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Data sharing: The PHOSP-COVID study protocol, consent form, definition, and derivation of clinical characteristics and outcomes, training materials, regulatory documents, information about requests for data access, and other relevant study materials are available online. UK Biobank information can be released once necessary approvals have been obtained. Other data (eg, the R code and protocol) will be made available on reasonable request to the corresponding author. Copyright © 2023 The Author(s). Background: Sleep disturbance is common following hospital admission both for COVID-19 and other causes. The clinical associations of this for recovery after hospital admission are poorly understood despite sleep disturbance contributing to morbidity in other scenarios. We aimed to investigate the prevalence and nature of sleep disturbance after discharge following hospital admission for COVID-19 and to assess whether this was associated with dyspnoea. Methods: CircCOVID was a prospective multicentre cohort substudy designed to investigate the effects of circadian disruption and sleep disturbance on recovery after COVID-19 in a cohort of participants aged 18 years or older, admitted to hospital for COVID-19 in the UK, and discharged between March, 2020, and October, 2021. Participants were recruited from the Post-hospitalisation COVID-19 study (PHOSP-COVID). Follow-up data were collected at two timepoints: an early time point 2–7 months after hospital discharge and a later time point 10–14 months after hospital discharge. Sleep quality was assessed subjectively using the Pittsburgh Sleep Quality Index questionnaire and a numerical rating scale. Sleep quality was also assessed with an accelerometer worn on the wrist (actigraphy) for 14 days. Participants were also clinically phenotyped, including assessment of symptoms (ie, anxiety [Generalised Anxiety Disorder 7-item scale questionnaire], muscle function [SARC-F questionnaire], dyspnoea [Dyspnoea-12 questionnaire] and measurement of lung function), at the early timepoint after discharge. Actigraphy results were also compared to a matched UK Biobank cohort (non-hospitalised individuals and recently hospitalised individuals). Multivariable linear regression was used to define associations of sleep disturbance with the primary outcome of breathlessness and the other clinical symptoms. PHOSP-COVID is registered on the ISRCTN Registry (ISRCTN10980107). Findings: 2320 of 2468 participants in the PHOSP-COVID study attended an early timepoint research visit a median of 5 months (IQR 4–6) following discharge from 83 hospitals in the UK. Data for sleep quality were assessed by subjective measures (the Pittsburgh Sleep Quality Index questionnaire and the numerical rating scale) for 638 participants at the early time point. Sleep quality was also assessed using device-based measures (actigraphy) a median of 7 months (IQR 5–8 months) after discharge from hospital for 729 participants. After discharge from hospital, the majority (396 [62%] of 638) of participants who had been admitted to hospital for COVID-19 reported poor sleep quality in response to the Pittsburgh Sleep Quality Index questionnaire. A comparable proportion (338 [53%] of 638) of participants felt their sleep quality had deteriorated following discharge after COVID-19 admission, as assessed by the numerical rating scale. Device-based measurements were compared to an age-matched, sex-matched, BMI-matched, and time from discharge-matched UK Biobank cohort who had recently been admitted to hospital. Compared to the recently hospitalised matched UK Biobank cohort, participants in our study slept on average 65 min (95% CI 59 to 71) longer, had a lower sleep regularity index (–19%; 95% CI –20 to –16), and a lower sleep efficiency (3·83 percentage points; 95% CI 3·40 to 4·26). Similar results were obtained when comparisons were made with the non-hospitalised UK Biobank cohort. Overall sleep quality (unadjusted effect estimate 3·94; 95% CI 2·78 to 5·10), deterioration in sleep quality following hospital admission (3·00; 1·82 to 4·28), and sleep regularity (4·38; 2·10 to 6·65) were associated with higher dyspnoea scores. Poor sleep quality, deterioration in sleep quality, and sleep regularity were also associated with impaired lung function, as assessed by forced vital capacity. Depending on the sleep metric, anxiety mediated 18–39% of the effect of sleep disturbance on dyspnoea, while muscle weakness mediated 27–41% of this effect. Interpretation: Sleep disturbance following hospital admission for COVID-19 is associated with dyspnoea, anxiety, and muscle weakness. Due to the association with multiple symptoms, targeting sleep disturbance might be beneficial in treating the post-COVID-19 condition. Funding: UK Research and Innovation, National Institute for Health Research, and Engineering and Physical Sciences Research Council. UK Research and Innovation, National Institute for Health Research, and Engineering and Physical Sciences Research Council.

Data sharing statement This is an Open Access article under the CC BY 4.0 license The ISARIC4C protocol, data sharing and publication policy are available at https://isaric4c.net. ISARIC4C's Independent Data and Material Access Committee welcomes applications for access to data and materials (https://isaric4c.net). The PHOSP-COVID protocol, consent form, definition and derivation of clinical characteristics and outcomes, training materials, regulatory documents, information about requests for data access, and other relevant study materials are available online: https://phosp.org/resource/. Access to these materials can be granted by contacting phosp@leicester.ac.uk and Phospcontracts@leicester.ac.uk. All data used in this study is available within ODAP and accessible under reasonable request. Data access criteria and information about how to request access is available online: https://phosp.org/resource/. If criteria are met and a request is made, access can be gained by signing the eDRIS user agreement. Supplementary data are available online at https://www.thelancet.com/journals/ebiom/article/PIIS2352-3964(22)00584-9/fulltext#supplementaryMaterial . Copyright © 2022 The Author(s). Background: Most studies of immunity to SARS-CoV-2 focus on circulating antibody, giving limited insights into mucosal defences that prevent viral replication and onward transmission. We studied nasal and plasma antibody responses one year after hospitalisation for COVID-19, including a period when SARS-CoV-2 vaccination was introduced. Methods: In this follow up study, plasma and nasosorption samples were prospectively collected from 446 adults hospitalised for COVID-19 between February 2020 and March 2021 via the ISARIC4C and PHOSP-COVID consortia. IgA and IgG responses to NP and S of ancestral SARS-CoV-2, Delta and Omicron (BA.1) variants were measured by electrochemiluminescence and compared with plasma neutralisation data. Findings: Strong and consistent nasal anti-NP and anti-S IgA responses were demonstrated, which remained elevated for nine months (p < 0.0001). Nasal and plasma anti-S IgG remained elevated for at least 12 months (p < 0.0001) with plasma neutralising titres that were raised against all variants compared to controls (p < 0.0001). Of 323 with complete data, 307 were vaccinated between 6 and 12 months; coinciding with rises in nasal and plasma IgA and IgG anti-S titres for all SARS-CoV-2 variants, although the change in nasal IgA was minimal (1.46-fold change after 10 months, p = 0.011) and the median remained below the positive threshold determined by pre-pandemic controls. Samples 12 months after admission showed no association between nasal IgA and plasma IgG anti-S responses (R = 0.05, p = 0.18), indicating that nasal IgA responses are distinct from those in plasma and minimally boosted by vaccination. Interpretation: The decline in nasal IgA responses 9 months after infection and minimal impact of subsequent vaccination may explain the lack of long-lasting nasal defence against reinfection and the limited effects of vaccination on transmission. These findings highlight the need to develop vaccines that enhance nasal immunity. Funding: This study has been supported by ISARIC4C and PHOSP-COVID consortia. ISARIC4C is supported by grants from the National Institute for Health and Care Research and the Medical Research Council. Liverpool Experimental Cancer Medicine Centre provided infrastructure support for this research. The PHOSP-COVD study is jointly funded by UK Research and Innovation and National Institute of Health and Care Research. The funders were not involved in the study design, interpretation of data or the writing of this manuscript. This work is supported by the following grants: The PHOSP-COVD study is jointly funded by UK Research and Innovation and National Institute for Health and Care Research (grant references: MR/V027859/1 and COV0319). ISARIC4C is supported by grants from the National Institute for Health and Care Research (award CO-CIN-01) and the Medical Research Council (grant MC_PC_19059) Liverpool Experimental Cancer Medicine Centre provided infrastructure support for this research (grant reference: C18616/A25153). Other grants which have supported this work include: the UK Coronavirus Immunology Consortium [funder reference:1257927], the Imperial Biomedical Research Centre (NIHR Imperial BRC, grant IS-BRC-1215-20013), the Health Protection Research Unit (HPRU) in Respiratory Infections at Imperial College London and NIHR HPRU in Emerging and Zoonotic Infections at University of Liverpool, both in partnership with Public Health England, [NIHR award 200907], Wellcome Trust and Department for International Development [215091/Z/18/Z], Health Data Research UK (HDR UK) [grant code: 2021.0155], Medical Research Council [grant code: MC_UU_12014/12], and NIHR Clinical Research Network for providing infrastructure support for this research. FL is supported by an MRC clinical training fellowship [award MR/W000970/1]. LPH is supported by Oxford NIHR Biomedical Research Centre. AART is supported by a BHF Intermediate Clinical Fellowship (FS/18/13/33281). SLRJ receives support from UKRI, GCRF, Rosetrees Trust, BHIVA, EDCTP, Globvac. JDC has grants from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Gilead Sciences, Grifols, Novartis and Insmed. RAE holds a NIHR Clinician Scientist Fellowship (CS-2016-16-020). AH is currently supported by UK Research and Innovation. NIHR and NIHR Manchester BRC. BR receives support from BHF Oxford Centre of Research Excellence, NIHR Oxford BRC and MRC. SJD is funded by an NIHR Global Research Professorship [NIHR300791]. DW is supported by an NIHR Advanced Fellowship. AH has received support from MRC and the Coronavirus Immunology Consortium (MR/V028448/1). LVW has received support from UKRI, GSK/Asthma + Lung UK and NIHR for this study. MGS has received support from NIHR UK, MRC UK and Health Protection Research Unit in Emerging & Zoonotic Infections, University of Liverpool. JKB is supported by the Wellcome Trust (223164/Z/21/Z) and UKRI (MC_PC_20004, MC_PC_19025, MC_PC_1905, MRNO2995X/1, and MC_PC_20029). PJMO is supported by a NIHR Senior Investigator Award [award 201385]. LT is supported by the Wellcome Trust [clinical career development fellowship grant number 205228/Z/16/Z], the Centre of Excellence in Infectious Diseases Research (CEIDR) and the Alder Hey Charity.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. This nonrandomized trial was designed to pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered over a single weekend for 24 couples that included an active-duty service member or veteran with PTSD who had deployed in support of combat operations following September 11, 2001. All couples completed treatment. Assessments conducted by clinical evaluators 1 and 3 months after the intervention revealed significant reductions in clinician-rated PTSD symptoms (ds = -0.77 and -0.98, respectively) and in patients' self-reported symptoms of PTSD (ds = -0.73 and -1.17, respectively), depression (ds = -0.60 and -0.75, respectively), anxiety (ds = -0.63 and -0.73, respectively), and anger (ds = -0.45 and -0.60, respectively), relative to baseline. By 3-month follow-up, partners reported significant reductions in patients' PTSD symptoms (d = -0.56), as well as significant improvements in their own depressive symptoms (d = -0.47), anxiety (d = -0.60), and relationship satisfaction (d = 0.53), relative to baseline. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for improving patient, partner, and relational well-being in military and veteran couples with PTSD.

Data sharing statement: PHOSP-COVID: The protocol, consent form, definition and derivation of clinical characteristics and outcomes, training materials, regulatory documents, requests for data access and other relevant study materials are available online at https://www.phosp.org. COVIDENCE UK: De-identified participant data will be made available upon reasonable request to the corresponding author. Supplementary data is available online at: https://www.sciencedirect.com/science/article/pii/S2666776223000546?via%3Dihub#appsec1 . Copyright © 2023 The Author(s). Background: The risk factors for recovery from COVID-19 dyspnoea are poorly understood. We investigated determinants of recovery from dyspnoea in adults with COVID-19 and compared these to determinants of recovery from non-COVID-19 dyspnoea. Methods: We used data from two prospective cohort studies: PHOSP-COVID (patients hospitalised between March 2020 and April 2021 with COVID-19) and COVIDENCE UK (community cohort studied over the same time period). PHOSP-COVID data were collected during hospitalisation and at 5-month and 1-year follow-up visits. COVIDENCE UK data were obtained through baseline and monthly online questionnaires. Dyspnoea was measured in both cohorts with the Medical Research Council Dyspnoea Scale. We used multivariable logistic regression to identify determinants associated with a reduction in dyspnoea between 5-month and 1-year follow-up. Findings: We included 990 PHOSP-COVID and 3309 COVIDENCE UK participants. We observed higher odds of improvement between 5-month and 1-year follow-up among PHOSP-COVID participants who were younger (odds ratio 1.02 per year, 95% CI 1.01–1.03), male (1.54, 1.16–2.04), neither obese nor severely obese (1.82, 1.06–3.13 and 4.19, 2.14–8.19, respectively), had no pre-existing anxiety or depression (1.56, 1.09–2.22) or cardiovascular disease (1.33, 1.00–1.79), and shorter hospital admission (1.01 per day, 1.00–1.02). Similar associations were found in those recovering from non-COVID-19 dyspnoea, excluding age (and length of hospital admission). Interpretation: Factors associated with dyspnoea recovery at 1-year post-discharge among patients hospitalised with COVID-19 were similar to those among community controls without COVID-19. Funding: PHOSP-COVID is supported by a grant from the MRC-UK Research and Innovation and the Department of Health and Social Care through the National Institute for Health Research (NIHR) rapid response panel to tackle COVID-19. The views expressed in the publication are those of the author(s) and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health and Social Care. COVIDENCE UK is supported by the UK Research and Innovation, the National Institute for Health Research, and Barts Charity. The views expressed are those of the authors and not necessarily those of the funders. PHOSP-COVID: This study would not be possible without all the participants who have given their time and support. We thank all the participants and their families. We thank the many research administrators, health-care and social-care professionals who contributed to setting up and delivering the study at all of the 65 NHS trusts/Health boards and 25 research institutions across the UK, as well as all the supporting staff at the NIHR Clinical Research Network, Health Research Authority, Research Ethics Committee, Department of Health and Social Care, Public Health Scotland, and Public Health England, and support from the ISARIC Coronavirus Clinical Characterisation Consortium. We thank Kate Holmes at the NIHR Office for Clinical Research Infrastructure (NOCRI) for her support in coordinating the charities group. The PHOSP-COVID industry framework was formed to provide advice and support in commercial discussions, and we thank the Association of the British Pharmaceutical Industry as well NOCRI for coordinating this. We are very grateful to all the charities that have provided insight to the study: Action Pulmonary Fibrosis, Alzheimer's Research UK, Asthma + Lung UK, British Heart Foundation, Diabetes UK, Cystic Fibrosis Trust, Kidney Research UK, MQ Mental Health, Muscular Dystrophy UK, Stroke Association Blood Cancer UK, McPin Foundations, and Versus Arthritis. We thank the NIHR Leicester Biomedical Research Centre patient and public involvement group and Long Covid Support. COVIDENCE UK: We thank all participants of COVIDENCE UK, and the following organisations who supported study recruitment: Asthma UK/British Lung Foundation, the British Heart Foundation, the British Obesity Society, Cancer Research UK, Diabetes UK, Future Publishing, Kidney Care UK, Kidney Wales, Mumsnet, the National Kidney Federation, the National Rheumatoid Arthritis Society, the North West London Health Research Register (DISCOVER), Primary Immunodeficiency UK, the Race Equality Foundation, SWM Health, the Terence Higgins Trust, and Vasculitis UK.

PURPOSE: The cost of cancer care is escalating dramatically, in part because of the rising expense of systemic cancer therapy. This creates financial dilemmas for patients and insurers and potential economic disruption for institutions attempting to provide cancer care to the underserved. Our institution initiated a drug recovery and copay assistance program (DRCAP) to mitigate the impact of the rising cost of parenteral medications. METHODS: We performed a 3-year review of our strategies to mitigate financial burden of parenteral therapeutics and supportive care medicines. Financial metrics were established and analyzed before and after implementing DRCAP. Medication encounters and associated costs were stratified by adolescents and young adults (15 to 39 years of age), and adults 40 years of age and older and were annualized from 2016 to 2018. RESULTS: The DRCAP resulted in a total of nearly $3.5 million worth of drugs replaced or copay assistance yearly in 2017 and 2018. This accounted for approximately 10% of our pharmacy budget for parenteral medications in each of these years. The vast majority was received in the form of drug replacement. The DRCAP resulted in assistance to 173 and 256 patients in 2017 and 2018, respectively. CONCLUSION: A DRCAP increased availability of otherwise unaffordable parenteral oncolytics and resulted in cost savings for our institution. Adolescents and young adults were disproportionately represented because of inadequate or no insurance. Despite the salutary benefits, such programs likely inflate the overall cost of cancer care. Cancer care providers participating in a DRCAP will remain in this conundrum until market forces can affect the cost of oncology therapeutics.

The past decade has witnessed a rapid increase in the number of frozen-thawed embryo transfer (FET) cycles. Several factors have contributed to the increase in FET cycles, including improvement in culture media, vitrification, and an increase in preimplantation genetic testing of embryos. However, the accelerated trend in FET cycles also suggests that FET may be preferred over fresh embryo transfer. The current review explores the factors that have influenced this practice shift toward preferential FET and why this shift may be premature.

Study question Can sequencing the sperm genome provide insight into the various forms of male factor infertility caused by sperm organelle ultrastructural defects? Summary answer A comprehensive genomic assessment of spermatozoal DNA is able to identify genetic causes of ultrastructural defects visualized by transmission electron microscopy (TEM). What is known already To evaluate a man’s reproductive potential, a conventional semen analysis through the assessment of concentration, motility, and morphology can indicate the proficiency of male gametes. Among those, conventional morphology assay can only provide indirect information on the different components of the sperm cell. The assessment of nanoscopic details such as chromatin, centriolar, mitochondrial, and axonemal components can only be observed by TEM. Indeed, TEM has been used to identify defects in the acrosome, chromatin compaction, and axonemal/periaxonemal structures. Furthermore, exome sequencing of spermatozoal DNA may identify novel causes and candidate genes for these ultrastructural defects. Study design, size, duration In the past 2 years, 20 men with history of fertilization failure or severe astheno-/terato-zoospermia were selected for TEM analysis of their spermatozoa, while 3 fertile men served as controls. Sperm head characteristics, intactness of fibrous sheath, and axonemal/periaxonemal structure were examined by diagnostic TEM. For consenting patients, NGS assessment was concurrently performed to identify mutations responsible for the structural abnormalities identified by TEM. Participants/materials, setting, methods TEM was performed on the ejaculates of 20 infertile patients and 3 fertile controls. Post-centrifugation cell pellets were resuspended, fixed, and dehydrated to be infiltrated and embedded onto the resin. Fixed specimens were sliced by ultramicrotome to 100-nm sections, then viewed by JEOL-1400 electron microscope at 300,000X magnification. At least 100 spermatozoa were evaluated by TEM. For consenting patients, DNA was extracted and amplified from at least 500 spermatozoa for concurrent NGS analysis. Main results and the role of chance Four types of sperm ultrastructural defects were observed, including globozoospermia, dysplasia of fibrous sheath (DFS), proximal centriole defect, and primary ciliary dyskinesia (PCD). One combined case of globozoospermia and DFS was identified. In globozoospermic patients (n = 13), 97-100% of the spermatozoa displayed characteristic spherical heads with absence of acrosomes, dispersed chromatin, and perinuclear theca deformities. Centrosomal and axonemal structures were conserved. NGS identified gene deletions (DPY19L, PICK1, SPATA16) directly related to the globozoospermic phenotype. In patients with DFS (n = 4), complete absence of flagellum was observed in 90-100% of spermatozoa. These defective gametes also displayed mitochondria disorganization, microtubular deformities, and cytoplasmic residues containing coiled flagellum with deformed capitulum within the plasma membrane. Contrary to the globozoospermia, acrosomes and nuclei appeared normal, indicating incomplete late spermiogenesis. Indeed, NGS confirmed gene deletions involved in flagellar development/function (AKAP4, SPAG16, CATSPER1). For the patient with proximal centriole defect (n = 1), sperm nucleus, fibrous sheath, and flagellar structure were conserved. However, 90% of proximal centrioles assessed exhibited microtubular disorganization, confirmed by ODF2 mutation per NGS. In the PCD patient (n = 1), chaotic flagellar microtubule arrangement and absence of outer dynein arms were prevalent in 90% of axonemal cross-sections examined, which was explained by a DNAH5 gene deletion. Limitations, reasons for caution While TEM can overcome the limitations of conventional semen analysis by providing direct visualization of the inner organelle arrangement of spermatozoa to accurately diagnose rare sperm pathologies, it is not routinely applied in clinics due to its high cost and technical specifications. Therefore, confirmatory NGS can provide additional diagnostic value. Wider implications of the findings Ultrastructural analysis with a concurrent genomic assessment characterized phenotypes and genotypes of rare sperm pathologies in infertile men. The utilization of TEM, corroborated by genomic assay, is therefore crucial for clinical and translational reproductive medicine to better characterize male factor infertility. Trial registration number N/A

Summary: The activation, growth, and maturation of oocytes to an ovulatory phase, termed folliculogenesis, is governed by the orchestrated activity of multiple specialized cell types within the ovary; yet, the mechanisms governing diversification and behavior of discrete cellular sub-populations within follicles are poorly understood. We use bulk and single-cell RNA sequencing to distinguish the transcriptional signature of prospectively isolated granulosa and theca/stroma cell subsets within human antral follicles derived from xenografts or ovaries. The analysis deconstructs phenotypic diversification within small (

Approximately 14% of military personnel and veterans who have deployed to the combat theater are at risk for combat-related posttraumatic stress disorder (PTSD). The treatment of combat-related PTSD in active duty service members and veterans is challenging. Combat trauma may involve multiple high levels of exposure to different types of traumatic events (e.g., human carnage after explosive blasts, life threat/injuries to self/others, etc.). Many service members and veterans are unable or unwilling to receive treatment in government facilities due to avoidance, scheduling difficulties, transportation or parking problems, concerns about career advancement, or stigma associated with seeking treatment. Innovative treatment-delivery approaches are needed to help overcome these barriers. The present study is a randomized clinical trial to evaluate three versions of Cognitive Processing Therapy (CPT; [54]) for the treatment of combat-related PTSD in active duty military service members and veterans: (1) standard In-Office CPT, (2) In-Home Telebehavioral Health CPT from the provider's office to the participant's home, and (3) In-Home CPT in which the provider delivers treatment in the participant's home. Use of an equipoise-stratified randomization design allows participants to decline one of the treatment arms. This research design partly overcomes the problems active duty military and veterans face when receiving PTSD treatment by allowing them to opt out of one inappropriate or unacceptable treatment modality and still permitting randomization to the two remaining treatment modalities. This manuscript provides an overview of the research design and methods for the study.

Li-S cells can have high gravimetric energy densities above 300 Wh kg−1 when the electrodes and cell components are optimized. Low electrolyte/sulfur mass ratios or more generallly, the relative amount of electrolyte in a Li-S cell have an especially high impact on the achievable gravimetric energy density. A negative side effect of low electrolyte/sulfur ratios are low cycle numbers due to electrolyte decomposition and the possibility that electrolyte becomes inaccessible at the lithium metal anode when the lithium becomes more and more porous during cycling. Electrode thickness measurements were performed during cycling for various cell chemistries such as lithium-sulfur (Li-S) with different cathode sulfur loadings and porosities, lithium-hard carbon (Li-HC), lithium-silicon (Li-Si), prelithiated HC-sulfur (LiHC-S), prelithiated Si-sulfur (LiSi-S) and Li-ion. The thickness measurements provided information about mechanical stress and irreversible thickness changes. The thickness measurements also helped to explain different electrolyte decomposition behavior and they can be used to discuss the impact of thickness changes on gas analysis. The electrolyte decomposition of the Li-S standard electrolyte based on lithium bis(trifluoromethanesulfonyl)imide (LiTFSI) in dimethoxyethane (DME): dioxolane (DIOX) with LiNO3 was examined by online mass spectrometry (MS) within Li-S, Li-HC, Li-Si, LiSi-S and LiHC-S cells. Several electrolyte decomposition products were verified by post-mortem gas chromatography (GC) and gas chromatography-mass spectrometry (GC-MS) of Li-S cells with cycled electrolyte.

Introduction Large, complicated ventral hernias are an increasingly common problem. The transversus abdominis muscle release (TAMR) is a recently described modification of posterior components separation for repair of such hernias. We describe our initial experience with TAMR and sublay mesh to facilitate abdominal wall reconstruction. Methods The study is a retrospective review of patients undergoing TAMR performed synchronously by gastrointestinal and plastic surgeons. Results Twelve consecutive patients had their ventral hernias repaired using the TAMR technique from June 2013 to June 2014. Median body mass index was 30.8kg/m2 (range 19.0–34.4kg/m2). Four had a previous ventral hernia repair. Three had previous laparostomies. Four had previous stomas and three had stomas created at the time of the abdominal wall reconstruction. Average transverse distance between the recti was 13cm (3-20cm). Median operative time was 383 minutes (150–550 minutes) and mesh size was 950cm2 (532–2400cm2). Primary midline fascial closure was possible in all cases, with no bridging. Median length of hospital stay was 7.5 days (4–17 days). Three developed minor abdominal wall wound complications. At median review of 24 months (18–37 months), there have been no significant wound problems, mesh infections or explants, and none has developed recurrence of their midline ventral hernia. Visual analogue scales revealed high patient satisfaction levels overall and with their final aesthetic appearance. Conclusions We believe that TAMR offers significant advantages over other forms of components separation in this patient group. The technique can be adopted successfully in UK practice and combined gastrointestinal and plastic surgeon operating yields good results.

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Campus law enforcement agencies (CLEs) are critical components of the criminal justice system; thus, how they organize is of special interest. CLEs are thought ideal for community policing, a strategy requiring organizational change, yet little research exists on CLE organizations or their use of community policing. This study examines community policing within CLEs and how it impacts organizational structures. The data were gathered in a national BJS survey of CLEs. Results indicated that community policing was only significantly related to formalization. Contrary to community policing mandates, community policing was related to more written policies. Implications and future research are discussed.

Study Objective To investigate the trends in liver function tests (LFTs), renal function tests (RFTs), and complete blood count (CBC) between day 1 and day 7 after single- or double-dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies. Design Single center, retrospective chart review (Canadian Task Force classification II-3). Setting University-affiliated center. Patients All patients with a sonographically confirmed ectopic pregnancy after fresh in vitro fertilization–embryo transfer cycles between January 2004 and June 2013 treated with MTX were included. Interventions Single- or double-dose MTX treatment. Measurements and Main Results LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and total bilirubin levels, were measured on day of MTX administration (baseline) and 7 days later (day 7). Similar measurements of RFTs (blood urea nitrogen [BUN] and creatinine) and CBC (white blood cell [WBC] and platelets) were also performed. The change in LFTs, RFTs, and CBC (Δ) between baseline and day 7 was calculated for both single- and double-dose MTX protocols. Furthermore, the change in LFTs, RFTs, and CBC (Δ baseline vs day 7) for single- and double-dose MTX protocols were compared. Complete data was available for 107 patients: 89 (83.2%) and 18 (16.8%) patients received single- and double-dose MTX treatment, respectively. For either single- or double-dose treatment, no significant difference was found between baseline and day 7 ALT, AST, albumin, total bilirubin, BUN, creatinine, WBC, or platelet levels after MTX treatment. A comparison of post-treatment changes in LFTs, RFTs, and CBC (Δ baseline vs day 7) also showed no difference between single- and double-dose protocols. Conclusion Our study suggests that repeating LFTs, RFTs, or CBC on day 7 after single- or double-dose MTX treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline testing on day 1.

Neurite outgrowth is an important morphological phenotype of neuronal cells that correlates with their function and cell health, yet there are limited methods available for measuring this phenomenon. Current approaches to measuring neurite outgrowth are laborious and time-consuming, relying largely upon immunocytochemical staining of neuronal markers (e.g., beta-III tubulin or MAP2) followed by manual or automated microscopy for image acquisition and analysis. Here we report the development of a quick and simple dual-color fluorescent dye-based staining method that allows for the simultaneous measurement of neuronal cell health and relative neurite outgrowth from the same sample. An orangered fluorescent dye that stains cell membrane surfaces is used as an indirect reporter of changes in relative neurite outgrowth due to alterations in the number or length of membrane projections emanating from neuronal cell bodies. Cell viability is assessed simultaneously via the use of a cell-permeant dye that is converted by intracellular esterase activity from a non-fluorescent substrate to a green-fluorescent product. Using Neuroscreen-1 cells (a PC-12 subclone), primary rat cortex neurons, and human induced pluripotent stem cell (iPSC)-derived neurons, we demonstrate that this multiplex assay allows for rapid visualization and unbiased, quantitative plate reader analysis of neuronal cell health and neurite outgrowth.

Development of more complex, biologically relevant, and predictive cell-based assays for compound screening is a major challenge in drug discovery. The focus of this study was to establish high-throughput compatible three-dimensional (3D) cardiotoxicity assays using human induced pluripotent stem cell-derived cardiomyocytes. Using both high-content imaging and fast kinetic fluorescence imaging, the impact of various compounds on the beating rates and patterns of cardiac spheroids was monitored by changes in intracellular Ca2+ levels with calcium-sensitive dyes. Advanced image analysis methods were implemented to provide multiparametric characterization of the Ca2+ oscillation patterns. In addition, we used confocal imaging and 3D analysis methods to characterize compound effects on the morphology of 3D spheroids. This phenotypic assay allows for the characterization of parameters such as beating frequency, amplitude, peak width, rise and decay times, as well as cell viability and morphological characteristics. A set of 22 compounds, including a number of known cardioactive and cardiotoxic drugs, was assayed at different time points, and the calculated EC50 values for compound effects were compared between 3D and two-dimensional (2D) model systems. A significant concordance in the phenotypes was observed for compound effects between the two models, but essential differences in the concentration responses and time dependencies of the compound-induced effects were observed. Together, these results indicate that 3D cardiac spheroids constitute a functionally distinct biological model system from traditional flat 2D cultures. In conclusion, we have demonstrated that phenotypic assays using 3D model systems are enabled for screening and suitable for cardiotoxicity assessment in vitro.

Objective To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)–intrauterine insemination (IUI) cycles. Design Retrospective cohort study. Setting University-affiliated center. Patient(s) Patients Intervention(s) Ovulation induction, hCG trigger, and IUI. Main Outcome Measure(s) Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size. Result(s) 1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1–22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1–20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89. Conclusion(s) hCG administration at a lead follicle size of 21.1–22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.

Study question Is supraphysiologic estradiol (E2) an independent predictor of low birth weight (LBW) in singletons born after fresh IVF-embryo transfer (ET) cycles? Summary answer Our results suggest that E2 > 2500 pg/ml is an independent predictor for LBW in full-term singletons born to normal responder patients undergoing fresh IVF-ET cycles. What is known already The pathogenesis of LBW in IVF singletons remains unknown. However, recent studies have suggested that the hyperestrogenic milieu generated during ovarian stimulation may create a sub-optimal peri-implantation environment, leading to placental dysfunction, and therefore, LBW. Study design, size, duration Retrospective cohort study of normal responder patients, Participants/materials, setting, methods A total of 6419 patients had live births after fresh IVF-ET during the study period, of which 2348 (36.6%) patients were excluded due to multiple gestation, vanishing twins or incomplete records. Perinatal outcomes recorded for all patients included birth weight, gestational age (GA) at delivery, mode of delivery and gender. Term birth, preterm birth (PTB) and LBW incidence proportions were plotted against E2 level on the day of trigger. The term LBW incidence proportion (i.e. singletons born at GA ≥ 37 weeks with birth weight Main results and the role of chance A total of 4071 patients with live singleton births were included. The median age, BMI, E2 level and birth weight for the study cohort was 36 (33-39) years, 22.3 (20.4-25.0) kg/m2, 1554 (1112.7-2179) pg/ml and 3289 (2920-3628) g, respectively. The incidence proportion of LBW rose from 6.4% (E2 2001-2500 pg/ml) to 20.7% (E2 3501-4000 pg/ml), without a corresponding rise in the incidence proportion of PTB. The odds of term LBW with E2 > 2500 pg/ml were 6.1-7.9 times higher compared to the referent E2 group. Multivariable logistic regression analysis revealed that E2 was an independent predictor for term LBW, even after adjusting for age, BMI, race, parity, infertility diagnosis, duration of ovarian stimulation, gonadotropin dosage and method of insemination (adjusted odds ratio 10.8, 95% CI 9.2-12.5). Receiver operating characteristic analysis generated an AUC estimate of 0.85 for E2 level as a predictor of LBW. Limitations reasons for caution The current study did not include analyses of hypertensive disorders of pregnancy or placental abnormalities. Furthermore, all patients were normal responders and of normal BMI, possibly limiting the overall generalizability of the study. Finally, as with any retrospective study, prospective data are required to validate the role of E2 in predicting LBW. Wider implications of the findings Our results emphasize the importance of minimizing the supraphysiologic elevations of E2 levels during ovarian stimulation in fresh IVF-ET cycles. This, in turn, can optimize the early peri-implantation environment and mitigate adverse perinatal outcomes such as LBW. Study funding/competing interest(s) Dr Paul J. Christos was partially supported by the following grant: Clinical and Translational Science Center at Weill Cornell Medical College (UL1-TR000457-06). Trial registration number N/A.

The current study investigates the utility of random-start ovarian stimulation in women desiring elective oocyte cryopreservation. Women in the study cohort underwent random-start ovarian stimulation, and were subdivided based on the phase of the menstrual cycle that ovarian stimulation began, i.e. early follicular, late follicular or luteal phase. Women undergoing conventional cycle day (CD) 2/3 ovarian stimulation start were controls. A total of 1302 women were included - 859 (66.0%) conventional CD 2/3, 342 (26.3%) early follicular, 42 (3.2%) late follicular and 59 (4.5%) luteal ovarian stimulation starts. There was no difference in the demographics or baseline ovarian stimulation characteristics. The duration of ovarian stimulation (11 versus 9 days; P < 0.001) and total dosage of gonadotrophins administered (4095.5 versus 3155 IU; P < 0.001) was higher in the random-start group. The number of total and MII oocytes in the control and random-start groups was similar. A non-significant trend towards increased cycle cancellation was noted in the late follicular start group (7.1%). Study findings indicate the number of total and MII oocytes derived from random-start protocols initiated during any phase of the menstrual cycle is similar to conventional CD 2/3 ovarian stimulation start protocols in women desiring elective oocyte cryopreservation.

Cell models are becoming more complex to better mimic the in vivo environment and provide greater predictivity for compound efficacy and toxicity. There is an increasing interest in exploring the use of three-dimensional (3D) spheroids for modeling developmental and tissue biology with the goal of accelerating translational research in these areas. Accordingly, the development of high-throughput quantitative assays using 3D cultures is an active area of investigation. In this study, we have developed and optimized methods for the formation of 3D liver spheroids derived from human iPS cells and used those for toxicity assessment. We used confocal imaging and 3D image analysis to characterize cellular information from a 3D matrix to enable a multi-parametric comparison of different spheroid phenotypes. The assay enables characterization of compound toxicities by spheroid size (volume) and shape, cell number and spatial distribution, nuclear characterization, number and distribution of cells expressing viability, apoptosis, mitochondrial potential, and viability marker intensities. In addition, changes in the content of live, dead, and apoptotic cells as a consequence of compound exposure were characterized. We tested 48 compounds and compared induced pluripotent stem cell (iPSC)-derived hepatocytes and HepG2 cells in both two-dimensional (2D) and 3D cultures. We observed significant differences in the pharmacological effects of compounds across the two cell types and between the different culture conditions. Our results indicate that a phenotypic assay using 3D model systems formed with human iPSC-derived hepatocytes is suitable for high-throughput screening and can be used for hepatotoxicity assessment in vitro.

The primary objective of this study is to compare the oocyte yield in breast cancer patients undergoing controlled ovarian stimulation (COS) using letrozole and gonadotropins with patients undergoing COS with standard gonadotropins for elective cryopreservation of oocytes. Odds ratios (OR) for the number of mature oocytes were estimated. Pregnancy outcomes for breast cancer patients undergoing frozen-thawed 2-PN embryo transfers (FETs) after oncologic treatment were also noted. 220 and 451 cycles were identified in the breast cancer and the elective cryopreservation groups, respectively. Patients in the former group had lower peak estradiol levels [464.5 (315.5-673.8) pg/mL] compared to the latter [1696 (1058-2393) pg/mL; p 0.01]. More oocytes were retrieved in the breast cancer group (12.3 ± 3.99) compared to the elective cryopreservation group (10.9 ± 3.86; p 0.01). The odds for mature oocytes with letrozole and gonadotropins was 2.71 (95% CI 1.29-5.72; p = 0.01). Fifty-six FETs occurred in the breast cancer group. The clinical pregnancy and live birth rates per FET cycle were 39.7%, and 32.3%, respectively. Our findings suggest that COS with letrozole and gonadotropins yield more mature oocytes at lower estradiol levels compared to COS with gonadotropins alone. Breast cancer patients undergoing FET after oncologic treatment have live birth rates comparable to age-matched counterparts.

Autophagy involves the isolation and targeting of unwanted cellular components to lysosomes for their digestion and reuse. Autophagic dysregulation has recently been implicated in a wide range of disease processes, yet facile methods for quantifying autophagy have been lacking in the field. Here we describe the generation of a quantitative plate reader assay for measuring the autophagic activity of cells. One of the best characterized autophagy markers is the protein LC3B, which normally resides in the cytosol (LC3B-I) but upon induction of autophagy becomes lipidated and embedded in autophagosomal membranes (LC3B-II). To quantify autophagy, we reasoned that GFP-tagged LC3B could serve as a time-resolved fluorescence resonance energy transfer (TR-FRET) acceptor upon cell lysis in the presence of terbium-labeled LC3B antibodies. Using this TR-FRET immunoassay approach, we screened a panel of LC3B antibodies and identified an antibody that exhibits strong preferential affinity toward autophagosome-associated LC3B-II and thereby facilitates specific detection of autophagic activity. The plate reader format provides both a quantitative and an objective result, thus overcoming some of the key limitations of the traditional immunoblotting and imaging approaches used to monitor autophagy. Moreover, since the assay step requires only a single addition of cell lysis buffer containing the detection antibody its simple workflow is both automation-friendly and scalable, which renders it suitable for high-throughput screening. We demonstrate how this TR-FRET immunoassay for GFP-tagged LC3B-II can be applied to quantitatively detect changes in the autophagy activity of cells, including estimating effects on autophagic flux.

Implementing functional cell-based screens in early antibody discovery has become increasingly important to select antibodies with the desired profile. However, this is limited by assay tolerance to crude antibody preparations and assay sensitivity. The current study aims to address this challenge and identify routes forward. Two common types of high-throughput screening (HTS) antibody sample, derived from either phage display or hybridoma techniques, have been screened across a wide range of CellSensor beta-lactamase reporter assays in a variety of cell backgrounds to more extensively characterize assay tolerance. Pathway-, sample-, and cell background-specific effects were observed. Reporter assays for agonism were less affected by crude antibody preparations, with 8 of 21 sample tolerant, and the potential to implement an additional 8 assays by choosing the best-tolerated sample type. Antagonist mode assays exhibited more complexity, with potentiating as well as inhibitory effects. However, 5 of 24 antagonist assays were fully tolerant, with the potential to implement an additional 11 assays. Different subsets of assays were affected in agonist versus antagonist mode, and hybridoma sample sets were better tolerated overall. The study clearly demonstrates the potential to use cell-based reporter assays in biologics HTS, particularly if the method of antibody production is considered in the context of the required assay mode (agonist/antagonist).

Effective and accurate detection of trace explosives is crucial in the effort to thwart terrorist explosives attacks. A National Institute of Standards and Technology (NIST) standard reference material (SRM) has been developed for the evaluation of trace explosives detectors that sample by collection of residue particles using swiping or air filtration. SRM 2907 Trace Terrorist Explosives Simulants consists of two materials individually simulating the residues of the plastic explosive Semtex [for pentaerytritol tetranitrate (PETN)] and the improvised explosive triacetone triperoxide (TATP). Unique challenges were encountered in the development of these materials, including the selection of suitable inert substrates, material preparation, thermal stability testing, and analytical method development. Two independent analytical methods based on liquid chromatography with ultraviolet absorbance and mass spectrometric detection, LC-UV and LC/MS, respectively, were developed and used to certify the mass fractions of PETN and TATP. These materials were further evaluated for their suitability on a field swipe-sampled trace explosives detectors based on ion mobility spectrometry (IMS).

A recently resolved debate centred on the interpretation of a major set of INAA data that was based on Olmec ceramics from Mexico. In an attempt to answer questions arising from the debate, this paper discusses the effect of numbers of samples chosen for data interpretation. It also presents interpretations of the ceramic data set based on a bivariate data-splitting approach and compares the results of this with the multivariate analysis approaches employed by the initial publishers of the data.

Trk receptor tyrosine kinases are required for signal transduction initiated by neurotrophins leading to cell proliferation, differentiation, survival and death. Alterations in Trk kinase activity have been linked to various diseases. To address the need for cell-based assays for screening and studying the selectivity of Trk kinase modulators, we developed high-throughput cell-based assays for Trk receptor kinases using nuclear factor of activated T-cells (NFAT) beta-lactamase reporter lines stably expressing full length human Trk kinases. These assays were functionally validated with cognate neurotrophin(s), inhibitors and TRK RNAi oligos and demonstrated for their utility in identifying potent and selective modulators of Trk receptor kinases.

A problem inherent to the use of cellular assays for drug discovery is their sensitivity to cytotoxic compounds, which can result in false hits from certain compound screens. To alleviate the need to follow-up hits from a reporter assay with a separate cytotoxicity assay, the authors have developed a multiplexed assay that combines the readout of a β-lactamase reporter with that of a homogeneous cytotoxicity indicator. Important aspects to the development of the multiplexed format are addressed, including results that demonstrate that the IC50 values of 40 select compounds in a β-lactamase reporter assay for nuclear factor κ B and SIE pathway antagonists are not affected by the addition of the cytotoxicity indicator. To demonstrate the improvement in hit confirmation, the multiplexed assay was used to perform a small-library screen (7728 compounds) for serotonin 5HT1A receptor antagonists. Hits identified from analysis of the β-lactamase reporter data alone were compared to those hits determined when the reporter and cytotoxicity data generated from the multiplexed assay were combined. Confirmation rates were determined from compound follow-up using dose-response analysis of the potential antagonist hits identified by the initial screen. In this representative screen, the multiplexed assay approach yielded a 19% reduction in the number of compounds flagged for followup, with a 37% decrease in the number of false hits, demonstrating that multiplexing a β-lactamase reporter assay with a cytotoxicity readout is a highly effective strategy for reducing false hit rates in cell-based compound screening assays. (Journal of Biomolecular Screening XXXX:xx-xx)

As training opportunities in cosmetic surgery become less frequent in teaching hospitals, this survey set out to examine the attitudes of patients towards extending this training into the independent health sector. We questioned 155 private patients, 95% of who were happy for trainees to sit in during their consultations. Of these, 85% were comfortable with the presence of the trainee throughout their appointments and 92% said they saw advantages in having such trainees present. However, patients were less enthusiastic about trainees carrying out procedures, under consultant supervision and for a reduced fee. The survey found that while 49% felt it was a good idea, only 32% would consider it for themselves. Seventeen percent of patients thought this offer alone was inappropriate. This survey has shown that while the vast majority of private patients supported and were happy to participate in higher surgical training during private consultations, fewer would consider the possibility of cosmetic surgery performed by supervised trainees for reduced fees. The implications of these findings for higher surgical training in Plastic Surgery in the UK are discussed.

Human mitochondrial DNA (mtDNA) mutations are important for forensic identifications and mitochondrial disease diagnostics. Low-frequency mutations, heteroplasmies, or SNPs scattered throughout the DNA in the presence of a majority of mtDNA with the Cambridge Reference Sequence (CRS) are almost impossible to detect. Therefore, the National Institute of Science and Technology has developed heteroplasmic human mtDNA Standard Reference Material (SRM) 2394 to allow scientists to determine their sensitivity in detecting such differences. SRM 2394 is composed of mixtures ranging from 1/99 to 50/50 of two 285-bp PCR products from two cell lines that differ at one nucleotide position. Twelve laboratories using various mutation detection methods participated in a blind interlaboratory evaluation of a prototype of SRM 2394. Most of these procedures were unable to detect the mutation when present below 20%, an indication that, in many real-life cases, low-frequency mutations remain undetected and that more sensitive mutation detection techniques are urgently needed.

Background: Most pathogenic human mitochondrial DNA (mtDNA) mutations are heteroplasmic (i.e., mutant and wild-type mtDNA coexist in the same individual) and are difficult to detect when their concentration is a small proportion of that of wild-type mtDNA molecules. We describe a simple methodology to detect low proportions of the single base pair heteroplasmic mutation, A3243G, that has been associated with the disease mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) in total DNA extracted from blood. Methods: Three peptide nucleic acids (PNAs) were designed to bind to the wild-type mtDNA in the region of nucleotide position 3243, thus blocking PCR amplification of the wild-type mtDNA while permitting the mutant DNA to become the dominant product and readily discernable. DNA was obtained from both apparently healthy and MELAS individuals. Optimum PCR temperatures were based on the measured ultraviolet thermal stability of the DNA/PNA duplexes. The presence or absence of the mutation was determined by sequencing. Results: In the absence of PNAs, the heteroplasmic mutation was either difficult to detect or undetectable by PCR and sequencing. Only PNA 3 successfully inhibited amplification of the wild-type mtDNA while allowing the mutant mtDNA to amplify. In the presence of PNA 3, we were able to detect the heteroplasmic mutation when its concentration was as low as 0.1% of the concentration of the wild-type sequence. Conclusion: This methodology permits easy detection of low concentrations of the MELAS A3243G mutation in blood by standard PCR and sequencing methods.

The two members of the P-type lectin family, the cation-dependent mannose 6-phosphate receptor (CD-MPR) and the insulin-like growth factor II/mannose 6-phosphate receptor (IGF-II/MPR), are distinguished from all other lectins by their ability to recognize phosphorylated mannose residues. The P-type lectins play an essential role in the generation of functional lysosomes within the cells of higher eukaryotes by directing newly synthesized lysosomal enzymes bearing the mannose 6-phosphate (M6P) signal to lysosomes. At the cell surface, the IGF-II/MPR also binds to the nonglycosylated polypeptide hormone, IGF-II, targeting this potent mitogenic factor for degradation in lysosomes. Moreover, in recent years, the multifunctional nature of the IGF-II/MPR has become increasingly apparent, as the list of extracellular ligands recognized by this receptor has grown to include a diverse spectrum of M6P-containing proteins as well as nonglycosylated ligands, implicating a role for the IGF-II/MPR in a number of important physiological pathways. Recent investigations have provided valuable insights into the molecular basis of ligand recognition by the MPRs as well as the complex intracellular trafficking pathways traversed by these receptors. This review provides a current view on the structures, functions, and medical relevance of the P-type lectins.

& 2002 Harcourt P doi:10.1054/nedt.2 I am pleased to be invited to comment on a paper that is both topical and relevant to the nursing profession as it copes with a period of rapid globalization. The effects of recent events in New York and Afghanistan emphasize how interdependent the nations of the world have become. We now have a global workforce and the migration of key workers, especially nurses, has become a part of every day life. The authors base their paper on the knowledge and experience derived from assessing nurses' qualifications in Australia, whereas my comments are born out of personal knowledge and experience of working with overseas registered nurses in the United Kingdom (UK). However, this is not just an issue affecting wealthy Western countries. I would suggest that the paper be read in the context of a worldwide shortage of nurses. Wickett and McCutcheon's paper does not address the moral or ethical issues of international nursing recruitment, commenting instead on the causes of nursing shortages in developed countries (Australia, USA, Canada and the UK) and the practicalities of assessing the qualifications of applicants seeking registration in Australia. The Commonwealth Steering Committee (2001) are on record as saying that nursing and midwifery shortages in some countries are pronounced to the extent where they may potentially threaten the delivery of nursing and midwifery service. This needs to be addressing as a matter of urgency. The authors are right when they refer to countries competing globally for nurses. Competition is the driving force in the market place, but in most competitions the weak and disadvantaged usually lose out. The losers in this market place, where rich

Occupationally acquired inter-digital pilonidal sinuses are seldom seen and typically found on the hands of hair dressers. Sheep shearing has traditionally been believed to be a cause of inter-digital pilonidal sinuses; although in reality it is infrequently so with only two previously reported cases in 1951 and 1966. We present a rare case of a shearer who worked with a variety of sheep and presented with a chronic pilonidal sinus in the 3rd web space of his hand. This work demonstrates for the first time a histological confirmation of the presence of wool, and in this case different varieties and coloured fibres within the sinus. The report presents our investigations into the aetiology and the mechanical theories supporting it. The clinical presentation and surgical management of this condition are discussed alongside occupational realities and expectations.