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Despite improvements in medical management of head and neck cancers, positive surgical margin rates have remained relatively unchanged in the past 30 years, emphasizing a need for improved intraoperative imaging and tumor visualization. This review provides a detailed summary on preoperative anatomic imaging techniques, nonspecific fluorescence imaging modalities, the recent emergence of tumor-targeting fluorophores for intraoperative imaging, and the future of fluorescence-guided surgery in head and neck cancer.

Control of the arboviral disease vector Aedes aegypti has shown variable levels of efficacy around the globe. We evaluated an Autocidal Gravid Ovitrap (AGO) intervention as a stand‐alone control tool for population suppression of A. aegypti in US communities bordering Mexico.We conducted a cluster randomized crossover trial with weekly mosquito surveillance of sentinel households from July 2017 to December 2018. The intervention took place from August to December of both years. Multilevel models (generalized linear and additive mixed models) were used to analyse the changes in population abundance of female A. aegypti.We observed that female populations were being suppressed 77% (2018) and four times lower outdoor female abundance when AGO coverage (number of intervention AGO traps that surrounded a sentinel home) was high (2.7 AGOs/house). However, we also observed that areas with low intervention AGO coverage resulted in no difference (2017) or slightly higher abundance compared to the control. These results suggest that coverage rate might play a critical role on how populations of female A. aegypti are being modulated in the field. The lack of larval source habitat reduction and the short duration of the intervention period might have limited the A. aegypti population suppression observed in this study. Synthesis and applications. The mosquito, A. aegypti, is a public health concern in most tropical and subtropical regions. With the rise of insecticide resistance, the evaluation of non‐chemical tools has become pivotal in the fight against arboviral disease transmission. Our study shows that the AGO intervention, as a stand‐alone control tool, is limited by its coverage in human settlements. Vector control programmes should consider, that if the target coverage rate is not achieved, measures will be ineffective unless coupled with other control approaches. Although our multilevel modelling was focused on A. aegypti and the AGO, the approach can be applied to other mosquito vector species., The mosquito, A. aegypti, is a public health concern in most tropical and subtropical regions. With the rise of insecticide resistance, the evaluation of non‐chemical tools has become pivotal in the fight against arboviral disease transmission. Our study shows that the AGO intervention, as a stand‐alone control tool, is limited by its coverage in human settlements. Vector control programmes should consider, that if the target coverage rate is not achieved, measures will be ineffective unless coupled with other control approaches. Although our multilevel modelling was focused on A. aegypti and the AGO, the approach can be applied to other mosquito vector species.

South Texas has experienced local transmission of Zika virus and of other mosquito-borne viruses such as chikungunya virus and dengue virus in the last decades. Using a mosquito surveillance program in the Lower Rio Grande Valley (LRGV) and San Antonio, TX, from 2016 to 2018, we detected the presence of an insect-specific virus, cell fusing agent virus (CFAV), in the Aedes aegypti mosquito population. We tested 6,326 females and 1,249 males from the LRGV and 659 females from San Antonio for CFAV by RT-PCR using specific primers. Infection rates varied from 0 to 261 per 1,000 mosquitoes in the LRGV and 115 to 208 per 1,000 in San Antonio depending on the month of collection. Infection rates per 1,000 individuals appeared higher in females collected from BG Sentinel 2 traps compared to Autocidal Gravid Ovitraps, but the ratio of the percentage of infected pools did not differ by trap type. The natural viral load in individual males ranged from 1.25 x 102 to 5.50 x 106 RNA copies and in unfed females from 5.42 x 103 to 8.70 x 106 RNA copies. Gravid females were found to harbor fewer viral particles than males and unfed females.

Aedes aegypti is the main vector of arboviral diseases such as dengue, chikungunya and Zika. A key feature for disease transmission modeling and vector control planning is adult mosquito dispersal. We studied Ae aegypti adult dispersal by conducting a mark-capture study of naturally occurring Ae. aegypti from discarded containers found along a canal that divided two residential communities in Donna, Texas, USA. Stable isotopes were used to enrich containers with either 13C or 15N. Adult mosquitoes were collected outdoors in the yards of households throughout the communities with BG Sentinel 2 traps during a 12-week period. Marked mosquito pools with stable isotopes were used to estimate the mean distance travelled using three different approaches (Net, Strip or Circular) and the probability of detecting an isotopically marked adult at different distances from the larval habitat of origin. We consistently observed, using the three approaches that male (Net: 220 m, Strip: 255 m, Circular: 250 m) Ae. aegypti dispersed further in comparison to gravid (Net: 135 m, Strip: 176 m, Circular: 189 m) and unfed females (Net: 192 m, Strip: 213 m, Circular: 198 m). We also observed that marked male capture probability slightly increased with distance, while, for both unfed and gravid females, such probability decreased with distance. Using a unique study design documenting adult dispersal from natural larval habitat, our results suggest that Ae. aegypti adults disperse longer distances than previously reported. These results may help guide local vector control authorities in their fight against Ae. aegypti and the diseases it transmits, suggesting coverage of 200 m for the use of insecticides and innovative vector control tools.

Tick-borne pathogens pose a significant risk to livestock, wildlife and public health. Host-seeking behaviours may depend on a combination of infection status and environmental factors. Here, we assessed the effects of habitat type and pathogen infection on host-seeking behaviour (questing) in the lone star tick, Amblyomma americanum. Ticks were collected using a tick drag from two different habitat types: xeric hammock and successional hardwood forests. Using a standardized assay, we recorded the likelihood of questing for each tick, the average height quested and total time spent questing and then tested each tick for the presence of Rickettsia spp. and Ehrlichia spp. using conventional polymerase chain reaction. We did not detect Ehrlichia in any ticks, although 30% tested positive for Rickettsia amblyommatis, a member of the Rickettsia spotted fever group. Ticks infected with R. amblyommatis spent less time questing compared to uninfected ticks, with infected ticks spending 85 s on average questing and uninfected ticks spending 112 s. Additionally, ticks collected from xeric hammock habitats spent over twice as long questing compared to ticks from successional hardwood forests. Ticks from xeric hammock spent 151 s on average questing while ticks from successional hardwood forest spent only 58 s during a 10-min observation period. These results demonstrate that habitat type and infection status can influence tick host-seeking behaviours, which can play a pivotal role in disease dynamics.

Aims COVID-19 has impacted diagnosis and treatment of colorectal cancer. Efforts to minimise patient contact have caused delays in cancer pathways, generating a potential risk to patient care. We aim to identify the pandemic effect on colorectal referral pathways. Methods All cancer referrals during March-June 2020 were reviewed to obtain information on the timeline and planning of investigation and treatment. The data was compared to evidence from the same referral period in 2019. Results 681 referrals were received during March-June 2020, compared to 1032 in 2019, indicating a 34% decrease. The majority of patients were reviewed in telephone clinic (76.2%) rather than physical appointments (15.4%). Although the commonest mode of investigation was endoscopy(46.2%), there was increased use of CT scan(35.8%). 114(17.1%) patients were not investigated, of which 40(35.1%) declined investigation, primarily due to COVID-19 apprehension. 6 patients were re-referred and 67(58.8%) were removed from the pathway for unknown reasons. 1 patient was subsequently admitted as an emergency. There were 44 new diagnoses of colorectal cancer based on MDT discussion, of which 14(31.8%) breached the investigation and 20(45.5%) the treatment date. 18 underwent curative surgery compared to 47 in the same period in 2019, indicating 61.7% less operative activity. Conclusions COVID-19 has changed surgical practice, forcing alternative clinic, investigation and treatment methods. Disruption of colorectal pathways is causing reduced referrals, investigation delays and less surgical activity. Delayed presentation with advanced disease may deprive the opportunity of treatment with curative intent.

Effective mosquito surveillance and management depend on a thorough understanding of the biology and feeding patterns unique to species and sex. Given that a propensity to sugar feed is necessary for some mosquito surveillance and newer control strategies, we sought to document the amount of total sugar in wild Aedes aegypti (L.) and Culex quinquefasciatus (Say) captured from five different locations in the Lower Rio Grande Valley (LRGV) of South Texas over 2 yr. We used Biogents Sentinel 2 (BGS2) traps in year 1 and aspirators, BGS2, and CDC resting traps in years 2 and 3 to collect adult mosquitoes. The hot anthrone test was used to quantify total sugar content in each mosquito. Additionally, the cold and hot anthrone tests were used to distinguish fructose content from total sugars for mosquitoes captured in 2019. Overall, Ae. aegypti females had significantly lower total sugar content than Ae. aegypti males as well as both sexes of Cx. quinquefasciatus. However, the percentage of Ae. aegypti positive for fructose consumption was four to eightfold higher than Ae. aegypti previously reported in other regions. The difference between locations was significant for males of both species, but not for females. Seasonality and trapping method also revealed significant differences in sugar content of captured mosquitoes. Our results reinforce that sugar feeding in female Ae. aegypti is less than Cx. quinquefasciatus, although not absent. This study provides necessary data to evaluate the potential effectiveness of sugar baits in surveillance and control of both Ae. aegypti and Cx. quinquefasciatus mosquitoes.

African swine fever virus (ASFV) continues to threaten global animal health and agricultural biosecurity. Mitigating the establishment of ASFV in the United States (U.S.) is contingent on (1) the identification of arthropod vectors and vertebrate hosts that are capable of viral maintenance and transmission in the U.S. and (2) knowledge of vector-host associations that may permit transmission. We aggregated data on vector competence, host competence and tick–host associations by systematic review of published articles and collection records to identify species that may support the invasion of ASFV in the U.S. Three species of competent soft ticks occur in the U.S., Ornithodoros coriaceus, Ornithodoros turicata, and Ornithodoros puertoricensis, however, vector competence for the majority of soft ticks in the U.S. remains unknown. Three species of competent vertebrate hosts currently occur in the U.S.: domestic pigs (Sus scrofa domesticus), feral hogs (Sus scrofa), and common warthogs (Phacochoerus africanus). Hierarchical hazard categories based on vector competence, tick–host contact rates, and vector abundance were used to semiquantitatively rank U.S. soft tick species by their relative risk for contributing to ASFV transmission to identify which soft tick species are a priority for future studies. High-risk vector and host species identified in this study can be used to focus ASFV risk assessments in the U.S., guide targeted surveillance and control strategies, and proactively prepare for an ASFV incursion event. Results indicate O. coriaceus, O. turicata, and O. puertoricensis demonstrate the highest relative risk for contributing to ASFV transmission in the U.S., however, many gaps in knowledge exist preventing the full evaluation of at least 30 soft tick species in the U.S. Further study is required to identify soft tick vectors that interact with feral swine populations, elucidate vector competence, and further understand the biology of soft tick species.

African swine fever virus (ASFV) causes a high-consequence foreign animal disease that has emerged along international trade routes. Owing to high lethality and resulting trade sanctions, establishment of this disease in the United States would have devastating economic consequences. ASFV can be transmitted by soft ticks in the genus Ornithodoros or directly between swine, including domestic, feral, and wild swine. Consequently, the spatial risk of ASFV establishment depends on where susceptible animals, with or without competent vectors, co-occur. We synthesized county-level historical records of soft tick occurrence, current maps of feral swine distribution, and domestic swine inventory to evaluate the risk of ASFV establishment and spillover in the United States. Areas of California, Florida, and much of the southwestern United States were classified as high risk for ASFV establishment and spillover should an introduction event occur. Our analyses indicate that California, Texas, Georgia, and Florida are high-priority candidates for proactive risk reduction strategies. Domestic swine are often produced in high-biosecurity environments, mitigating health risks associated with contacting infected hosts and vectors. However, small-scale and organic pig producers in much of the southern United States remain more vulnerable to disease emergence.

The yellow fever mosquito, Aedes aegypti, has facilitated the re-emergence of dengue virus (DENV) and emergence of chikungunya virus (CHIKV) and Zika virus (ZIKV) in the Americas and the Caribbean. The recent transmission of these arboviruses in the continental United States has been limited, to date, to South Florida and South Texas despite Ae. aegypti occurring over a much larger geographical region within the country. The main goal of our study was to provide the first long term longitudinal study of Ae. aegypti and enhance the knowledge about the indoor and outdoor relative abundance of Ae. aegypti as a proxy for mosquito-human contact in South Texas, a region of the United States that is at high risk for mosquito-borne virus transmission. Here, the relative abundance of indoors and outdoors mosquitoes of households in eight different communities was described. Surveillance was done weekly from September 2016 to April 2018 using the CDC Autocidal Gravid Ovitraps in low- and middle-income communities. A total of 69 houses were included in this survey among which 36 were in the low-income communities (n = 11 for Donna, n = 15 for Progresso, n = 5 for Mesquite, n = 5 for Chapa) and 33 in middle-income communities (n = 9 for La Feria, n = 8 for Weslaco, n = 11 for McAllen, and n = 5 for Rio Rico). Overall, Ae. aegypti was the dominant species (59.2% of collections, n = 7255) followed by Culex spp. mosquitoes (27.3% of collections, n = 3350). Furthermore, we demonstrated for Ae. aegypti that 1) outdoor relative abundance was higher compared to indoor relative abundance, 2) low-income communities were associated with an increase in mosquito relative abundance indoors when compared to middle-income communities, 3) no difference was observed in the number of mosquitoes collected outdoors between low-income and middle-income communities, and 4) warmer months were positively correlated with outdoor relative abundance whereas no seasonality was observed in the relative abundance of mosquitoes indoors. Additionally, Ae. aegypti mosquitoes collected in South Texas were tested using a specific ZIKV/CHIKV multiplex real-time PCR assay, however, none of the mosquitoes tested positive. Our data highlights the occurrence of mosquitoes indoors in the continental United States and that adults are collected nearly every week of the calendar year. These mosquito data, obtained concurrently with local ZIKV transmission of 10 locally acquired cases in nearby communities, represent a baseline for future studies in the Lower Rio Grande Valley (LRGV) including vector control interventions relying on the oviposition behavior to reduce mosquito populations and pathogen transmission.

Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundred and ten patients were included, 403 underwent decision of care withholding/withdrawal, and among them 362 underwent effective care withdrawal. Among the 510 patients, mean CAESAR score was 55/75 (± 6) for nurses and 62/75 (± 5) for physicians (P P = 0.06). CAESAR score and Numeric Analogic Scale were significantly but weakly correlated. They were significantly higher for both nurses and physicians if the patient died after a decision of withholding/withdrawal. In multivariable analysis, among the 362 patients with effective care withdrawal, disagreement on the intensity of life support between caregivers, non-invasive ventilation and monitoring and blood tests the day of death were associated with lower score for nurses. For physicians, cardiopulmonary resuscitation the day of death was associated with lower score in multivariable analysis. Conclusion Experience of EOL was better in patients with withholding/withdrawal decision as compared to those without. Our results suggest that improvement of nurses’ participation in the end-of-life process, as well as less invasive care, would probably improve the experience of EOL for both nurses and physicians. Registration: ClinicalTrial.gov: NCT03392857.

Early childhood education settings can be understood as public forums where adults and children engage together in the implementation of national policy. The authors reflect on ethical dilemmas for leaders in early childhood education arising from the implementation of national policy. Dilemmas can be problematic in the sense that they are unresolved or routine-like as they pervade practice. Inspired by Shapiro and Stefkovich’s framework of multiple ethical paradigms, the authors analyse complex dilemmas arising for leaders in early childhood education as they implement national policy in the micro system with children, families and the community. Leaders are positioned in these contexts as principally concerned with the positive exploration of ethical dilemmas. The authors’ analysis gives visibility to the ways in which leaders may draw on theory and experience in the early childhood education setting to navigate ethical dilemmas within a marketised system. Knowledge of ethics and practice may be tacit, partial and incomplete; however, fragments are pieced together as ethical praxis.

Mosquito-borne viruses are emerging or re-emerging globally, afflicting millions of people around the world. Aedes aegypti, the yellow fever mosquito, is the principal vector of dengue, Zika, and chikungunya viruses, and has well-established populations across tropical and subtropical urban areas of the Americas, including the southern United States. While intense arboviral epidemics have occurred in Mexico and further south in the Americas, local transmission in the United States has been minimal. Here, we study Ae. aegypti and Culex quinquefasciatus host feeding patterns and vertebrate host communities in residential environments of South Texas to identify host-utilization relative to availability. Only 31% of Ae. aegypti blood meals were derived from humans, while 50% were from dogs and 19% from other wild and domestic animals. In Cx. quinquefasciatus, 67% of blood meals were derived from chicken, 22% came from dogs, 9% from various wild avian species, and 2% from other mammals including one human, one cat, and one pig. We developed a model for the reproductive number, R0, for Zika virus (ZIKV) in South Texas relative to northern Mexico using human disease data from Tamaulipas, Mexico. We show that ZIKV R0 in South Texas communities could be greater than one if the risk of human exposure to Ae. aegypti bites in these communities is at least 60% that of Northern Mexico communities. The high utilization of non-human vertebrates and low risk of human exposure in South Texas diminishes the outbreak potential for human-amplified urban arboviruses transmitted by Ae. aegypti.

West Nile virus (WNV) and Flanders virus (FLAV) co-occur in regions of North America. Because both viruses are maintained in a transmission cycle involving Culex mosquitoes and birds, screening mosquitoes for FLAV has been suggested as an enhancement to WNV surveillance and epidemic prediction. Using samples collected in 2010 and 2012 in Chicago, IL, USA, we demonstrate the presence of FLAV in four out of 287 (1.4%) Culex pools. We estimated minimum infection rates for WNV and FLAV to be 5.66 and 1.22 in 2010 and 8.74 and 0.61 in 2012, respectively. FLAV occurred 1 and 3 wk prior to the peak of WNV transmission in 2010 and 2012, respectively. FLAV sequences from Chicago were genetically diverse and phylogenetically representative of lineage A viruses from across the United States.

Several mosquito-borne diseases affecting humans are emerging or reemerging in the United States. The early detection of pathogens in mosquito populations is essential to prevent and control the spread of these diseases. In this study, we tested the potential applicability of the Lawrence Livermore Microbial Detection Array (LLMDA) to enhance biosurveillance by detecting microbes present in Aedes aegypti, Aedes albopictus, and Culex mosquitoes, which are major vector species globally, including in Texas. The sensitivity and reproducibility of the LLMDA were tested in mosquito samples spiked with different concentrations of dengue virus (DENV), revealing a detection limit of >100 but

Much of the bluetongue (BT) and epizootic hemorrhagic disease (EHD) research in North America focuses on white-tail deer and Culicoides sonorensis (Wirth & Jones) (Diptera: Ceratopogonidae), though several other biting midge species have been suggested as vectors. Culicoides stellifer (Coquillett) has been associated with hosts susceptible to hemorrhagic disease (HD), and more recently, specimens from Florida have tested positive for EHD and BT viral RNA. If C. stellifer is acting as a vector, this could have an impact on the distribution of HD in North America. To determine if gene flow is occurring across the range of C. stellifer within the southeast United States, a mitochondrial haplotype analysis was performed using the COI gene. Our haplotype network showed no population structure in C. stellifer from Florida, Texas, and South Carolina, as the overall genetic divergence between these sites was equal to the genetic divergence within each. We also compared these haplotypes to published sequences of C. stellifer collected in Ontario, Canada. Surprisingly, the genetic diversity of the flies from Ontario was two times greater than what was observed between the southeast U.S. collection sites. This considerable divergence could be evidence of a cryptic species. A better understanding of the connectivity between C. stellifer populations across all of North America will give insight into the distribution of HD. Our results show that gene flow is occurring between sites in the southeastern United States and potentially throughout the eastern distribution of the species.

Transgender and gender nonconforming (TGNC) older adults have valuable life experiences that inform the daily practice of healthcare. Recent research shows that TGNC elders report that 35% of their providers knew little or nothing about TGNC health (James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M (2016) The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality), and 50% stated that they had to advocate for themselves, in some cases, having to be the main source through which providers learn about the basics of affirmative care (Grant JM, Mottet LA, Tanis J, Herman JL, Harrison J, Keisling M (2010) National transgender discrimination survey report on health and health-care. Washington, DC: National Center for Transgender Equality and the National Gay and Lesbian Task Force). Personal narratives that focus on TGNC elders in health-care are authentic and compelling but rare. This chapter offers the personal stories of 7 TGNC elders. The authors and artists have contributed stories and artwork that speak to their resilience and strength and the real and powerful impact of affirmative care. The letters and artwork are addressed directly to health-care providers, to offer insight and support as providers deepen the quality of care they provide to this community.

Introduction Active surveillance (AS) is an option in the management of men with low-stage, low-risk prostate cancer. These patients, who often require prolonged follow-up, can put a strain on outpatient resources. Nurses are ideally placed to develop advanced roles to help meet this increased demand-a model we have utilised since 2014. We set about to comprehensively evaluate our nurse-led AS (NLAS) programme. Patients and methods An audit of patient notes was carried out to assess compliance with trust and national guidelines. A questionnaire was designed to capture patients' experiences of NLAS. This was piloted and then distributed to all patients in our NLAS programme. A second questionnaire was designed to assess the views of stakeholders within the department. Results Compliance with various aspects of local guidelines ranged from 88.8% to 100%. 143 patients are currently in the programme with a mean duration of AS of 37.03 months. 104 questionnaires were returned. Most of the patients were aware of the role of the nurse prior to their visit, and all were happy to meet with a nurse. All of the patients indicated their confidence in the nurse monitoring their prostate-specific antigen. Among those requiring further investigations, 85.3% were happy with the information they received prior to their tests. Overall, 96.2% were either very satisfied or satisfied with NLAS. All stakeholders held positive views about NLAS. Conclusions NLAS is safe and effective. Patients and stakeholders alike held positive views of the programme.

Background and Purpose Electrical bioimpedance spectroscopy (BIS) allows the evaluation of limb extracellular fluid (R0) and total fluid (Rinf). BIS could facilitate post-surgical oedema evaluation after total knee arthroplasty (TKA), as it is easily performed and is non-invasive. However, neither its applicability in this context nor the influence of metallic implants on measurement has been evaluated. The aim of this study was to evaluate the influence of TKA implants on the BIS R0 and Rinf variables used for oedema evaluation. Method This was a prospective non-randomized comparative clinical trial. One oedema-free group of patients with TKA was compared with a group presenting similar characteristics except for the arthroplasty, to assess the influence of the implant on BIS measurement in the absence of oedema. The TKA group included 15 patients who had undergone surgery more than a year previously, and the control group included 19 patients awaiting TKA surgery. Volume and perimeter measurements served as reference criterions. The lower limb percentage differences for BIS, knee perimeter and volume were calculated. The significance of differences between groups was calculated for all measurement methods, using the Mann–Whitney test. The setting was a Department of Orthopedic Surgery and Traumatology in a university hospital. Results The differences between groups were not significant for R0, Rinf, volume and perimeter. R0 showed the smallest mean difference in limb percentage difference between groups [means (SD): TKA 3.98 (8.09), controls 3.97 (5.16)]. Conclusions The lower-leg percentage difference in the TKA group is comparable with that of healthy subjects. R0 can be used for oedema evaluation following TKA surgery, as there was no sign of alteration from the metallic implant. These findings indicate the potential for early oedema evaluation after TKA. More research is warranted to extensively validate the application of BIS for oedema evaluation after TKA. Copyright © 2012 John Wiley & Sons, Ltd.

To determine the psychometric properties of an adapted version of the Falls Efficacy Scale (FES) in older rehabilitation patients.Cross-sectional survey.Postacute rehabilitation facility in Switzerland.Seventy elderly persons aged 65 years and older receiving postacute, inpatient rehabilitation.Not applicable.FES questions asked about subject's confidence (range, 0 [none]-10 [full]) in performing 12 activities of daily living (ADLs) without falling. Construct validity was assessed using correlation with measures of physical (basic ADLs [BADLs]), cognitive (Mini-Mental State Examination [MMSE]), affective (15-item Geriatric Depression Scale [GDS]), and mobility (Performance Oriented Mobility Assessment [POMA]) performance. Predictive validity was assessed using the length of rehabilitation stay as the outcome. To determine test-retest reliability, FES administration was repeated in a random subsample (n=20) within 72 hours.FES scores ranged from 10 to 120 (mean, 88.7+/-26.5). Internal consistency was optimal (Cronbach alpha=.90), and item-to-total correlations were all significant, ranging from .56 (toilet use) to .82 (reaching into closets). Test-retest reliability was high (intraclass correlation coefficient, .97; 95% confidence interval, .95-.99; P.001). Subjects reporting a fall in the previous year had lower FES scores than nonfallers (85.0+/-25.2 vs 94.4+/-27.9, P=.054). The FES correlated with POMA (Spearman rho=.40, P.001), MMSE (rho=.37, P=.001), BADL (rho=.43, P.001), and GDS (rho=-.53, P.001) scores. These relationships remained significant in multivariable analysis for BADLs and GDS, confirming FES construct validity. There was a significant inverse relationship between FES score and the length of rehabilitation stay, independent of sociodemographic, functional, cognitive, and fall status.This adapted FES is reliable and valid in older patients undergoing postacute rehabilitation. The independent association between poor falls efficacy and increased length of stay has not been previously described and needs further investigations.

Dengue has emerged globally as a major human health problem since the 1950s and is now the most important arboviral disease of humans, infecting nearly 400 million people annually. While some cases are asymptomatic, others can develop a febrile illness (dengue fever) or even progress to severe and fatal dengue. Dengue is caused by any of four closely related but distinct viruses, known as Dengue virus serotype 1 to 4 (DENV-1 to DENV-4) which are maintained in endemic transmission to humans in large urban centers of the tropics by Aedes mosquitoes. Since the early 1960s, Puerto Rico, a major metropolitan center in the Caribbean, has experienced increasingly larger and clinically more severe epidemics following the introduction of all four dengue serotypes. The first dengue hemorrhagic fever epidemic in 1986, and a particularly severe outbreak in 1998 were dominated by novel DENV-4 strains that evolved in Puerto Rico, replacing earlier strains and spreading throughout the region. Sequence characterization of 54 complete DENV-4 genomes and their comparative evolution against 74 previously published viral sequences from the region over several decades shows that DENV-4 strains from these periods were genetically distinct based on unique changes in the envelope and non-structural genes. Their replacement of earlier strains in Puerto Rico progressed rapidly, suggesting that strong natural selection played a role in their fixation. This study confirms that DENVs evolve through rapid lineage turnover driven in part by natural selection and genetic drift.

Replication of arboviruses in their arthropod vectors is controlled by innate immune responses. The RNA sequence-specific break down mechanism, RNA interference (RNAi), has been shown to be an important innate antiviral response in mosquitoes. In addition, immune signaling pathways have been reported to mediate arbovirus infections in mosquitoes; namely the JAK/STAT, immune deficiency (IMD) and Toll pathways. Very little is known about these pathways in response to chikungunya virus (CHIKV) infection, a mosquito-borne alphavirus (Togaviridae) transmitted by aedine species to humans resulting in a febrile and arthralgic disease. In this study, the contribution of several innate immune responses to control CHIKV replication was investigated. In vitro experiments identified the RNAi pathway as a key antiviral pathway. CHIKV was shown to repress the activity of the Toll signaling pathway in vitro but neither JAK/STAT, IMD nor Toll pathways were found to mediate antiviral activities. In vivo data further confirmed our in vitro identification of the vital role of RNAi in antiviral defence. Taken together these results indicate a complex interaction between CHIKV replication and mosquito innate immune responses and demonstrate similarities as well as differences in the control of alphaviruses and other arboviruses by mosquito immune pathways., Author Summary Chikungunya virus (CHIKV) is a mosquito-borne human-pathogenic arbovirus of the Togaviridae family, genus Alphavirus. Arbovirus replication in vectors, such as mosquitoes, is not passively tolerated but leads to immune responses, that control virus infection. These responses therefore represent interesting targets for novel intervention strategies. Mosquito antiviral immune responses, such as small RNA pathways or immune signaling pathways, are increasingly well studied but it is not known which one mediate antiviral effects against CHIKV in particular. Here we screened four key immune responses in vitro for their antiviral potential against CHIKV and only the exogenous RNA interference was found to mediate antiviral activity. This was confirmed in vivo in Aedes aegypti mosquitoes. Immune signaling pathways were not found to mediate antiviral activity but were inhibited by CHIKV. This shows interesting differences and similarities to other mosquito-borne alphaviruses that increase our understanding of alphavirus-mosquito interactions.

This month our pioneers series continues by looking at the work of two educators whose influence is reflected in the resurgence of putting the needs of the child at the heart of early years provision.

This month, the pioneers series continues with a look at two progressive educators whose work exerts a major influence on current early years thinking and practice: Chris Athey and John Dewey.

The pioneers series continues with a look at the impact of two pioneers whose work continues to have a direct influence on the education of young children: Rudolf Steiner and Dr David Weikart.

The pioneers series continues with a look at the work and influence of Colwyn Trevarthen and Vivian Gussin Paley, two current researchers whose observations have led to a greater understanding of play.

The pioneers series continues with a look at the work and influence of Johann Pestalozzi and Maria Montessori, both of whom continue to have a major influence on early years education and learning.

Our series continues with a look at the work of Gunilla Dahlberg and Peter Moss, both of whom take a post-modern approach to early years learning, policy and provision for both children and families.

In the fifth article of our series on pioneers we look at how the reports authored and championed by Sir Christopher Ball, Lady Bridget Plowden and Dame Angela Rumbold influenced education policy.

Margaret Donaldson and Loris Malaguzzi came from very different cultures and backgrounds, but had a similar passion for ensuring that the natural abilities of children were at the heart of early years practice.

In this month's article, Estelle Martin takes a closer look at Jean Piaget and Lev Vygotsky, two of the most influential figures in the history of early childhood education whose influence is still felt today.

The second in this12-part series examining the pioneers and key influences of early years education through the ages examines the work, philosophy and influence of Margaret McMillan and Susan Isaacs.

Detailed observation and assessment are essential practices for all early years practitioners if planning is to be responsive to young children's learning requirements, as Estelle Martin explains.

The number of documents, policies and frameworks that defend and enhance the rights of children grows each year, but how can we be sure our own practice supports them? Estelle Martin explains.

Effective leadership and working collaboratively provide the foundation for high quality childcare and education. Estelle Martin explores methods of nurturing and promoting team ethics.

Estelle Martin examines the role early years settings can play in helping children and families affected by domestic violence.

To investigate the relationship between levels of cognitive impairment and health services utilization in older patients undergoing post-acute rehabilitation.Cross-sectional study.Post-acute rehabilitation facility.Patients (N = 1764) aged 70 years and older admitted over 3 years.Sociodemographic, medical, and functional data were collected upon admission. Based on discharge diagnoses, patients were classified as cognitively intact, cognitively impaired with no dementia (CIND), and demented.Dementia and CIND were diagnosed in 425 (24.1%) and 301 (17.1%) patients, respectively. Gradients from cognitively intact to cognitively impaired to demented patients were observed in median length of stay (19, 22, and 25 days, P.001), and institutionalization rates at discharge (4.2%, 7.6%, and 28.8%, P.001). Among patients discharged home, similar gradients were observed in utilization of home care (68.2%, 79.7%, and 83.3%, P.001) and day care (3.1%, 7.1%, and 14.3%, P.001). After adjustment, compared with cognitively intact patients, only those with dementia still had longer stays (+2.7 days) and increased odds of institutionalization (adjOR 6.1, 95% CI 4.0-9.3, P.001). Among patients discharged home, use of home and day care remained higher in those with dementia (adjOR 1.8, 95% CI 1.2-2.7, P = .005, and adjOR 1.8, 95% CI 1.2-2.7, P = .005, respectively), while CIND patients had higher odds of using home care (adjOR 1.6, 95% CI 1.1-2.4, P = .028).Among patients undergoing post-acute rehabilitation, those with dementia had increased use of both institutional and community care, whereas those with CIND had increased use of home care services only. Future studies should investigate specific strategies susceptible to reduce the related burden on health care systems.

International audience; Abstract The Aedes albopictus mosquito has been involved as the principal vector of recent major outbreaks due to the chikungunya virus (CHIKV). The species is naturally infected by two strains of Wolbachia (wAlbA and wAlbB). Wolbachia infections are thought to have spread by manipulating the reproduction of their hosts; cytoplasmic incompatibility is the mechanism used by Wolbachia to invade natural populations of many insects including Ae. albopictus. Here, we report a study on the effects of removing Wolbachia from Ae. albopictus on CHIKV replication and examine the consequences of CHIKV infection on some life-history traits (survival and reproduction) of Wolbachia-free Ae. albopictus. We found that Wolbachia-free mosquitoes maintained a highly heterogeneous CHIKV replication compared to Wolbachia-infected individuals. In Wolbachia-infected Ae. albopictus, the regular increase of CHIKV followed by a steady viral load from day 4 post-infection onwards was concomitant with a decline in Wolbachia density. This profile was also detected when examining the two key organs for viral transmission, the midgut and the salivary glands. Moreover, Wolbachia-free Ae. albopictus was not altered in life-history traits such as survival, oviposition and hatching characteristics whether infected or not with CHIKV. We found that Wolbachia is not essential for viral replication, its presence could lead to optimize replication from day 4 post-infection onwards, coinciding with a decrease in Wolbachia density. Wolbachia may regulate viral replication in Ae. albopictus, with consequences on survival and reproduction.

Background First described in humans in 1964, reports of co-infections with dengue (DENV) and chikungunya (CHIKV) viruses are increasing, particularly after the emergence of chikungunya (CHIK) in the Indian Ocean in 2005–2006 due to a new variant highly transmitted by Aedes albopictus. In this geographic area, a dengue (DEN) outbreak transmitted by Ae. albopictus took place shortly before the emergence of CHIK and co-infections were reported in patients. A co-infection in humans can occur following the bite of two mosquitoes infected with one virus or to the bite of a mosquito infected with two viruses. Co-infections in mosquitoes have never been demonstrated in the field or in the laboratory. Thus, we question about the ability of a mosquito to deliver infectious particles of two different viruses through the female saliva. Methodology/Principal Findings We orally exposed Ae. albopictus from La Reunion Island with DENV-1 and CHIKV isolated respectively during the 2004–2005 and the 2005–2006 outbreaks on this same island. We were able to show that Ae. albopictus could disseminate both viruses and deliver both infectious viral particles concomitantly in its saliva. We also succeeded in inducing a secondary infection with CHIKV in mosquitoes previously inoculated with DENV-1. Conclusions/Significance In this study, we underline the ability of Ae. albopictus to be orally co-infected with two different arboviruses and furthermore, its capacity to deliver concomitantly infectious particles of CHIKV and DENV in saliva. This finding is of particular concern as Ae. albopictus is still expanding its geographical range in the tropical as well as in the temperate regions. Further studies are needed to try to elucidate the molecular/cellular basis of this phenomenon., Author Summary Dengue (DEN) and chikungunya (CHIK) are two mosquito borne infections transmitted by Aedes mosquitoes in the tropical world. Ae. albopictus has been shown to efficiently transmit the new variant of CHIK virus (CHIKV) that emerged in the Indian Ocean region in 2005. At the same time, this vector is able to sustain outbreaks due to DEN virus (DENV). Since this CHIK emergence, co-infections DENV-CHIKV in humans have been regularly reported. This phenomenon, known for a long time, may be due to two consecutive bites from two mosquitoes infected by one virus or by the bite of a mosquito infected by both viruses. We used two viral strains isolated in La Reunion Island, DENV-1 in 2004 and CHIKV in 2005, and co-infected an autochthonous strain of Ae. albopictus, testing experimentally one of the possible ways to get co-infections in humans. We were able to show the ability of Ae. albopictus to replicate simultaneously both arboviruses and, furthermore, to deliver both infectious viral particles concomitantly in their saliva. This finding is of particular interest since Ae. albopictus is now widely distributed all around the world and still expanding its geographical range.