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Engagement of TRAIL or Fas death receptors can trigger the assembly of cytoplasmic caspase-8/FADD/RIPK1 (FADDosome) signaling complexes that promote nuclear factor κB (NF-κB) activation. Here, we present a protocol for immunoprecipitation of TRAIL- or Fas-induced FADDosomes from human cell lines. We describe steps for stimulating human cells with TRAIL or Fas ligand, followed by preparation of membrane death receptor-associated, as well as cytoplasmic FADDosome, signaling complexes. This protocol has application in the analysis of death receptor-induced signaling complex formation. For complete details on the use and execution of this protocol, please refer to Davidovich et al. 1 ., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

B cells are critical to the pathogenesis of multiple sclerosis (MS), an autoimmune disease of the central nervous system. B cell depletion using anti-CD20 monoclonal antibodies (mAbs) has proven to be an extremely successful treatment strategy, with profound suppression of both clinical and radiological evidence of focal inflammatory disease. Several anti-CD20 mAbs are now licensed for use in MS, with ublituximab being the latest to gain regulatory approval. The unique properties of each of the anti-CD20 mAb may result in nuanced differences in timing, duration and depth of B cell depletion, with the potential for such differences to have a clinical relevance to both drug efficacy and adverse effects. In this review, we summarize the design, development, and current place in MS therapy for ublituximab., Competing Interests: Dr. Jiwon Oh has received grant funding from Biogen-Idec, Roche, and EMD-Serono and has received personal compensation for consulting or speaking from: Biogen-Idec, EMD-Serono, Eli-Lilly, Horizon Therapeutics, Novartis, Roche, and Sanofi-Genzyme. The authors report no other conflicts of interest in this work., (© 2024 Martin et al.)

The recent approval of formulations of the endogenous neurosteroid allopregnanolone (brexanolone) and the synthetic neuroactive steroid SAGE-217 (zuranolone) to treat postpartum depression (PPD) has encouraged further research to elucidate why these potent enhancers of GABA A R function are clinically effective in this condition. Dopaminergic projections from the ventral tegmental area (VTA) to the nucleus accumbens are associated with reward/motivation and brain imaging studies report that individuals with PPD show reduced activity of this pathway in response to reward and infant engagement. However, the influence of neurosteroids on GABA-ergic transmission in the nucleus accumbens has received limited attention. Here, we investigate, in the medium spiny neurons (MSNs) of the mouse nucleus accumbens core, the effect of allopregnanolone, SAGE-217 and other endogenous and synthetic steroids of interest on fast phasic and tonic inhibition mediated by synaptic (α1/2βγ2) and extrasynaptic (α4βδ) GABA A Rs, respectively. We present evidence suggesting the resident tonic current results from the spontaneous opening of δ-GABA A Rs, where the steroid-enhanced tonic current is GABA-dependent. Furthermore, we demonstrate local neurosteroid synthesis in the accumbal slice preparation and reveal that GABA-ergic neurotransmission of MSNs is influenced by an endogenous neurosteroid tone. Given the dramatic fluctuations in allopregnanolone levels during pregnancy and postpartum, this neurosteroid-mediated local fine-tuning of GABAergic transmission in the MSNs will probably be perturbed.

Purpose: Poorer health outcomes for transgender and gender diverse (TGD) individuals have been associated with lack of health care provider knowledge and personal bias. Training at all levels of medical education has been positioned as one strategy to combat these inequities. This study sought to characterize preclinical medical student attitude, skill, and knowledge pre- and post-teaching with TGD community volunteers., Methods: This matched pre- and post-test study was conducted from July 2020 to August 2021 capturing two preclinical medical student cohorts exposed to the same teaching intervention. Students completed the Transgender Attitudes and Beliefs Scale (TABS) and the Transgender Development of Clinical Skills Scale (T-DOCSS) at baseline, 1 week, and 1 month after the clinical skills session. Tutors' attitudes to TGD health were measured before facilitating teaching, using the Attitudes Toward Transgender Patients and Beliefs and Knowledge about Treating Transgender Patients scales., Results: Fifty-nine students completed questionnaires at three time points and were included in this study. Total TABS and T-DOCCS scores increased from preintervention to 1-week follow-up, maintained at 1 month, with significant changes in Interpersonal Comfort and Sex and Gender Beliefs subscales. Scores on the Human Value subscale did not change, remaining consistently high. Postintervention knowledge-question scores were high. Nine of 13 tutors completed surveys, demonstrating overall positive attitudes toward gender diversity and TGD health., Conclusion: This study demonstrates improvement in preclinical medical student attitudes and self-reported skill toward gender health care sustained at 1 month after small-group teaching with TGD community volunteers., Competing Interests: The authors declare no conflicts of interest., (Copyright 2024, Mary Ann Liebert, Inc., publishers.)

The most prevalent viral pathogen of honeybees is Deformed Wing Virus (DWV) and its two most widely studied and common master-variants are DWV-A and DWV-B. The prevalence of DWV variants in the UK and in the US is changing, with the prevalence of the DWV-A strain declining and DWV-B increasing over time. In 2012, only DWV-A was detected on the Hawaiian Islands of Oahu. In this study we focused on a colony-level survey of DWV strains in a single apiary and examined the prevalence of DWV variants over the course of two years. In 2018 and 2019, a total of 16 colonies underwent viral testing in January, May, and September. Of those 16 colonies, four were monitored in both 2018 and 2019. Individual colonies showed variability of DWV master variants throughout the sampling period. DWV-A was consistently detected; however, the detection of DWV-B was variable across time in individual colonies. Ultimately, this study demonstrated a seasonal variation in both viral prevalence and load for DWV-B, providing a perspective on the dynamic nature of DWV master variants emerging in Hawaii.

Phenylketonuria (PKU) is an inborn error of amino acid metabolism. If untreated, PKU can result in global developmental delay, learning difficulties or seizures. For that reason, PKU is included in the UK neonatal screening programme. We describe a patient in his sixth decade presenting with progressive cognitive decline and spasticity, in whom a diagnosis of PKU was eventually reached. We note that although we currently have a robust neonatal screening programme, this has not always been the case. Patients born before 1969 were not screened, and tests used in early screening programmes were less sensitive than those used today. This case serves as a reminder that inherited metabolic disorders may present in later life and may mimic the neurocognitive and radiological picture of other white matter syndromes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: People who report sexual assault express concerns regarding contracting sexually transmitted infection (STI); however, published literature regarding the risk of STI transmission in this context is sparse., Method: We audited STI and blood-borne virus (BBV) testing at a forensic and medical sexual assault care service in the Australian Capital Territory between 2004 and 2022. Eligibility for testing among 1928 presentations was defined based on risk (eg, reported penetration). Testing at presentation included chlamydia and gonorrhoea 1850, syphilis and BBV 1472, and after 2-6 weeks, 890 out of 1928 (46.2%) and after 3 months 881 out of 1928 (45.7%), respectively., Results: At presentation, 100 out of 1928 (5.2%) individuals were diagnosed with chlamydia, of those, 95 out of 1799 (5.3%) were female, and 5 out of 121 (4.1%) were male. Gonorrhoea was diagnosed in 7 out of 1920 (0.4%), 5 out of 95 female and 2 out of 5 male. Hepatitis B, which was all pre-existing, was diagnosed in 5 out of 1799 (0.3%). Overall, chlamydia prophylaxis was given to 203 out of 1928 (10.5%) and HIV post-exposure prophylaxis to 141 out of 1928 (7.3%).At 2-6 weeks of follow-up, 10 out of 890 (1.1%) individuals were diagnosed with chlamydia, with no gonorrhoea diagnosed. There were no cases of syphilis, hepatitis B or HIV diagnosed at 3-month serology testing in 881 individuals. Chlamydia detection at follow-up was more common in the group aged 15-29 years. Of those provided with chlamydia prophylaxis, 203 out of 1928, only 16 out of 203 (7.9%) were diagnosed with chlamydia., Conclusions: The offer of STI testing is almost universally accepted by individuals presenting for post-sexual assault care. There were no identifiable factors to justify the routine use of chlamydia prophylaxis. STI testing provided an opportunity for screening and should remain part of the clinical care of people who report sexual assault., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

TRAIL and FasL are potent inducers of apoptosis but can also promote inflammation through assembly of cytoplasmic caspase-8/FADD/RIPK1 (FADDosome) complexes, wherein caspase-8 acts as a scaffold to drive FADD/RIPK1-mediated nuclear factor κB (NF-κB) activation. cFLIP is also recruited to FADDosomes and restricts caspase-8 activity and apoptosis, but whether cFLIP also regulates death receptor-initiated inflammation is unclear. Here, we show that silencing or deletion of cFLIP leads to robustly enhanced Fas-, TRAIL-, or TLR3-induced inflammatory cytokine production, which can be uncoupled from the effects of cFLIP on caspase-8 activation and apoptosis. Mechanistically, cFLIP L suppresses Fas- or TRAIL-initiated NF-κB activation through inhibiting the assembly of caspase-8/FADD/RIPK1 FADDosome complexes, due to the low affinity of cFLIP L for FADD. Consequently, increased cFLIP L occupancy of FADDosomes diminishes recruitment of FADD/RIPK1 to caspase-8, thereby suppressing NF-κB activation and inflammatory cytokine production downstream. Thus, cFLIP acts as a dual suppressor of apoptosis and inflammation via distinct modes of action., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Apoptosis is a mode of programmed cell death that plays important roles in tissue sculpting during development, in the maintenance of tissue homeostasis in the adult, and in the eradication of injured or infected cells during pathological processes. Numerous physiological as well as pathological stimuli trigger apoptosis, such as engagement of plasma-membrane-associated Fas, TRAIL, or TNF receptors, growth factor deprivation, hypoxia, radiation, and exposure to diverse cytotoxic drugs. Apoptosis is coordinated by members of the caspase family of cysteine proteases, which, upon activation, trigger a series of dramatic morphological and biochemical changes including retraction from the substratum, cell shrinkage, extensive and protracted plasma membrane blebbing, chromatin condensation, DNA hydrolysis, nuclear fragmentation, and proteolytic cleavage of numerous caspase substrates. These dramatic structural and biochemical alterations result not only in the controlled dismantling of the cell, but also in the rapid recognition and removal of apoptotic cells by phagocytes through the cell surface display of phagocytotic triggers such as phosphatidylserine. Necrosis, which is typically nonprogrammed or imposed upon the cell by overwhelming membrane or organelle damage, is characterized by high-amplitude cell swelling, followed by rapid plasma membrane rupture and release of cellular contents into the extracellular space. Necrosis is often provoked by infectious agents or severe departure from physiological conditions due to toxins, temperature extremes, or physical injury. However, forms of programmed necrosis (necroptosis, pyroptosis, ferroptosis) can also occur in specific circumstances. Nonprogrammed and programmed necrosis can be distinguished from apoptosis by morphological features, based on the rapid uptake of vital dyes, and through the application of specific inhibitors of key molecules associated with the latter modes of cell death. This unit describes protocols for the measurement of apoptosis and necrosis and for distinguishing apoptosis from programmed as well as conventional necrosis. © 2023 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Analysis of cell morphology by phase-contrast microscopy Alternative Protocol 1: Assessment of morphological changes using eosin-methylene blue staining Alternative Protocol 2: Analysis of nuclear morphology by fluorescence microscopy Support Protocol: Preparation of cytospins Basic Protocol 2: Measurement of plasma membrane composition with annexin V and propidium iodide Basic Protocol 3: Measurement of DNA fragmentation by flow cytometry Alternative Protocol 3: Analysis of DNA fragmentation by the TUNEL assay Basic Protocol 4: Measurement of caspase activation by flow cytometry Basic Protocol 5: Discriminating between apoptosis, necrosis, necroptosis, and ferroptosis., (© 2023 The Authors. Current Protocols published by Wiley Periodicals LLC.)

Memory formation is typically divided into phases associated with encoding, storage, consolidation, and retrieval. The neural determinants of these phases are thought to differ. This study first investigated the impact of the experience of novelty in rats incurred at a different time, before or after, the precise moment of memory encoding. Memory retention was enhanced. Optogenetic activation of the locus coeruleus mimicked this enhancement induced by novelty, both when given before and after the moment of encoding. Optogenetic activation of the locus coeruleus also induced a slow-onset potentiation of field potentials in area CA1 of the hippocampus evoked by CA3 stimulation. Despite the locus coeruleus being considered a primarily noradrenergic area, both effects of such stimulation were blocked by the dopamine D1/D5 receptor antagonist SCH 23390. These findings substantiate and enrich the evidence implicating the locus coeruleus in cellular aspects of memory consolidation in hippocampus.

Bcl-2 family proteins serve as key regulators of apoptosis and are frequently overexpressed in cancer. Consequently, small-molecule Bcl-2-antagonists (BH3 mimetics) have emerged as a new class of targeted therapeutics. A recent study by Zhao et al. has unexpectedly found that BH3 mimetics can also activate dendritic cells (DCs) to prime for T cell-mediated tumor clearance., Competing Interests: Declaration of interests No competing interests to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Contextual fear conditioning (CFC) is mediated by a neural circuit that includes the hippocampus, prefrontal cortex, and amygdala, but the neurophysiological mechanisms underlying the regulation of CFC by neuromodulators remain unclear. Dopamine D1-like receptors (D1Rs) in this circuit regulate CFC and local synaptic plasticity, which is facilitated by synchronized oscillations between these areas. In rats, we determined the effects of systemic D1R blockade on CFC and oscillatory synchrony between dorsal hippocampus (DH), prelimbic (PL) cortex, basolateral amygdala (BLA), and ventral hippocampus (VH), which sends hippocampal projections to PL and BLA. D1R blockade altered DH-VH and reduced VH-PL and VH-BLA synchrony during CFC, as inferred from theta and gamma coherence and theta-gamma coupling. D1R blockade also impaired CFC, as indicated by decreased freezing at retrieval, which was characterized by altered DH-VH and reduced VH-PL, VH-BLA, and PL-BLA synchrony. This reduction in VH-PL-BLA synchrony was not fully accounted for by non-specific locomotor effects, as revealed by comparing between epochs of movement and freezing in the controls. These results suggest that D1Rs regulate CFC by modulating synchronized oscillations within the hippocampus-prefrontal-amygdala circuit. They also add to growing evidence indicating that this circuit synchrony at retrieval reflects a neural signature of learned fear., (© 2023. Springer Nature Limited.)

Research suggests that physical exercise can promote an anti-inflammatory and neuroprotective state. If so, increasing or optimizing exercise could be considered a 'disease-modifying intervention' in neuroinflammatory diseases, such as multiple sclerosis (MS). Exercise intervention studies conducted in animal models of MS are promising. Various aerobic and strength training regimes have been shown to delay disease onset and to reduce both the clinical and pathological disease severity in mice. However, fundamental differences between the physiology of animals and humans, the disease states studied, and the timing of exercise intervention are significant. In animal models of MS, most exercise interventions begin before disease initiation and before any clinical sign of disease. In contrast, studies in humans recruit participants on average nearly a decade after diagnosis and often once disability is established. If, as is thought to be the case for disease-modifying treatments, the immunomodulatory effect of exercise decreases with advancing disease duration, current studies may therefore fail to detect the true disease-modifying potential. Clinical studies in early disease cohorts are needed to determine the role of exercise as a disease-modifying intervention for people with MS., Competing Interests: S-JM has received a grant from the MS Society of Canada and funding for international conference attendance from EMD-Serono. RS received grants from the MS Society of Canada and the J.P. Bickell Foundation, received consulting fees from Biogen-Idec and Novartis, received payment or honoraria for lectures, presentations, speaker's bureaus, manuscript writing or educational events from Biogen-Idec, Sanofi Genzyme, and EMD-Serono, has participated on advisory boards for Novartis and BMS, and received support to attend a scientific meeting from EMD-Serono., (Copyright © 2023 Martin and Schneider.)

Background: Granulocyte-macrophage colony stimulating factor (GM-CSF) is a pro-inflammatory cytokine secreted by various immune cells. Several studies have demonstrated an expansion of GM-CSF producing T cells in the blood or CSF of people with MS (pwMS). However, whether this equates to greater concentrations of circulating cytokine remains unknown as quantification is difficult with traditional assays., Objective: To determine whether GM-CSF can be quantified and whether GM-CSF levels are elevated in pwMS., Methods: We employed Single Molecule Array (Simoa) to measure GM-CSF in both CSF and blood. We then investigated relationships between GM-CSF levels and measures of blood-CSF-barrier integrity., Results: GM-CSF was quantifiable in all samples and was significantly higher in the CSF of pwMS compared with controls. No association was found between CSF GM-CSF levels and Q-Albumin - a measure of blood-CSF-barrier integrity. CSF GM-CSF correlated with measures of intrathecal inflammation, and these relationships were greater in primary progressive MS compared with relapsing-remitting MS., Conclusion: GM-CSF levels are elevated specifically in the CSF of pwMS. Our results suggest that elevated cytokine levels may reflect (at least partial) intrathecal production, as opposed to simple diffusion across a dysfunctional blood-CSF-barrier., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship and/or publication of this article: Dr S-JM has received funding for international conference attendance from EMD-Serono. Ms. KB-A has nothing to disclose. Dr GS has received payment or honoraria for presentations, lectures, or educational events from EMD-Serono. Dr GS has received funding for international conference attendance from EMD-Serono. Dr GS received support to attend a scientific meeting and advisory board from EMD-Serono. Dr AM has received payment or honoraria for lectures, presentations, speakers’ bureaus and other educational initiatives from Biogen-Idec, EMD-Serono and Novartis. Dr JO has received grants from the MS Society of Canada, Biogen-Idec, Brain Canada, Roche, the NIH and EMD-Serono. Dr JO has received consulting fees from Biogen-Idec, BMS, Sanofi-Genzyme, Novartis, EMD-Serono, Eli Lilly and Roche. Dr JO has received payment or honoraria for lectures, presentations, speaker’s bureaus, manuscript writing or educational events from Biogen-Idec, Roche, Sanofi-Genzyme, Novartis and EMD-Serono. Dr JO has participated on advisory boards for Sanofi-Genzyme, EMD-Serono, Roche, Novartis, Biogen-Idec and BMS. JO is the MS Society of Canada Medical Advisory Committee Chair. Dr RS received grants from the MS Society of Canada and the J.P. Bickell Foundation. Dr RS has received consulting fees from Biogen-Idec and Novartis. Dr RS has received payment or honoraria for lectures, presentations, speaker’s bureaus, manuscript writing or educational events from Biogen-Idec, Sanofi-Genzyme and EMD-Serono. Dr RS has participated on advisory boards for Novartis and BMS. Dr RS has received support to attend a scientific meeting from EMD-Serono.

We have recently introduced a new item to our neurology Grand Rounds-the '1-3-5 presentation'. The format comprises a presentation on one topic, using three slides and lasting no more than 5 minutes. This a useful way of covering brief single topics and introducing and sparking discussion on more complex ones. '1-3-5s' have proven popular in our department and we have compiled a library of these presentations that is hosted on a YouTube channel. This article discusses the benefits and prospects for this format and encourages other units to provide similar opportunities for teaching and learning among all clinical grades., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: COVID-19 pandemic had tremendously affected all the aspects of human life during the past 3 years. In this study, we focused on kidney transplant patients' course from the COVID-19 diagnosis, immunosuppressive medication modification, hospitalization, and COVID-19 complications and how the COVID-19 infection affected the kidney and patients' quality of life during the hospitalization and after the discharge., Material and Method: A retrospective analysis of a prospectively collected database of all kidney transplants adult patients who had a positive COVID-19 PCR from 1 January 2020 to 30 December 2022, and had a history of kidney transplant at the SUNY Upstate Medical Hospital was done to identify the cases., Results: 188 patients met the inclusion criteria and were included in the study. Based on the immunosuppressive regimen modification during COVID-19 infection, patients divided into two groups; in 143 (76%) patients, the immunosuppressive medication was reduced, and in 45 (24%) of patients, the immunosuppressive regimen continued as before during the COVID-19 infection. The mean time from the transplant to the diagnosis of COVID-19 was 67 months in the group we reduced the IM regimen, and 77 months in the group without changes in IM regimen. The mean recipients' age was 50.7 ± 12.9 years in the group we reduced the IM regimen, and 51.8 ± 16.4 years in the group without changes in IM regimen (P = 0.64). The vaccination rate against COVID-19 with at least 2 doses of either the CDC recommended Moderna or Pfizer vaccines was 80.2% in the group we reduced the IM regimen, and 84.8% in the group without changes in IM regimen (P = 0.55). The hospitalization rate due to COVID-19 related symptoms was 22.4% % in the group we reduced the IM regimen, and 35.5% in the group without changes in IM regimen (P = 0.12). However, the ICU admission rate was higher in the group we reduced the IM regimen, but the difference was not significant (26.5% Vs.6.25%, P = 0.12). 6 episodes of biopsy-proven rejection in the group with IM reduction was observed, which were 3 episodes of acute antibody-mediated rejections (ABMR) and 3 episodes of acute T-Cell-mediated rejections (TCMR), and 3 episodes in the group without any change in IM regimen, which were 2 episodes of ABMR and 1 episode of TCMR (P = 0.51). No significant difference was mentioned in the eGFR and serum creatinine after the comparison between the groups after 12 months of follow up. 124 patients responded to the post-COVID-19 questionnaires and were included in the data analysis. The response rate was 66%. Fatigue and exertion were the most reported symptom with a 43.9% prevalence., Conclusions: We found that immunosuppressive regimen minimization did not impact the kidney function in the long-term and it might be a helpful strategy to minimize the effect of COVID-19 infection on patients' condition during the hospital stay. With all the treatments, vaccinations, and precautions, still some patients did not achieve the complete recovery compared to their pre-COVID-19 health status. Fatigue was the main reported symptom amongst all the reported symptoms., Competing Interests: Declaration of Competing Interest The authors declare that they do not have any personal or financial conflicts of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Cisgender women account for 1 of every 5 new US HIV diagnoses, with most cases (85%) attributed to heterosexual contact. HIV preexposure prophylaxis is an effective prevention strategy; however, preexposure prophylaxis awareness and prescriptions among women are low., Objective: This study aimed to increase preexposure prophylaxis counseling and uptake among cisgender women attending obstetrics and gynecology clinics., Study Design: The study included 3 obstetrics and gynecology clinics within a single health system in a high HIV prevalence region. There were 3 phases: baseline (the 3-month period before the clinical trial that included provider education and training of a registered nurse about preexposure prophylaxis), clinical trial (the 3-month period during which eligible patients were randomized to an active control or preexposure prophylaxis registered nurse intervention), and maintenance (the 3-month period after the trial ended). Electronic medical record clinical decision support tools were available to both arms during the clinical trial, which included best practice alerts, order sets, progress note templates, and written and video preexposure prophylaxis educational materials for patients. In the intervention arm, a preexposure prophylaxis nurse contacted and counseled patients and was equipped to prescribe preexposure prophylaxis. Moreover, this study evaluated the phases through the "reach, effectiveness, adoption, implementation, and maintenance" framework. The primary outcome of the study was effectiveness (eg, percentage of eligible patients with documented HIV prevention counseling in the electronic medical record or preexposure prophylaxis prescriptions). The secondary outcomes included reach (eg, percentage of best practice alerts that providers acted on or the percentage of eligible patients who spoke with the preexposure prophylaxis registered nurse), adoption (eg, percentage of eligible patients with a best practice alert that triggered or the percentage of eligible patients the preexposure prophylaxis registered nurse attempted to contact), and maintenance (eg, percentage of patients with documented HIV prevention counseling or preexposure prophylaxis prescriptions during the maintenance phase)., Results: There were 904 unique patients in all phases with a mean age of 28.8±7.7 years, and 416 patients (46%) were pregnant; moreover, 436 patients were randomized in the clinical trial phase. Concerning reach and adoption, best practice alerts were triggered for 100% of eligible encounters; however, the providers acted on 52% of them. The preexposure prophylaxis nurse attempted to contact every patient and successfully spoke with 81.2% of them in the preexposure prophylaxis registered nurse arm. Concerning effectiveness, there were significantly more patients counseled about preexposure prophylaxis in the preexposure prophylaxis registered nurse group than in the active control group (66.5% vs 12.3%, respectively; P<.001), although preexposure prophylaxis prescriptions were equivalent (P=1.0). Among the subgroup of patients who were counseled about preexposure prophylaxis, 18.5% of patients in the active control arm and 3.4% in the preexposure prophylaxis registered nurse arm were prescribed preexposure prophylaxis (P=.02). Concerning maintenance, clinical decision support tools alone resulted in preexposure prophylaxis counseling of 1.0% of patients during the maintenance phase vs 0.6% of patients during the baseline phase and 11.2% of patients during the clinical trial phase (P<.001). Preexposure prophylaxis prescriptions were not statistically different among the 3 phases (P=.096)., Conclusion: A preexposure prophylaxis nurse effectively increased HIV prevention discussions but did not lead to more preexposure prophylaxis prescriptions than the preexposure prophylaxis-focused clinical decision support tools used by providers. The decrease in preexposure prophylaxis counseling after the trial phase suggests that persistent interventions are needed to maintain effects., (Copyright © 2023. Published by Elsevier Inc.)

Left ventricular masses are rare entities that often require surgical excision when diagnosed due to the risk of embolization. We report 2 separate patients presenting with evidence of cerebral embolization both of whom were diagnosed with isolated left ventricular masses and underwent surgical excision through a robot-assisted approach. Microscopic pathology revealed a myxoma and hemangioma, respectively. Both cases demonstrate that left ventricular masses can be feasibly excised through a robot-assisted minithoracotomy approach., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Pharmacists play a key role in antimicrobial stewardship (AMS). Consensus-based national AMS competencies for undergraduate healthcare professionals in the UK reflect the increasing emphasis on competency-based healthcare professional education. However, the extent to which these are included within undergraduate pharmacy education programmes in the UK is unknown., Objectives: To explore which of the AMS competencies are delivered, including when and at which level, within UK undergraduate MPharm programmes., Methods: A cross-sectional online questionnaire captured the level of study of the MPharm programme in which each competency was taught, the method of delivery and assessment of AMS education, and examples of student feedback., Results: Ten institutions completed the survey (33% response rate). No institution reported covering all 54 AMS competencies and 5 of these were taught at half or fewer of the institutions. Key gaps were identified around taking samples, communication, outpatient parenteral antimicrobial therapy and surgical prophylaxis. The minimum time dedicated to AMS teaching differed between institutions (range 9-119 h), teaching was generally through didactic methods, and assessment was generally through knowledge recall and objective structured clinical examinations. Feedback from students suggests they find AMS and antimicrobial resistance (AMR) to be complex yet important topics., Conclusions: UK schools of pharmacy should utilize the competency framework to identify gaps in their AMS, AMR and infection teaching. To prepare newly qualified pharmacists to be effective at delivering AMS and prescribing antimicrobials, schools of pharmacy should utilize more simulated environments and clinical placements for education and assessment of AMS., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

This work demonstrates for the first-time biobased, temperature-responsive diblock copolymer nanoparticles synthesized by reversible addition-fragmentation chain-transfer (RAFT) aqueous emulsion polymerization-induced self-assembly (PISA). Here, monomers derived from green solvents of the lactic acid portfolio, N,N -dimethyl lactamide acrylate (DMLA) and ethyl lactate acrylate (ELA), were used. First, DMLA was polymerized by RAFT aqueous solution polymerization to produce a hydrophilic PDMLA macromolecular chain transfer agent (macro-CTA), which was chain extended with ELA in water to form amphiphilic PDMLA- b -PELA diblock copolymer nanoparticles by RAFT aqueous emulsion polymerization. PDMLA x homopolymers were synthesized targeting degrees of polymerization, DP x from 25 to 400, with relatively narrow molecular weight dispersities ( Đ < 1.30). The PDMLA 64 - b -PELA y diblock copolymers (DP y = 10-400) achieved dispersities, Đ , between 1.18 and 1.54 with two distinct glass transition temperatures ( T g ) identified by differential scanning calorimetry (DSC). T g(1) (7.4 to 15.7 °C) representative of PELA and T g(2) (69.1 to 79.7 °C) of PDMLA. Dynamic light scattering (DLS) studies gave particle z-average diameters between 11 and 74 nm (PDI = 0.04 to 0.20). Atomic force microscopy (AFM) showed evidence of spherical particles when dispersions were dried at ∼5 °C and film formation when dried at room temperature. Many of these polymers exhibited a reversible lower critical solution temperature (LCST) in water with a concomitant increase in z -average diameter for the PDMLA- b -PELA diblock copolymer nanoparticles., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

Purpose: Existing and emerging visual acuity methods like dynamic and dichoptic presentation, preferential looking and eye tracking promise to afford better and earlier assessment in children with and without amblyopia so we propose methods needed to easily evaluate and compare their metrics., Subjects and Methods: Patients older than 8 years with treated amblyopia and superb vision (logMAR -0.1 to -0.3) normals performed timed, patched eETDRS with Sloan matching card at 3.00 m and PDI Check dichoptic near rivalry dynamic test to demonstrate test re-Test and compared disparate acuity with intraclass correlation (ICC) and Bland Altman 95% limits of agreement (LOA) to generate a simple method of qualifying acuity test matching., Results: 26 amblyopic patients and 11 superb-vision normals performed eETDRS retest, PDI Check retest and combined ICC of 0.98, 0.60 and 0.27, respectively, and Bland Altman LOA of 0.24, 2.06 and 2.28 logMAR. The time to test one eye with eETDRS had median (interquartile range; IQR) duration of 280 (205 to 346) seconds, while the PDI Check autostereoscopic dichoptic for both eyes only took 39 (30 to 47) seconds. Optimum ICC and LOA for visual acuity comparison should be >0.95 and <0.3 logMAR, whereas "good" ICC and should be 0.75-0.89 ICC and 1.0-1.49 logMAR LOA., Conclusion: Superb vision subjects (logMAR < -0.1) and treated amblyopic patients confirmed optimum comparable eETDRS, and fair test re-Test PDI Check but suppression on near dichoptic testing confirmed disparity compared to optimized eETDRS distance acuity., Competing Interests: Dr. Arnold is board-member of PDI Check and patent holder concerning autostereoscopic vision testing. He is also coordinator of the Alaska Blind Child Discovery which has received discounted technology from several vendors. Dr. Arnold was board-member of Glacier Medical Software which marketed NICU vision screening cloud-based software ROP Check. Dr. Arnold is an investigator and protocol developer for the Pediatric Eye Disease Investigator Group (PEDIG). No other conflicts of interest for other co-authors., (© 2023 Hepler et al.)

Scholarship flourishes in inclusive environments where open deliberations and generative feedback expand both individual and collective thinking. Many researchers, however, have limited access to such settings, and most conventional academic conferences fall short of promises to provide them. We have written this Field Report to share our methods for cultivating a vibrant intellectual community within the Science and Technology Studies Food and Agriculture Network (STSFAN). This is paired with insights from 21 network members on aspects that have allowed STSFAN to thrive, even amid a global pandemic. Our hope is that these insights will encourage others to cultivate their own intellectual communities, where they too can receive the support they need to deepen their scholarship and strengthen their intellectual relationships., (© The Author(s) 2023.)

Apoptosis is a form of regulated cell death (RCD) that involves proteases of the caspase family. Pharmacological and genetic strategies that experimentally inhibit or delay apoptosis in mammalian systems have elucidated the key contribution of this process not only to (post-)embryonic development and adult tissue homeostasis, but also to the etiology of multiple human disorders. Consistent with this notion, while defects in the molecular machinery for apoptotic cell death impair organismal development and promote oncogenesis, the unwarranted activation of apoptosis promotes cell loss and tissue damage in the context of various neurological, cardiovascular, renal, hepatic, infectious, neoplastic and inflammatory conditions. Here, the Nomenclature Committee on Cell Death (NCCD) gathered to critically summarize an abundant pre-clinical literature mechanistically linking the core apoptotic apparatus to organismal homeostasis in the context of disease., (© 2023. The Author(s), under exclusive licence to ADMC Associazione Differenziamento e Morte Cellulare.)

The global spread of the parasitic mite Varroa destructor instigated a substantial decline in both managed and feral honeybee (Apis mellifera) colonies mainly across the Northern hemisphere. In response, many beekeepers began to treat their colonies with chemical acaricides to control mite populations in managed colonies. However, some countries or beekeepers allowed their bees to develop mite-resistance by adopting a "treatment-free" approach, rather than using selective breeding programs. Yet, the distribution and proportion of beekeepers either treating or not within the United Kingdom (UK) is unknown, as it is in most Northern hemisphere countries. Therefore, the aim of this study was to conduct a beekeeper survey to determine the current treatment strategies within the UK. We gathered 2,872 beekeeper responses from an estimated 30,000 UK beekeepers belonging to 242 bee-associations in the winter of 2020/21. The survey indicated that the majority (72-79%) of UK beekeepers are still treating their bees for Varroa, typically twice-yearly using chemical-based methods. Six percent or 1,800 UK beekeepers were treatment-free for six years or more. This is reflected by our finding that 78 associations out of 242 consist of responders who entirely treated, while only four associations had more than 75% of their members that were non-treating. Overall treatment status was not affected by association currently. Using the baseline data from this survey it will be possible in the future to observer if a shift towards treatment-free beekeeping occurs or not., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Valentine, Martin. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Most human immunodeficiency virus (HIV) seroconversions in people who have initiated preexposure prophylaxis (PrEP) occur in the context of insufficient adherence. We describe participants who seroconverted after being dispensed PrEP in a large PrEP implementation study in Australia., Methods: Expanded PrEP Implementation in Communities in New South Wales was an implementation study of daily oral PrEP in individuals aged ≥18 years at high risk for acquiring HIV. HIV seroconversions were defined as a positive HIV test by either antigen, antibody, or detectable HIV viral load after enrollment. Insufficient adherence, measured by dispensing logs or participant self-report, was defined as <4 PrEP doses per week., Results: A total of 9596 participants were enrolled and dispensed PrEP between 1 March 2016 and 30 April 2018; 30 were diagnosed with HIV by 31 March 2019. The median (interquartile range [IQR]) age was 31 (25-38) years, all identified as male, 29 (97%) identified as gay or homosexual, and 20 (69%) lived in a postcode with a low concentration of gay male residents. The median (IQR) days from first PrEP dispensing to diagnosis was 409 (347-656). There was no evidence that participants who seroconverted had been sufficiently adherent to PrEP. Nineteen (63%) participants who seroconverted were diagnosed with chlamydia, gonorrhoea, syphilis, or new hepatitis C infection. One participant had resistance to emtricitabine (M184V mutation) at diagnosis., Conclusions: Participants who seroconverted were insufficiently adherent to PrEP despite being at high risk for acquiring HIV. Understanding the reasons for poor PrEP adherence in individuals who subsequently acquire HIV is critical to improving PrEP effectiveness., Competing Interests: Potential conflicts of interest. N. J. D. has received research support through the Gilead Australia Fellowship for an unrelated project (paid to institution). A. C. has received research funding from Gilead Sciences, MSD, and ViiV Healthcare (paid to institution); consulting fees, lecture and travel sponsorships from Gilead Sciences, MSD. and ViiV Healthcare (paid to author); and has served on advisory boards for Gilead Sciences, MSD. and ViiV Healthcare (paid to author). I. Z. has received previous research support from Gilead Sciences for research unrelated to the current work and is a member of the Australian Nation PrEP Guideline Writing Group. P. R. has received research funding from Gilead Sciences, and honoraria for speaking from Gilead Sciences, MSD, and ViiV. B. B. reports grants from Gilead Sciences (Unrestricted research grant, 2021-22) and ViiV Healthcare (Unrestricted research grant, 2022-23), honorarium from Gilead Sciences (speakers fee, 2020), and support from ViiV Healthcare (Travel to Melbourne for meeting, 2022). A. E. G. reports royalties or licenses from ViiV, implementation research on injectable PrEP (paid to institution), support from ViiV for attending a meeting on injectable treatment (2022) and is a member of the Governing council of the International AIDS society. R. G. is an investigator on a project that receives funding from Gilead (unrelated to this project). J. H. is an executive member for the board at NSW Gender Centre inc. S. J. M. reports support from Gilead to attend local education evenings (does not include national or international meetings; unpaid participation, local restaurant dinner and talk). B. Y. reports support from Mylan Pty Ltd (travelled to Canberra, Australian Capital Territory to present EPIC-NSW study at a clinical care meeting at Canberra Hospital on 28 August 2019). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The costimulatory inhibitor Belatacept (Bela) has been shown to be an effective alternative in several clinical situations, including chronic antibody-mediated rejection, calcineurin toxicity, and de novo alloantibody formation. To further explore the usefulness of Belatacept under various clinical scenarios, we performed a retrospective analysis of a prospective database of all recipients who had a BPAR diagnosis of CAMR and were converted to a Belatacept maintenance immunosuppression regimen after kidney transplantation., Material and Method: We conducted a retrospective analysis of a prospectively collected database of all kidney transplants adult patients at SUNY Upstate Medical Hospital from 1 January 2013 to 31 December 2021. Our inclusion criteria were the patients who have been diagnosed with CAMR according to their renal biopsy based on the 2013 Banff criteria. The primary objective was to compare the kidney viability and function using GFR between the two interest groups and finally compare the outcomes., Results: A total of 48 patients met our inclusion criteria based on the kidney biopsy result, which showed chronic antibody-mediated graft rejection (CAMR). Nineteen patients (39.6%) were converted to the Belatacept, and we continued the previous immunosuppression regimen in 29 patients (60.4%). The mean time from the transplant date to the diagnosis of CAMR was 1385 days in the Belatacept group and 914 days for the non-Belatacept group (P = 0.15). The mean GFR comparison at each time point between the groups did not show a significant difference, and Belatacept did not show superiority compared to the standard immunosuppression regimen in terms of kidney function preservation. 1 (5.2%) patient from the Belatacept group and 1 (3.4%) patient from the non-Belatacept group had a biopsy-proven acute rejection (BPAR) after CAMR confirmation, and it was comparable (P = 0.76). De novo synthesis of the DSA rate was 12.5% in the Belatacept group and 15% In the non-Belatacept group, which was comparable. (P = 0.90). The patient survival rate was 100% in both groups., Conclusions: We conclude that compared to the standard Tacrolimus/MMF/Prednisone regimen, Belatacept did not significantly benefit in preserving the GFR in long-term follow-ups and stabilizing the DSA production, which is one of the main factors resulting in chronic graft failure., Competing Interests: Declaration of Competing Interest The authors declare that they do not have any personal or financial conflicts of interest. Funding statement The authors declare that there was no source of funding for this project., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Interleukin-1 (IL-1) family cytokines are key barrier cytokines that are typically expressed as inactive, or partially active, precursors that require proteolysis within their amino termini for activation. IL-37 is an enigmatic member of the IL-1 family that has been proposed to be activated by caspase-1 and to exert anti-inflammatory activity through engagement of the IL-18R and SIGIRR. However, here we show that the longest IL-37 isoform, IL-37b, exhibits robust proinflammatory activity upon amino-terminal proteolysis by neutrophil elastase or cathepsin S. In sharp contrast, caspase-1 failed to process or activate IL-37 at concentrations that robustly activated its canonical substrate, IL-1β. IL-37 and IL-36 exhibit high structural homology, and, consistent with this, a K53-truncated form of IL-37, mimicking the cathepsin S-processed form of this cytokine, was found to exert its proinflammatory effects via IL-36 receptor engagement and produced an inflammatory signature practically identical to IL-36. Administration of K53-truncated IL-37b intraperitoneally into wild-type mice also elicited an inflammatory response that was attenuated in IL-36R -/- animals. These data demonstrate that, in common with other IL-1 family members, mature IL-37 can also elicit proinflammatory effects upon processing by specific proteases.

The Varroa destructor ectoparasitic mite has spread globally and in conjunction with Deformed Wing Virus has killed millions of honeybee (Apis mellifera) colonies. This has forced Northern hemisphere beekeepers into using miticides to avoid mass colony losses. However, in many Southern hemisphere countries widespread treatment did not occur since miticides were prohibitively expensive, or a centralised choice was made not to treat, both allowing natural selection to act. The Varroa mite initially caused high losses before mite-resistance appeared in the honeybee populations. Initially, mite-resistance was only associated with African and Africanised honeybees. Although recently, several isolated mite-resistant European honeybee populations have appeared. Here we studied the mite-resistance in Cuba and found high rates of recapping of infested worker cells (77%), high removal of mites (80%) and corresponding low mite fertility (r = 0.77). These are all traits found in all naturally evolved Varroa-resistant populations. We can confirm Cuba has the world's largest European mite-resistant population with 220,000 colonies that have been treatment-free for over two decades and illustrating the power of natural selection. Cuban honeybees are also highly productive, 40-70 kg of honey produced annually, and are mild mannered. Cuba is an excellent example of what is possible when honeybees are allowed to adapt naturally to Varroa with minimal human interference., (© 2022. The Author(s).)

Background: Non-occupational Post-Exposure Prophylaxis (nPEP) is an effective HIV prevention strategy in gay and bisexual men (GBM) taken after possible exposure. HIV Pre-Exposure Prophylaxis (PrEP) is also a highly effective HIV prevention strategy., Methods: A retrospective audit of medical records of GBM presenting to a sexual health centre and provided with nPEP compared two periods to determine if nPEP usage changed following availability of PrEP. In the first period (P1) PrEP was available through extended trials. In the second period (P2) PrEP became more accessible through the Australian Pharmaceutical Benefits Scheme (PBS). Period comparisons were performed using a two-population test of proportions with one-tailed testing and significance set at P < .05 using SPSS Statistics Version 25., Results: There were 232 GBM provided with nPEP in P1, and 202 in P2. A two-population test of proportions demonstrated that GBM presentations for nPEP decreased significantly from 302/4779 (6.3%) of GBM visits in P1 to 221/7205 (3.1%) in P2 when PrEP was more accessible (Z=8.53, P < .001). PrEP uptake after presenting for nPEP increased from 30 (12.9%) of total GBM visits in P1 to 69 (34.2%) in P2 (Z=5.26, p < .001)., Conclusions: GBM accessing nPEP decreased with statistical significance post introduction of PBS PrEP.

Members of the extended IL-1 cytokine family play key roles as instigators of inflammation in numerous infectious and sterile injury contexts and are highly enriched at barrier surfaces such as the skin, lungs and intestinal mucosa. Because IL-1 family cytokines do not possess conventional ER-golgi trafficking and secretory signals, these cytokines are typically released into the extracellular space due to tissue damage resulting in necrosis, or pathogen detection resulting in pyroptosis. The latter feature, in combination with other factors, suggests that IL-1 family cytokines serve as canonical damage-associated molecular patterns (DAMPs), which instigate inflammation in response to tissue damage. However, IL-1 family cytokines also require a proteolytic activation step and diverse intracellular, extracellular and non-self proteases have been identified that are capable of processing and activating members of this family. This suggests that IL-1 family members function as sentinels for aberrant protease activity, which is frequently associated with infection or tissue damage. Here, we overview the diversity of proteases implicated in the activation of IL-1 family cytokines and suggest that this ancient cytokine family may have evolved to complement 'pattern recognition receptors', by serving as 'activity recognition receptors' enabling the detection of aberrant enzyme activity indicative of 'danger'., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aim: To evaluate the use of low-dose naltrexone (LDN) as a broad-spectrum analgesic. Methods: Retrospective cohort study from a single pain management practice using data from 2014 to 2020. Thirty-six patients using LDN for ≥2 months were matched to 42 controls. Pain scores were assessed at initial visit and at most recent/final documented visit using a 10-point scale. Results: Cases reported significantly greater pain reduction (-37.8%) than controls (-4.3%; p < 0.001). Whole sample multivariate modeling predicts 33% pain reduction with LDN, with number needed to treat (for 50% pain reduction) of 3.2. Patients with neuropathic pain appeared to benefit even more than those with 'nociceptive'/inflammatory pain. Conclusion: LDN is effective in a variety of chronic pain states, likely mediated by TLR-4 antagonism.

Objective: Multiple sclerosis (MS) is an inflammatory degenerative condition of central nervous system. The disease course and presentation of MS is highly heterogeneous. Advanced retinal imaging techniques such as optic coherence tomography (OCT) can capture abnormalities of anterior visual pathway with high resolution, which may contribute greater insights into the pathophysiology of MS., Methods: People with newly diagnosed relapsing-remitting MS were recruited for FutureMS retinal imaging study from two study centres in Scotland. The baseline visit was completed within 6 months of diagnosis with initial follow-up 12 months after the baseline visit. The assessments included in FutureMS retinal imaging study were visual acuity test, self-reported eye questionnaire and OCT scan., Results: A total of 196 FutureMS participants completed the retinal imaging study of FutureMS with 185 participants at M0 and 155 at M12. A total of 144 participants completed both M0 and M12 visits. At the whole cohort level, the distribution of retinal measures is generally consistent between baseline and follow-up., Conclusion: The FutureMS retinal imaging study aims to demonstrate that patient with MS present with different extent of retinal abnormalities that can be captured by retinal imaging modalities such as OCT soon after diagnosis. These changes may sensitively mirror the brain atrophy or serve as predictors for disease activity. By developing sensitive, quantifiable and objective retinal biomarkers, FutureMS retinal imaging study will provide an opportunity to stratify patient with MS at an early stage and support future therapeutic strategies for a better outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Inflammation driven by environmental allergens is an important source of morbidity in diseases such as asthma and eczema. How common allergens promote inflammation is still poorly understood, but previous studies have implicated the protease activity associated with many allergens as an important component of the pro-inflammatory properties of these agents. The IL-1 family cytokine, IL-33, has recently been shown to undergo processing and activation by proteases associated with multiple common allergens. However, it remains unclear whether the sensing of exogenous protease activity-as a proxy for the detection of invasive microbes, allergens and parasitic worms-is a general property of IL-1 family cytokines. In common with the majority of IL-1 family members, cytokines within the IL-36 sub-family (IL-36α, IL-36β and IL-36γ) are expressed as inactive precursors that require proteolysis within their N-termini for activation. Here we show that proteases associated with multiple common allergens of plant, insect, fungal and bacterial origin (including: Aspergillus fumigatus , ragweed, rye, house dust mite, cockroach and Bacillus licheniformis ) are capable of processing and activating IL-36 family cytokines, with IL-36β being particularly susceptible to activation by multiple allergens. Furthermore, extracts from several allergens also processed and enhanced IL-1α activity. This suggests that multiple IL-1 family cytokines may serve as sentinels for exogenous proteases, coupling detection of such activity to unleashing the pro-inflammatory activity of these cytokines. Taken together with previous data on the diversity of proteases capable of activating IL-1 family cytokines, this suggests that members of this cytokine family may function as 'activity recognition receptors' for aberrant protease activity associated with infection, tissue injury or programmed necrosis., 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 © 2022 Frezza, Najda, Davidovich, Sullivan and Martin.)

Purpose: Multiple sclerosis (MS) is an immune-mediated, neuroinflammatory disease of the central nervous system and in industrialised countries is the most common cause of progressive neurological disability in working age persons. While treatable, there is substantial interindividual heterogeneity in disease activity and response to treatment. Currently, the ability to predict at diagnosis who will have a benign, intermediate or aggressive disease course is very limited. There is, therefore, a need for integrated predictive tools to inform individualised treatment decision making., Participants: Established with the aim of addressing this need for individualised predictive tools, FutureMS is a nationally representative, prospective observational cohort study of 440 adults with a new diagnosis of relapsing-remitting MS living in Scotland at the time of diagnosis between May 2016 and March 2019., Findings to Date: The study aims to explore the pathobiology and determinants of disease heterogeneity in MS and combines detailed clinical phenotyping with imaging, genetic and biomarker metrics of disease activity and progression. Recruitment, baseline assessment and follow-up at year 1 is complete. Here, we describe the cohort design and present a profile of the participants at baseline and 1 year of follow-up., Future Plans: A third follow-up wave for the cohort has recently begun at 5 years after first visit and a further wave of follow-up is funded for year 10. Longer-term follow-up is anticipated thereafter., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Most life-threatening conditions form a coherent clinical picture, with examination findings confirming the patient's history. However, pain out of proportion to examination findings can also signify an emergency - acute compartment syndrome, bowel ischaemia, necrotising fasciitis and acute aortic dissection may all present in this way. A lack of situational awareness leads doctors to erroneously rely on examination findings to flag impending catastrophe, but in such cases misdiagnosis or delayed treatment can have dire consequences. Patients with unexplained pain risk significant morbidity and mortality, and doctors are vulnerable to litigation and reputational damage. This article addresses this danger, exploring the causes and pathology of pain that is out of proportion, and presenting an approach to mitigate risk and prevent catastrophe.

Background: Patient-reported outcomes and satisfaction following short length of stay (LoS) after total knee arthroplasty (TKA) in the Australian regional context remain unexplored. This study reports complications, outcomes and satisfaction of patients discharged from an enhanced recovery protocol (ERP), 6 weeks after TKA in a regional hospital., Methods: Prospective recruitment occurred between 2018 and 2019. Demographics, intraoperative data, complications and emergency department (ED) presentations were retrieved from hospital records. Complications were graded for severity using a published scale. Knee range of motion (ROM), timed up-and-go (TUG), 6-min walk test (6MWT) and Oxford Knee Scores (OKS) were assessed preoperatively and 6 weeks postoperatively. Patient satisfaction was assessed via questionnaire at the postoperative follow-up., Results: One hundred patients/117 primary TKAs were prospectively included. Median LoS was 2 days (interquartile range 1-3 days) with 74.4% and 88.4% of patients satisfied with their knee and LoS, at 6 weeks respectively. Twenty-seven patients presented to the ED a total of 37 times with complication severity of Grade III or less, and 10 patients were readmitted. Significant improvements in objective and subjective outcomes were observed, however only change in median OKS exceeded the minimal clinically important difference (MCID) threshold., Conclusion: An enhanced recovery protocol after TKA in a regional hospital can achieve a median LoS of 2 days without compromising patient-reported outcomes and objective functional measures, whilst maintaining a high level of patient satisfaction with both the surgery and LoS. Further work is required to better optimize management of largely low-grade complications in this patient population., (© 2022 Royal Australasian College of Surgeons.)

Unhealthy exercise (UE) is a common symptom of eating disorders (EDs) associated with elevated chronicity and relapse. Previous research suggests that UE serves an emotion regulation function, especially to reduce negative affect. UE may be especially prevalent among individuals with anorexia nervosa (AN), as UE and restrictive eating may be used to avoid unpleasant emotions. It is unclear whether changes in emotion avoidance (EA) can lead to changes in UE over time. The current study examined whether month 1 EA mediated the relation between baseline UE and month 2 UE in a clinical sample of 127 patients (M age  = 22.52 [SD = 11.75], 92.9% female) recruited from an ED outpatient treatment program. The current study also explored whether this mediation was stronger for individuals with AN than other ED diagnoses. Findings revealed that changes in EA significantly mediated the relation between changes in UE from baseline to month 2 of treatment. ED diagnosis did not moderate this relation. Findings suggest that improvements in EA may reduce UE over time. Treatment should target UE through cultivation of increased emotion acceptance.Level of evidence Level III: evidence obtained from well-designed cohort study., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

In 1977, a sample of diseased adult honeybees (Apis mellifera) from Egypt was found to contain large amounts of a previously unknown virus, Egypt bee virus, which was subsequently shown to be serologically related to deformed wing virus (DWV). By sequencing the original isolate, we demonstrate that Egypt bee virus is in fact a fourth unique, major variant of DWV (DWV-D): more closely related to DWV-C than to either DWV-A or DWV-B. DWV-A and DWV-B are the most common DWV variants worldwide due to their close relationship and transmission by Varroa destructor. However, we could not find any trace of DWV-D in several hundred RNA sequencing libraries from a worldwide selection of honeybee, varroa and bumblebee samples. This means that DWV-D has either become extinct, been replaced by other DWV variants better adapted to varroa-mediated transmission, or persists only in a narrow geographic or host range, isolated from common bee and beekeeping trade routes., (© 2022. The Author(s).)

Chest pain is a common presenting complaint with a broad differential diagnosis. Even after the full array of special investigations, a cause cannot be found in some patients. Psychological factors can play a significant role in the perception of chest pain. Patients with such a psychological disturbance may not meet the full criteria for a diagnosable psychiatric illness, and thus cannot be assigned a specific diagnosis. Not knowing how to manage this situation can lead to poor rapport between doctor and patient. Through their clinical acumen, judicious use of special investigations and by forming a therapeutic alliance, clinicians can identify and help these patients.

Purpose: Rim lesions, characterised by a paramagnetic rim on susceptibility-based MRI, have been suggested to reflect chronic inflammatory demyelination in multiple sclerosis (MS) patients. Here, we assess, through susceptibility-weighted imaging (SWI), the prevalence, longitudinal volume evolution and clinical associations of rim lesions in subjects with early relapsing-remitting MS (RRMS)., Methods: Subjects (n = 44) with recently diagnosed RRMS underwent 3 T MRI at baseline (M0) and 1 year (M12) as part of a multi-centre study. SWI was acquired at M12 using a 3D segmented gradient-echo echo-planar imaging sequence. Rim lesions identified on SWI were manually segmented on FLAIR images at both time points for volumetric analysis., Results: Twelve subjects (27%) had at least one rim lesion at M12. A linear mixed-effects model, with 'subject' as a random factor, revealed mixed evidence for the difference in longitudinal volume change between rim lesions and non-rim lesions (p = 0.0350 and p = 0.0556 for subjects with and without rim lesions, respectively). All 25 rim lesions identified showed T1-weighted hypointense signal. Subjects with and without rim lesions did not differ significantly with respect to age, disease duration or clinical measures of disability (p > 0.05)., Conclusion: We demonstrate that rim lesions are detectable in early-stage RRMS on 3 T MRI across multiple centres, although their relationship to lesion enlargement is equivocal in this small cohort. Identification of SWI rims was subjective. Agreed criteria for defining rim lesions and their further validation as a biomarker of chronic inflammation are required for translation of SWI into routine MS clinical practice., (© 2021. The Author(s).)