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Abstract In healthy adults different language abilities—sentence processing versus emotional prosody—are supported by the left (LH) versus the right hemisphere (RH), respectively. However, after LH stroke in infancy, RH regions often support both abilities with normal outcomes. This finding raises an important question: How does the functional map of RH regions change to support both emotional prosody and also typically left-lateralized language functions after an early LH stroke? Does sentence processing simply become reflected into RH frontotemporal regions and overlap with emotional prosody processing? Or do these functions overlap less than would be expected with simple mirroring? In the current work we used task fMRI to examine precisely how sentence processing and emotional prosody processing are both organized in the intact RH of individuals who suffered a large LH perinatal arterial ischemic stroke (LHPS participants). We evaluated the activation of two fMRI tasks that probed auditory sentence processing and emotional prosody processing, comparing the overlap for these two functions in the RH of individuals with perinatal stroke with the symmetry of these functions in the LH and RH of their healthy siblings. We found less activation overlap in the RH of individuals with LH perinatal stroke than would be expected if both functions retained their typical spatial layout, suggesting that their spatial segregation may be an important feature of a functioning language system.

At the optimum temperature, which is the ideal range in which seeds germinate most efficiently, seed germination may be lower than expected under favorable conditions, and this is indicative of seed dormancy. Also, germination may be enhanced by additional and interacting factors, such as nitrate and light. However, little is known about the interplay between temperature, nitrate, and seed germination. Using seeds from 22 accessions of four Plantago species that occupy distinct pedoclimates, we applied a factorial experimental design to assess the relationship between exogenously applied nitrate (KNO3) and temperature on germination in a Petri dish experiment. The data explore the relationship between seed germination, temperatures, and seed- and maternal-source soil N content as either nitrite (NO2−), nitrate (NO3−), or ammonium (NH4+). The interpretation also considered the total N and C contents of seeds, and the soil of the maternal plant (of the test seed) sources. Significant interspecific effects of nitrate and temperature on seed germination were observed. The capacity of nitrate to enhance final germination may be diminished substantially at supra-optimum temperatures, e.g., P. lagopus germination at 15 °C was 7% lower than that seen for water-only treatment. In contrast, at sub-optimum and alternating temperatures, nitrate enhanced final germination differentially across the species tested. This suggests a shift to enhanced germination at lower temperatures in the presence of sufficient soil nitrate, facilitating seedling establishment earlier in the growing season. The seeds of some Plantago species showed increased germination as a function of nitrate and temperature, particularly those of P. lagopus. The findings indicate that species (and genotype) responses correlated with the prevailing temperature and rainfall patterns of the locality; such local adaptation would ensure that seed germination and establishment occur during a period when environmental conditions are optimal.

Abstract Background Within England, children and young people entering police custody are referred to Liaison and Diversion (L&D) teams. These teams liaise with healthcare and other support services aiming to divert children and young people away from the criminal justice system. Although targeted psychological interventions are not typically offered to children and young people by L&D teams, evidence suggests that Solution Focused Brief Therapy (SFBT) leads to a reduction in internalising and externalising behaviour problems. Methods A two-arm individually randomised controlled trial (RCT) with internal pilot and process evaluation will be conducted with approximately 448 children and young people aged 10–17 years presenting at police custody suites who are referred to the L&D team or recruited via online routes if they have previously presented at any police custody suite in England. The primary outcome is the Self-Report Delinquency Measure (SRDM) at 6 months post-randomisation. Analyses will be performed using intention-to-treat. Results The statistical analysis plan (SAP) for the trial is described. The plan details of analyses to be undertaken which will be reported in the primary and any secondary publications. The plan was developed and published prior to locking our database and unblinding to treatment allocation. Discussion This RCT will evaluate the effectiveness of SFBT in reducing offending behaviours in CYP presenting at police custody suites including testing of moderating factors and sensitivity of the primary analyses. Trial registration ClinicalTrials.gov ISRCTN14195235. Registered on June 16, 2023.

Abstract Background UKA is a well-established treatment option for anteromedial osteoarthritis of the knee, resulting in superior functional outcomes but also higher revision rates than TKA. This study aimed to compare the outcomes of UKA, TKA, UKA converted to TKA using identical standard implants and revised TKA to support clinical decision-making. Methods In this study, we retrospectively examined 116 patients who underwent UKA, 77 patients who received TKA, 28 patients whose UKA was converted to TKA using identical standard implants, and 21 patients who had a one-stage revision of TKA. The mean age at operation was 66.5 years (39–90 years), with a mean BMI of 28.8 kg/m2 (17.4–58.8) and a mean follow-up period of four years (0.9–9.9 years). We assessed various PROMs, including Oxford Knee Score, UCLA score, KSS score, and a modified WOMAC-Score as well as patient satisfaction and ability to resume daily activities, work, and sports. Results The highest patient satisfaction was seen in the UKA. All scores were significantly higher for UKA than for TKA, converted UKA, and revised TKA. None of the scores showed a significant inferiority of converted UKA to TKA. In the case of revision, two scores showed significantly better results for converted UKA than for revised TKA. Conclusions Our results indicated that patients initially treated with UKA did not have significantly worse functional outcomes after conversion to TKA, given the use of identical standard implants. This highlights the effectiveness of UKA as a therapeutic option with outcomes superior to those of primary TKA and the importance of a bone-sparing procedure. Conversely, revision TKA is linked to poorer functional outcomes compared to both primary arthroplasties.

Abstract Benign prostatic hyperplasia (BPH) may decrease patient quality of life and often leads to acute urinary retention and surgical intervention. While effective treatments are available, many BPH patients do not respond or develop resistance to treatment. To understand molecular determinants of clinical symptom persistence after initiating BPH treatment, we investigated gene expression profiles before and after treatments in the prostate transitional zone of 108 participants in the Medical Therapy of Prostatic Symptoms (MTOPS) Trial. Unsupervised clustering revealed molecular subgroups characterized by expression changes in a large set of genes associated with resistance to finasteride, a 5α-reductase inhibitor. Pathway analyses within this gene cluster found finasteride administration induced changes in fatty acid metabolism, amino acid metabolism, immune response, steroid hormone metabolism, and kinase activity within the transitional zone. We found that patients without this transcriptional response were highly likely to develop clinical progression, which is expected in 13.2% of finasteride-treated patients. Importantly, a patient’s transcriptional response to finasteride was associated with their pre-treatment kinase expression. Further, we identified novel expression signatures of finasteride resistance among the transcriptionally responded patients. These patients showed different gene expression profiles at baseline and increased prostate transitional zone volume compared to the patients who responded to the treatment. Our work suggests molecular mechanisms of clinical resistance to finasteride treatment that could be potentially helpful for personalized BPH treatment as well as new drug development to increase patient drug response.

Abstract Background Monitoring blood oxygenation is essential in immobilised rhinoceros, which are susceptible to opioid-induced hypoxaemia. This study assessed the reliability, clinical performance and trending ability of the Nonin PalmSAT 2500 A pulse oximeter’s and the Masimo Radical-7 pulse co-oximeter’s dual-wavelength technology, with their probes placed at two measurement sites, the inner surface of the third-eyelid and the scarified ear pinna of immobilised white rhinoceroses. Eight white rhinoceros were immobilised with etorphine-based drug combinations and given butorphanol after 12 min, and oxygen after 40 min, of recumbency. The Nonin and Masimo devices, with dual-wavelength probes attached to the third-eyelid and ear recorded arterial peripheral oxygen-haemoglobin saturation (SpO2) at pre-determined time points, concurrently with measurements of arterial oxygen-haemoglobin saturation (SaO2), from drawn blood samples, by a benchtop AVOXimeter 4000 co-oximeter (reference method). Reliability of the Nonin and Masimo devices was evaluated using the Bland-Altman and the area root mean squares (ARMS) methods. Clinical performance of the devices was evaluated for their ability to accurately detect clinical hypoxemia using receiver operating characteristic (ROC) curves and measures of sensitivity, specificity, and positive and negative predictive values. Trending ability of the devices was assessed by calculating concordance rates from four-quadrant plots. Results Only the Nonin device with transflectance probe attached to the third-eyelid provided reliable SpO2 measurements across the 70 to 100% saturation range (bias − 1%, precision 4%, ARMS 4%). Nonin and Masimo devices with transflectance probes attached to the third-eyelid both had high clinical performance at detecting clinical hypoxaemia [area under the ROC curves (AUC): 0.93 and 0.90, respectively]. However, the Nonin and Masimo devices with transmission probes attached to the ear were unreliable and provided only moderate clinical performance. Both Nonin and Masimo devices, at both measurement sites, had concordance rates lower than the recommended threshold of ≥ 90%, indicating poor trending ability. Conclusions The overall assessment of reliability, clinical performance and trending ability indicate that the Nonin device with transflectance probe attached to the third-eyelid is best suited for monitoring of blood oxygenation in immobilised rhinoceros. The immobilisation procedure may have affected cardiovascular function to an extent that it limited the devices’ performance.

Abstract Background Spatial behavior, including home-ranging behaviors, habitat selection, and movement, can be extremely informative in estimating how animals respond to landscape heterogeneity. Responses in these spatial behaviors to features such as human land modification and resources can highlight a species’ spatial strategy to maximize fitness and minimize mortality. These strategies can vary on spatial, temporal, and individual scales, and the combination of behaviors on these scales can lead to very different strategies among species. Methods Harnessing the variation present at these scales, we characterized how species may respond to stimuli in their environments ranging from broad- to fine-scale spatial responses to human modification in their environment. Using 15 bobcat-years and 31 coyote-years of GPS data from individuals inhabiting a landscape encompassing a range of human land modification, we evaluated the complexity of both species’ responses to human modification on the landscape through their home range size, habitat selection, and functional response behaviors, accounting for annual, seasonal, and diel variation. Results Bobcats and coyotes used different strategies in response to human modification in their home ranges, with bobcats broadly expanding their home range with increases in human modification and displaying temporal consistency in functional response in habitat selection across both season and time of day. Meanwhile, coyotes did not expand their home ranges with increased human modification, but instead demonstrated fine-scale responses to human modification with habitat selection strategies that sometimes varied by time of day and season, paired with functional responses in selection behaviors. Conclusions These differences in response to habitat, resources, and human modification between the two species highlighted the variation in spatial behaviors animals can use to exist in anthropogenic environments. Categorizing animal spatial behavior based on these spatiotemporal responses and individual variation can help in predicting how a species will respond to future change based on their current spatial behavior.

ABSTRACT We present the case of a man in his 70s who developed acute confusion from hypertensive encephalopathy triggered by indomethacin. He was recently prescribed indomethacin, a non‐steroidal anti‐inflammatory drug (NSAID) for headaches. However, his headaches were in the context of worsening hypertension that was treated with trandolapril. The use of indomethacin consequently worsened his underlying condition. On presentation to the emergency department, his blood pressure was 190/110 mmHg. Bloodwork including electrolytes, glucose, metabolic studies, renal and liver function were within normal limits; infectious workup including blood and urine cultures subsequently returned negative; and brain computed tomography and magnetic resonance imaging revealed no acute process to explain his presentation. Indomethacin was discontinued and the patient's hypertension was treated with amlodipine. Both his confusion and underlying headaches resolved as his blood pressure normalized. The patient was diagnosed with hypertensive encephalopathy triggered by indomethacin. NSAID use can trigger blood pressure decompensation, especially in patients with underlying hypertension; this effect is particularly pronounced in patients treated with anti‐hypertensive medications that inhibit the renin‐angiotensin‐aldosterone (RAS) system. Symptomatic treatment with NSAIDs is not without potential harm; it is important to carefully consider a patient's underlying diagnosis, indication for therapy and risk for adverse effects.

Objective: Mitomycin C (MMC), a DNA-damaging chemotherapeutic, is commonly used clinically for recurrent cervical carcinoma (CC), either alone or in combination. MMC generates DNA damage resulting in CC cell death yet also induces increased AKT-BAD phosphorylation associated with drug resistance and reduced clinical benefit. The present study evaluates the efficacy of combined MMC and a BAD phosphorylation inhibitor in CC. Methods: The association and function of phosphorylation of BAD on serine 99 (pBADS99) for cell survival of both MMC-resistant or sensitive-CC cells was explored. BAD was mutated to BADS99A to examine the requirement of BADS99 for CC cell survival and a novel small-molecule inhibitor of pBADS99 was utilized. Cell proliferation, survival, foci formation, and patient-derived organoids (PDOs) assays were utilized to determine efficacy, synergy and related mechanisms. Results: MMC IC50 was positively correlated to the cell line pBADS99/BAD ratio. Increased BADS99 phosphorylation was observed in both MMC-sensitive or -resistant CC cells after MMC treatment. Inhibition of pBADS99 in CC cell lines produced synergistic apoptosis through BAD-mediated apoptotic pathways and enhanced DNA damage in response to MMC. The concurrent use of pharmacological inhibition of pBADS99 and MMC was synergistic, resulting in diminished cell viability and inducing apoptotic cell death in MMC-sensitive and -resistant CC cell lines or patient-derived organoids. Conclusion: A combination of MMC with inhibition of BAD phosphorylation potentiated efficacy compared to single agent treatment. The potential further development of such strategies may provide outcome benefits to patients with CC.

Small molecule-driven JNK activation has been found to induce apoptosis and paraptosis in cancer cells. Herein pharmacological effects of synthetic oxazine (4aS, 7aS)-3-((4-(4‑chloro-2-fluorophenyl)piperazin-1-yl)methyl)-4-phenyl-4, 4a, 5, 6, 7, 7a-hexahydrocyclopenta[e] [1,2]oxazine (FPPO; BSO-07) on JNK-driven apoptosis and paraptosis has been demonstrated in human breast cancer (BC) MDA-MB231 and MCF-7 cells respectively. BSO-07 imparted significant cytotoxicity in BC cells, induced activation of JNK, and increased intracellular reactive oxygen species (ROS) levels. It also enhanced the expression of apoptosis-associated proteins like PARP, Bax, and phosphorylated p53, while decreasing the levels of Bcl-2, Bcl-xL, and Survivin. Furthermore, the drug altered the expression of proteins linked to paraptosis, such as ATF4 and CHOP. Treatment with N-acetyl-cysteine (antioxidant) or SP600125 (JNK inhibitor) partly reversed the effects of BSO-07 on apoptosis and paraptosis. Advanced in silico bioinformatics, cheminformatics, density Fourier transform and molecular electrostatic potential analysis further demonstrated that BSO-07 induced apoptosis and paraptosis via the ROS/JNK pathway in human BC cells.

OBJECTIVES:. Persistent skeletal muscle dysfunction in survivors of critical illness due to acute respiratory failure is common, but biological data elucidating underlying mechanisms are limited. The objective of this study was to elucidate the prevalence of skeletal muscle weakness and fatigue in survivors of critical illness due to COVID-19 and determine if cellular changes associate with persistent skeletal muscle dysfunction. DESIGN:. A prospective observational study in two phases: 1) survivors of critical COVID-19 participating in physical outcome measures while attending an ICU Recovery Clinic at short-term follow-up and 2) a nested cohort of patients performed comprehensive muscle and physical function assessments with a muscle biopsy; data were compared with non-COVID controls. SETTING:. ICU Recovery Clinic and clinical laboratory. PATIENTS/SUBJECTS:. Survivors of critical COVID-19 and non-COVID controls. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. One hundred twenty patients with a median of 56 years old (interquartile range [IQR], 42–65 yr old), 43% female, and 33% individuals of underrepresented race attended follow-up 44 ± 17 days after discharge. Patients had a median Acute Physiology and Chronic Health Evaluation-II score of 24.0 (IQR, 16–29) and 98 patients (82%) required mechanical ventilation with a median duration of 14 days (IQR, 9–21 d). At short-term follow-up significant physical dysfunction was observed with 93% of patients reporting generalized fatigue and performing mean 218 ± 151 meters on 6-minute walk test (45% ± 30% of predicted). Eleven patients from this group agreed to participate in long-term assessment and muscle biopsy occurring a mean 267 ± 98 days after discharge. Muscle tissue from COVID exhibited a greater abundance of M2-like macrophages and satellite cells and lower activity of mitochondrial complex II and complex IV compared with controls. CONCLUSIONS:. Our findings suggest that aberrant repair and altered mitochondrial activity in skeletal muscle associates with long-term impairments in patients surviving an ICU admission for COVID-19.

Background Interventions for anxiety need to be adapted to meet the needs of autistic people with moderate to severe learning disabilities and successfully modelled before evidence about efficacy can be generated from clinical trials. Objectives The objectives were to: (1) adapt a behavioural intervention for anxiety, develop an intervention fidelity checklist and logic model, and appraise candidate outcome measures, together with carers, autistic people, and clinicians, (2) characterise treatment-as-usual, (3) model the adapted intervention to determine the acceptability and feasibility for all stakeholders, judge the appropriateness of outcome measures, examine the feasibility and acceptability of consent and associated processes and (4) describe factors that facilitate or challenge intervention delivery. Design This study had two phases. Phase 1a: using consensus methods, an intervention adaptation group was formed who met to adapt the intervention, appraise candidate outcome measures, and contribute to the development of the intervention fidelity checklists and logic model. Phase 1b: a national online survey was conducted with professionals to characterise treatment-as-usual. Phase 2: this was a single-group non-randomised feasibility study designed to model the intervention to test intervention feasibility and acceptability, outcome measures, and aspects of the research process. Setting Participants were recruited from National Health Service community adult learning disabilities teams in England. Participants Participants aged 16 and over with a diagnosis of autism, moderate to severe learning disabilities, an anxiety disorder, and a carer who was available to take part in the intervention. For those who lacked capacity to make a decision about taking part, a consultee had to provide advice that the participant should be included in the study. Interventions The intervention comprised 12 sessions alongside treatment-as-usual. Main outcome measures The feasibility and acceptability of the intervention and research processes, outcome measure completion rates, and intervention adherence. Results The intervention was successfully adapted and modelled with 28 autistic participants with moderate to severe learning disabilities. The intervention was judged to be feasible and acceptable by autistic adults with learning disabilities, carers, and therapists. Carers and therapists suggested minor intervention revisions. Carers completed 100% of outcome measures and the missing data rate was low; however, they indicated that some of the questions were repetitive and said they had difficulty responding to some items. The use of the Mental Capacity Act, 2005, led to an average 5-week delay to participant enrolment. The accrual rate was affected by the COVID-19 pandemic and improved during the summer and early autumn of 2022. Limitations Randomisation was not modelled within this feasibility study, although carers and therapists indicated that this would be acceptable. Conclusions The BEAMS-ID intervention and associated study processes were judged to be feasible and acceptable. The intervention required minor revision. Future work The BEAMS-ID intervention should be tested further within a trial. Study registration This study is registered as ISRCTN12637590. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129804) and is published in full in Health Technology Assessment; Vol. 28, No. 72. See the NIHR Funding and Awards website for further award information. Plain language summary This study was about autistic adults with moderate to severe learning disabilities who have anxiety. There are good interventions for anxiety, but these need to change to meet the needs of autistic adults with moderate to severe learning disabilities. An example of such an intervention is called exposure therapy. This study had two parts. In the first part, we worked with autistic adults, carers and family members, and professionals to adapt an existing anxiety intervention. We also completed a national survey to find out what interventions people are getting now. In the second part, the intervention was tested with 28 autistic adults with moderate to severe learning disabilities. We asked participants, carers and clinicians about their experiences of being part of the study and receiving the intervention. We successfully changed an existing intervention together with autistic adults, carers and family members, and professionals. The intervention included relaxation training and exposure therapy. From our national survey, we found out that autistic people with moderate to severe learning disabilities who have problems with anxiety are most often offered psychological interventions (e.g. relaxation) or medication (e.g. sertraline) for anxiety. Exposure therapy was not offered very frequently. We tried out our intervention and autistic people with moderate to severe learning disabilities told us that they liked coming to the intervention and liked that their carer attended. Carers liked taking part in the research and were positive about the intervention. Therapists told us that the intervention was suitable and were positive about the training they received in delivering the intervention. Both carers and therapists suggested some changes to the intervention to help improve it in the future. We recommended that a larger study should now be completed. Scientific summary Background A large number of people with autism and learning disabilities have problems with anxiety. There is evidence that talking psychological therapies are an effective intervention for anxiety, but many of these interventions have not been tested with people who have both autism and learning disabilities. These interventions need to be adapted before they can be used with this population because of their difficulties with verbal communication, restricted and repetitive behaviours, and behaviours that challenge. Objectives We aimed to (1) work with our patient and public involvement (PPI) partners to adapt an existing intervention manual for anxiety disorders for use with autistic adults with moderate to severe learning disabilities and (2) complete a feasibility study to try out our intervention and seek feedback from participants, families and therapists. In addition, we collected information about what interventions people are currently receiving to characterise treatment-as-usual (TAU) and test out some outcome measures. Phase 1a: adaptation Our objectives were: to establish an intervention adaptation group (IAG) and, during a series of meetings, adapt an existing intervention to treat anxiety symptoms in autistic adults who have moderate to severe learning disabilities to develop an intervention fidelity checklist that can be used alongside the intervention manual to appraise and consider several candidate outcome measures of anxiety-related symptoms and make a recommendation for use within Phase 2 to develop an intervention logic model. Phase 1b: description of treatment-as-usual Our objective was to complete a national survey of existing interventions for adults with anxiety disorders who have moderate to severe learning disabilities. The survey was constructed using items adapted from the Template for Intervention Description and Replication (TIDieR) checklist to ensure a clear description of TAU. This phase ran concurrently with Phase 1a and Phase 2. This allowed for the capture of data to allow for the characterisation of TAU, including any specific interventions offered. We invited participation from all community-based services for people with autism and/or learning disabilities across the United Kingdom. Phase 2: feasibility study Our objectives were: to model the manualised intervention to determine the acceptability and feasibility for all stakeholders, including autistic adults with moderate to severe learning disabilities, carers, and clinicians, and adjust as required to judge the appropriateness, including response rates, of our measures of anxiety-related symptomatology for use within a larger study to examine the feasibility and acceptability of consent and associated processes in the context of the Mental Capacity Act, 2005 and to describe factors that facilitate or challenge the implementation of our intervention. Methods Study design Phase 1a (intervention adaptation) An IAG was established, and during a series of five meetings an existing intervention used to treat anxiety symptoms in adults with autism was adapted for use with people who also have moderate to severe learning disabilities. Phase 1b (treatment-as-usual survey) A national survey of existing community-based interventions for adults with anxiety disorders who have moderate to severe learning disabilities was conducted. The TIDieR checklist was used to inform the development of our survey questions to ensure a clear description of TAU. Phase 2 (feasibility study) This study was a single-arm, non-randomised, feasibility study, with autistic people who have moderate to severe learning disabilities. Participants and their carers received the adapted intervention developed in Phase 1a, in conjunction with any other intervention they were receiving. Both qualitative and quantitative research methods were used to address key components of feasibility. Setting and participants Phase 1a (intervention adaptation) The IAG included eight key stakeholders who were representatives from our PPI partners, carers and family members, people with autism and/or learning disabilities, and clinicians, along with members of the research team. Phase 1b (treatment-as-usual survey) All services for adults with autism and learning disabilities (and learning disabilities services providing support to those who also have autism); this included NHS mental health and learning disabilities services, and the independent and charitable sector, including social enterprises within the UK. The total of number of survey responses was N = 76. Phase 2 (feasibility study) This single-arm non-randomised feasibility study took place within the NHS health services in England. We aimed to recruit up to 30 participants from the following NHS services across England: Coventry and Warwickshire Partnership NHS Trust, Herefordshire and Worcestershire Health and Care NHS Trust, Leicestershire Partnership NHS Trust, Solent NHS Trust, and Mersey Care NHS Foundation Trust. A total of 28 participants were enrolled, and 18% were from a non-white background, while 53.6% had severe learning disabilities. Intervention Participants within this study received up to 12 sessions of individual and manualised behaviour therapy, each lasting between 60 and 90 minutes with support from carers. The intervention was exposure therapy and was adapted for use with this population and manualised. Assessment of feasibility of delivery and acceptability of the intervention We examined the views of participants, parents/carers, and therapists to address (1) intervention accessibility and acceptability, (2) helpful/unhelpful aspects, including barriers to change, (3) the value of our adaptations, (4) relationships with therapists, (5) acceptability of consent processes, (6) acceptability of outcome measures and (7) acceptability of randomisation within a future trial. We completed semistructured interviews with seven parents/carers and eight therapists. Interviews using Talking Mats® were also completed with five autistic adults with moderate to severe learning disabilities who received the intervention to explore their experience of the intervention and their outcomes. Collection of outcome data Phase 1a (intervention adaptation) We held five meetings with the IAG and made use of consensus methods following discussion to make decisions about intervention adaptations, the content of our fidelity checklist, and our selection of candidate outcome measures. Phase 1b Questions for the TAU survey included the type of support/intervention, who, how and where it is delivered, along with dose and any modifications adapted from the TIDieR checklist. The online survey was delivered using Qualtrics (Qualtrics, Provo, UT, USA) or as a telephone interview. This phase lasted 14 months, running concurrently with Phase 1a and Phase 2. Phase 2 Participants were enrolled in the study for approximately 6 months. Participants were assessed at three times points: (1) screening for eligibility, (2) baseline assessment within 4 weeks before commencement of the intervention and (3) within 4 weeks following the completion of the intervention. Eligibility assessments included measures of adaptive behaviour, autistic symptoms, and symptoms of anxiety disorders. Our outcome assessments included measures of anxiety, emotional and behavioural problems, behaviours that challenge, and engagement within the community. Patient and public involvement and engagement Patient and public involvement and engagement was firmly and genuinely an integral part of our methodology. We partnered with the National Autistic Society (NAS), who worked collaboratively with us to adapt our intervention, along with carers, autistic people, and clinicians. They helped prepare study documentation, recruit participants, and collaboratively disseminate information about this study. Autistic people, carers and clinicians were members of the Study Steering Group and shared oversight of our project progress. Our IAG was formed of carers, autistic people and clinicians who are experienced with working with autistic people with moderate to severe learning disabilities. Results Phase 1a We successfully adapted the intervention, developed a logic model and intervention fidelity checklist, and chose outcome measures collaboratively with the IAG. Phase 1b Seventy-eight health and social care professionals responded to our survey and 76 provided data about TAU. The majority worked for the NHS. The most frequently offered anxiety intervention was described as psychological interventions, but exposure therapy was said to be infrequently provided. Respondents also described the adaptations they made to psychological interventions for use with adults with learning disability. These adaptations included: providing communication support, adjusting session content or activities, adjusting the timing, duration, frequency and number of sessions, involving carers within the intervention, or making changes to a person’s environment. The next most offered intervention was medication. Respondents also described less frequently offered interventions including speech and language therapy, occupational therapy, sensory strategies, communication training, increased staff support, touch therapy and music therapy. Four respondents indicated that physical health support was also offered as an intervention for anxiety. Phase 2 (1) Acceptability and feasibility of the intervention: the intervention was feasible to deliver and acceptable to autistic adults with moderate to severe learning disabilities, carers and therapists. Carers and therapists made some suggestions for revisions to the intervention which focused upon reinforcing the importance of consistent carer attendance during the intervention, and the inclusion of further guidance about ensuring that the intervention is person-centred by adapting the timing, frequency, and number of intervention sessions, making use of bespoke or personalised intervention materials, further guidance about delivering relaxation, and strengthening information about the nature and degree of adaptations that can be made by therapists. All suggestions were considered feasible to implement. (2) Appropriateness of outcome measures: percentage of missing data across the outcome measures was low and ranged from 0% to 2.38% and carers completed 100% of all outcome measures. However, carers commented that some of the items were repetitive, and some said they had difficulties answering some questions. However, others said they were acceptable and easy to complete. (3) Feasibility and acceptability of consent and associated processes: carers indicated that the study participant information sheets and associated processes were clear, helpful, and straightforward. Seventy-nine per cent of autistic participants with moderate to severe learning disabilities were judged to lack capacity to make a decision about taking part in this study. On average, it took nearly 5 weeks to seek consultee advice and enrol these participants. (4) Factors that facilitate or challenge the implementation of our intervention: autistic participants with moderate to severe learning disabilities indicated that they liked coming to the intervention sessions and the information booklets that were used during the intervention. They also indicated that they liked some core aspects of the intervention (e.g. fear ladders, relaxation, visual schedules). Carers indicated that the intervention facilitators were adaptations to meet individual needs, the experience of attending therapy and a positive therapeutic relationship with the therapist. Therapists reported that the intervention facilitators were the inclusion of a clear structure, therapist understanding of people with learning disabilities, carer understanding and engagement, effectively meeting carer need, using adapted materials, high-quality training in the intervention, access to supervision, specific aspects of the intervention (e.g. preference assessments, reinforcement, carer-only sessions, positive therapeutic relationship), and intervention flexibility. Carers reported that the key barriers were not directly attributable to the intervention (e.g. illness, holidays, or lack of staff), or were related to challenges accessing intervention material to be used during exposure, or difficulties with using the intervention with some individuals due to additional complexity, the quantity of information provided, and the time commitment required. Therapists suggested that the barriers were challenges adapting relaxation techniques, difficulties with participant engagement and motivation, different carers attending intervention sessions, difficulties with some intervention components with some individuals, quantity of information, and behaviours that challenge. Conclusions The BEAMS-ID intervention was judged to be feasible to deliver and acceptable to autistic adults with moderate to severe learning disabilities, carers and therapists. Carers and therapists made some helpful suggestions for revisions which can be easily incorporated into the existing manualised intervention with minor revision. This study took place during the COVID-19 pandemic and the recruitment of participants during Phase 2 was at a lower rate than anticipated, considering that the study was funded prior to the onset of the pandemic. Nevertheless, 93% of the planned sample size was successfully recruited, and it was noted that the accrual rate improved during the summer of 2022 and was higher within sites who joined towards the end of the study period. The participant attrition rate was low and not attributable to the intervention or study processes. This study benefited from genuine patient and public involvement and engagement during the adaptation of the intervention, development of fidelity checklist and logic model, choice of outcome measures and study management. Following minor revisions to the intervention, and further consideration of outcome measures based upon carer feedback, the BEAMS-ID intervention should be tested in a randomised trial. Protocol The study protocol is available from https://fundingawards.nihr.ac.uk/award/NIHR129804. Study registration This study is registered as ISRCTN12637590. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129804) and is published in full in Health Technology Assessment; Vol. 28, No. 72. See the NIHR Funding and Awards website for further award information.

Background There is a lack of interventions for specific phobia in children and adolescents with moderate to severe intellectual disabilities. Objectives The objectives were to: (a) develop an intervention for specific phobia, together with an intervention fidelity checklist and logic model, and evaluate candidate outcome measures, together with parents/carers and clinicians; (b) describe treatment as usual; (c) model the intervention to determine the acceptability and feasibility for all stakeholders, judge the appropriateness of outcome measures, explore recruitment pathways, and examine the feasibility and acceptability of consent and associated processes; and (d) describe factors that facilitate or challenge the intervention. Design Phase 1a: using consensus methods, an Intervention Development Group was established who met to develop the intervention, review candidate outcome measures and contribute to the development of the intervention fidelity checklists and logic model. Phase 1b: a national online survey was conducted with parents and professionals to describe treatment as usual. Phase 2: a single-group non-randomised feasibility study was designed to model the intervention and to test intervention feasibility and acceptability, outcome measures and aspects of the research process. Setting Phase 2: participants were recruited from National Health Service community child learning disabilities teams and special schools in England. Treatment was delivered in the child learning disabilities teams. Participants Children aged 5–15 years with moderate to severe learning disability and specific phobia, and their parents/carers. Interventions The SPIRIT intervention comprised two half-day workshops and eight support sessions plus treatment as usual. Main outcomes The feasibility and acceptability of the intervention and research processes, recruitment, outcome measure completion rates and acceptability, and intervention adherence. Parents completed all of the outcome measures, with very low rates of missing data. The recruitment of sites and participants was impacted by the COVID-19 pandemic. Results The intervention was successfully developed and modelled with 15 participants with moderate to severe learning disabilities and their parents. The intervention was judged to be feasible and acceptable by parents/carers and therapists. Parents/carers and therapists suggested minor intervention revisions. Limitations Randomisation was not modelled within this feasibility study, although the majority of parents and therapists indicated that this would be acceptable. Conclusions The SPIRIT intervention and associated study processes were judged to be feasible and acceptable. The intervention requires minor revisions. Future work The SPIRIT intervention should be tested further within a clinical trial. Study registration Current Controlled Trials ISRCTN34766613. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR130177) and is published in full in Health Technology Assessment; Vol. 28, No. 64. See the NIHR Funding and Awards website for further award information. Plain language summary This study was about children and adolescents who have moderate to severe learning disabilities and specific phobia. This study had two parts. In the first part, we worked with parents of young people with learning disabilities and therapists to develop a treatment for specific phobia in children and adolescents with moderate to severe learning disabilities. We also collected information about what treatment young people were currently getting. To do this, we conducted a national (United Kingdom) survey of parents/carers who have a child with a learning disability and a phobia, along with a survey of health professionals who work with children with learning disabilities. Together with parents and therapists, we developed a treatment for specific phobia in children and adolescents with moderate to severe learning disabilities. We collected information about what treatments young people received for specific phobia and found that many do not receive any treatment for their specific phobia. In the second part, we wanted to find out whether the treatment was acceptable to parents and therapists. To do this, we tried out the treatment with 15 children and adolescents. We had difficulties getting people involved in the study due to the COVID-19 pandemic. We got enough people involved to help us to work out whether the treatment was acceptable to parents and therapists. We interviewed parents and therapists to find out how they felt about the treatment and being part of the study. We also talked to therapists to ask them what they thought about the treatment. Parents told us that they liked being involved in the study and found the treatment helped them to help their children. Parents and therapists suggested some changes to the treatment to help improve it in the future. It was recommended that a larger study should be completed. Scientific summary Background Many children with learning disabilities have significant fears or phobias. These can, for example, include a severe fear of dogs or other animals, visiting the dentist, or having an injection. Children and adolescents with learning disabilities are at least twice as likely to experience specific phobia than their typically developing peers. There is good evidence that psychological therapies, particularly exposure-based therapies, are an effective treatment for phobias, but these treatments have not been evaluated for use with people with learning disabilities, in particular for children and adolescents with moderate to severe learning disabilities. Due to difficulties with verbal communication, understanding, restricted and repetitive behaviours, and challenging behaviour, these treatments need to be adapted before they can be used. Objectives The aim of this study was to, using coproduction with our patient and public involvement (PPI) partners, develop and evaluate the feasibility of an exposure-based intervention for specific phobia in children and adolescents with moderate to severe learning disabilities. This work was undertaken in two phases: (1a) development of the intervention and (1b) description of treatment as usual (TAU); and (2) evaluation of the feasibility of the proposed intervention. Phase 1a: development The objectives were to: establish an Intervention Development Group (IDG), and using coproduction over a series of meetings, develop an intervention for specific phobia for use with children and adolescents who have moderate to severe learning disabilities with and without autism develop a treatment fidelity checklist to be used alongside the intervention manual appraise and consider several candidate outcome measures of anxiety-related symptoms, and secondary outcomes, and make a recommendation for use within phase 2. Phase 1b: description of treatment as usual The objective was to describe the current standard treatment provided for children and adolescents with moderate to severe learning disabilities and specific phobia within the UK. Phase 2: feasibility study The objectives were to: evaluate the manualised intervention to determine the acceptability and feasibility for all stakeholders, including children and young people, carers and therapists judge the appropriateness of the measures of anxiety-related symptomatology, and secondary outcomes, for use within a larger study explore recruitment pathways describe factors that challenge or facilitate the implementation of the intervention (e.g. comorbid behaviour problems, other mental health problems, community resources to support exposure) determine the feasibility and acceptability of consent and associated processes determine the acceptability of randomisation in a future trial describe the parameters of a future study to examine the effectiveness of exposure-based therapy to treat phobias in this population. Methods Study design Phase 1a (intervention development): an IDG was established. Informed by co-applicant Williams’s existing intervention developed for dog phobia in adolescents with severe learning disabilities and little to no speech, we developed an intervention that aimed to be developmentally appropriate for use with both children and adolescents with moderate to severe learning disabilities, and with phobia related to any specific stimulus, as defined by the DSM-5 [American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th edn. Washington, DC: American Psychiatric Association; 2013] (animal, natural environment, blood-injection-injury, situational, other). Phase 1b (TAU survey): to determine current community-based TAU, an online survey (UK-wide) was conducted of parents/carers who identified their child (aged 5–15 years) with moderate to severe learning disabilities as having a specific phobia, together with interviews/online survey of professionals. Phase 2 (feasibility study): this study was a single-arm, non-randomised feasibility study, with participants receiving the intervention developed in phase 1a, in conjunction with any other treatment they were receiving. Overall, the study ran from January 2021 to June 2023. Setting and participants Phase 1a (intervention development) The IDG recruited six key stakeholders who were representatives from our PPI partners, carers and family members and clinicians. The Principal Investigator, Study Manager and Research Assistant attended all of the IDG meetings. Other members of the research team attended the IDG sessions as observers only. Phase 1b (TAU survey) The study aimed to recruit 50 parents/carers who identified their child with moderate to severe learning disability as having a specific phobia and 25 learning disability professionals (health professionals, service providers and commissioners). We utilised our existing Midlands and wider UK networks of schools, support groups, charities and our PPI partner (the Foundation for People with Learning Disabilities) to disseminate the online survey to parents/carers of children and adolescents throughout England, Wales, Northern Ireland and Scotland. We also used our existing learning disabilities health professional networks, together with the local National Institute for Health and Care Research Clinical Research Network. The survey included questions informed by the Template for Intervention Description and Replication (TIDieR) checklist. The TIDieR checklist is used to provide a description of an intervention, including the use of any associated materials. Phase 2 (feasibility study) This single-arm, non-randomised feasibility study took place within the NHS – either specialist learning disabilities or mainstream child and adolescent mental health services in England. Five NHS services across England were recruited for this study: Cambridgeshire Community Services NHS Trust, Dorset Healthcare University NHS Foundation Trust, Avon and Wiltshire Mental Health Partnership NHS Trust, Norfolk Community Health and Care NHS Trust and Hertfordshire Community NHS Trust. Children currently receiving treatment for specific phobia or psychological intervention for other anxiety disorders were not eligible to participate. A total of 15 participants were recruited. Intervention During phase 1a, the exposure-based intervention for children with severe learning disabilities and limited communication skills developed by co-applicant Williams informed the development of an intervention for both children and adolescents with moderate to severe learning disabilities and with specific phobias. The intervention consisted of two parts: (1) a parents/carers skills training group workshop (two half-days), and (2) weekly therapist support telephone calls with individual parents/carers over 8 weeks, lasting approximately 30 minutes each, with an additional 30 minutes of therapist time to prepare and write notes after the session. Assessment of feasibility of delivery and acceptability of the intervention We examined the views of parents/carers and therapists to address: (a) intervention accessibility and acceptability; (b) helpful/unhelpful aspects, including barriers to change; (c) the value of our adaptations; (d) relationships with therapists within the intervention; (e) acceptability of consent processes; (f) acceptability of outcome measures; and (g) acceptability of randomisation within a future trial. We completed semistructured interviews with five parents/carers and five therapists. We aimed to complete interviews with the young people who received the intervention to explore their experience of the intervention and the outcomes for them. Although we planned to use augmented communication methods to aid our interview as much as possible, all parents indicated that their child would not be able to participate in an interview due to limited communication skills. Recruitment Phase 1b The online survey was delivered using Qualtrics® (Qualtrics, Provo, UT, USA). This phase lasted 14 months, running concurrently with phase 1a and phase 2. Fifty-two parents completed the survey on TAU. The health professionals survey covered the same content as the parent survey, in relation to support/treatment proved for specific phobia. Although originally conceived as an interview, the survey was also offered as an online survey to facilitate recruitment. Twenty-five professionals completed the online survey. Phase 2 Young people were enrolled in the study for approximately 6 months and were assessed at three time points: (1) eligibility assessment; (2) baseline assessment within 4 weeks prior to commencement of the intervention; and (3) assessment at completion of the intervention. The primary outcome measure was a parent/carer-completed checklist of symptoms of phobia and their severity. As there were no measures of specific phobia available, we modified existing measures to assess symptoms and their impact. Together with the IDG, in phase 1a of the project, the child version of the Severity Measure for Specific Phobia was adapted, modifying it consistent with the recommended adaptations in the Diagnostic Manual – Intellectual Disability (DM-ID-2) (Fletcher RJ, Barnhill J, Cooper SA, editors. Diagnostic Manual – Intellectual Disability 2: A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. 2nd edn. Kingston, NY: National Association for the Dually Diagnosed; 2017), and adapting it to be completed by a parent/carer. The impact of the phobia was also considered using an adapted version of the Strengths and Difficulties Questionnaire impact supplement (Goodman R. The extended version of the Strengths and Difficulties Questionnaire as a guide to child psychiatric caseness and consequent burden. J Child Psychol Psychiatry 1999;40:791–801), modified to be focused on specific phobia and to be appropriate for children with moderate to severe learning disabilities (Impact of Phobia measure). The IDG also considered a range of secondary outcomes, including: (a) specific phobia diagnosis {e.g. diagnostic checklist using DM-ID-2 or clinical interview [Anxiety Disorders Interview Schedule (Silverman W, Albano A. Anxiety Disorders Interview Schedule. Oxford: Oxford University Press; 1996)]}; (b) emotional and behaviour problems {Developmental Behavior Checklist-2 [Gray KM, Tonge B, Einfeld S, Gruber C, Klein A. Developmental Behavior Checklist (DBC2). 2nd edn. Torrance, California: Western Psychological Services; 2018]}; (c) challenging behaviour [Behavior Problems Inventory (Rojahn J, Rowe E, Sharber A, Hastings R, Matson J, Didden R, et al. The behavior problems inventory‐short form for individuals with intellectual disabilities: Part I: development and provisional clinical reference data. J Intellect Disabil Res 2012;56:527–45)]; and (d) physiological measures (heart rate). These measures were completed prior to commencement of the intervention, and within 4 weeks after the completion of the intervention. Patient and public involvement Patient and public involvement was a key part of our methods. We partnered with the Foundation for People with Learning Disabilities, who worked with us collaboratively to support coproduction (with family carers) to develop the intervention. Service users, carers and clinicians were members of our Study Steering Group and shared oversight of the progress of the project. PPI partners played a key role in contributing to the preparation of study documents, provided advice on recruitment, and helped to collaboratively disseminate information about the study findings. Results Phase 1a We successfully adapted the intervention, developed a logic model and intervention fidelity checklist and selected outcome measures collaboratively with the IDG. Phase 1b A national survey of TAU was undertaken to describe interventions for specific phobia in children and adolescents with moderate to severe learning disabilities. Parents/carers (n = 52) of children and adolescents with specific phobia and moderate to severe learning disabilities were surveyed as well as professionals (n = 25) working in services providing care to children and adolescents with moderate to severe learning disabilities. A key finding from the survey was that a significant proportion of parents (73%) reported not being offered any treatment for their child’s specific phobia. Of those who did receive treatment for their child, a range of treatments were offered, with the most frequent being medication. Other treatments were psychological, and included exposure therapy, sensory integration therapy and counselling. While the majority of treatments provided were in community-based health and social care settings, 28% were school based. Of the professionals who completed the TAU survey, the majority worked in health and care services (95%), and one was based in a school. Just over half (54%) indicated that their service offered treatment for specific phobia. Of these, 50% offered exposure therapy. Other therapies were also offered including cognitive behavioural therapy (CBT), medication, acceptance and commitment therapy, primary care support, systemic intervention and psychoeducation. With the exception of CBT, the other therapies did not include a graded exposure component. Phase 2 Acceptability and feasibility of the intervention The intervention was feasible to deliver and was acceptable to the parents of children with moderate to severe learning disabilities and to therapists. A number of revisions were suggested by the parents to improve clarity of some of the materials. Parents and therapists felt that some flexibility in the delivery of the support sessions would be useful. A number of the challenges identified by the therapists could be addressed in minor revisions to the therapist training workshop. Appropriateness of the outcome measures The study outcome measures were judged to be appropriate. With the exception of one parent, all measures were completed by parents/carers who remained in the study at both time points. The percentage of missing data on completed measures was extremely low. Recruitment pathways Recruitment of sites was challenging, with the two original planned sites withdrawing from the study due to capacity issues. The study team discussed participation in the study with 22 sites in order to recruit 5. Sites often declined to be involved on the basis of staff capacity. Barriers to taking part in the study were primarily COVID-19 related. Recruitment of participants was also challenging. Sites reported finding it challenging to identify potential participants from caseloads, as information on systems did not tend to record specific phobia as a primary problem. Three of the five sites were only able to recruit through current caseloads, while two sites were able to recruit externally (recruiting through local special schools and support/advocacy organisations in the region). In total, 93 potential participants were identified and contacted about the study; 47 of these were identified by NHS sites (caseloads) and 46 through external recruitment, highlighting the importance of being able to recruit from organisations external to the NHS sites. Factors that facilitate or challenge the implementation of the intervention For parents, logistical issues around finding time to do the tasks involved in the intervention presented a key challenge. Other challenges included sharing the data sheets with the therapists and the need for further support with understanding reinforcement. Accessing the feared stimulus (e.g. dogs) was a challenge for some. Therapists felt that the structure of the intervention and the troubleshooting component in particular facilitated the implementation of the intervention, and that placing parents as the experts on their child and their needs was a strength. Challenges included some difficulties with implementing the relaxation strategies, ensuring the exposure steps were sufficiently small and steps were not skipped, motivating parents, managing negative experiences during exposure, and accessing a dog for exposure steps. A number felt that more support/time was needed for parents. Feasibility and acceptability of consent and associated processes Parents/carers reported no difficulties with the participant information sheets and consent forms. Acceptability of randomisation in a future trial The majority (60%) of parents felt that participating in a future trial with randomisation was acceptable; however, 40% were concerned they may not be able to access the intervention. Therapists felt that it would be acceptable if all children were able to be offered the intervention at the end of the trial. Conclusions The SPIRIT intervention was judged to be feasible to deliver and acceptable to parents of children and adolescents with moderate to severe intellectual disabilities and therapists. Carers and therapists made some helpful suggestions for revisions which can be easily incorporated into the existing manualised intervention with minor revisions. This study took place during the COVID-19 pandemic, and the recruitment of sites and participants during phase 2 was at a lower rate than anticipated. The study aimed to recruit up to 20 participants and recruited 15. The participant attrition rate was low and not attributable to the intervention or study processes. This study benefited from genuine PPI during the adaptation of the intervention, development of the fidelity checklist and logic model, choice of outcome measures and study management. Following minor revisions to the intervention, the SPIRIT intervention should be tested in a randomised trial. Study registration Current Controlled Trials ISRCTN34766613. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR130177) and is published in full in Health Technology Assessment; Vol. 28, No. 64. See the NIHR Funding and Awards website for further award information.

Abstract Vulval lichen sclerosus (VLS) is an inflammatory skin disease characterised by itching, apareunia, loss of vulval architecture and scarring. Heterogeneity in outcome reporting precludes comparison between treatments. This study aimed to systematically review outcome measures used to evaluate the efficacy of VLS treatments and present patients' treatment priorities. This review followed the PRISMA guidelines using a registered protocol (PROSPERO: CRD42022356738). Multiple databases were searched, along with grey literature on Clinicaltrials.gov, European Union Clinical Trials and International Standard Randomised controlled trial (RCT) registries. All RCTs assessing any treatment for VLS were eligible for inclusion. A total of 775 patients were assessed across 21 RCTs. The assessment tools reported outcomes in the following domains: patient‐reported symptoms assessed with one validated scale in 12 studies and seven non‐validated scales in nine studies; sexual function with validated female sexual function index and female sexual distress scale in two studies and two non‐validated scales in two studies; quality of life with three validated scales in three studies and clinician‐reported objective outcomes with two validated scales in three studies and six non‐validated scales in fourteen studies. Histological changes were assessed in 10 studies and tissue biomechanics in one study. We also carried out an online survey completed by 809 women with VLS to assess their research and disease treatment priorities and identified validated outcome measures to assess these. There is high variability in assessing treatment outcomes for VLS. We identified validated assessment tools which could be implemented in VLS studies to evaluate the effectiveness of treatments.

Abstract Hypervariable region sequencing of the 16S ribosomal RNA (rRNA) gene plays a critical role in microbial ecology by offering insights into bacterial communities within specific niches. While providing valuable genus-level information, its reliance on data from targeted genetic regions limits its overall utility. Recent advances in sequencing technologies have enabled characterisation of the full-length 16S rRNA gene, enhancing species-level classification. Although current short-read platforms are cost-effective and precise, they lack full-length 16S rRNA amplicon sequencing capability. This study aimed to evaluate the feasibility of a modified 150 bp paired-end full-length 16S rRNA amplicon short-read sequencing technique on the Illumina iSeq 100 and 16S rRNA amplicon assembly workflow by utilising a standard mock microbial community and subsequently performing exploratory characterisation of captive (zoo) and free-ranging African elephant (Loxodonta africana) respiratory microbiota. Our findings demonstrate that, despite generating assembled amplicons averaging 869 bp in length, this sequencing technique provides taxonomic assignments consistent with the theoretical composition of the mock community and respiratory microbiota of other mammals. Tentative bacterial signatures, potentially representing distinct respiratory tract compartments (trunk and lower respiratory tract) were visually identified, necessitating further investigation to gain deeper insights into their implication for elephant physiology and health.

Abstract Background Ixabepilone may retain activity in paclitaxel-resistant disease. We previously reported improved response rates (ORR), progression-free (PFS), and overall survival (OS) conferred by ixabepilone+bevacizumab (IXA + BEV) compared to monotherapy (IXA) in heavily pre-treated ovarian cancers. We now describe a mature data set. Subset analyses were performed in patients with different taxane sensitivities and dose modifications. Methods Patients previously treated with paclitaxel were stratified by prior BEV and randomized to receive IXA 20 mg/m2 days 1,8,15 ± BEV 10 mg/kg days 1,15 of a 28-day cycle in a multi-site prospective randomized phase 2 trial. Results Thirty-seven patients were randomized to IXA and 39 patients to IXA + BEV. At the final data cutoff (05/27/2023), ORR was higher in the IXA + BEV arm (38.4% vs. 8.1%, p = 0.003). Dose reductions were necessary in most participants but did not diminish PFS/OS benefits. Most patients were paclitaxel-refractory/-resistant (51%, n = 19/37;67%, n = 26/39); the remainder were taxane-sensitive. The addition of BEV to IXA conferred benefit in PFS (5.5 vs. 2.2 mo; HR 0.31, 90%CI 0.20–0.49, p

This article presents the results of an ongoing inventory of Ascomycota in Yunnan, China, carried out as part of the research project series “Exploring ascomycete diversity in Yunnan”. From over 100 samples collected from diverse host substrates, microfungi have been isolated, identified and are currently being documented. The primary objective of this research is to promote the discovery of novel taxa and explore the ascomycete diversity in the region, utilising a morphology-phylogeny approach. This article represents the second series of species descriptions for the project and introduces three undocumented species found in the families Bambusicolaceae, Dictyosporiaceae and Periconiaceae, belonging to the suborder Massarineae (Pleosporales, Dothideomycetes). These novel taxa exhibit typical morphological characteristics of Bambusicola, Periconia and Trichobotrys, leading to their designation as Bambusicola hongheensis, Periconia kunmingensis and Trichobotrys sinensis. Comprehensive multigene phylogenetic analyses were conducted to validate the novelty of these species. The results revealed well-defined clades that are clearly distinct from other related species, providing robust support for their placement within their respective families. Notably, this study unveils the phylogenetic affinity of Trichobotrys within Dictyosporiaceae for the first time. Additionally, the synanamorphism for the genus Trichobotrys is also reported for the first time. Detailed descriptions, illustrations and updated phylogenies of the novel species are provided, and thus presenting a valuable resource for researchers and mycologists interested in the diversity of ascomycetes in Yunnan. By enhancing our understanding of the Ascomycota diversity in this region, this research contributes to the broader field of fungal taxonomy and their phylogenetic understanding.

Background: By the time chronic lung allograft dysfunction (CLAD), with its main phenotypes bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), is diagnosed by pulmonary function testing, irreversible damage to the lung allograft may already have occurred. Dynamic 19F-MRI of inhaled perfluoropropane may detect subtle changes in regional lung ventilation and provides a quantitative measure of regional lung function. We assessed feasibility of detecting regional ventilation dysfunction due to CLAD in lung transplant recipients. Methods: Dynamic 19F-MRI was performed in ten lung transplant recipients, four without CLAD and six with CLAD (5 BOS, 1 RAS). Gas wash-in and washout dynamics were assessed and regional lung clearance index (RLCI) provided a quantitative metric of regional lung ventilation. Results: BOS patients had substantially greater variation in regional ventilation compared with stable patients, with more regions of reduced ventilation, especially in the periphery. Tracer washout was homogeneous and rapid in stable patients but highly heterogeneous in CLAD. CLAD patients exhibited significant difference in RLCI between central and peripheral lung regions (p = 0.0016) and a wider interquartile range of RLCI for wash-in compared with stable patients (no CLAD 4.1, BOS 10.5, p = 0.036). FEV1 (% of baseline) negatively correlated with ventilation during wash-in, most strongly for the periphery (r = −0.844, p = 0.0021). Conclusions: Dynamic 19F-MRI identified quantifiable differences in regional ventilation in lung transplant recipients with and without CLAD and was well tolerated. Larger longitudinal studies using this approach will determine if early detection of changes in regional ventilation in lung transplant patients allows earlier CLAD detection.

Background and purpose: Bladder cancer (BC) is a common malignancy in the Western World with men being diagnosed almost four times as often as women. The etiology of bladder cancer may involve sex hormones. Prostate cancer (PCa) patients treated with chemical castration, such as androgen deprivation therapy, or surgical castration, may therefore have a lower risk of developing bladder cancer. Patients/material and methods: In a nation-wide population-based cohort study using national Danish registry data, we included a cohort of men with a first-time PCa diagnosis between 2002 and 2018 divided according to antihormonal treatment in the first year after PCa diagnosis and a comparison cohort consisting of 10 age-matched persons for each PCa patient. Each individual was followed from 1 year after PCa diagnosis until death or end of follow-up. We computed cumulative incidences (risk) and hazard ratios (HRs) for BC. In a second cohort analysis, we determined overall survival and BC-specific mortality, determined from date of BC diagnosis until death. Results and interpretation: We included 48,776 PCa patients of whom 13,592 were treated with chemical castration, 2,261 with surgical castration, and 32,923 received no antihormonal treatment. The 5-year risk of BC for each PCa group was 1.1%, 0.7%, and 1.3%, respectively, corresponding to an adjusted HR of 1.13 (95% CI 0.98; 1.31), 0.95 (95% CI 0.62; 1.47), and 1.18 (95% CI 1.09; 1.28) compared to individuals without PCa. Patients receiving antihormonal treatment had a slightly lower incidence of BC compared to individuals without PCa, however, this was not supported by the HRs. The treatment, however, was not associated with overall survival.

Summary: Autoimmune patients have a significantly increased risk of developing coronary artery disease (CAD) compared to the general population. However, autoimmune patients often lack traditional risk factors for CAD and there is increasing recognition of inflammation in CAD development. In this study, we leveraged genome-wide association study (GWAS) data to understand whether there is a genetic relationship between CAD and autoimmunity. Statistical genetic comparison methods were used to identify correlated and causal SNPs between various autoimmune diseases and CAD. Pleiotropic SNPs were identified by cross-phenotype association analysis (CPASSOC) and overlap between GWAS. Causal SNPs were identified using Mendelian Randomization (MR) and Colocalization (COLOC). Using SNP-to-gene mapping, we additionally identified pleiotropic and causal genes and pathways associated between autoimmunity and CAD, which were contextualized by documentation of enrichment in individual cell types identified from coronary atherosclerotic plaques by single-cell RNA sequencing. These results provide insight into potential inflammatory therapeutic targets for CAD.

Abstract The effects of small‐scale topography‐induced land surface heterogeneity are not well represented in current Earth System Models (ESMs). In this study, a new topography‐based subgrid structure referred to as topographic units (TGU) designed to better capture subgrid topographic effects, and methods to downscale atmospheric forcing to the land TGUs have been implemented in the Energy Exascale Earth System Model (E3SM) Land Model (ELM). Effects of the subgrid scheme and downscaling methods on ELM simulated land surface processes are evaluated over the conterminous United States (CONUS). For this purpose, ELM simulations are performed using two configurations without (NoD ELM) and with (D ELM) downscaling, both using TGUs derived for the 0.5‐degree grids and the same land surface parameters. Simulations using the two ELM configurations are compared over the CONUS domain, regional levels, and at observational sites (e.g., SNOTEL). The CONUS‐level results suggest that D ELM simulates more snowfall and snow water equivalent (SWE), higher runoff, and less ET during spring and summer. Regional‐level results suggest more pronounced impacts of downscaling over regions dominated by higher elevation TGUs and regions with maximum precipitation occurring during cool seasons. Results at the SNOTEL sites suggest that D ELM has superior capability of reproducing the observed SWE at 83% of the sites, with more pronounced performance over topographically heterogeneous TGUs with their maximum precipitation occurring during cool seasons. The results highlight the importance of improving representation of small‐scale surface heterogeneity in ESMs and motivate future research to understand their effects on land‐atmosphere interactions, streamflow, and water resources management over mountainous regions.

Background: This retrospective study aimed to investigate the outcomes and adverse events (AEs) associated with adjuvant radiotherapy with helical tomotherapy (hT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Methods: Twenty-eight patients with DCIS underwent postoperative hT between 2011 and 2020. hT was chosen since it provided optimal target coverage and tolerable organ-at-risk doses to the lungs and heart when tangential 3-dimensional conformal radiotherapy (3D-CRT) was presumed to provide unfavorable dosimetry. The median total (single) dose was 50.4 Gy (1.8 Gy). The median time between BCS and the start of hT was 5 weeks (range, 4-38 weeks). Statistical analysis included local recurrence-free survival, overall survival (OS), and secondary cancer-free survival. AEs were classified according to the Common Toxicity Criteria for Adverse Events, version 5. Results: The patients’ median age was 58 years. The median follow-up period was 61 months (range, 3-123 months). The 1-, 3-, and 5-year OS rates were 100% each. None of the patients developed secondary cancer, local recurrence, or invasive breast cancer during follow-up. The most common acute AEs were dermatitis (n = 27), fatigue (n = 4), hyperpigmentation (n = 3), and thrombocytopenia (n = 4). The late AE primarily included surgical scars (n = 7) and hyperpigmentation (n = 5). None of the patients experienced acute or late AEs > grade 3. The mean conformity and homogeneity indices were 0.9 (range, 0.86-0.96) and 0.056 (range, 0.05-0.06), respectively. Conclusion: hT after BCS for DCIS is a feasible and safe form of adjuvant radiotherapy for patients in whom 3D-CRT is contraindicated due to unfavorable dosimetry. During follow-up, there were no recurrences, invasive breast cancer diagnoses, or secondary cancers, while the adverse effects were mild.

Objective Omega-3 polyunsaturated fatty acids (PUFAs) play a critical role in regulating inflammation and lipid metabolism. This study sought to ascertain the frequency of omega-3 deficiency in patients with SLE and investigate whether supplementation with krill oil concentrate (KOC) could replenish omega-3 levels and decrease SLE disease activity.Methods A multicentre, randomised, double-blind, placebo-controlled trial was conducted in adult patients with active SLE. Eligible patients were randomised to receive 4 g/day KOC or placebo (vegetable oil mixture) for the first 24 weeks, and thereafter patients could opt to enter an open-label extension. The primary end point was improvement of the red blood cell Omega-3 Index from baseline to week 24. Changes in clinical features, including SLE Disease Activity Index 2000 (SLEDAI-2K) disease activity scores, were also monitored.Results Seventy-eight patients met eligibility criteria and were randomised to a treatment group (n=39 per group). The baseline Omega-3 Index in the total SLE cohort was a mean 4.43% (±SD 1.04%). After 4 weeks of KOC treatment, the Omega-3 Index rapidly increased to 7.17%±1.48% (n=38) and after 24 weeks to 8.05%±1.79% (n=25) (each p

Background: Single ventricle (SV) patients with interrupted inferior vena cava (iIVC) and azygos continuation are at high risk for unbalanced hepatic venous flow (HVF) distribution to the lungs after Fontan completion and subsequent pulmonary arteriovenous malformations (AVMs) formation. Objectives: The aim of the study was to utilize computational fluid dynamics (CFD) analysis to avoid maldistribution of HVF to the lungs after Fontan surgery. Methods: Four SV subjects with iIVC were prospectively studied with a 3-dimensional (3D) modeling workflow with digital 3D models created from segmented magnetic resonance images or computer tomography scans, virtual surgery, and CFD analysis over multiple physiologic states for the evaluation of operative plans to achieve balanced HVF to both lungs. Three of the patients were Fontan revision candidates with existing AVMs. All patients underwent Fontan completion or revision surgery. Results: CFD predicted that existing or proposed Fontan completion in all patients would result in 100% of HVF to one lung. Improved HVF balance was achieved with CFD analysis of alternative surgical approaches resulting in the average distribution of HVF to the right/left pulmonary arteries of 37%/63% ± 10.4%. A hepatoazygos shunt was required in all patients and additional creation of an innominate vein in one. CFD analysis was validated by the comparison of pre-operative predicted and postoperative MRI-measured total right/left pulmonary flow (51%/49% ± 5.4% vs 49%/51% ± 8.5%). Conclusions: A 3D modeling workflow with CFD simulation for SV patients with iIVC may avoid HVF maldistribution and development of AVMs after Fontan completion.

Abstract The determination of the temperature in and above the slab in subduction zones, using models where the top of the slab is precisely known, is important to test hypotheses regarding the causes of arc volcanism and intermediate-depth seismicity. While 2D and 3D models can predict the thermal structure with high precision for fixed slab geometries, a number of regions are characterized by relatively large geometrical changes over time. Examples include the flat slab segments in South America that evolved from more steeply dipping geometries to the present day flat slab geometry. We devise, implement, and test a numerical approach to model the thermal evolution of a subduction zone with prescribed changes in slab geometry over time. Our numerical model approximates the subduction zone geometry by employing time dependent deformation of a Bézier spline that is used as the slab interface in a finite element discretization of the Stokes and heat equations. We implement the numerical model using the FEniCS open source finite element suite and describe the means by which we compute approximations of the subduction zone velocity, temperature, and pressure fields. We compute and compare the 3D time evolving numerical model with its 2D analogy at cross-sections for slabs that evolve to the present-day structure of a flat segment of the subducting Nazca plate.

Abstract Quantitative assessment of retinal microvasculature in optical coherence tomography angiography (OCTA) images is important for studying, diagnosing, monitoring, and guiding the treatment of ocular and systemic diseases. However, the OCTA user community lacks universal and transparent image analysis tools that can be applied to images from a range of OCTA instruments and provide reliable and consistent microvascular metrics from diverse datasets. We present a retinal extension to the OCTA Vascular Analyser (OCTAVA) that addresses the challenges of providing robust, easy-to-use, and transparent analysis of retinal OCTA images. OCTAVA is a user-friendly, open-source toolbox that can analyse retinal OCTA images from various instruments. The toolbox delivers seven microvascular metrics for the whole image or subregions and six metrics characterising the foveal avascular zone. We validate OCTAVA using images collected by four commercial OCTA instruments demonstrating robust performance across datasets from different instruments acquired at different sites from different study cohorts. We show that OCTAVA delivers values for retinal microvascular metrics comparable to the literature and reduces their variation between studies compared to their commercial equivalents. By making OCTAVA publicly available, we aim to expand standardised research and thereby improve the reproducibility of quantitative analysis of retinal microvascular imaging. Such improvements will help to better identify more reliable and sensitive biomarkers of ocular and systemic diseases.

Abstract Background Within England, children and young people (CYP) who come into police custody are referred to Liaison and Diversion (L&D) teams. L&D teams have responsibility for liaising with healthcare and other support services while working to divert CYP away from the criminal justice system but have traditionally not provided targeted psychological interventions to CYP. Considering evidence that Solution Focused Brief Therapy (SFBT) leads to a reduction in internalising and externalising behaviour problems in CYP, the aim of this randomised controlled trial (RCT) was to determine whether there is a difference between services as usual (SAU) plus SFBT offered by trained therapists working within a L&D team, and SAU alone, in reducing offending behaviours in 10–17-year-olds presenting at police custody. Methods Design: two-arm individually RCT with internal pilot and process evaluation. Participants: N = approximately 448 CYP aged 10–17 years presenting at one of three police custody suites in the area served by Lancashire and South Cumbria NHS Foundation Trust (LSCFT) who are referred to the L&D team. Participants will be recruited and allocated to intervention:control on a 1:1 basis. Interviews will be performed with 30–40 CYP in the intervention arm, 15 CYP in the control arm, up to 20 parents/guardians across both arms, up to 15 practitioners, and up to 10 site staff responsible for screening CYP for the trial. Intervention and control: Those allocated to the intervention will be offered SAU plus SFBT, and control participants will receive SAU only. Primary outcome: CYP frequency of offending behaviours assessed through the Self-Report Delinquency Measure (SRDM) at 12 months post-randomisation. Secondary outcomes: criminal offence data (national police database); emotional and behavioural difficulties (self-report and parent/guardian reported); gang affiliation (self-report). Process evaluation: evaluation of acceptability and experiences of the CYP, parents/guardians, site staff and practitioners; fidelity of SFBT delivery. Discussion This two-arm individually RCT will evaluate the effectiveness of SFBT in reducing offending behaviours in CYP presenting at police custody suites within the area served by LSCFT. Our process evaluation will assess the fidelity of delivery of SFBT, the factors affecting implementation, the acceptability of SFBT in CYP aged 10–17 years and recruitment and reach. We will also examine systems and structures for future delivery, therefore assessing overall scalability. Trial registration ClinicalTrials.gov ISRCTN14195235 . Registered on June 16, 2023.

This paper presents an assessment of background radiation levels within the Niger Delta University campus, Bayelsa State Nigeria. A portable Geiger-Muller tube (Radiation Alert) was used to detect the background ionizing radiation within a temperature range of -100 ℃ to 500 ℃. Results of absorbed dose rate in air in the main campus, open field and new campus vary from 104.4 nGy/h to 278.4 nGy/h with an average of 156.6 nGy/h, 34.8 nGy/h to 174.0 nGy/h with an average of 95.7 nGy/h and 69.6 nGy/h to 174.0 nGy/h with an average of 113.1 nGy/h respectively. The annual effective dose estimates ranged from 0.160 mSv/y to 0.427 mSv/y with an average of 0.024 mSv/y, 0.053 to 0.267 mSv/y with an average of 0.147 mSv/y and 0.107 to 0.267 mSv/y with a mean of 0.173 mSv/y in the main campus, open field and new campus respectively. The excess lifetime cancer risks ranged from 0.442 to 01.174 x 10-3 with a mean of 0.663 x 10-3, 0.146 to 0.736 x 10-3 with an average of 0.405 x 10-3 and 0.295 to 0.736 x 10-3 with average 0.479 x 10-3 in main campus, open field and new campus respectively. The estimated averages of absorbed dose rates in the air within Niger Delta University were above the world average of 57 nGy/h. Annual Effective Dose Equivalent (AEDE) are below the safe limit of 1 mSv/y for humans. The results of this study provide baseline information on the background ionizing radiation and can be referenced for future works in the area.

Abstract Therapeutic targeting of KRAS-mutant pancreatic ductal adenocarcinoma (PDAC) has remained a significant challenge in clinical oncology. Direct targeting of KRAS has proven difficult, and inhibition of the KRAS effectors have shown limited success due to compensatory activation of survival pathways. Being a core downstream effector of the KRAS-driven p44/42 MAPK and PI3K/AKT pathways governing intrinsic apoptosis, BAD phosphorylation emerges as a promising therapeutic target. Herein, a positive association of the pBADS99/BAD ratio with higher disease stage and worse overall survival of PDAC was observed. Homology-directed repair of BAD to BADS99A or small molecule inhibition of BADS99 phosphorylation by NCK significantly reduced PDAC cell viability by promoting cell cycle arrest and apoptosis. NCK also abrogated the growth of preformed colonies of PDAC cells in 3D culture. Furthermore, high-throughput screening with an oncology drug library to identify potential combinations revealed a strong synergistic effect between NCK and MEK inhibitors in PDAC cells harboring either wild-type or mutant-KRAS. Mechanistically, both mutant-KRAS and MEK inhibition increased the phosphorylation of BADS99 in PDAC cells, an effect abrogated by NCK. Combined pBADS99-MEK inhibition demonstrated strong synergy in reducing cell viability, enhancing apoptosis, and achieving xenograft stasis in KRAS-mutant PDAC. In conclusion, the inhibition of BADS99 phosphorylation enhances the efficacy of MEK inhibition, and their combined inhibition represents a mechanistically based and potentially effective therapeutic strategy for the treatment of KRAS-mutant PDAC.

Abstract Data sharing is necessary to maximize the actionable knowledge generated from research data. Data challenges can encourage secondary analyses of datasets. Data challenges in biomedicine often rely on advanced cloud-based computing infrastructure and expensive industry partnerships. Examples include challenges that use Google Cloud virtual machines and the Sage Bionetworks Dream Challenges platform. Such robust infrastructures can be financially prohibitive for investigators without substantial resources. Given the potential to develop scientific and clinical knowledge and the NIH emphasis on data sharing and reuse, there is a need for inexpensive and computationally lightweight methods for data sharing and hosting data challenges. To fill that gap, we developed a workflow that allows for reproducible model training, testing, and evaluation. We leveraged public GitHub repositories, open-source computational languages, and Docker technology. In addition, we conducted a data challenge using the infrastructure we developed. In this manuscript, we report on the infrastructure, workflow, and data challenge results. The infrastructure and workflow are likely to be useful for data challenges and education.

Whilst conducting surveys of lignicolous microfungi in Yunnan Province, we collected a large number of taxa that resemble Montagnula (Didymosphaeriaceae, Pleosporales). Our phylogenetic study on Montagnula involved analysing sequence data from ribosomal RNA genes (nc18S, nc28S, ITS) and protein-coding genes (rpb2, tef1-α). We present a biphasic approach (morphological and molecular phylogenetic evidence) that supports the recognition of four new species in Montagnula viz., M. lijiangensis, M. menglaensis, M. shangrilana and M. thevetiae. The global diversity of Montagnula is also inferred from metabarcoding data and published records based on field observations. Metabarcoding data from GlobalFungi and field observations provided insights into the global diversity and distribution patterns of Montagnula. Studies conducted in Asia, Australia, Europe, and North America revealed a concentration of Montagnula species, suggesting regional variations in ecological preferences and distribution. Montagnula species were found on various substrates, with sediments yielding a high number of sequences. Poaceae emerged as a significant contributor, indicating a potential association between Montagnula species and grasses. Culture-based investigations from previously published data revealed Montagnula species associations with 105 plant genera (in 45 plant families), across 55 countries, highlighting their wide ecological range and adaptability. This study enhances our understanding of the taxonomy, distribution, and ecological preferences of Montagnula species. It emphasizes their role in the decomposition of organic matter in grasslands and savannah systems and suggests further investigation into their functional roles in ecosystem processes. The global distribution patterns and ecological interactions of Montagnula species underscore the need for continued research and conservation efforts.

Abstract Background Older care home residents are a vulnerable group of people with atrial fibrillation (AF) at high risk of adverse health events. The Atrial Fibrillation Better Care (ABC: Avoid stroke; Better symptom management; Cardiovascular and other comorbidity management) pathway is the gold-standard approach toward integrated AF care, and pharmacists are a potential resource with regards to its’ implementation. The aim of this study was to determine the feasibility of pharmacist-led medicines optimisation in care home residents, based on the ABC pathway compared to usual care. Methods Individually randomised, prospective pilot and feasibility study of older (aged ≥ 65 years) care home residents with AF (ISRCTN14747952); residents randomised to ABC pathway optimised care versus usual care. The primary outcome was a description of study feasibility (resident and care home recruitment and retention). Secondary outcomes included the number and type of pharmacist medication recommendations and general practitioner (GP) implementation. Results Twenty-one residents were recruited and 11 (mean age [standard deviation] 85.0 [6.5] years, 63.6% female) were randomised to receive pharmacist-led medicines optimisation. Only 3/11 residents were adherent to all three components of the ABC pathway. Adherence was higher to ‘A’ (9/11 residents) and ‘B’ (9/11 residents) components compared to ‘C’ (3/11 residents). Four ABC-specific medicines recommendations were made for three residents, and two were implemented by residents’ GPs. Overall ABC adherence rates did not change after pharmacist medication review, but adherence to ‘A’ increased (from 9/11 to 10/11 residents). Other ABC recommendations were inappropriate given residents’ co-morbidities and risk of medication-related adverse effects. Conclusions The ABC pathway as a framework was feasible to implement for pharmacist medication review, but most residents’ medications were already optimised. Low rates of adherence to guideline-recommended therapy were a result of active decisions not to treat after assessment of the net risk–benefit.

Abstract Aberrant activation of the PI3K/AKT signaling axis along with the sustained phosphorylation of downstream BAD is associated with a poor outcome of TNBC. Herein, the phosphorylated to non-phosphorylated ratio of BAD, an effector of PI3K/AKT promoting cell survival, was observed to be correlated with worse clinicopathologic indicators of outcome, including higher grade, higher proliferative index and lymph node metastasis. The structural optimization of a previously reported inhibitor of BAD-Ser99 phosphorylation was therefore achieved to generate a small molecule inhibiting the phosphorylation of BAD at Ser99 with enhanced potency and improved oral bioavailability. The molecule 2-((4-(2,3-dichlorophenyl)piperazin-1-yl)(pyridin-3-yl)methyl) phenol (NCK) displayed no toxicity at supra-therapeutic doses and was therefore assessed for utility in TNBC. NCK promoted apoptosis and G0/G1 cell cycle arrest of TNBC cell lines in vitro, concordant with gene expression analyses, and reduced in vivo xenograft growth and metastatic burden, demonstrating efficacy as a single agent. Additionally, combinatorial oncology compound library screening demonstrated that NCK synergized with tyrosine kinase inhibitors (TKIs), specifically OSI-930 or Crizotinib in reducing cell viability and promoting apoptosis of TNBC cells. The synergistic effects of NCK and TKIs were also observed in vivo with complete regression of a percentage of TNBC cell line derived xenografts and prevention of metastatic spread. In patient-derived TNBC xenograft models, NCK prolonged survival times of host animals, and in combination with TKIs generated superior survival outcomes to single agent treatment. Hence, this study provides proof of concept to further develop rational and mechanistic based therapeutic strategies to ameliorate the outcome of TNBC.

Abstract Kagome lattice magnets are an interesting class of materials as they can host topological properties in their magnetic and electronic structures. YMn6Sn6 is one such compound in which various exotic magnetic and electronic topological properties have been realized. Here, by means of a partial substitution of Sn with an isovalent and slightly smaller atom Ge, we demonstrate the sensitivity of such chemical substitution on the magnetic structure and its influence in the electronic properties. Magnetic structure of YMn6Sn4Ge2 determined by neutron diffraction reveals an incommensurate staggered magnetic spiral with a slightly larger spiral pitch than in YMn6Sn6. This change in magnetic structure influences the Fermi surface enhancing the out-of-plane conductivity. Such a sensitivity to the partial chemical substitution provides a great potential for engineering the magnetic phases and associated electronic properties not only in YMn6Sn6, but also in the large family of 166 rare-earth kagome magnet.

Abstract Background Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to manage anxiety in adults with an autism diagnosis. However, their effectiveness and adverse effect profile in the autistic population are not well known. This trial aims to determine the effectiveness and cost-effectiveness of the SSRI sertraline in reducing symptoms of anxiety and improving quality of life in adults with a diagnosis of autism compared with placebo and to quantify any adverse effects. Methods STRATA is a two-parallel group, multi-centre, pragmatic, double-blind, randomised placebo-controlled trial with allocation at the level of the individual. It will be delivered through recruiting sites with autism services in 4 regional centres in the United Kingdom (UK) and 1 in Australia. Adults with an autism diagnosis and a Generalised Anxiety Disorder Assessment (GAD-7) score ≥ 10 at screening will be randomised 1:1 to either 25 mg sertraline or placebo, with subsequent flexible dose titration up to 200 mg. The primary outcome is GAD-7 scores at 16 weeks post-randomisation. Secondary outcomes include adverse effects, proportionate change in GAD-7 scores including 50% reduction, social anxiety, obsessive-compulsive symptoms, panic attacks, repetitive behaviours, meltdowns, depressive symptoms, composite depression and anxiety, functioning and disability and quality of life. Carer burden will be assessed in a linked carer sub-study. Outcome data will be collected using online/paper methods via video call, face-to-face or telephone according to participant preference at 16, 24 and 52 weeks post-randomisation, with brief safety checks and data collection at 1–2, 4, 8, 12 and 36 weeks. An economic evaluation to study the cost-effectiveness of sertraline vs placebo and a QuinteT Recruitment Intervention (QRI) to optimise recruitment and informed consent are embedded within the trial. Qualitative interviews at various times during the study will explore experiences of participating and taking the trial medication. Discussion Results from this study should help autistic adults and their clinicians make evidence-based decisions on the use of sertraline for managing anxiety in this population. Trial registration ISRCTN, ISRCTN15984604 . Registered on 08 February 2021. EudraCT 2019-004312-66. ANZCTR ACTRN12621000801819. Registered on 07 April 2021.

One of the major goals of total knee arthroplasty (TKA) is to restore the physiological function of the knee. In order to select the appropriate TKA design for a specific patient, it would be helpful to understand whether there is an association between passive knee kinematics intraoperatively and during complex activities, such as ascending stairs. Therefore, the primary objective of this study was to compare the anterior–posterior (AP) range of motion during simulated passive flexion and stair ascent at different conditions in the same knees using a six-degrees-of-freedom joint motion simulator, and secondary, to identify whether differences between TKA designs with and without a post-cam mechanism can be detected during both activities, and if one design is superior in recreating the AP translation of the native knee. It was shown that neither TKA design was superior in restoring the mean native AP translation, but that both CR/CS and PS TKA designs may be suitable to restore the individual native kinematic pattern. Moreover, it was shown that passive and complex loading scenarios do not result in exactly the same kinematic pattern, but lead to the same choice of implant design to restore the general kinematic behavior of the native individual knee.

Background: The activation of the growth hormone receptor (GHR) is a major determinant of body growth. Defective GHR signaling, as seen in human Laron dwarfism, resulted in low plasma IGF-1 concentrations and limited growth, but also marked absence in the development of breast cancer and type 2 diabetes. In vitro, we identified a small molecule (C#1) that inhibits the translation of GHR mRNA to receptor protein. Methods: Before its application in humans as a potential anticancer drug, C#1 was tested in animals to evaluate whether it could be administered to achieve a plasma concentration in vivo that inhibits cell proliferation in vitro without causing unwanted toxicity. To evaluate the efficacy and toxicity of C#1, a group of six intact female Beagle dogs was treated daily each morning for 90 days with an oral solution of C#1 in Soiae oleum emulgatum at a dose of 0.1 mg/kg body weight. During treatment, dogs were closely monitored clinically, and blood samples were taken to measure plasma C#1 concentrations, complete blood counts (CBC), clinical chemistry, and endocrinology. At the end of the treatment, dogs were euthanized for gross and histopathological analysis. An additional group of six female Beagle dogs was included for statistical reasons and only evaluated for efficacy during treatment for 30 days. Results: Daily administration of C#1 resulted in a constant mean plasma concentration of approximately 50 nmol/L. In both groups, two out of six dogs developed decreased appetite and food refusal after 4–5 weeks, and occasionally diarrhea. No significant effects in CBC or routine clinical chemistry were seen. Plasma IGF-1 concentrations, used as biomarkers for defective GHR signaling, significantly decreased by 31% over time. As plasma growth hormone (GH) concentrations decreased by 51% as well, no proof of GHR dysfunction could be established. The measured 43% decrease in plasma acylated/non-acylated ghrelin ratios will also lower plasma GH concentrations by reducing activation of the GH secretagogue receptor (GHSR). C#1 did not directly inhibit the GHSR in vivo, as shown in vitro. There were no significant effects on glucose, lipid, or folate/homocysteine metabolism. Conclusions: It is concluded that with daily dosing of 0.1 mg C#1/kg body weight, the induction of toxic effects prevented further increases in dosage. Due to the concomitant decrease in both IGF-1 and GH, in vivo inhibition of GHR could not be confirmed. Since the concept of specific inhibition of GHR synthesis by small molecules remains a promising strategy, searching for compounds similar to C#1 with lower toxicity should be worthwhile.

The autoimmune disease lupus erythematosus (lupus) is characterized by photosensitivity, where even ambient ultraviolet radiation (UVR) exposure can lead to development of inflammatory skin lesions. We have previously shown that Langerhans cells (LCs) limit keratinocyte apoptosis and photosensitivity via a disintegrin and metalloprotease 17 (ADAM17)-mediated release of epidermal growth factor receptor (EGFR) ligands and that LC ADAM17 sheddase activity is reduced in lupus. Here, we sought to understand how the lupus skin environment contributes to LC ADAM17 dysfunction and, in the process, differentiate between effects on LC ADAM17 sheddase function, LC ADAM17 expression, and LC numbers. We show through transcriptomic analysis a shared IFN-rich environment in non-lesional skin across human lupus and three murine models: MRL/lpr, B6.Sle1yaa, and imiquimod (IMQ) mice. IFN-I inhibits LC ADAM17 sheddase activity in murine and human LCs, and IFNAR blockade in lupus model mice restores LC ADAM17 sheddase activity, all without consistent effects on LC ADAM17 protein expression or LC numbers. Anti-IFNAR-mediated LC ADAM17 sheddase function restoration is associated with reduced photosensitive responses that are dependent on EGFR signaling and LC ADAM17. Reactive oxygen species (ROS) is a known mediator of ADAM17 activity; we show that UVR-induced LC ROS production is reduced in lupus model mice, restored by anti-IFNAR, and is cytoplasmic in origin. Our findings suggest that IFN-I promotes photosensitivity at least in part by inhibiting UVR-induced LC ADAM17 sheddase function and raise the possibility that anifrolumab ameliorates lupus skin disease in part by restoring this function. This work provides insight into IFN-I-mediated disease mechanisms, LC regulation, and a potential mechanism of action for anifrolumab in lupus.

Background: An estimated 300 million people live with asthma globally. In England, a significant percentage live with poorly controlled asthma symptoms. Community pharmacists might be able to play a role in filling gaps in asthma care as they have the expertise and are in regular contact with patients with long term conditions. This study described patients' experiences of the management of their asthma in the general physician (GP) practice and community pharmacy settings and explored patients' views on providing support for them in community pharmacy. Method: This is a descriptive qualitative study. Thirteen adult asthma patients were recruited from a GP practice in the Northwest of England. Semi-structured qualitative interviews were conducted face-to-face or by telephone. The interviews were recorded, transcribed and analysed using a thematic analysis approach. Ethics approval was obtained before the study commenced and all participants gave informed written consent to participate. Results: We identified challenges in the current asthma care provided to patients with asthma including lack of continuity of care, inability to book an appointment and other experienced differences in the quality of asthma care provided to them and/or access to annual asthma reviews across different GP practices. Additionally, there is lack of awareness of services provided in community pharmacy. These challenges along with having comorbidities alongside asthma may negatively affect asthma patients' engagement with their asthma appointments and their behaviour toward their asthma. Conclusions: Patients showed trust in community pharmacists same as other HCPs to support them with their asthma care. Patients thought that being provided with regular asthma care including reviews in community pharmacy might be a suitable approach to respond to patients' needs and preferences in terms of their asthma management because of ease of access to community pharmacy. Pharmacists could be involved in the provision of community pharmacy-based asthma interventions that involve more than inhaler technique education. Further research should focus on developing structured approaches for asthma patient education that can be implemented consistently in the context of community pharmacy in England.

Purpose: Clinical and imaging surveillance of patients with brain metastases is important after stereotactic radiosurgery (SRS) because many will experience intracranial progression (ITCP) requiring multidisciplinary management. The prognostic significance of neurologic symptoms at the time of ITCP is poorly understood. Methods and Materials: This was a multi-institutional, retrospective cohort study from 2015 to 2020, including all patients with brain metastases completing an initial course of SRS. The primary outcome was overall survival (OS) by presence of neurologic symptoms at ITCP. OS, freedom from ITCP (FF-ITCP), and freedom from symptomatic ITCP (FF-SITCP) were assessed via Kaplan-Meier method. Cox proportional hazard models tested parameters impacting FF-ITCP and FF-SITCP. Results: Among 1383 patients, median age was 63.4 years, 55% were female, and common primaries were non-small cell lung (49%), breast (15%), and melanoma (9%). At a median follow-up of 8.72 months, asymptomatic and symptomatic ITCP were observed in 504 (36%) and 194 (14%) patients, respectively. The majority of ITCP were distant ITCP (79.5%). OS was worse with SITCP (median, 10.2 vs 17.9 months, P < .001). SITCP was associated with clinical factors including total treatment volume (P = .012), melanoma histology (P = .001), prior whole brain radiation therapy (P = .003), number of brain metastases (P < .001), interval of 1 to 2 years from primary and brain metastasis diagnosis (P = .012), controlled extracranial disease (P = .042), and receipt of pre-SRS chemotherapy (P = .015). Patients who were younger and received post-SRS chemotherapy (P = .001), immunotherapy (P < .001), and targeted or small-molecule inhibitor therapy (P < .026) had better FF-SITCP. Conclusions: In this cohort study of patients with brain metastases completing SRS, neurologic symptoms at ITCP is prognostic for OS. This data informs post-SRS surveillance in clinical practice as well as future prospective studies needed in the modern management of brain metastases.

BAK and BAX execute intrinsic apoptosis by permeabilising the mitochondrial outer membrane. Their activity is regulated through interactions with pro-survival BCL-2 family proteins and with non-BCL-2 proteins including the mitochondrial channel protein VDAC2. VDAC2 is important for bringing both BAK and BAX to mitochondria where they execute their apoptotic function. Despite this important function in apoptosis, while interactions with pro-survival family members are well characterised and have culminated in the development of drugs that target these interfaces to induce cancer cell apoptosis, the interaction between BAK and VDAC2 remains largely undefined. Deep scanning mutagenesis coupled with cysteine linkage identified key residues in the interaction between BAK and VDAC2. Obstructive labelling of specific residues in the BH3 domain or hydrophobic groove of BAK disrupted this interaction. Conversely, mutating specific residues in a cytosol-exposed region of VDAC2 stabilised the interaction with BAK and inhibited BAK apoptotic activity. Thus, this VDAC2-BAK interaction site can potentially be targeted to either inhibit BAK-mediated apoptosis in scenarios where excessive apoptosis contributes to disease or to promote BAK-mediated apoptosis for cancer therapy.

Abstract Background Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC). Methods This population‐based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post‐RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out‐of‐pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit). Results A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16–1.29) and ED encounter (OR 1.20, 95% CI 1.14–1.27) while Asian (OR 0.76, 95% CI 0.69–0.85) and Hispanic (OR 0.74, 95% CI 0.69–0.78, p

Initiation of chromosome replication is an essential stage of the bacterial cell cycle that is controlled by the DnaA protein. With the aim of developing novel antimicrobials, we have targeted the initiation of DNA replication, using antisense peptide nucleic acids (PNAs), directed against DnaA translation. A series of anti-DnaA PNA conjugated to lysine-rich bacterial penetrating peptides (PNA-BPPs) were designed to block DnaA translation. These anti-DnaA PNA-BPPs inhibited growth of wild-type Escherichia coli cells at low micromolar concentrations, and cells exposed to anti-DnaA PNA-BPPs exhibited characteristic hallmarks of chromosome replication inhibition. These results present one of very few compounds successfully targeting initiation of chromosome replication, an essential step in the bacterial cell cycle.

IntroductionPhosphorus (P) deficiency in plants creates a variety of metabolic perturbations that decrease photosynthesis and growth. Phosphorus deficiency is especially challenging for the production of bioenergy feedstock plantation species, such as poplars (Populus spp.), where fertilization may not be practically or economically feasible. While the phenotypic effects of P deficiency are well known, the molecular mechanisms underlying whole-plant and tissue-specific responses to P deficiency, and in particular the responses of commercially valuable hardwoods, are less studied. MethodsWe used a multi-tissue and multi-omics approach using transcriptomic, proteomic, and metabolomic analyses of the leaves and roots of black cottonwood (Populus trichocarpa) seedlings grown under P-deficient (5 µM P) and replete (100 µM P) conditions to assess this knowledge gap and to identify potential gene targets for selection for P efficiency.ResultsIn comparison to seedlings grown at 100 µM P, P-deficient seedlings exhibited reduced dry biomass, altered chlorophyll fluorescence, and reduced tissue P concentrations. In line with these observations, growth, C metabolism, and photosynthesis pathways were downregulated in the transcriptome of the P-deficient plants. Additionally, we found evidence of strong lipid remodeling in the leaves. Metabolomic data showed that the roots of P-deficient plants had a greater relative abundance of phosphate ion, which may reflect extensive degradation of P-rich metabolites in plants exposed to long-term P-deficiency. With the notable exception of the KEGG pathway for Starch and Sucrose Metabolism (map00500), the responses of the transcriptome and the metabolome to P deficiency were consistent with one another. No significant changes in the proteome were detected in response to P deficiency.Discussion and conclusionCollectively, our multi-omic and multi-tissue approach enabled the identification of important metabolic and regulatory pathways regulated across tissues at the molecular level that will be important avenues to further evaluate for P efficiency. These included stress-mediating systems associated with reactive oxygen species maintenance, lipid remodeling within tissues, and systems involved in P scavenging from the rhizosphere.