, respectively), while mathematical processing (main effect: p = 0.002, ηp2 = 0.232) was significantly higher at 60POST compared to both PRE (p = 0.019) and POST (p = 0.005). No other significant changes in cognitive task performance were observed (p's > 0.05).ConclusionsThe HISEP is a feasible and time-effective fatiguing exercise stimulus capable of eliciting acute cognitive dysfunction in psychomotor and memory task performance. NCT05100589.

IntroductionThe oral trichomonad Trichomonas tenax is increasingly appreciated as a likely contributor to periodontitis, a chronic inflammatory disease induced by dysbiotic microbiota, in humans and domestic animals and is strongly associated with its worst prognosis. Our current understanding of the molecular basis of T. tenax interactions with host cells and the microbiota of the oral cavity are still rather limited. One laboratory strain of T. tenax (Hs-4:NIH/ATCC 30207) can be grown axenically and two draft genome assemblies have been published for that strain, although the structural and functional annotation of these genomes is not available.MethodsGenSAS and Galaxy were used to annotate two publicly available draft genomes for T. tenax, with a focus on protein-coding genes. A custom pipeline was used to annotate the CAZymes for T. tenax and the human sexually transmitted parasite Trichomonas vaginalis, the most well-characterized trichomonad. A combination of bioinformatics analyses was used to screen for homologs of T. vaginalis virulence and colonization factors within the T. tenax annotated proteins.ResultsOur annotation of the two T. tenax draft genome sequences and their comparison with T. vaginalis proteins provide evidence for several candidate virulence factors. These include candidate surface proteins, secreted proteins and enzymes mediating potential interactions with host cells and/or members of the oral microbiota. The CAZymes annotation identified a broad range of glycoside hydrolase (GH) families, with the majority of these being shared between the two Trichomonas species.DiscussionThe presence of candidate T. tenax virulence genes supports the hypothesis that this species is associated with periodontitis through direct and indirect mechanisms. Notably, several GH proteins could represent potential new virulence factors for both Trichomonas species. These data support a model where T. tenax interactions with host cells and members of the oral microbiota could synergistically contribute to the damaging inflammation characteristic of periodontitis, supporting a causal link between T. tenax and periodontitis.

Abstract Cannabis producers, consumers, and regulators need fast, accurate, point‐of‐use sensors to detect Δ9‐tetrahydrocannabinol (THC) and cannabidiol (CBD) from both liquid and vapor source samples, and phthalocyanine‐based organic thin‐film transistors (OTFTs) provide a cost‐effective solution. Chloro aluminum phthalocyanine (Cl‐AlPc) has emerged as a promising material due to its unique coordinating interactions with cannabinoids, allowing for superior sensitivity. This work explores the molecular engineering of AlPc to tune and enhance these interactions, where a series of novel phenxoylated R‐AlPcs are synthesized and integrated into OTFTs, which are then exposed to THC and CBD solution and vapor samples. While the R‐AlPc substituted molecules have a comparable baseline device performance to Cl‐AlPc, their new crystal structures and weakened intermolecular interactions increase sensitivity to THC. Grazing‐incidence wide‐angle X‐ray scattering (GIWAXS) and atomic force microscopy (AFM) are used to investigate this film restructuring, where a significant shift in the crystal structure, grain size, and film roughness is detected for the R‐AlPc molecules that do not occur with Cl‐AlPc. This significant crystal reorganization and film restructuring are the driving force behind the improved sensitivity to cannabinoids relative to Cl‐AlPc and demonstrate that analyte–semiconductor interactions can be enhanced through chemical modification to create more responsive OTFT sensors.

Genomic screened homeobox 1 (Gsx1 or Gsh1) is a neurogenic transcription factor required for the generation of excitatory and inhibitory interneurons during spinal cord development. In the adult, lentivirus (LV) mediated Gsx1 expression promotes neural regeneration and functional locomotor recovery in a mouse model of lateral hemisection spinal cord injury (SCI). The LV delivery method is clinically unsafe due to insertional mutations to the host DNA. In addition, the most common clinical case of SCI is contusion/compression. In this study, we identify that adeno-associated virus serotype 6 (AAV6) preferentially infects neural stem/progenitor cells (NSPCs) in the injured spinal cord. Using a rat model of contusion SCI, we demonstrate that AAV6 mediated Gsx1 expression promotes neurogenesis, increases the number of neuroblasts/immature neurons, restores excitatory/inhibitory neuron balance and serotonergic neuronal activity through the lesion core, and promotes locomotor functional recovery. Our findings support that AAV6 preferentially targets NSPCs for gene delivery and confirmed Gsx1 efficacy in clinically relevant rat model of contusion SCI.

BackgroundTelepsychiatry (TP), a live video meeting, has been implemented in many contexts and settings. It has a distinct advantage in the psychiatric emergency department (ED) setting, as it expedites expert assessments for psychiatric patients. However, limited knowledge exits for TP’s effectiveness in the ED setting, as well as the process of implementing TP in this setting. ObjectiveThis scoping review aimed to review the existing evidence for the administrative and clinical outcomes for TP in the ED setting and to identify the barriers and facilitators to implementing TP in this setting. MethodsThe scoping review was conducted according to the guidelines for the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Three electronic databases were examined: PubMed, Embase, and Web of Science. The databases were searched from January 2013 to April 2023 for papers and their bibliography. A total of 2816 potentially relevant papers were retrieved from the initial search. Studies were screened and selected independently by 2 authors. ResultsA total of 11 articles were included. Ten papers reported on administrative and clinical outcomes of TP use in the ED setting and 1 on the barriers and facilitators of its implementation. TP is used in urban and rural areas and for settings with and with no on-site psychiatric services. Evidence shows that TP reduced waiting time for psychiatric evaluation, but in some studies, it was associated with prolonged total length of stay in the ED compared with in-person evaluation. Findings indicate lower admission rates in patients assessed with TP in the ED. Limited data were reported for TP costs, its use for involuntary commitment evaluations, and its use for particular subgroups of patients (eg, those with a particular diagnosis). A single paper examined TP implementation process in the ED, which explored the barriers and facilitators for implementation among patients and staff in a rural setting. ConclusionsBased on the extant studies, TP seems to be generally feasible and acceptable to key stakeholders. However, this review detected a gap in the literature regarding TP’s effectiveness and implementation process in the ED setting. Specific attention should be paid to the examination of this service for specific groups of patients, as well as its use to enable assessments for possible involuntary commitment.

Abstract Introduction With locally advanced pancreatic cancer (LAPC), uncontrolled local tumor growth frequently leads to mortality. Advancements in radiotherapy (RT) techniques have enabled conformal delivery of escalated‐dose RT (EDR), which may have potential local control and overall survival (OS) benefits based on retrospective and early prospective studies. With evidence for EDR emerging, we characterized the adoption of EDR across the United States and its associated outcomes. Methods We searched the National Cancer Database for nonsurgically managed LAPC patients diagnosed between 2004 and 2019. Pancreas‐directed RT with biologically effective doses (BED10) ≥39 and ≤70 Gy was labeled conventional‐dose RT (CDR), and BED10 >70 and ≤132 Gy was labeled EDR. We identified associations of EDR and OS using logistic and Cox regressions, respectively. Results Among the definitive therapy subset (n = 54,115) of the entire study cohort (n = 91,493), the most common treatments were chemotherapy alone (69%), chemotherapy and radiation (29%), and RT alone (2%). For the radiation therapy subset (n = 16,978), use of pancreas‐directed RT remained between 13% and 17% over the study period (ptrend > 0.999). Using multivariable logistic regression, treatment at an academic/research facility (adjusted odds ratio [aOR] 1.46, p

We are extremely grateful our esteemed colleagues Craig Pickering, Duarte Araújo, Keith Davids, and Kevin Till have read and offered insightful reflections on the target article “Talent inclusion and genetic testing in sport: A practitioner’s guide”. We take the opportunity in the present article to respond to the three commentaries provided by these authors. In our target article, we highlighted at this moment in time, there is unequivocal disapproval in the scientific community with regards to the implementation of genetic testing in sport. Despite an insufficient evidence base, however, various stakeholders (e.g., athletes, support staff) have used, and will likely continue using, genetic tests. We offered potential explanations regarding the allure of genetic information to sports stakeholders before suggesting some imperfect solutions in terms of increasing genetic literacy, promoting talent inclusion, and following a minimum set of best practice guidelines.

IntroductionOral cavity squamous cell carcinoma (OSCC) occurs most frequently in patients >60 years old with a history of tobacco and alcohol use. Epidemiological studies describe increased incidence of OSCC in younger adults (

Abstract Objectives Certain low‐level immune‐related adverse events (irAEs) have been associated with survival benefits in patients with various solid tumors on immune checkpoint inhibitors (ICIs). We aimed to investigate the association between irAEs and response to neoadjuvant ICIs in patients with head and neck squamous cell carcinoma (HNSCC) and to identify differences in circulating cytokine levels based on irAE status. Methods This was a retrospective cohort study including three neoadjuvant clinical trials from July 2017 to January 2022: NCT03238365 (nivolumab ± tadalafil), NCT03854032 (nivolumab ± BMS986205), NCT03618654 (durvalumab ± metformin). The presence and type of irAEs, pathologic treatment response, and survival were compared. Canonical linear discriminant analysis (LDA) was performed to identify combinations of circulating cytokines predictive of irAEs using plasma sample multiplex assay. Results Of 113 participants meeting inclusion criteria, 32 (28.3%) developed irAEs during treatment or follow‐up. Positive p16 status was associated with irAEs (odds ratio [OR] 2.489; 95% CI 1.069–6.119; p = 0.043). irAEs were associated with pathologic treatment response (OR 3.73; 95% CI 1.34–10.35; p = 0.011) and with higher OS in the combined cohort (HR 0.319; 95% CI 0.113–0.906; p = 0.032). Patients with irAEs within the nivolumab cohort had significant elevations of select cytokines pre‐treatment. Canonical LDA identified key drivers of irAEs among all trials, which were highly predictive of future irAE status. Conclusions irAEs are associated with response to neoadjuvant ICI therapy in HNSCC and can serve as clinical indicators for improved clinical outcomes. irAEs can be predicted by concentrations of several circulating cytokines prior to treatment.

The hypothalamus and dorsal vagal complex (DVC) are both important for integration of signals that regulate energy balance. Increased leptin transgene expression in either the hypothalamus or DVC of female rats was shown to decrease white adipose tissue and circulating levels of leptin and adiponectin. However, in contrast to hypothalamus, leptin transgene expression in the DVC had no effect on food intake, circulating insulin, ghrelin and glucose, nor on thermogenic energy expenditure. These findings imply different roles for hypothalamus and DVC in leptin signaling. Leptin signaling is required for normal bone accrual and turnover. Leptin transgene expression in the hypothalamus normalized the skeletal phenotype of leptin-deficient ob/ob mice but had no long-duration (≥10 weeks) effects on the skeleton of leptin-replete rats. The goal of this investigation was to determine the long-duration effects of leptin transgene expression in the DVC on the skeleton of leptin-replete rats. To accomplish this goal, we analyzed bone from three-month-old female rats that were microinjected with recombinant adeno-associated virus encoding either rat leptin (rAAV-Leptin, n = 6) or green fluorescent protein (rAAV-GFP, control, n = 5) gene. Representative bones from the appendicular (femur) and axial (3rd lumbar vertebra) skeleton were evaluated following 10 weeks of treatment. Selectively increasing leptin transgene expression in the DVC had no effect on femur cortical or cancellous bone microarchitecture. Additionally, increasing leptin transgene expression had no effect on vertebral osteoblast-lined or osteoclast-lined bone perimeter or marrow adiposity. Taken together, the findings suggest that activation of leptin receptors in the DVC has minimal specific effects on the skeleton of leptin-replete female rats.

ABSTRACT Intervening proteins (inteins) are translated as subdomains within host proteins and removed through an intein-driven splicing reaction where the flanking sequences (exteins) are joined with a peptide bond. Previously, we developed a self-removing translation reporter for labeling Ebola virus (EBOV). In this reporter, an intein (RadA) containing the fluorescent protein ZsGreen (ZsG) is inserted within the EBOV protein VP30. Upon VP30-RadA-ZsG expression from the viral genome, RadA-ZsG is removed from VP30 through the protein splicing activity of RadA, generating functional, non-tagged VP30 and functional ZsGreen. While incorporation of our VP30-RadA-ZsG fusion reporter into recombinant EBOV (rEBOV-RadA-ZsG) resulted in an infectious virus that expresses ZsG upon infection of cells, this virus displayed a replication defect compared to wild-type EBOV, which might be the result of insufficient RadA splicing. Here, we demonstrate that the serial passaging of rEBOV-RadA-ZsG in human cells led to an increase in replication efficiency compared to unpassaged rEBOV-RadA-ZsG. Sequencing of passaged viruses revealed intein-specific mutations. These mutations improve intein activity in both prokaryotic and eukaryotic systems, as well as in multiple extein contexts. Taken together, our findings offer a novel means to select for inteins with enhanced catalytic properties that appear independent of extein context and expression system.IMPORTANCEIntervening proteins (inteins) are self-removing protein elements that have been utilized to develop a variety of innovative protein engineering technologies. Here, we report the isolation of inteins with improved catalytic activity through viral passaging. Specifically, we inserted a highly active intein within an essential protein of Ebola virus and serially passaged this recombinant virus, which led to intein-specific hyper-activity mutations. The identified mutations showed improved intein activity within both bacterial and eukaryotic expression systems and in multiple extein contexts. These results present a new strategy for developing inteins with improved splicing activity.

ABSTRACT Escherichia coli is a diverse pathogen, causing a range of disease in humans, from self-limiting diarrhea to urinary tract infections (UTIs). Uropathogenic E. coli (UPEC) is the most frequently observed uropathogen in UTIs, a common disease in high-income countries, incurring billions of dollars yearly in treatment costs. Although E. coli is easily grown and identified in the clinical laboratory, genotyping the pathogen is more complicated, yet critical for reducing the incidence of disease. These goals can be achieved through whole-genome sequencing of E. coli isolates, but this approach is relatively slow and typically requires culturing the pathogen in the laboratory. To genotype E. coli rapidly and inexpensively directly from clinical samples, including but not limited to urine, we developed and validated a multiplex amplicon sequencing assay, called ColiSeq. The assay consists of targets designed for E. coli species confirmation, high resolution genotyping, and mixture deconvolution. To demonstrate its utility, we screened the ColiSeq assay against 230 clinical urine samples collected from a hospital system in Flagstaff, Arizona, USA. A limit of detection analysis demonstrated the ability of ColiSeq to identify E. coli at a concentration of ~2 genomic equivalent (GEs)/mL and to generate high-resolution genotyping at a concentration of 1 × 105 GEs/mL. The results of this study suggest that ColiSeq could be a valuable method to understand the source of UPEC strains and guide infection mitigation efforts. As sequence-based diagnostics become accepted in the clinical laboratory, workflows such as ColiSeq will provide actionable information to improve patient outcomes.IMPORTANCEUrinary tract infections (UTIs), caused primarily by Escherichia coli, create an enormous health care burden in the United States and other high-income countries. The early detection of E. coli from clinical samples, including urine, is important to target therapy and prevent further patient complications. Additionally, understanding the source of E. coli exposure will help with future mitigation efforts. In this study, we developed, tested, and validated an amplicon sequencing assay focused on direct detection of E. coli from urine. The resulting sequence data were demonstrated to provide strain level resolution of the pathogen, not only confirming the presence of E. coli, which can focus treatment efforts, but also providing data needed for source attribution and contact tracing. This assay will generate inexpensive, rapid, and reproducible data that can be deployed by public health agencies to track, diagnose, and potentially mitigate future UTIs caused by E. coli.

Background: Although the clinical factors associated with progression of coronary artery disease have been well studied, the angiographic predictors are less defined. Objectives: Our objective was to study the clinical and angiographic factors that associate with progression of coronary artery stenoses. Methods: We conducted a retrospective analysis of consecutive patients undergoing multiple, clinically indicated invasive coronary angiograms with an interval greater than 6 months, between January 2013 and December 2016. Lesion segments were analysed using Quantitative Coronary Angiography (QCA) if a stenosis ≥ 20 % was identified on either angiogram. Stenosis progression was defined as an increase ≥ 10 % in stenosis severity, with progressor groups analysed on both patient and lesion levels. Mixed-effects regression analyses were performed to evaluate factors associated with progression of individual stenoses. Results: 199 patients were included with 881 lesions analysed. 108 (54.3 %) patients and 186 (21.1 %) stenoses were classified as progressors. The median age was 65 years (IQR 56–73) and the median interval between angiograms was 2.1 years (IQR 1.2–3.0). On a patient level, age, number of lesions and presence of multivessel disease at baseline were each associated with progressor status. On a lesion level, presence of a stenosis downstream (OR 3.07, 95 % CI 2.04–4.63, p

Acinetobacter baumannii has emerged as a multidrug-resistant (MDR) superbug by causing severe infections, with high mortality rates. The ability of A. baumannii to form biofilms significantly contributes to its persistence in diverse environmental and hospital settings. Here we report that farnesol, an FDA-approved commercial cosmetic and flavoring agent, demonstrates efficacy for both inhibition of biofilm formation, and disruption of established A. baumannii biofilms. Moreover, no resistance to farnesol was observed even after prolonged culture in the presence of sub-inhibitory farnesol doses. Farnesol combats A. baumannii biofilms by direct killing, while also facilitating biofilm detachment. Furthermore, farnesol was safe, and effective, for both prevention and treatment of A. baumannii biofilms in an ex vivo burned human skin model. Since current treatment options for A. baumannii biofilm infections were mainly counted on the combination therapy of last-resort antibiotics, and clearly non-sustainable due to robust MDR phenotype of A. baumannii, we propose that farnesol alone can be repurposed as a highly effective agent for both preventing and treating life-threating biofilm-associated infections of A. baumannii due to its proven safety, convenient topical delivery, and excellent efficiency, plus its superiority of evading resistance development.

Background: This retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids. Methods: Patients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M). Results: Patients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P

Abstract Background Recurring COVID-19 waves highlight the need for tools able to quantify transmission risk, and identify geographical areas at risk of outbreaks. Local outbreak risk depends on complex immunity patterns resulting from previous infections, vaccination, waning and immune escape, alongside other factors (population density, social contact patterns). Immunity patterns are spatially and demographically heterogeneous, and are challenging to capture in country-level forecast models. Methods We used a spatiotemporal regression model to forecast subnational case and death counts and applied it to three EU countries as test cases: France, Czechia, and Italy. Cases in local regions arise from importations or local transmission. Our model produces age-stratified forecasts given age-stratified data, and links reported case counts to routinely collected covariates (e.g. test number, vaccine coverage). We assessed the predictive performance of our model up to four weeks ahead using proper scoring rules and compared it to the European COVID-19 Forecast Hub ensemble model. Using simulations, we evaluated the impact of variations in transmission on the forecasts. We developed an open-source RShiny App to visualise the forecasts and scenarios. Results At a national level, the median relative difference between our median weekly case forecasts and the data up to four weeks ahead was 25% (IQR: 12–50%) over the prediction period. The accuracy decreased as the forecast horizon increased (on average 24% increase in the median ranked probability score per added week), while the accuracy of death forecasts was more stable. Beyond two weeks, the model generated a narrow range of likely transmission dynamics. The median national case forecasts showed similar accuracy to forecasts from the European COVID-19 Forecast Hub ensemble model, but the prediction interval was narrower in our model. Generating forecasts under alternative transmission scenarios was therefore key to capturing the range of possible short-term transmission dynamics. Discussion Our model captures changes in local COVID-19 outbreak dynamics, and enables quantification of short-term transmission risk at a subnational level. The outputs of the model improve our ability to identify areas where outbreaks are most likely, and are available to a wide range of public health professionals through the Shiny App we developed.

Abstract Background Peri-sinus structures such as arachnoid granulations (AG) and the parasagittal dural (PSD) space have gained much recent attention as sites of cerebral spinal fluid (CSF) egress and neuroimmune surveillance. Neurofluid circulation dysfunction may manifest as morphological changes in these structures, however, automated quantification of these structures is not possible and rather characterization often requires exogenous contrast agents and manual delineation. Methods We propose a deep learning architecture to automatically delineate the peri-sinus space (e.g., PSD and intravenous AG structures) using two cascaded 3D fully convolutional neural networks applied to submillimeter 3D T 2-weighted non-contrasted MRI images, which can be routinely acquired on all major MRI scanner vendors. The method was evaluated through comparison with gold-standard manual tracing from a neuroradiologist (n = 80; age range = 11–83 years) and subsequently applied in healthy participants (n = 1,872; age range = 5-100 years), using data from the Human Connectome Project, to provide exemplar metrics across the lifespan. Dice-Sørensen and a generalized linear model was used to assess PSD and AG changes across the human lifespan using quadratic restricted splines, incorporating age and sex as covariates. Results Findings demonstrate that the PSD and AG volumes can be segmented using T 2-weighted MRI with a Dice-Sørensen coefficient and accuracy of 80.7 and 74.6, respectively. Across the lifespan, we observed that total PSD volume increases with age with a linear interaction of gender and age equal to 0.9 cm3 per year (p

Abstract Bone marrow fibrosis (BMF) is a pathological feature of myelofibrosis, with higher grades associated with poor prognosis. Limited data exist on the association between outcomes and BMF changes. We present BMF data from Janus kinase (JAK) inhibitor–naive patients from SIMPLIFY‐1 (NCT01969838), a double‐blind, randomized, phase 3 study of momelotinib vs ruxolitinib. Baseline and week 24 bone marrow biopsies were graded from 0 to 3 as per World Health Organization criteria. Other assessments included Total Symptom Score, spleen volume, transfusion independence status, and hemoglobin levels. Paired samples were available from 144 and 160 patients randomized to momelotinib and ruxolitinib. With momelotinib and ruxolitinib, transfusion independence was achieved by 87% and 44% of patients with BMF improvement of ≥1 grade and 76% and 56% of those with stable/worsening BMF; there was no association between BMF changes and transfusion independence for either arm (momelotinib, p = .350; ruxolitinib, p = .096). Regardless of BMF changes, hemoglobin levels also generally increased on momelotinib but decreased on ruxolitinib. In addition, no associations between BMF changes and spleen (momelotinib, p = .126; ruxolitinib, p = .407)/symptom (momelotinib, p = .617; ruxolitinib, p = .833) outcomes were noted, and no improvement in overall survival was observed with ≥1‐grade BMF improvement (momelotinib, p = .395; ruxolitinib, p = .407). These data suggest that the anemia benefit of momelotinib is not linked to BMF changes, and question the use of BMF assessment as a surrogate marker for clinical benefit with JAK inhibitors.

To support the ongoing management of viral respiratory diseases while transitioning out of the acute phase of the COVID-19 pandemic, many countries are moving toward an integrated model of surveillance for SARS-CoV-2, influenza virus, and other respiratory pathogens. Although many surveillance approaches catalyzed by the COVID-19 pandemic provide novel epidemiologic insight, continuing them as implemented during the pandemic is unlikely to be feasible for nonemergency surveillance, and many have already been scaled back. Furthermore, given anticipated cocirculation of SARS-CoV-2 and influenza virus, surveillance activities in place before the pandemic require review and adjustment to ensure their ongoing value for public health. In this report, we highlight key challenges for the development of integrated models of surveillance. We discuss the relative strengths and limitations of different surveillance practices and studies as well as their contribution to epidemiologic assessment, forecasting, and public health decision-making.

This paper introduces Xanthomelon amurndamilumila sp. nov., a newly-discovered land snail species inhabiting the North East Isles, offshore from Groote Eylandt (= Ayangkidarrba), north-western Gulf of Carpentaria, in the Northern Territory, Australia. Specimens of this species were first collected during the 2021 Bush Blitz expedition to Groote Eylandt, a large offshore archipelago previously unexplored for land snails. The taxonomic status of the new species was established through a comprehensive analysis of comparative morphology and mitochondrial genetics: X. amurndamilumila forms a maximally supported clade closely related to X. arnhemense and is characterised by a unique combination of morphological characteristics, including smaller shell size, distinctive sculpture of collabral ridges and specific features of its reproductive anatomy. The genetic divergence and phylogenetic relationships suggest historical isolation. While the discovery of X. amurndamilumila sp. nov. enriches our understanding of land snail diversity in the Northern Territory, its conservation status is of concern on North East Island because of habitat degradation caused by feral deer.

Abstract CRISPR genome editing approaches theoretically enable researchers to define the function of each human gene in specific cell types, but challenges remain to efficiently perform genetic perturbations in relevant models. In this work, we develop a library cloning protocol that increases sgRNA uniformity and greatly reduces bias in existing genome-wide libraries. We demonstrate that our libraries can achieve equivalent or better statistical power compared to previously reported screens using an order of magnitude fewer cells. This improved cloning protocol enables genome-scale CRISPR screens in technically challenging cell models and screen formats.

Abstract The circadian clock regulator Bmal1 modulates tumorigenesis, but its reported effects are inconsistent. Here, we show that Bmal1 has a context-dependent role in mouse melanoma tumor growth. Loss of Bmal1 in YUMM2.1 or B16-F10 melanoma cells eliminates clock function and diminishes hypoxic gene expression and tumorigenesis, which could be rescued by ectopic expression of HIF1α in YUMM2.1 cells. By contrast, over-expressed wild-type or a transcriptionally inactive mutant Bmal1 non-canonically sequester myosin heavy chain 9 (Myh9) to increase MRTF-SRF activity and AP-1 transcriptional signature, and shift YUMM2.1 cells from a Sox10high to a Sox9high immune resistant, mesenchymal cell state that is found in human melanomas. Our work describes a link between Bmal1, Myh9, mouse melanoma cell plasticity, and tumor immunity. This connection may underlie cancer therapeutic resistance and underpin the link between the circadian clock, MRTF-SRF and the cytoskeleton.

Abstract The growing number of scientific publications on climate change has outstripped the capacity of individuals to keep up with the literature, even when confined to selected sub-topics such as chapter sections of IPCC reports. The IPCC would benefit from the assistance of modern technology, the engagement and insights of a far larger pool of experts, and more frequent updates. Here we describe how technology can be tailored to provide asynchronous and connected platforms that can enhance expert’s collaborations through their potential for scalability and inclusivity, and help keep assessments up-to-date. We detail our experience with the ScienceBrief.org platform, which was developed and used during 2017–2021. We show that the timely release of short scientific briefs (e.g. on wildfires), made possible by the platform, led to broad and accurate coverage of science in mainstream and social media, including policy-oriented websites, and therefore served to broaden public exposure and understanding of science, and counter climate misinformation. While a good visual interface and user flow were necessary, incentives were key for expert’s engagement with the platform, which, while positive, remained low. We suggest that a collaborative technology platform like ScienceBrief, tailored to support a modernised process of elaborating IPCC reports, could greatly enhance IPCC assessments by making them more open and accessible, further increasing transparency. It would also enable the comprehensive inclusion of evidence and facilitate broad and high-quality scientific engagement, including from early careers and scientists from around the world. This could first be tested at the scoping stage.

Abstract GCLiPP is a global RNA interactome capture method that detects RNA-binding protein (RBP) occupancy transcriptome-wide. GCLiPP maps RBP-occupied sites at a higher resolution than phase separation-based techniques. GCLiPP sequence tags correspond with known RBP binding sites and are enriched for sites detected by RBP-specific crosslinking immunoprecipitation (CLIP) for abundant cytosolic RBPs. Comparison of human Jurkat T cells and mouse primary T cells uncovers shared peaks of GCLiPP signal across homologous regions of human and mouse 3′ UTRs, including a conserved mRNA-destabilizing cis-regulatory element. GCLiPP signal overlapping with immune-related SNPs uncovers stabilizing cis-regulatory regions in CD5, STAT6, and IKZF1.

Abstract For trace gas sensing and precision spectroscopy, optical cavities incorporating low-loss mirrors are indispensable for path length and optical intensity enhancement. Optical interference coatings in the visible and near-infrared (NIR) spectral regions have achieved total optical losses below 2 parts per million (ppm), enabling a cavity finesse in excess of 1 million. However, such advancements have been lacking in the mid-infrared (MIR), despite substantial scientific interest. Here, we demonstrate a significant breakthrough in high-performance MIR mirrors, reporting substrate-transferred single-crystal interference coatings capable of cavity finesse values from 200 000 to 400 000 near 4.5 µm, with excess optical losses (scatter and absorption) below 5 ppm. In a first proof-of-concept demonstration, we achieve the lowest noise-equivalent absorption in a linear cavity ring-down spectrometer normalized by cavity length. This substantial improvement in performance will unlock a rich variety of MIR applications for atmospheric transport and environmental sciences, detection of fugitive emissions, process gas monitoring, breath-gas analysis, and verification of biogenic fuels and plastics.

Abstract Background Those experiencing houselessness rely on obtaining food from community organizers and donations. Simultaneously, the houseless face disproportionally high rates of medical conditions that may be affected by diet including diabetes, hypertension, and hyperlipidemia. There is limited literature on the resources and barriers of the houseless community regarding optimal nutrition from an actionable perspective. Further, less data is available on how street medicine organizations may best impact the nutrition of the unhoused they serve. Elucidating this information will inform how organizational efforts may best support the nutrition of the houseless community. Methods In partnership with the medical student-run organization, Chicago Street Medicine, at Northwestern University Feinberg School of Medicine, twenty adults experiencing houselessness in Chicago, Illinois participated in the cross-sectional study. A 10-item survey was verbally administered to characterize the participants’ daily food intake, food sources, barriers, resources, and nutritional preferences and needs. All data was directly transcribed into REDCap. Descriptive statistics were generated. Results Individuals consumed a median of 2 snacks and meals per day (IQR: 1–3). No participant consumed adequate servings of every food group, with only one participant meeting the dietary intake requirements for one food group. Participants most often received their food from donations (n = 15), purchasing themselves (n = 11), food pantries (n = 4), and shelters (n = 3). Eleven of nineteen participants endorsed dental concerns as a major barrier to consuming certain foods. Twelve participants had access to a can opener and twelve could heat their meals on a stove or microwave. Seven had access to kitchen facilities where they may prepare a meal. Approximately half of participants had been counseled by a physician to maintain a particular diet, with most related to reducing sugar intake. Conclusion Most houseless participants were unable to acquire a balanced diet and often relied on organizational efforts to eat. Organizations should consider the chronic health conditions, dentition needs, and physical resources and barriers to optimal nutrition when obtaining food to distribute to the unhoused.

AbstractResearch objective Medications for opioid use disorder (MOUDs) – including methadone, buprenorphine, and naltrexone – are the most effective treatments for opioid use disorder (OUD). Historically, insurers have required prior authorization for MOUD, but prior authorization is often reported as a key barrier to MOUD prescribing. Some states have passed laws prohibiting MOUD prior authorization requirements. We sought to identify the frequency of MOUD prior authorization prohibitions in state laws and to categorize types of prohibitions.Methods We searched for regulations and statutes present in all U.S. states and Washington DC between 2005 and 2019 using MOUD-related terms in Westlaw legal software. In qualitative software, we coded laws discussing MOUD prior authorization using template analysis – a mixed deductive/inductive approach. Finally, we used coded laws to identify frequencies of states with prior authorization prohibitions, including changes over time.Results No states had laws prohibiting MOUD prior authorization between 2005 and 2015, with the first prohibition appearing in 2016. By 2019, fifteen states had MOUD prior authorization prohibitions. States varied significantly in their approach to prohibiting MOUD prior authorization. In 2019, it was more common for states to have MOUD prior authorization prohibitions applying to all insurers (n = 10 states) than to only Medicaid (n = 7 states) or only non-Medicaid insurers (n = 1 state). In 2019, general prior authorization prohibitions (n = 10 states) were more common than prohibitions only applicable to medications on the formulary, prohibitions only applicable to medications on the preferred drug list, prohibitions only applicable during the first 5 days of treatment, and prohibitions only applicable during the first 30 days of treatment.Conclusions The number of states with an MOUD prior authorization law prohibition increased in recent years. Such laws could help expand access to life-saving OUD treatments by making it easier for clinicians to prescribe MOUD.KEY MESSAGESNo states had MOUD prior authorization prohibitions between 2005 and 2015 in state statutes or regulations, and only one state had such a prohibition in 2016.By 2019, fifteen states had an MOUD prior authorization prohibition law.States varied significantly in their approach to prohibiting MOUD prior authorization, including with respect to the insurer type, duration of the prohibition, and applicable medication.

Environmental impacts of urbanization, such as increased air pollution, pose significant challenges for developing countries. This study examines land cover changes and their relationship with particulate matter 2.5 (PM2.5) concentrations in two upazilas of Bangladesh from 2001 to 2019 using GIS and remote sensing techniques. Results show significant urban expansion (i.e., increase in built-up area) in both upazilas, corresponding with increasing PM2.5 levels. Linear regression reveals correlations between land cover types and PM2.5 levels. Mixed forests and waterbodies tend to be negatively associated with PM2.5 concentrations; on the other hand, built-up and barren land show a positive correlation with PM2.5. The most significant increase in built-up land and PM2.5 was in Madhabpur, indicating urgent environmental and health issues. This study emphasizes the critical role of sustainable urban planning and environmental conservation in mitigating urbanization’s adverse effects on air quality, advocating for preserving natural landscapes to maintain ecological balance, protecting urban health, and providing policymakers with insights to develop strategies addressing urban expansion and air pollution.

Background: Recent evidence in systems neuroscience suggests that lighting conditions affect the whole chain of brain processing, from retina to high-level cortical networks, for perceptual and cognitive function. Here, visual adaptation levels to three different environmental lighting conditions, (1) darkness, (2) daylight, and (3) prolonged exposure to very bright light akin to sunlight, were simulated in lab to investigate the effects of light adaptation levels on classic cases of subjective contrast, assimilation, and contrast-induced relative depth in achromatic, i.e., ON–OFF pathway mediated visual configurations. Methods: After adaptation/exposure to a given lighting condition, configurations were shown in grouped and ungrouped conditions in random order to healthy young humans in computer-controlled two-alternative forced-choice procedures that consisted of deciding, as quickly as possible, which of two background patterns in a given configuration of achromatic contrast appeared lighter, or which of two foreground patterns appeared to stand out in front, as if it were nearer to the observer. Results: We found a statistically significant effect of the adaptation levels on the consciously perceived subjective contrast (F(2,23) = 20.73; p < 0.001) and the relative depth (F(2,23) = 12.67; p < 0.001), a statistically significant interaction between the adaptation levels and the grouping factor (F(2,23) = 4.73; p < 0.05) on subjective contrast, and a statistically significant effect of the grouping factor on the relative depth (F(2,23) = 13.71; p < 0.01). Conclusions: Visual adaption to different lighting conditions significantly alters the conscious perception of contrast and assimilation, classically linked to non-linear functional synergies between ON and OFF processing channels in the visual brain, and modulates the repeatedly demonstrated effectiveness of luminance contrast as a depth cue; the physically brighter pattern regions in the configurations are no longer consistently perceived as nearer to a conscious observer under daylight and extreme bright light adapted (rod-saturated) conditions.

As of 2024, SARS-CoV-2 continues to propagate and drift as an endemic virus, impacting healthcare for years. The largest sequencing initiative for any species was initiated to combat the virus, tracking changes over time at a full virus base-pair resolution. The SARS-CoV-2 sequencing represents a unique opportunity to understand selective pressures and viral evolution but requires cross-disciplinary approaches from epidemiology to functional protein biology. Within this work, we integrate a two-year genotyping window with structural biology to explore the selective pressures of SARS-CoV-2 on protein insights. Although genotype and the Spike (Surface Glycoprotein) protein continue to drift, most SARS-CoV-2 proteins have had few amino acid alterations. Within Spike, the high drift rate of amino acids involved in antibody evasion also corresponds to changes within the ACE2 binding pocket that have undergone multiple changes that maintain functional binding. The genotyping suggests selective pressure for receptor specificity that could also confer changes in viral risk. Mapping of amino acid changes to the structures of the SARS-CoV-2 co-transcriptional complex (nsp7-nsp14), nsp3 (papain-like protease), and nsp5 (cysteine protease) proteins suggest they remain critical factors for drug development that will be sustainable, unlike those strategies targeting Spike.

Background/Objectives: This study examined the differences in participant force production and pain between a squat maximal voluntary isometric contraction (IMVIC) performed with either a waist belt (WB) or full-body harness (FBH) on the Desmotec D.EVO isoinertial device (D.EVO). Agreement between FBH IMVIC and a traditional force plate squat MVIC (TMVIC) was also assessed. Methods: Twenty adults completed FBH, WB, and TMVIC assessments on two separate occasions. Two-way treatment x time ANOVAs were conducted to compare force outputs and pain between treatments (FBH vs. WB) across time. Test-retest reliability was assessed using intraclass correlation coefficients. Associations between outcomes were determined using Pearson’s r. Standard error of estimate, constant error, total error, and Bland-Altman plots were used to assess agreement between IMVIC and TMVIC. Results: FBH and WB IMVIC exhibited good to excellent reliability (ICC2,1 = 0.889–0.994) and strong associations (r = 0.813 and 0.821, respectively) when compared to TMVIC. However, agreement between FBH and TMVIC was poor. No significant interaction or main effects were observed for pain. FBH maximum isometric force (MIF) was significantly higher than WB MIF. WB IMVIC was the only significant predictor of TMVIC (R2 = 0.674). Conclusions: Our findings indicate that the D.EVO should not be utilized as a replacement for a traditional MVIC setup.