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Background: Respiratory syncytial virus (RSV) is a leading cause of infant respiratory disease. Recent approval of preventive measures like a long-acting monoclonal antibody and a maternal vaccine signals a potential shift in early-life RSV infection control. However, success hinges on acceptance., Methods: We conducted a cross-sectional survey among pregnant women and partners in the Netherlands, recruited via healthcare professionals, social media platforms, and the 9-Months Fair. The survey assessed willingness and motivation for maternal RSV vaccination and neonatal RSV immunization, including strategy preferences and informational needs., Results: In total 1001 pregnant women (mean age: 31.1 years) and their partners (mean age: 33.2 years) completed the survey. On average, they were 24 weeks pregnant at the time, and 54.6 % had no other children yet. The majority was Dutch-born (95.2 % of women); with 68.3 % of women having completed higher education and with overall strong pro-vaccination attitudes (93.9 % of partners intended to vaccinate their expected newborn). The overall acceptability to vaccination and immunization was high, with 87 % of respondents indicating they would (likely) accept both strategies. A positive attitude towards both methods was associated with previous experience with severity of RSV, intention to vaccinate the newborn and parental vaccination status during childhood and current pregnancy. When the choice was given, the majority of participants, in particular those with children and the intention to breastfeed, favoured maternal vaccination over passive immunization of infants (75.3 % of the pregnant and 71.6 % of the partners). A majority of the respondents cited optimal protection for the child and knowledge of RSV as important factors for accepting RSV prophylaxis., Conclusions: While most participants would accept both strategies for RSV protection of their infant, a majority, especially those with other children, favoured maternal vaccination, due to concerns about infant safety and awareness of RSV severity., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: An accurate diagnosis of early-onset sepsis (EOS) is challenging because of subtle symptoms and the lack of a good diagnostic tool, resulting in considerable antibiotic overtreatment. A biomarker, discriminating between infected and non-infected newborns at an early stage of the disease, could improve EOS prediction. Numerous biomarkers have been tested, but have never been compared directly., Objectives: We aimed to provide a comprehensive overview of early biomarkers and their diagnostic value in maternal samples, umbilical cord blood, and neonatal serum., Data Sources: PubMed-Medline, EMBASE, The Cochrane Library, and Web of Science were searched up to 1 March 2023, without restrictions on publication date, population, or language., Study Eligibility Criteria: Articles describing the diagnostic value of at least one biomarker in the detection of EOS in neonates, independent of gestational age, were included., Assessment of Risk of Bias: The QUADAS-2 tool was used to assess study quality., Methods of Data Synthesis: Three independent researchers assessed the articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Meta-analysis was performed with all manuscripts describing diagnostic accuracy using a random-effects model., Results: Of 2296 identified articles, 171 reports were included in the systematic review and 69 in the meta-analysis. Literature showed mixed and inconsistent evidence for most biomarkers and sample types, because of a lack of a uniform EOS case definition, small sample sizes, and large heterogeneity between studies. Interesting markers were procalcitonin (pooled sensitivity 79%, 95% CI 71-84%; specificity 91%, 95% CI 83-96%, n = 11) and interleukin (IL)-6 (pooled sensitivity 83%, 95% CI 71-90%; specificity 87%, 95% CI 78-93%, n = 8) in umbilical cord blood and presepsin (pooled sensitivity 82%, 95% CI 62-93%; specificity 86%, 95% CI 73-93%, n = 3) and serum amyloid A (pooled sensitivity 92%, 95% CI 75-98%; specificity 96%, 95% CI 78-99%, n = 4) in neonatal serum. Studies on the combination of biomarkers were scarce., Conclusions: A biomarker stand-alone test is currently not reliable for direct antibiotic stewardship in newborns, although several biomarkers show promising initial results. Further research into biomarker combinations could lead to an improved EOS diagnosis, reduce antibiotic overtreatment, and prevent associated health-related problems., (Copyright © 2024 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

The difficulty in recognizing early-onset neonatal sepsis (EONS) in a timely manner due to non-specific symptoms and the limitations of diagnostic tests, combined with the risk of serious consequences if EONS is not treated in a timely manner, has resulted in a low threshold for starting empirical antibiotic treatment. New guideline strategies, such as the neonatal sepsis calculator, have been proven to reduce the antibiotic burden related to EONS, but lack sensitivity for detecting EONS. In this review, the potential of novel, targeted preventive and diagnostic methods for EONS is discussed from three different perspectives: maternal, umbilical cord and newborn perspectives. Promising strategies from the maternal perspective include Group B Streptococcus (GBS) prevention, exploring the virulence factors of GBS, maternal immunization and antepartum biomarkers. The diagnostic methods obtained from the umbilical cord are preliminary but promising. Finally, promising fields from the newborn perspective include biomarkers, new microbiological techniques and clinical prediction and monitoring strategies. Consensus on the definition of EONS and the standardization of research on novel diagnostic biomarkers are crucial for future implementation and to reduce current antibiotic overexposure in newborns.

Objective: Hearing impairment may lead to an increased need to recover from fatigue and distress after a day of work. Also, hearing impairment may negatively affect the balance between workload and control over it (job demand and job control). The uptake of hearing solutions may have a positive effect on these outcomes. We aimed to assess the longitudinal relationship between change in speech recognition in noise and changes in need for recovery after work and job demand and job control, and the influence of hearing solutions on these relationships over a period of 5 years. Research questions (RQs) were as follows: (1) Is a 5-year change in speech recognition in noise associated with a change in need for recovery after work over that same 5-year period?; (2) Is a 5-year change in speech recognition in noise associated with a change in job demand and job control over that same 5-year period?; (3) What is the effect of hearing solution uptake in the 5-year period on the change in these outcomes in that same 5-year period?, Method: Data of the Netherlands Longitudinal Study on Hearing, collected between 2006 and January 2019, were divided into two 5-year follow-up intervals: T0 (baseline) to T1 (5-year follow-up) and T1 (5-year follow-up) to T2 (10-year follow-up). An online digit-triplet in noise test was used to assess speech recognition in noise. Online questionnaires on demographic, socioeconomic, and work-related characteristics were administered. For RQ1-RQ2, the study sample included adults working ≥12 hours per week, with at least two consecutive measurements (n = 783). For RQ3, employees who had not yet obtained hearing solutions at baseline, but who would be eligible based on a speech reception threshold in noise ≥ -5.5 dB signal-to-noise ratio (SNR), were included (n = 147). Longitudinal linear regression analyses using mixed models were performed to assess RQ1-RQ3., Results: After adjusting for baseline values, 5-year change in speech recognition in noise showed a statistically significant association with 5-year change in need for recovery. A worsening of 1 dB SNR in speech recognition in noise in an individual was associated with an increase of 0.72 units in need for recovery (scale range 0 to 100). A 5-year change in speech recognition in noise was not significantly associated with a 5-year change in job demand or job control. The uptake of hearing solutions in the 5-year period did not have a significant effect on change in need for recovery in that same 5-year period., Conclusion: The significant longitudinal association between 5-year worsening in speech recognition in noise and increase in need for recovery over the same time period strengthens the evidence for the importance of early detection of a worsening in speech recognition in noise to identify employees with an increase in need for recovery. The absence of an effect of the uptake of a hearing solution on need for recovery indicates that additional alternative interventions may be needed to foster beneficial use of hearing solutions as well as to mitigate the increased need for recovery in case of worsening speech recognition in noise., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Up to 7% of neonates born in high-income countries receive antibiotics for suspected early-onset sepsis (EOS). Culture-proven neonatal sepsis has a prevalence of 0.2%, suggesting considerable overtreatment. We studied the diagnostic accuracy of umbilical cord blood and infant blood procalcitonin (PCT) in diagnosing EOS to improve antibiotic stewardship. Methods: Umbilical cord blood PCT was tested in newborns ≥ 32 weeks of gestation. Groups were defined as following: A) culture-proven or probable EOS ( n = 25); B) Possible EOS, based on risk factors for which antibiotics were administered for <72 h ( n = 49); C) Risk factor(s) for EOS without need for antibiotic treatment ( n = 181); D) Healthy controls ( n = 74). Additionally, venous or capillary blood PCT and C-reactive protein (CRP) were tested if blood drawing was necessary for standard care. Results: Between June 2019 and March 2021, 329 newborns were included. Umbilical cord blood PCT was significantly higher in group A than in group C and D. No difference between venous or arterial samples was found. Sensitivity and specificity for cord blood procalcitonin were 83 and 62%, respectively (cut-off 0.1 ng/mL). Antepartum maternal antibiotic administration was associated with decreased PCT levels in both cord blood and infant blood directly postpartum in all groups combined. Conclusion: Umbilical cord blood PCT levels are increased in newborns ≥32 weeks with a proven or probable EOS and low in newborns with risk factors for infection, but PCT seems not a reliable marker after maternal antibiotic treatment. PCT could be useful to distinguish infected from healthy newborns with or without EOS risk factors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Dongen, van Leeuwen, de Groot, Vollebregt, Schiering, Wevers, Euser and van Houten.)

Objective: To identify predictors of the 5-year uptake of hearing aids (HAs) and hearing assistive technology (HAT) in a sample of Dutch employees eligible for HAs and/or HAT. The potential predictors included demographic factors (age, sex, marital status, and living situation), education, hearing factors (ability to recognize speech in noise and self-reported hearing disability), distress, self-efficacy, and work-related factors (job demand, job control, and need for recovery)., Design: Five-year follow-up data of the Netherlands Longitudinal Study on Hearing (NL-SH) collected until January 2019 were included. An online digit-triplet in noise test, the National Hearing Test (NHT), was used to assess speech-recognition-in-noise ability. In addition, online questionnaires on demographic, socioeconomic, self-reported hearing disability, health, and work-related characteristics were administered. Adults who worked over 12 hours per week, who had not yet taken up HAs or HAT, but who would be eligible for HAs/HAT based on their NHT score (insufficient or poor hearing ability), were included in the study. The 5-year uptake of HAs/HAT was defined as a dichotomous variable of self-reported HA/HAT use reported 5 years later. Generalized Estimating Equations analyses were performed to analyze the associations between potential predicting factors and the 5-year uptake of HAs/HAT, taking into account the repeated measurements of the predicting factors and the 5-year uptake of HAs/HAT., Results: Data of 218 participants were included. The cumulative incidence of the 5-year uptake of HAs/HAT was 15 to 33%, of which 52 employees took up HAs and 11 employees took up HAT. Married participants had increased odds for 5-year uptake of HAs/HAT compared with unmarried participants (odds ratio [OR] = 2.13, 95% confidence interval [CI] = 1.05 to 4.35). Higher self-reported hearing disability (per one unit, scale range 0 to 74) was associated with increased odds for 5-year uptake of HAs/HAT (OR = 1.05, 95% CI = 1.03 to 1.07). Job demand showed a significant interaction with sex (p = 0.002), and therefore, stratified analyses were performed. In male participants, participants with higher job demand scores (per one unit, scale range 12 to 48) had increased odds for 5-year uptake of HAs/HAT (OR = 1.18, 95% CI = 1.05 to 1.35). No difference was seen in females., Conclusion: This study confirms that factors predicting the uptake of HAs/HAT in the general or older populations, including marital status and self-reported hearing disability, also extend to the working population. The identification of job demand as a predictor of the uptake of HAs/HAT (in males only) was a novel finding. It demonstrates the importance of considering work-related factors in aural rehabilitation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Authors. Ear & Hearing is published on behalf of the American Auditory Society, by Wolters Kluwer Health, Inc.)

Objectives: According to the International Classification of Functioning, Disability and Health (ICF), functioning reflects the interplay between an individual's body structures and functions, activities, participation, environmental, and personal factors. To be useful in clinical practice, these concepts need to be operationalized into a practical and integral instrument. The Brief ICF Core Set for Hearing Loss (CSHL) provides a minimum standard for the assessment of functioning in adults with hearing loss. The objective of the present study was to operationalize the Brief CSHL into a digital intake tool that could be used in the otology-audiology practice for adults with ear and hearing problems as part of their intake assessment., Design: A three-step approach was followed: (1) Selecting and formulating questionnaire items and response formats, using the 27 categories of the Brief CSHL as a basis. Additional categories were selected based on relevant literature and clinical expertise. Items were selected from existing, commonly used disease-specific questionnaires, generic questionnaires, or the WHO's official descriptions of ICF categories. The response format was based on the existing item's response categories or on the ICF qualifiers. (2) Carrying out an expert survey and a pilot study (using the three-step test interview. Relevant stakeholders and patients were asked to comment on the relevance, comprehensiveness, and comprehensibility of the items. Results were discussed in the project group, and items were modified based on consensus. (3) Integration of the intake tool into a computer-based system for use in clinical routine., Results: The Brief CSHL was operationalized into 62 items, clustered into six domains: (1) general information, including reason for visit, sociodemographic, and medical background; (2) general body functions; (3) ear and hearing structures and functions; (4) activities and participation (A&P); (5) environmental factors (EF); and (6) personal factors (mastery and coping). Based on stakeholders' responses, the instructions of the items on A&P and EF were adapted. The three-step test interview showed that the tool had sufficient content validity but that some items on EF were redundant. Overall, the stakeholders and patients indicated that the intake tool was relevant and had a logical and clear structure. The tool was integrated in an online portal., Conclusions: In the current study, an ICF-based e-intake tool was developed that aims to screen self-reported functioning problems in adults with an ear/hearing problem. The relevance, comprehensiveness, and comprehensibility of the originally proposed item list was supported, although the stakeholder and patient feedback resulted into some changes of the tool on item-level. Ultimately, the functioning information obtained with the tool could be used to promote patient-centered ear and hearing care taking a biopsychosocial perspective into account.

Purpose: Previous research indicated that the Patient-Reported Outcomes Measurement Information System (PROMIS®) item bank v2.0 'Ability to Participate in Social Roles and Activities' may miss subdomains of social participation. The purpose of this study was to generate items for these missing subdomains and to evaluate their content validity., Methods: A three-step approach was followed: (1) Item generation for 16 International Classification of Functioning Disability and Health subdomains currently not covered by the item bank; (2) Evaluation of content validity of generated items through expert review (n = 20) and think-aloud interviews with a purposeful sample of people with and without (chronic) health conditions (n = 10), to assess item comprehensibility, relevance, and comprehensiveness; and 3) Item revision based on the results of step 2, in a consensus procedure., Results: First, 48 items were generated. Second, overall, content experts indicated that the generated items were relevant. Furthermore, based on experts' responses, items were simplified and 'participation in social media' was identified as an important additional subdomain of social participation. Additionally, 'participating in various social roles simultaneously' was identified as a missing item. Based on the responses of the interviewed adults items were simplified. Third, in total 17 items, covering 17 subdomains, were proposed to be added to the original item bank., Discussion: The relevance, comprehensibility and comprehensiveness of the 17 proposed items were supported. Whether the proposed extension of the item bank leads to better psychometric properties of the item bank should be tested in a large-scale field study.

Objective: To examine the construct validity, reliability and responsiveness of the Otology Questionnaire Amsterdam (OQUA)., Design: Multicentre, longitudinal study in 2 separate cohorts of patients visiting an ENT surgeon via an online survey programme., Setting: Tertiary ENT clinics., Participants: Cohort 1 consisted of patients at their first visit at an ENT outpatient clinic with an ear complaint. Cohort 2 consisted of patients who underwent surgery, with a 3-month follow-up post-surgery., Main Outcome Measures: Construct validity: Hypothesis testing, internal consistency and inter-item correlation. Reliability: Test-retest reliability. The construct approach was used for assessing responsiveness. Hypotheses were formulated based on the association between the OQUA and Glasgow Health Status Inventory (GHSI) or Global Rating Scale (GRS)., Results: Construct validity: The correlation between the individual items in the impact domain ranged from 0.424 to 0.737. Confirmatory factor analysis showed a good fit. As expected, the OQUA impact showed strong relationships with GHSI total and general scale. Reliability: The test-retest reliability coefficient ranged from 0.541 to 0.838. Responsiveness: All hypotheses were conformed. As expected, the change score of the OQUA showed good correlation between OQUA impact and GHSI and moderate correlation between the GRS and OQUA complaints., Conclusion: The OQUA has 8 complaint domains (earache, pressure sensation, itching, tinnitus, hearing loss, ear discharge, loss of taste and dizziness) and 1 impact domain. Each domain results in one score of 0-100. The OQUA shows good results for construct validity, (test-retest) reliability and responsiveness, supporting the potential benefit for the patient with an ear complaint visiting the ENT surgeon. The extensive validation furthermore confirms a certified generic otology PROM with an impact and a complaints' part, to be used in different types of otologic interventions and patient groups., (© 2020 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd.)

Objective: To develop an intervention for the implementation of an ICF-based e-intake tool in clinical oto-audiology practice. Design: Intervention design study using the eight-stepped Behaviour Change Wheel. Hearing health professionals' (HHPs) and patients' barriers to and enablers of the use of the tool were identified in our previous study (steps 1-4). Following these steps, relevant intervention functions and policy categories were selected to address the reported barriers and enablers (steps 5-6); and behaviour change techniques and delivery modes were chosen for the selected intervention functions (steps 7-8). Results: For HHPs, the intervention functions education, training, enablement, modelling, persuasion and environmental restructuring were selected (step 5). Guidelines, service provision, and changes in the environment were identified as appropriate policy categories (step 6). These were linked to nine behaviour change techniques (e.g. information on health consequences), delivered through educational/training materials and workshops, and environmental factors (steps 7-8). For patients, the intervention functions education and enablement were selected, supported through service provision (steps 5-6). These were linked to three behaviour change techniques (e.g. environmental factors), delivered through their incorporation into the tool (steps 7-8). Conclusions: A multifaceted intervention was proposed to support the successful implementation of the intake tool.

Tuberculous meningitis (TBM), the most severe extrapulmonary manifestation of tuberculosis, is caused by the pathogen Mycobacterium tuberculosis The M. tuberculosis complex includes seven lineages, all described to harbor a unique geographical dissemination pattern and clinical presentation. In this study, we set out to determine whether a certain M. tuberculosis lineage demonstrated tropism to cause TBM in patients from Cape Town, South Africa. DNA was extracted from formalin-fixed paraffin-embedded central nervous system (CNS) tissue from a unique neuropathological cohort of 83 TBM patients, collected between 1975 and 2012. M. tuberculosis lineages 1, 2, 3, and 4 were determined using an allele-specific PCR and Sanger sequencing. Of the 83 patient specimens tested, bacterial characterization could be performed on 46 specimens (55%). M. tuberculosis lineage 4 was present in 26 patient specimens (56%), and non-lineage 4 was identified in 10 cases (22%). Moreover, genomic heterogeneity was detected in the CNS specimens of 7 adults and 3 children. We could show that infection of the CNS is not restricted to a single M. tuberculosis lineage and that even young children with rapid progression of disease can harbor more than one M. tuberculosis lineage in the CNS., (Copyright © 2019 American Society for Microbiology.)

Objectives: The International Classification of Functioning, Disability, and Health (ICF) Core Sets for Hearing Loss (CSHL) consists of short lists of categories from the entire ICF classification that are thought to be the most relevant for describing the functioning of persons with hearing loss. A comprehensive intake that covers all factors included in the ICF CSHL holds the promise of developing a tailored treatment plan that fully complements the patient's needs. The Comprehensive CSHL contains 117 categories and serves as a guide for multiprofessional, comprehensive assessment. The Brief CSHL includes 27 of the 117 categories and represents the minimal spectrum of functioning of persons with HL for single-discipline encounters or clinical trials. The authors first sought to benchmark the extent to which Audiologist (AUD) and Otorhinolaryngologist (ORL) discipline-specific intake documentation, as well as Mayo Clinic's multidisciplinary intake documentation, captures ICF CSHL categories., Design: A retrospective study design including 168 patient records from the Department of Otorhinolaryngology/Audiology of Mayo Clinic in Jacksonville, Florida. Anonymized intake documentation forms and reports were selected from patient records filed between January 2016 and May 2017. Data were extracted from the intake documentation forms and reports and linked to ICF categories using pre-established linking rules. "Overlap," defined as the percentage of ICF CSHL categories represented in the intake documentation, was calculated across document types. In addition, extra non-ICF CSHL categories (ICF categories that are not part of the CSHL) and extra constructs (constructs that are not part of the ICF classification) found in the patient records were described., Results: The total overlap of multidisciplinary intake documentation with ICF CSHL categories was 100% for the Brief CSHL and 50% for the Comprehensive CSHL. Brief CSHL overlap for discipline-specific documentation fell short at 70% for both AUD and ORL. Important extra non-ICF CSHL categories were identified and included "sleep function" and "motor-related functions and activities," which mostly were reported in relation to tinnitus and vestibular disorders., Conclusion: The multidisciplinary intake documentation of Mayo Clinic showed 100% overlap with the Brief CSHL, while important areas of nonoverlap were identified in AUD- and ORL-specific reports. The ICF CSHL provides a framework for describing each hearing-impaired individual's unique capabilities and needs in ways currently not documented by audiological and otological evaluations, potentially setting the stage for more effective individualized patient care. Efforts to further validate the ICF CSHL may require the involvement of multidisciplinary institutions with commonly shared electronic health records to adequately capture the breath of the ICF CSHL.

The authors are developing an intake tool based on the Brief International Classification of Functioning Disability and Health Core Set for Hearing Loss, by operationalizing its categories into a Patient Reported Outcome Measure. This study was aimed at identifying enablers and barriers to using this tool as perceived by hearing health professionals (HHPs) and patients. Focus groups and interviews were held with HHPs (ENT surgeons, N = 14; audiologists, N = 8) and patients (N = 18). Interview questions were based on the Capability-Opportunity-Motivation-Behavior (COM-B) model. Using the COM-B model and the Theoretical Domains Framework (TDF), transcript fragments were divided into meaning units, which were then categorized into capability-, opportunity- and motivation-related barriers and enablers. These were further specified into TDF domains. HHP barriers included: lack of time to use the tool (O); and fear of being made responsible for addressing any emerging problems, which may be outside the expertise of the HHP (M). Enablers included integration of the tool in the electronic patient record (O); opportunity for the patient to be better prepared for the intake visit (M); and provision of a complete picture of the patient's functioning via the tool (M). Patient' barriers included fear of losing personal contact with the HHP (M); and fear that use of the tool might negatively affect conversations with the HHP (M). Enablers included knowledge on the aim and relevance of the tool (C); expected better self-preparation (M); and a more focused intake (M). These findings suggest that an intervention is needed to enhance HHPs' knowledge, skills and motivation regarding the relevance and the clinical usefulness of the tool. Providing clear and specific information on the purpose of the tool can also enhance patient motivation. For both HHPs and patients, opportunities relating to the (digital) administration and the design of the tool provide additional targets for successful implementation., Competing Interests: The authors have declared that no competing interests exist.

Central nervous system (CNS) infection by Mycobacterium tuberculosis is one of the most devastating complications of tuberculosis, in particular in early childhood. In order to induce CNS infection, M. tuberculosis needs to cross specialised barriers protecting the brain. How M. tuberculosis crosses the blood-brain barrier (BBB) and enters the CNS is not well understood. Here, we use transparent zebrafish larvae and the closely related pathogen Mycobacterium marinum to answer this question. We show that in the early stages of development, mycobacteria rapidly infect brain tissue, either as free mycobacteria or within circulating macrophages. After the formation of a functionally intact BBB, the infiltration of brain tissue by infected macrophages is delayed, but not blocked, suggesting that crossing the BBB via phagocytic cells is one of the mechanisms used by mycobacteria to invade the CNS. Interestingly, depletion of phagocytic cells did not prevent M. marinum from infecting the brain tissue, indicating that free mycobacteria can independently cause brain infection. Detailed analysis showed that mycobacteria are able to cause vasculitis by extracellular outgrowth in the smaller blood vessels and by infecting endothelial cells. Importantly, we could show that this second mechanism is an active process that depends on an intact ESX-1 secretion system, which extends the role of ESX-1 secretion beyond the macrophage infection cycle., (© 2018 The Authors Cellular Microbiology Published by John Wiley & Sons Ltd.)

The pathogen Mycobacterium tuberculosis employs a range of ESX-1 substrates to manipulate the host and build a successful infection. Although the importance of ESX-1 secretion in virulence is well established, the characterization of its individual components and the role of individual substrates is far from complete. Here, we describe the functional characterization of the Mycobacterium marinum accessory ESX-1 proteins EccA1, EspG1 and EspH, i.e. proteins that are neither substrates nor structural components. Proteomic analysis revealed that EspG1 is crucial for ESX-1 secretion, since all detectable ESX-1 substrates were absent from the cell surface and culture supernatant in an espG1 mutant. Deletion of eccA1 resulted in minor secretion defects, but interestingly, the severity of these secretion defects was dependent on the culture conditions. Finally, espH deletion showed a partial secretion defect; whereas several ESX-1 substrates were secreted in normal amounts, secretion of EsxA and EsxB was diminished and secretion of EspE and EspF was fully blocked. Interaction studies showed that EspH binds EspE and therefore could function as a specific chaperone for this substrate. Despite the observed differences in secretion, hemolytic activity was lost in all M. marinum mutants, implying that hemolytic activity is not strictly correlated with EsxA secretion. Surprisingly, while EspH is essential for successful infection of phagocytic host cells, deletion of espH resulted in a significantly increased virulence phenotype in zebrafish larvae, linked to poor granuloma formation and extracellular outgrowth. Together, these data show that different sets of ESX-1 substrates play different roles at various steps of the infection cycle of M. marinum., Competing Interests: The authors have declared that no competing interests exist.

The central nervous system (CNS) has specific barriers that protect the brain from potential threats and tightly regulate molecular transport. Despite the critical functions of the CNS barriers, the mechanisms underlying their development and function are not well understood, and there are very limited experimental models for their study. Claudin 5 is a tight junction protein required for blood brain barrier (BBB) and, probably, choroid plexus (CP) structure and function in vertebrates. Here, we show that the gene claudin 5a is the zebrafish orthologue with high fidelity expression, in the BBB and CP barriers, that demonstrates the conservation of the BBB and CP between humans and zebrafish. Expression of claudin 5a correlates with developmental tightening of the BBB and is restricted to a subset of the brain vasculature clearly delineating the BBB. We show that claudin 5a -expressing cells of the CP are ciliated ependymal cells that drive fluid flow in the brain ventricles. Finally, we find that CP development precedes BBB development and that claudin 5a expression occurs simultaneously with angiogenesis. Thus, our novel transgenic zebrafish represents an ideal model to study CNS barrier development and function, critical in understanding the mechanisms underlying CNS barrier function in health and disease., Competing Interests: Competing interestsThe authors declare no competing or financial interests., (© 2018. Published by The Company of Biologists Ltd.)

Objective: Development of the 'Otology Questionnaire Amsterdam' (OQUA), a patient reported outcome measure (PROM), measuring the severity and impact of ear complaints of patients visiting an ENT surgeon., Design: Multicenter, cross-sectional study. Phase 1: qualitative research. In-depth interviews (N = 16) to identify relevant types of ear complaints and to formulate items. Pilot study of the first and second draft of the OQUA (N = 32, N = 39). Phase 2: quantitative research. Field-testing of the OQUA (N = 352). Item reduction based on inter-item correlation, factor analysis and expert opinion., Setting: Two secondary and two tertiary ENT clinics., Participants: Patients over the age of sixteen visiting an ENT surgeon with an ear complaint., Main Outcome Measures: Phase 1: meaning units and frequency of selected descriptions. Phase 2: inter-item correlation, factor loading and Cronbach's Alpha (α)., Results: Phase 1: eight relevant types of ear complaints were identified: earache, pressure in ear, hearing loss, tinnitus, otorrhoea, itch, dizziness and loss of taste. Phase 2: factor analysis generated a factor 'impact' (α = 0.913). The current version of the OQUA consists of 34 items, covers eight types of ear complaints and consists of two constructs: complaints and impact., Conclusion: The OQUA is a generic, otologic PROM designed to evaluate the severity of ear complaints and their impact on patients lives., (© 2017 The Authors. Clinical Otolaryngology Published by John Wiley & Sons Ltd.)

Purpose: The construct validity, test-retest reliability, and measurement error of the Arm Function in Multiple Sclerosis Questionnaire (AMSQ) were examined. Additionally, the influence of administration-method on reliability and measurement error was investigated., Method: 112 Dutch adult MS-patients from an academic- and a residential care-facility participated. Questionnaires were administered on paper, online or as interview, and patients performed several performance tests. Construct validity was assessed by testing pre-defined hypotheses. Reliability was assessed using Intraclass Correlation Coefficients (ICCs), Standard Error of Measurements (SEMs) and Smallest Detectable Changes (SDCs)., Results: For construct validity (N = 105) 9 of 13 hypotheses were confirmed (69%). As expected, the AMSQ showed moderate to strong relationships with the instruments measuring similar constructs. The test-retest reliability coefficient was 0.96 (95% Confidence Interval 0.94-0.97); SEM was 6.3 (6.3% of scale range); SDC was 17.5 (on a sale from 0 to 100). Different administration-methods showed good reliability (ICC 0.88-0.94) and small standard errors (SEM 5.6-7.2)., Conclusion: The AMSQ shows satisfying results for validity and excellent reliability; allowing for proper use in research. Due to a large SDC value, caution is needed when using the AMSQ in individual patient care. Further research should determine whether the SDC is smaller than the minimal important change. Implications for Rehabilitation The Arm Function in Multiple Sclerosis Questionnaire (AMSQ) measures activity limitations due to hand and arm functioning in patients with Multiple Sclerosis (MS). Results of this study confirm adequate validity and reliability of the AMSQ in patient with MS. The equivalence of scores from online, paper or interview administration is supported. A change score of ≥18 points on the scale of the AMSQ (on a scale 0-100) needs to occur to be certain a change beyond measurement error has occurred in an individual patient.

Objectives: The International Classification of Functioning Disability and Health (ICF) Core Sets for Hearing Loss (HL) were developed to serve as a standard for the assessment and reporting of the functioning and health of patients with HL. The aim of the present study was to compare the content of the intake documentation currently used in secondary and tertiary hearing care settings in the Netherlands with the content of the ICF Core Sets for HL. Research questions were (1) to what extent are the ICF Core Sets for HL represented in the Dutch Otology and Audiology intake documentation? (2) are there any extra ICF categories expressed in the intake documentation that are currently not part of the ICF Core Sets for HL, or constructs expressed that are not part of the ICF?, Design: Multicenter patient record study including 176 adult patients from two secondary, and two tertiary hearing care settings. The intake documentation was selected from anonymized patient records. The content was linked to the appropriate ICF category from the whole ICF classification using established linking rules. The extent to which the ICF Core Sets for HL were represented in the intake documentation was determined by assessing the overlap between the ICF categories in the Core Sets and the list of unique ICF categories extracted from the intake documentation. Any extra constructs that were expressed in the intake documentation but are not part of the Core Sets were described as well, differentiating between ICF categories that are not part of the Core Sets and constructs that are not part of the ICF classification., Results: In total, otology and audiology intake documentation represented 24 of the 27 Brief ICF Core Set categories (i.e., 89%), and 60 of the 117 Comprehensive ICF Core Set categories (i.e., 51%). Various ICF Core Sets categories were not represented, including higher mental functions (Body Functions), civic life aspects (Activities and Participation), and support and attitudes of family (Environmental Factors). One extra ICF category emerged from the intake documentation that is currently not included in the Core Sets: sleep functions. Various Personal Factors emerged from the intake documentation that are currently not defined in the ICF classification., Conclusions: The results showed substantial overlap between the ICF Core Sets for HL and the intake documentation of otology and audiology, but also revealed areas of nonoverlap. These findings contribute to the evaluation of the content validity of the Core Sets. The overlap can be viewed as supportive of the Core Sets' content validity. The nonoverlap in Core Sets categories indicates that current Dutch intake procedures may not cover all aspects relevant to patients with ear/hearing problems. The identification of extra constructs suggests that the Core Sets may not include all areas of functioning that are relevant to Dutch Otology and Audiology patients. Consideration of incorporating both aspects into future intake practice deserves attention. Operationalization of the ICF Core Sets categories, including the extra constructs identified in this study, into a practical and integral intake instrument seems an important next step.

Purpose: To develop a comprehensive, conceptual model detailing the aspects of a child's life (<18 years) that are affected by low vision., Methods: Three stakeholders were involved in the developmental process of the conceptual model: children and adolescents with a visual impairment (n = 40), parents of children with a visual impairment (n = 25) and professionals of multidisciplinary rehabilitation centres and specialised schools (n = 25). Qualitative methods including focus groups, online and face-to-face brainstorming sessions and concept mapping were used to investigate the impact of visual impairment on the lives of children and adolescents and to create the conceptual model. To aid interpretation of the large age range, four age-bands were formed., Results: For each age-band (0-2, 3-6, 7-12 and 13-17 years), a total of 153, 200, 297 and 306 statements were generated by all stakeholders, respectively. The conceptual models show that low vision affects the sensorial development as well as the physical, psychological and social well-being of children and adolescents. In addition, identified external factors (i.e. education/employment and parental influence) can either facilitate or hinder participation., Conclusions: The developed model shows which life aspects of children are affected by low vision. The needs identified by children and adolescents correspond not entirely to the perspective of parents and low vision professionals. Future research should focus on developing and validating a new questionnaire based on the conceptual model. This will aid goal setting, rehabilitation referral and the accomplishment of developmental milestones and life transitions of children and adolescents with a visual impairment, ultimately improving their participation and quality of life., Competing Interests: A grant for this study was provided by Royal Dutch Visio. The authors declare that they have no conflict of interest.

Mycobacterium tuberculosis is protected by an unusual and highly impermeable cell envelope that is critically important for the successful colonization of the host. The outermost surface of this cell envelope is formed by capsular polysaccharides that play an important role in modulating the initial interactions once the bacillus enters the body. Although the bioenzymatic steps involved in the production of the capsular polysaccharides are emerging, information regarding the ability of the bacterium to modulate the composition of the capsule is still unknown. Here, we study the mechanisms involved in regulation of mycobacterial capsule biosynthesis using a high throughput screen for gene products involved in capsular α-glucan production. Utilizing this approach we identified a group of mutants that all carried mutations in the ATP-binding cassette phosphate transport locus pst These mutants collectively exhibited a strong overproduction of capsular polysaccharides, including α-glucan and arabinomannan, suggestive of a role for inorganic phosphate (Pi) metabolism in modulating capsular polysaccharide production. These findings were corroborated by the observation that growth under low Pi conditions as well as chemical activation of the stringent response induces capsule production in a number of mycobacterial species. This induction is, in part, dependent on σ factor E. Finally, we show that Mycobacterium marinum, a model organism for M. tuberculosis, encounters Pi stress during infection, which shows the relevance of our findings in vivo., (© 2016 by The American Society for Biochemistry and Molecular Biology, Inc.)

Purpose: To gain qualitative insight into the rehabilitation needs of visually impaired young adults (18-25 years) and how these needs relate to the International Classification of Functioning, Disability and Health (ICF) and patient characteristics., Methods: Rehabilitation needs and patient characteristics of young adults (N = 392) who applied for multidisciplinary services in 2012 and 2013 were obtained from structured and semi-structured intake records. Linking rules were used to assess how the needs related to Environmental Factors, Body Functions, Body Structures, and Activity and Participation (A&P) ICF components. The relationship between the type of rehabilitation goal and patient characteristics was assessed using multivariate logistic regression analyses., Results: Most rehabilitation needs (67.6%; N = 510) were found on the A&P component of the ICF. Most prevalent needs were related to 'major life areas' (e.g. finding internship or job), followed by the chapters: 'mobility' (e.g. self-reliance in travelling), 'communication' (e.g. using communication devices and techniques), 'general tasks and demands' (e.g. psychological aspects of vision loss) and 'domestic life' (e.g. household tasks). Patients in one of the multidisciplinary rehabilitation centres (odds ratio (OR) = 7.07; 95% confidence interval (CI) [2.97-16.83]) and patients with comorbidity (OR = 3.82; 95% CI [1.62-9.02]) were more likely to report rehabilitation needs related to chapter E3 'support and relationships'., Conclusion: 'Major life areas' prevail in the content of rehabilitation needs, but tend to overshadow topics regarding peer interaction and social, community and civic life. A suitable survey method for young adults with visual impairments is required that contains rehabilitation domains and goals relevant to their lives and development., (© 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Microfluidic flow based multiplexed devices have gained significant promise in detecting biomarkers in complex biological samples. However, to fully exploit their use in bioanalysis, issues such as (i) low sensitivity and (ii) high levels of nonspecific adsorption of non-target species have to be overcome. Herein, we describe a new multiplexed device for the sensitive detection of multiple protein biomarkers in serum by using an alternating current (ac) electrohydrodynamics (ac-EHD) induced surface shear forces based phenomenon referred to as nanoshearing. The tunable nature (via manipulation of ac field) of these nanoshearing forces can alter the capture performance of the device (e.g., improved fluid transport enhances number of sensor-target collisions). This can also selectively displace weakly (nonspecifically) bound molecules from the electrode surface (i.e., fluid shear forces can be tuned to shear away nonspecific species present in biological samples). Using this approach, we achieved sensitive (100 fg mL(-1)) naked eye detection of multiple protein targets spiked in human serum and a 1000-fold enhancement in comparison to hydrodynamic flow based devices for biomarker detection. We believe that this approach could potentially represent a clinical diagnostic tool that can be integrated into resource-limited settings for sensitive detection of target biomarkers using naked eye.

Over the past decade the zebrafish (Danio rerio) has become an attractive new vertebrate model organism for studying mycobacterial pathogenesis. The combination of medium-throughput screening and real-time in vivo visualization has allowed new ways to dissect host pathogenic interaction in a vertebrate host. Furthermore, genetic screens on the host and bacterial sides have elucidated new mechanisms involved in the initiation of granuloma formation and the importance of a balanced immune response for control of mycobacterial pathogens. This article will highlight the unique features of the zebrafish-Mycobacterium marinum infection model and its added value for tuberculosis research., (Copyright © 2015 Cold Spring Harbor Laboratory Press; all rights reserved.)

Tuberculous meningitis (TBM) is one of the most severe extrapulmonary manifestations of tuberculosis, with a high morbidity and mortality. Characteristic pathological features of TBM are Rich foci, i.e. brain- and spinal-cord-specific granulomas formed after hematogenous spread of pulmonary tuberculosis. Little is known about the early pathogenesis of TBM and the role of Rich foci. We have adapted the zebrafish model of Mycobacterium marinum infection (zebrafish-M. marinum model) to study TBM. First, we analyzed whether TBM occurs in adult zebrafish and showed that intraperitoneal infection resulted in granuloma formation in the meninges in 20% of the cases, with occasional brain parenchyma involvement. In zebrafish embryos, bacterial infiltration and clustering of infected phagocytes was observed after infection at three different inoculation sites: parenchyma, hindbrain ventricle and caudal vein. Infection via the bloodstream resulted in the formation of early granulomas in brain tissue in 70% of the cases. In these zebrafish embryos, infiltrates were located in the proximity of blood vessels. Interestingly, no differences were observed when embryos were infected before or after early formation of the blood-brain barrier (BBB), indicating that bacteria are able to cross this barrier with relatively high efficiency. In agreement with this observation, infected zebrafish larvae also showed infiltration of the brain tissue. Upon infection of embryos with an M. marinum ESX-1 mutant, only small clusters and scattered isolated phagocytes with high bacterial loads were present in the brain tissue. In conclusion, our adapted zebrafish-M. marinum infection model for studying granuloma formation in the brain will allow for the detailed analysis of both bacterial and host factors involved in TBM. It will help solve longstanding questions on the role of Rich foci and potentially contribute to the development of better diagnostic tools and therapeutics., (© 2014. Published by The Company of Biologists Ltd.)

The causative agent of tuberculosis (TB), Mycobacterium tuberculosis, remains an important worldwide health threat. Although TB is one of the oldest infectious diseases of man, a detailed understanding of the mycobacterial mechanisms underlying pathogenesis remains elusive. Here, we studied the role of the α(1→2) mannosyltransferase MptC in mycobacterial virulence, using the Mycobacterium marinum zebrafish infection model. Like its M. tuberculosis orthologue, disruption of M. marinum mptC (mmar&#95;3225) results in defective elongation of mannose caps of lipoarabinomannan (LAM) and absence of α(1→2)mannose branches on the lipomannan (LM) and LAM mannan core, as determined by biochemical analysis (NMR and GC-MS) and immunoblotting. We found that the M. marinum mptC mutant is strongly attenuated in embryonic zebrafish, which rely solely on innate immunity, whereas minor virulence defects were observed in adult zebrafish. Strikingly, complementation with the Mycobacterium smegmatis mptC orthologue, which restored mannan core branching but not cap elongation, was sufficient to fully complement the virulence defect of the mptC mutant in embryos. Altogether our data demonstrate that not LAM capping, but mannan core branching of LM/LAM plays an important role in mycobacterial pathogenesis in the context of innate immunity., (© 2013 John Wiley & Sons Ltd.)