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Dental disease in childhood has the potential to inform about food availability, social status, and feeding practices, in addition to contributing to a child’s overall health status. This paper presents the first comprehensive overview of carious lesion frequencies in 433 non-adults (1-17 years), and 6,283 erupted permanent and deciduous teeth from 15 urban and rural Romano-British settlements. Pooled deciduous and permanent caries rates were significantly higher in major urban sites (1.8%) compared to rural settlements (0.4%), with children from urban sites having significantly higher lesion rates in the deciduous dentition (3.0%), and in younger age groups with mixed dentitions. The differences in dental caries between urban and rural populations suggest disparities in maternal oral health, early childhood feeding practices, food preparation and access to refined carbohydrates. A richer, perhaps more ‘Roman’, cuisine was eaten in the urban settlements, as opposed to a more modest diet in the countryside. The effect of early childhood stress on caries frequency was explored using evidence for enamel hypoplasia. Co-occurrence of caries and enamel hypoplasia was highest in the major urban cohort (5.8%) and lowest in the rural sample (1.3%), suggesting that environmental stress was a contributing factor to carious lesion development in Romano-British urban children.

Histoplasmosis is a common fungal infection, normally infecting people exposed to demolition sites or bat/bird droppings in the central and eastern states. When a child presents with a chest mass and eosinophilia in a non-endemic region the likelihood of an infectious process like pulmonary histoplasmosis is unknown. A seven year old immunocompetent child with a mediastinal mass and eosinophilia presented with acute cough, fever, non-bloody emesis, and four pound weight loss. A neoplastic work up was negative. Further evaluation showed a positive M band (chronic histoplasmosis infection) and negative H band (acute infection). Tissue obtained by thoracotomy demonstrated necrotizing granulomatous inflammation with calcification consistent with histoplasmosis. Patient recovered after completion of a twelve week course of itraconazole. A mediastinal mass in a symptomatic child has a 50% risk of cancer as the primary diagnosis. The Infectious Disease Society of America guidelines recommend treatment of histoplasmosis granulomatous disease with itraconazole if symptomatic and surgery only for obstruction. Thus our patient did not have a clear indication for surgery. In a child with a mediastinal mass, despite low risk factors should they be evaluated for a fungal infection prior to invasive surgery? This case demonstrates that histoplasmosis can cause a granuloma in a non-endemic region and that an infectious etiology ought to be considered when working up a symptomatic child with a chest mass as it may prevent unnecessary surgery. Keywords: Histoplasmosis, Fungal, Cough, Chest mass, Eosinophilia, Thoracotomy, Mediastinal

Background: The government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. © Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0) in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round. Objectives: The study aims were to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances. Design: A multimethod study design was undertaken using realist evaluation methodology. The study was conducted in four phases: (1) theory development; (2) a national survey of all NHS acute trusts in England; (3) in-depth case studies of six wards, involving individual interviews, observations, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of the study findings. Setting: The study was conducted in acute NHS trusts in England. Participants: A total of 108 acute NHS trusts participated in the survey. Seventeen senior managers, 33 front-line nurses, 28 non-nursing professionals, 34 patients and 28 carers participated in individual interviews. Thirty-nine members of nursing staff were shadowed during their delivery of intentional rounding and the direct care received by 28 patients was observed. Review methods: A realist synthesis was undertaken to identify eight context–mechanism–outcome configurations, which were tested and refined using evidence collected in subsequent research phases. Results: The national survey showed that 97% of NHS trusts had implemented intentional rounding in some way. Data synthesis from survey, observation and interview findings showed that only two of the original eight mechanisms were partially activated (consistency and comprehensiveness, and accountability). The evidence for two mechanisms was inconclusive (visibility of nurses and anticipation); there was minimal evidence for one mechanism (multidisciplinary teamwork and communication) and no evidence for the remaining three (allocated time to care, nurse–patient relationships and communication, and patient empowerment). A total of 240 intentional rounds were observed within 188 hours of care delivery observation. Although 86% of all intentional rounding interactions were observed to be documented, fidelity to the original intervention [i.e. the Studer Group protocol (Studer Group. Best Practices: Sacred Heart Hospital, Pensacola, Florida. Hourly Rounding Supplement. Gulf Breeze, FL: Studer Group; 2007)] was generally low. Limitations: Intentional rounding was often difficult for researchers to observe, as it was rarely delivered as a discrete activity but instead undertaken alongside other nursing activities. Furthermore, a lack of findings about the influence of intentional rounding on patient outcomes in the safety thermometer data limits inferences on how mechanisms link to clinical outcomes for patients. Conclusions: The evidence from this study demonstrates that the effectiveness of intentional rounding, as currently implemented and adapted in England, is very weak and falls short of the theoretically informed mechanisms. There was ambivalence and concern expressed that intentional rounding oversimplifies nursing, privileges a transactional and prescriptive approach over relational nursing care, and prioritises accountability and risk management above individual responsive care. Future work: It is suggested that the insights and messages from this study inform a national conversation about whether or not intentional rounding is the optimum intervention to support the delivery of fundamental nursing care to patients, or if the time is right to shape alternative solutions. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Post-exertional malaise (PEM) is the hallmark clinical feature of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). PEM involves a constellation of substantially disabling signs and symptoms that occur in response to physical, mental, emotional, and spiritual over-exertion. Because PEM occurs in response to over-exertion, physiological measurements obtained during standardized exertional paradigms hold promise to contribute greatly to our understanding of the cardiovascular, pulmonary, and metabolic states underlying PEM. In turn, information from standardized exertional paradigms can inform patho-etiologic studies and analeptic management strategies in people with ME/CFS. Several studies have been published that describe physiologic responses to exercise in people with ME/CFS, using maximal cardiopulmonary testing (CPET) as a standardized physiologic stressor. In both non-disabled people and people with a wide range of health conditions, the relationship between exercise heart rate (HR) and exercise workload during maximal CPET are repeatable and demonstrate a positive linear relationship. However, smaller or reduced increases in heart rate during CPET are consistently observed in ME/CFS. This blunted rise in heart rate is called chronotropic intolerance (CI). CI reflects an inability to appropriately increase cardiac output because of smaller than expected increases in heart rate. The purposes of this review are to (1) define CI and discuss its applications to clinical populations; (2) summarize existing data regarding heart rate responses to exercise obtained during maximal CPET in people with ME/CFS that have been published in the peer-reviewed literature through systematic review and meta-analysis; and (3) discuss how trends related to CI in ME/CFS observed in the literature should influence future patho-etiological research designs and clinical practice.

Proper determination of cell fates depends on epigenetic information that is used to preserve memory of decisions made earlier in development. Post-translational modification of histone residues is thought to be a central means by which epigenetic information is propagated. In particular, modifications of histone H3 lysine 27 (H3K27) are strongly correlated with both gene activation and gene repression. H3K27 acetylation is found at sites of active transcription, whereas H3K27 methylation is found at loci silenced by Polycomb group proteins. The histones bearing these modifications are encoded by the replication-dependent H3 genes as well as the replication-independent H3.3 genes. Owing to differential rates of nucleosome turnover, H3K27 acetylation is enriched on replication-independent H3.3 histones at active gene loci, and H3K27 methylation is enriched on replication-dependent H3 histones across silenced gene loci. Previously, we found that modification of replication-dependent H3K27 is required for Polycomb target gene silencing, but it is not required for gene activation. However, the contribution of replication-independent H3.3K27 to these functions is unknown. Here, we used CRISPR/Cas9 to mutate the endogenous replication-independent H3.3K27 to a non-modifiable residue. Surprisingly, we find that H3.3K27 is also required for Polycomb target gene silencing despite the association of H3.3 with active transcription. However, the requirement for H3.3K27 comes at a later stage of development than that found for replication-dependent H3K27, suggesting a greater reliance on replication-independent H3.3K27 in post-mitotic cells. Notably, we find no evidence of global transcriptional defects in H3.3K27 mutants, despite the strong correlation between H3.3K27 acetylation and active transcription.

Background: Schwartz Center Rounds® (Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care. Objectives: How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care. Design: (1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation). Setting: (1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey). Participants: (1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings. Results: (1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p

Wild birds are considered the natural reservoir of influenza A viruses (IAVs) making them critical for IAV surveillance efforts. While sea ducks have played a role in novel IAV emergence events that threatened food security and public health, very few surveillance samples have been collected from sea duck hosts. From 2014–2018, we conducted surveillance focused in the Mississippi flyway, USA at locations where sea duck harvest has been relatively successful compared to our other sampling locations. Our surveillance yielded 1662 samples from sea ducks, from which we recovered 77 IAV isolates. Our analyses identified persistence of sea duck specific IAV lineages across multiple years. We also recovered sea duck origin IAVs containing an H4 gene highly divergent from the majority of North American H4-HA with clade node age of over 65 years. Identification of IAVs with long branch lengths is indicative of substantial genomic change consistent with persistence without detection by surveillance efforts. Sea ducks play a role in the movement and long-term persistence of IAVs and are likely harboring more undetected IAV diversity. Sea ducks should be a point of emphasis for future North American wild bird IAV surveillance efforts.

We report reoccurrence of highly pathogenic avian influenza A(H5N2) virus clade 2.3.4.4 in a wild mallard in Alaska, USA, in August 2016. Identification of this virus in a migratory species confirms low-frequency persistence in North America and the potential for re-dissemination of the virus during the 2016 fall migration.

Reduced NME1 expression in melanoma cell lines, mouse models of melanoma, and melanoma specimens in human patients is associated with increased metastatic activity. Herein, we investigate the role of NME1 in repair of double-stranded breaks (DSBs) and choice of double-strand break repair (DSBR) pathways in melanoma cells. Using chromatin immunoprecipitation, NME1 was shown to be recruited rapidly and directly to DSBs generated by the homing endonuclease I-PpoI. NME1 was recruited to DSBs within 30 min, in concert with recruitment of ataxia-telangiectasia mutated (ATM) protein, an early step in DSBR complex formation, as well as loss of histone 2B. NME1 was detected up to 5 kb from the break site after DSB induction, suggesting a role in extending chromatin reorganization away from the repair site. shRNA-mediated silencing of NME1 expression led to increases in the homologous recombination (HR) and non-homologous end-joining (NHEJ) pathways of double-strand break repair (DSBR), and reduction in the low fidelity, alternative-NHEJ (A-NHEJ) pathway. These findings suggest low expression of NME1 drives DSBR towards higher fidelity pathways, conferring enhanced genomic stability necessary for rapid and error-free proliferation in invasive and metastatic cells. The novel mechanism highlighted in the current study appears likely to impact metastatic potential and therapy-resistance in advanced melanoma and other cancers.

Social ritual in a Mexican village is described as structural hierarchy with a common semantic base. Stretches of rule-governed behavior are generated through a series of metaphoric transformations of physiological process. The concordant structure that is so-derived constitutes a semantic network that provides and reinforces cultural equilibrium and shared ideology. [ABSTRACT FROM PUBLISHER]

Research regarding noninvasive brain stimulation technologies for the treatment of mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), and mixed (mTBI/PTSD) trauma syndromes has been increasing exponentially. Technologies with the greatest potential thus far include repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and cranial electrotherapy stimulation (CES). The nature and some of the controversies distinguishing mTBI, PTSD, and mTBI/PTSD are reviewed along with evidence for shared underlying mechanisms. An overview of treatment applications for rTMS, tDCS, and CES are also reviewed. A novel variant of a minute pulsed electromagnetic stimulation technology linked to ongoing electroencephalograph monitoring known as the Flexyx Neurotherapy System is introduced with an overview of the technology and technique, as well as a summary of supportive data to date that explores potential applications for amelioration of these syndromes.

Background and objectives: Medical school curricula increasingly seek to promote medical students’ commitment to redressing health disparities, but traditional pedagogical approaches have fallen short of this goal. The objective of this work was to assess the value of using community-based guided tours of disadvantaged neighborhoods to fill this gap. Methods: A total of 50 second-year medical students participated in a guided tour of disadvantaged public housing neighborhoods in Richmond, Virginia. Students completed self-reflexive writing exercises during a post-tour debriefing session. Student writings were analyzed to assess the tour’s effect on their awareness of poverty’s impact on vulnerable populations’ health and wellbeing, and their personal reactions to the tour. Results: Student writings indicated that the activity fostered transformative learning experiences around the issue of poverty and its effects on health and stimulated a personal commitment to working with underserved populations. Themes from qualitative analysis included: increased awareness of the extent of poverty, enhanced self-reflexive attitude towards personal feelings, biases and misperceptions concerning the poor, increased intentional awareness of the effects of poverty on patient health and well-being, and, encouragement to pursue careers of medical service. Conclusions: This pilot demonstrated that incorporating self-reflexive learning exercises into a brief community-based guided tour can enhance the social consciousness of medical students by deepening understandings of health disparities and promoting transformative learning experiences.

Patients with human immunodeficiency virus (HIV) have an increased risk of inoculation with nontyphoid Salmonella compared to the general population. While nontyphoid Salmonella commonly manifests as gastroenteritis, Salmonella bacteremia can be seen in patients with HIV. We present a case of disseminated Salmonellosis in a patient with HIV complicated by bronchopleural fistula and secondary empyema. Case Presentation. A 40-year-old African American male with HIV noncompliant with HAART therapy presented with complaints of generalized weakness, weight loss, cough, night sweats, and nonbloody, watery diarrhea of four weeks’ duration. A computed tomography (CT) scan demonstrated a bilobed large, thick-walled cavitary lesion in the right upper lobe communicating with the pleural space to form a bronchopleural fistula. Thoracentesis yielded growth of nontyphi Salmonella species consistent with empyema; he was treated with intravenous Ceftriaxone and underwent placement of chest tube for drainage of empyema with instillation of alteplase/dornase twice daily for three days. Repeat CT chest showed a hydropneumothorax. The patient subsequently underwent video-assisted thoracoscopy with decortication. The patient continued to improve and follow-up CT chest demonstrated improved loculated right pneumothorax with resolution of the right bronchopleural fistula and resolution of the cavitary lesions. Discussion. We describe one of the few cases of development of bronchopulmonary fistula and the formation of empyema in the setting of disseminated Salmonella. Empyema complicated by bronchopulmonary fistula likely led to failure of intrapleural fibrinolytic therapy and the patient ultimately required decortication in addition to antibiotics. While Salmonella bacteremia can be seen in immunocompromised patients, extraintestinal manifestations of Salmonella infection such as empyema and bronchopleural fistulas are uncommon. Bronchopleural fistulas most commonly occur as a postoperative complication of pulmonary resection. Conclusions. This case highlights the unusual pulmonary manifestations that can occur due to disseminated Salmonella in an immunocompromised patient as well as complex management decisions related to these complications.

Immersive Virtual Learning Environments (IVLEs) are an increasingly popular tool used extensively in modern training techniques, but little is known about the learning transfer process accompanying curricula based on these methods and the ability of the technique to teach procedures. As an advantageous instrument in teaching and developing psychomotor and spatial activities, further research and assessment into the strengths and applications of IVLE in training activities is needed to evaluate the contributions of this tool in transportation training and development. Using a highway flagman IVLE training program, the purpose of this study was to evaluate the learning experience and learning gains of participants enrolled in the training. The training program's successes in reaching a wide range of learners and recreating real-world situations support the use of IVLE-based learning to increase engagement and knowledge transfer.

Novel Eurasian lineage avian influenza A(H5N8) virus has spread rapidly and globally since January 2014. In December 2014, H5N8 and reassortant H5N2 viruses were detected in wild birds in Washington, USA, and subsequently in backyard birds. When they infect commercial poultry, these highly pathogenic viruses pose substantial trade issues.

Repulsive guidance molecule A (RGMa) is a potent inhibitor of neuronal regeneration and a regulator of cell death, and it plays a role in multiple sclerosis (MS). In autopsy material from progressive MS patients, RGMa was found in active and chronic lesions, as well as in normal-appearing gray and white matter, and was expressed by cellular meningeal infiltrates. Levels of soluble RGMa in the cerebrospinal fluid were decreased in progressive MS patients successfully treated with intrathecal corticosteroid triamcinolone acetonide (TCA), showing functional improvements. In vitro, RGMa monoclonal antibodies (mAbs) reversed RGMa-mediated neurite outgrowth inhibition and chemorepulsion. In animal models of CNS damage and MS, RGMa antibody stimulated regeneration and remyelination of damaged nerve fibers, accelerated functional recovery, and protected the retinal nerve fiber layer as measured by clinically relevant optic coherence tomography. These data suggest that targeting RGMa is a promising strategy to improve functional recovery in MS patients.

Based on the floristic composition and structural aspects, the formation tropical dry forest of the reserve "Los Besotes" (Valledupar, Cesar; 248 y 1046m of altitude) was characterized. In 35 individuals from nine dominant tree species in two forest types, the phenological characteristics were assessed. Seven monitoring were performed along one year according to the scheme of distribution of rainfall. The leaf fall in the forests of Myrcianthes aff. fragrans and Brosimum alicastrum did not exceed 20% regardless of the climatic period (drought or rainy seasons). In others dominant understory species the leaf fall was less than 40%, thus species of the canopy are classified as evergreen while those of the understory as semideciduous. Blooming peaked during the dry season while fruit production peaked during the two rainy seasons. In the forest ofBursera simaruba and Pterocarpus acapulcensis the leaf fall exceeded 60% in the dry season, while in the rainy season was only 30%. The leaf fall increased to 60% in others dominant understory species. Both canopy as well as understory species are deciduous. Blooming was observed during the dry season (December to March, and July), but it is also likely to occur in October; fruit production was observed at the end of the rainy season. In the tropical dry forest formation evergreen plant communities with low values of leaf fall (40%) and deciduous communities with values greater than 60% are recognized.

Asian highly pathogenic avian influenza A(H5N8) viruses spread into North America in 2014 during autumn bird migration. Complete genome sequencing and phylogenetic analysis of 32 H5 viruses identified novel H5N1, H5N2, and H5N8 viruses that emerged in late 2014 through reassortment with North American low-pathogenicity avian influenza viruses.