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Yersinia pestis, the causative agent of plague and a biological threat agent, presents an urgent need for novel medical countermeasures due to documented cases of naturally acquired antibiotic resistance and potential person-to-person spread during a pneumonic infection. Immunotherapy has been proposed as a way to circumvent current and future antibiotic resistance. Here, we describe the development and characterization of two affinity matured human antibodies (αF1Ig AM2 and αF1Ig AM8) that promote survival of mice after exposure to aerosolized Y. pestis. We share details of the error prone PCR and yeast display technology-based affinity maturation process that we used. The resultant matured antibodies have nanomolar affinity for Y. pestis F1 antigen, are produced in high yield, and are resilient to 37°C stress for up to 6 months. Importantly, in vitro assays using a murine macrophage cell line demonstrated that αF1Ig AM2 and αF1Ig AM8 are opsonic. Even more importantly, in vivo studies using pneumonic plague mouse models showed that 100% of the mice receiving 500 μg of IgGs αF1Ig AM2 and αF1Ig AM8 survived lethal challenge with aerosolized Y. pestis CO92. Combined, these results provide evidence of the quality and robustness of αF1Ig AM2 and αF1Ig AM8 and support their development as potential medical countermeasures against plague.

Fire suppression has negatively impacted thousands of acres of private and public lands in the United States. As a case study, the New Jersey Pine Barrens (NJPB) are a disturbance driven ecosystem that is experiencing serious ecological implications due to a loss of traditional forest thinning activities such as harvesting for forest products or thinning for wildfire fuel-load reduction measures coupled with a long-standing philosophy of fire suppression and dormant-season prescribed burning. Dense closed-canopy forest conditions, dissimilar to historic open-canopy forests of the NJPB, have reduced abundance and diversity of certain flora and fauna, including regionally imperiled breeding birds. In recent years, active forest stewardship (e.g., thinning, clear-cutting, and burning) has occurred on private and some public lands within the NJPB; however, the impact of such management on breeding birds is unclear due to a paucity of research on this subject within the NJPB. During 2012, 2013, 2016, and 2017, we conducted repeat-visit point counts (n = 1,800) for breeding songbirds across 75 control and 75 treatment sites within the NJPB to assess the influence of forest structure at three strata levels (groundcover, midstory profile, and canopy) on breeding bird communities. Specifically, we constructed a hierarchical community abundance model within a Bayesian framework for Bird Conservation Region (BCR) 30 priority upland birds (n = 12) within three species suites: Forested Upland, Scrub-Shrub (or Young Forest), and Grassland. At the community level, we found a negative relationship between bird abundance and live tree basal area. At the BCR 30 suite level, we found no relationship between Forested Upland suite-level abundance and any of the measured covariates; however, we found a negative relationship between percentage of woody groundcover and Scrub-Shrub suite-level abundance, and negative relationship between horizontal visual obstruction at 2 m above ground level and Grassland suite-level abundance. Furthermore, the two latter species suites exhibited a strong negative relationship with basal area. We recommend active forest stewardship that specifically targets opening the canopy to achieve basal areas between ~0-15 m2/ha via selective thinning, shelter cutting, and small-scale clear cutting. Mechanical treatment and prescribed burning would produce such conditions and have the added benefit of reducing fuel loads across this ~4,500 km2 landscape as well as assisting in carbon defense strategies for the region.

Although most birds are considered to be at least partially monogamous, molecular evidence continues to uncover that many species can have multiple sexual mates. Many species of Waterfowl (Order Anseriformes) consistently deploy alternative breeding strategies, and although cavity nesting species have been well studied, few attempts to understand rates of alternative breeding strategies exist in the Anatini tribe. Here, we assay mitochondrial DNA and thousands of nuclear markers across 20 broods of American black ducks (Anas rubripes; “black duck”) that included 19 females and 172 offspring to study population structure as well as types and rates of secondary breeding strategies in coastal North Carolina. First, we report high levels of relatedness among nesting black ducks and offspring and while 17 (of 19) females were of pure black duck descent, three were found to be black duck x mallard (A. platyrhynchos) hybrids. Next, we evaluated for mismatched mitochondrial DNA and paternity identities across each female’s clutch to determine types and frequency of alternative or secondary breeding strategies. Although we report that nest parasitism occurred in two nests, 37% (7 of 19) of the sampled nests were multi-paternal as a result of extra-pair copulation. In addition to being part of a mix of strategies used to increase fecundity by successfully breeding females, we posit nest densities providing easier alternative mate access for males also explains high rates of extra-pair copulation among our sampled black ducks. Ultimately, however, while some proportion of females of many species engage in forms of secondary breeding strategies, we conclude that the decision to do so appears to be seasonally flexible for each individual.

Advances in observational and computational assets have led to revolutions in the range and quality of results in many science and engineering settings. However, those advances have led to needs for new research in treating model errors and assessing their impacts. We consider two settings. The first involves physically-based statistical models that are sufficiently manageable to allow incorporation of a stochastic "model error process". In the second case we consider large-scale models in which incorporation of a model error process and updating its distribution is impractical. Our suggestion is to treat dimension-reduced model output as if it is observational data, with a data model that incorporates a bias component to represent the impacts of model error. We believe that our suggestions are valuable quantitative, yet relatively simple, ways to extract useful information from models while including adjustment for model error. These ideas are illustrated and assessed using an application inspired by a classical oceanographic problem.

This study compares pandemic experiences of Missouri’s 115 counties based on rurality and sociodemographic characteristics during the 1918–20 influenza and 2020–21 COVID-19 pandemics. The state’s counties and overall population distribution have remained relatively stable over the last century, which enables identification of long-lasting pandemic attributes. Sociodemographic data available at the county level for both time periods were taken from U.S. census data and used to create clusters of similar counties. Counties were also grouped by rural status (RSU), including fully (100%) rural, semirural (1–49% living in urban areas), and urban (>50% of the population living in urban areas). Deaths from 1918 through 1920 were collated from the Missouri Digital Heritage database and COVID-19 cases and deaths were downloaded from the Missouri COVID-19 dashboard. Results from sociodemographic analyses indicate that, during both time periods, average farm value, proportion White, and literacy were the most important determinants of sociodemographic clusters. Furthermore, the Urban/Central and Southeastern regions experienced higher mortality during both pandemics than did the North and South. Analyses comparing county groups by rurality indicated that throughout the 1918–20 influenza pandemic, urban counties had the highest and rural had the lowest mortality rates. Early in the 2020–21 COVID-19 pandemic, urban counties saw the most extensive epidemic spread and highest mortality, but as the epidemic progressed, cumulative mortality became highest in semirural counties. Additional results highlight the greater effects both pandemics had on county groups with lower rates of education and a lower proportion of Whites in the population. This was especially true for the far southeastern counties of Missouri (“the Bootheel”) during the COVID-19 pandemic. These results indicate that rural-urban and socioeconomic differences in health outcomes are long-standing problems that continue to be of significant importance, even though the overall quality of health care is substantially better in the 21st century.

The aim of this retrospective cohort study was to provide a single-center clinical audit of complications for single chamber permanent pacemaker implantation (PPI) techniques and determine if the clinical parameters, PPI technique or complications were associated with outcome. The electronic medical records were searched for dogs treated for bradyarrhythmia with PPI. Data related to presenting complaint, signalment of the dog, ECG diagnosis, echocardiographic findings, PPI technique, and programing of the pacemaker were recorded. Survival length (days) was recorded as the last veterinary visit; if the dog was dead the reason was documented. Cumulative survival of each pacemaker was examined by a Kaplan-Meier survival curve and the two techniques compared with a logrank test. Chi-square was used to determine the association between major complications and death. A total of 66 dogs with 52 transvenous and 30 epicardial PPIs were included. All epicardial pacemakers were implanted via transdiaphragmatic approach. A total of 31 life-threatening complications were reported. There were nine deaths related to major complications (13.6% of the study sample). The median follow-up period was 366 days, with a median survival of 255 days, and a significant difference in cumulative survival of each pacemaker (P = 0.01) between epicardial (93 days, range 0-1882 days) and transvenous (334 days, range 0-2745) PPIs but no significant difference in cumulative survival between the two techniques when only the first pacemaker was considered (p = 0.07). The presence of a major complications had a significant association with death due to pacemaker complications (P

We introduce a novel method called Prophetic Granger Causality (PGC) for inferring gene regulatory networks (GRNs) from protein-level time series data. The method uses an L1-penalized regression adaptation of Granger Causality to model protein levels as a function of time, stimuli, and other perturbations. When combined with a data-independent network prior, the framework outperformed all other methods submitted to the HPN-DREAM 8 breast cancer network inference challenge. Our investigations reveal that PGC provides complementary information to other approaches, raising the performance of ensemble learners, while on its own achieves moderate performance. Thus, PGC serves as a valuable new tool in the bioinformatics toolkit for analyzing temporal datasets. We investigate the general and cell-specific interactions predicted by our method and find several novel interactions, demonstrating the utility of the approach in charting new tumor wiring.

IntroductionAcute traumatic coagulopathy has been associated with shock and tissue injury, and may be mediated via activation of the protein C pathway. Patients with acute traumatic coagulopathy have prolonged PT and PTT, and decreased activity of factors V and VIII; they are also hypocoagulable by thromboelastometry (ROTEM) and other viscoelastic assays. To test the etiology of this phenomenon, we hypothesized that such coagulopathy could be induced in vitro in healthy human blood with the addition of activated protein C (aPC).MethodsWhole blood was collected from 20 healthy human subjects, and was "spiked" with increasing concentrations of purified human aPC (control, 75, 300, 2000 ng/mL). PT/PTT, factor activity assays, and ROTEM were performed on each sample. Mixed effect regression modeling was performed to assess the association of aPC concentration with PT/PTT, factor activity, and ROTEM parameters.ResultsIn all subjects, increasing concentrations of aPC produced ROTEM tracings consistent with traumatic coagulopathy. ROTEM EXTEM parameters differed significantly by aPC concentration, with stepwise prolongation of clotting time (CT) and clot formation time (CFT), decreased alpha angle (α), impaired early clot formation (a10 and a20), and reduced maximum clot firmness (MCF). PT and PTT were significantly prolonged at higher aPC concentrations, with corresponding significant decreases in factor V and VIII activity.ConclusionA phenotype of acute traumatic coagulopathy can be induced in healthy blood by the in vitro addition of aPC alone, as evidenced by viscoelastic measures and confirmed by conventional coagulation assays and factor activity. This may lend further mechanistic insight to the etiology of coagulation abnormalities in trauma, supporting the central role of the protein C pathway. Our findings also represent a model for future investigations in the diagnosis and treatment of acute traumatic coagulopathy.

Neuromotor dysfunction after a concussion is common, but balance tests used to assess neuromotor dysfunction are typically subjective. Current objective balance tests are either cost- or space-prohibitive, or utilize a static balance protocol, which may mask neuromotor dysfunction due to the simplicity of the task. To address this gap, our team developed an Android-based smartphone app (portable and cost-effective) that uses the sensors in the device (objective) to record movement profiles during a stepping-in-place task (dynamic movement). The purpose of this study was to examine the extent to which our custom smartphone app and protocol could discriminate neuromotor behavior between concussed and non-concussed participants. Data were collected at two university laboratories and two military sites. Participants included civilians and Service Members (N = 216) with and without a clinically diagnosed concussion. Kinematic and variability metrics were derived from a thigh angle time series while the participants completed a series of stepping-in-place tasks in three conditions: eyes open, eyes closed, and head shake. We observed that the standard deviation of the mean maximum angular velocity of the thigh was higher in the participants with a concussion history in the eyes closed and head shake conditions of the stepping-in-place task. Consistent with the optimal movement variability hypothesis, we showed that increased movement variability occurs in participants with a concussion history, for which our smartphone app and protocol were sensitive enough to capture.

Thy-1 is a cell surface protein that is expressed during the differentiation of retinal ganglion cells (RGCs). Optic nerve injury induces progressive loss in the number of RGCs expressing Thy-1. The rate of this loss is fastest during the first week after optic nerve injury and slower in subsequent weeks. This study was undertaken to determine whether oral treatment with a water-soluble N-hydroxy-2,2,6,6-tetramethylpiperidine derivative (OT-440) protects against loss of Thy-1 promoter activation following optic nerve crush and whether this effect targets the earlier quick phase or the later slow phase. The retina of mice expressing cyan fluorescent protein under control of the Thy-1 promoter (Thy1-CFP mice) was imaged using a blue-light confocal scanning laser ophthalmoscope (bCSLO). These mice then received oral OT-440 prepared in cream cheese or dissolved in water, or plain vehicle, for two weeks and were imaged again prior to unilateral optic nerve crush. Treatments and weekly imaging continued for four more weeks. Fluorescent neurons were counted in the same defined retinal areas imaged at each time point in a masked fashion. When the counts at each time point were directly compared, the numbers of fluorescent cells at each time point were greater in the animals that received OT-440 in cream cheese by 8%, 27%, 52% and 60% than in corresponding control animals at 1, 2, 3 and 4 weeks after optic nerve crush. Similar results were obtained when the vehicle was water. Rate analysis indicated the protective effect of OT-440 was greatest during the first two weeks and was maintained in the second two weeks after crush for both the cream cheese vehicle study and water vehicle study. Because most of the fluorescent cells detected by bCSLO are RGCs, these findings suggest that oral OT-440 can either protect against or delay early degenerative responses occurring in RGCs following optic nerve injury.

Nest parasitism is a common reproductive strategy used by many species of cavity nesting birds. Among these, the wood duck (Aix sponsa) is known to have evolved very specific strategies of when and whom to parasitize that is often based on population and/or environmental queues. Here, we investigated the genetic relationship of two female wood ducks competing over an artificial nesting box in Delaware, including the continued incubation of one female despite the death and body remains of the other female throughout the incubation process. We test whether such an extreme case of nest parasitism can be explained by relatedness, egg lineage composition, or a combination of other factors. To do so, we extracted genomic DNA from blood and tissue of the females, as well as chorioallantoic membranes of all viable and inviable eggs. Subsequently, we assessed relatedness among females and eggs based on hundreds of nuclear loci and the mitochondrial control region. We concluded that (1) the two incubating females were entirely unrelated, (2) the single clutch is in fact represented by a minimum of four unrelated females, and (3) a single female can lay eggs sired by different males. The latter finding is the first direct evidence for successful extra-pair copulation in wood ducks. With decreasing costs and increasing effectiveness, genomic methods have the potential to provide important insights into more complex ecological and evolutionary tactics of such populations.

ObjectiveThe vaginal microbiota in bacterial vaginosis (BV) typically has low abundance of lactic acid producing lactobacilli. Lactic acid has properties that may make it effective for treating BV and/or restoring an optimal lactobacillus-dominated vaginal microbiota. We conducted a systematic review to describe the effect of intravaginal lactic acid-containing products on BV cure, and their impact on vaginal microbiota composition (PROSPERO registration: CRD42018115982).MethodsPubMed, Embase and OVID were searched from inception to November 2019 to identify eligible studies. Included studies evaluated an intravaginal lactic acid-containing product and reported BV cure using established diagnostic methods, and/or vaginal microbiota composition using molecular methods. Studies were independently screened and assessed, and the proportion of women cured post-treatment was calculated. Study results were described in a qualitative manner.ResultsWe identified 1,883 articles and assessed 57 full-texts for eligibility. Seven different lactic acid-containing products were evaluated and differed with respect to excipients, lactic acid concentration and pH. Most studies had medium or high risk of bias. Three trials compared the efficacy of a lactic acid-containing product to metronidazole for BV cure. One study found lactic acid to be equivalent to metronidazole and two studies found lactic acid to be significantly inferior to metronidazole. Two studies included a control group receiving a placebo or no treatment. One reported lactic acid to be superior than no treatment and the other reported lactic acid to be equivalent to placebo. Lactic acid-containing products did not significantly impact the vaginal microbiota composition.ConclusionThere is a lack of high-quality evidence to support the use of lactic acid-containing products for BV cure or vaginal microbiota modulation. However, adequately powered and rigorous randomised trials with accompanying vaginal microbiota data are needed to evaluate the efficacy of lactic acid as a BV treatment strategy.

While firefighters currently have low smoking rates, rates of smokeless tobacco (SLT) use among this population are remarkably high and substantially greater than similar occupational groups, and the general population. This study explored determinants associated with SLT use, barriers to cessation, and motivators for SLT cessation in the fire service. Key informant interviews were conducted in 23 career firefighters who were current (n = 14) and former (n = 9) SLT users from across the U.S. Discussions were recorded and independently coded according to questions and themes. Major themes that developed among firefighters regarding SLT use determinants included positive perceptions of SLT products, social influences from their peers and family members, acceptability of SLT use in the fire service, and a coping resource for job stress. Firefighters discussed several barriers to SLT cessation, including intrapersonal barriers such as SLT use habits and its dependency, concerns about withdrawal symptoms; and social-environmental barriers including lack of support from health and other services providers, and lack of enforcement of existing tobacco policies regarding SLT use. Firefighters also mentioned both internal and external motivators for cessation. Internal motivators included self-motivation and their health concerns while external motivators included friends and family support, incentives or rewards, and price of SLT products. Findings provide unique perspectives from firefighters on factors that influence SLT use and barriers and motivators to SLT cessation. These are insufficiently assessed and considered by the fire service organizations and their health care providers. Thus, the organizations must understand these issues in order to mitigate barriers and motivate the personnel to quit using SLT. Information gained from firefighters who were current and former SLT users can be used to develop an effective, culturally-tailored intervention that is acceptable to fire service personnel.

Fire suppression has negatively impacted thousands of acres of private and public lands in the United States. As a case study, the New Jersey Pine Barrens (NJPB) are a disturbance driven ecosystem that is experiencing serious ecological implications due to a loss of traditional forest thinning activities such as harvesting for forest products or thinning for wildfire fuel-load reduction measures coupled with a long-standing philosophy of fire suppression and dormant-season prescribed burning. Dense closed-canopy forest conditions, dissimilar to historic open-canopy forests of the NJPB, have reduced abundance and diversity of certain flora and fauna, including regionally imperiled breeding birds. In recent years, active forest stewardship (e.g., thinning, clear-cutting, and burning) has occurred on private and some public lands within the NJPB; however, the impact of such management on breeding birds is unclear due to a paucity of research on this subject within the NJPB. During 2012, 2013, 2016, and 2017, we conducted repeat-visit point counts (n = 1,800) for breeding songbirds across 75 control and 75 treatment sites within the NJPB to assess the influence of forest structure at three strata levels (groundcover, midstory profile, and canopy) on breeding bird communities. Specifically, we constructed a hierarchical community abundance model within a Bayesian framework for Bird Conservation Region (BCR) 30 priority upland birds (n = 12) within three species suites: Forested Upland, Scrub-Shrub (or Young Forest), and Grassland. At the community level, we found a negative relationship between bird abundance and live tree basal area. At the BCR 30 suite level, we found no relationship between Forested Upland suite-level abundance and any of the measured covariates; however, we found a negative relationship between percentage of woody groundcover and Scrub-Shrub suite-level abundance, and negative relationship between horizontal visual obstruction at 2 m above ground level and Grassland suite-level abundance. Furthermore, the two latter species suites exhibited a strong negative relationship with basal area. We recommend active forest stewardship that specifically targets opening the canopy to achieve basal areas between ~0–15 m2/ha via selective thinning, shelter cutting, and small-scale clear cutting. Mechanical treatment and prescribed burning would produce such conditions and have the added benefit of reducing fuel loads across this ~4,500 km2 landscape as well as assisting in carbon defense strategies for the region. [ABSTRACT FROM AUTHOR]

BACKGROUND:Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. MATERIALS AND METHODS:We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. RESULTS:Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08-2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87-1.05 in univariable and HR 1.03 [95% CI 0.95-1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91-1.06) in univariable and 1.05 (95% CI 0.99-1.11) in multivariable analysis). CONCLUSIONS:For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.

Bacterial efflux pumps are an important pathogenicity trait because they extrude a variety of xenobiotics. Our laboratory previously identified in silico Burkholderia collagen-like protein 8 (Bucl8) in the hazardous pathogens Burkholderia pseudomallei and Burkholderia mallei. We hypothesize that Bucl8, which contains two predicted tandem outer membrane efflux pump domains, is a component of a putative efflux pump. Unique to Bucl8, as compared to other outer membrane proteins, is the presence of an extended extracellular region containing a collagen-like (CL) domain and a non-collagenous C-terminus (Ct). Molecular modeling and circular dichroism spectroscopy with a recombinant protein, corresponding to this extracellular CL-Ct portion of Bucl8, demonstrated that it adopts a collagen triple helix, whereas functional assays screening for Bucl8 ligands identified binding to fibrinogen. Bioinformatic analysis of the bucl8 gene locus revealed it resembles a classical efflux-pump operon. The bucl8 gene is co-localized with downstream fusCDE genes encoding fusaric acid (FA) resistance, and with an upstream gene, designated as fusR, encoding a LysR-type transcriptional regulator. Using reverse transcriptase (RT)-qPCR, we defined the boundaries and transcriptional organization of the fusR-bucl8-fusCDE operon. We found exogenous FA induced bucl8 transcription over 80-fold in B. pseudomallei, while deletion of the entire bucl8 locus decreased the minimum inhibitory concentration of FA 4-fold in its isogenic mutant. We furthermore showed that the putative Bucl8-associated pump expressed in the heterologous Escherichia coli host confers FA resistance. On the contrary, the Bucl8-associated pump did not confer resistance to a panel of clinically-relevant antimicrobials in Burkholderia and E. coli. We finally demonstrated that deletion of the bucl8-locus drastically affects the growth of the mutant in L-broth. We determined that Bucl8 is a component of a novel tetrapartite efflux pump, which confers FA resistance, fibrinogen binding, and optimal growth.

UltraPrep is an open-source, two-step method for purification of cell-free DNA that entails extraction of total DNA followed by size-selective enrichment of the smaller fragments that are characteristic of DNA originating from fragmentation between nucleosome. The advantages of the two related protocols that are described are that they can easily accommodate a wide range of sample input volumes, they rely on simple, magnetic bead-based technology, the yields of cfDNA are directly comparable to the most popular methods for cfDNA purification, and they dramatically reduce the cost of cfDNA isolation relative to currently available commercial methods. We provide a framework for physical and molecular quality analysis of purified cfDNA and demonstrate that the cfDNA generated by UltraPrep meets or exceeds the quality metrics of the most commonly used procedure. In addition, our method removes high molecular weight genomic DNA (hmwgDNA) that can interfere with downstream assay results, thereby addressing one of the primary concerns for preanalytical collection of blood samples.

PurposeThis study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates.MethodsIn this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team.ResultsHospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED.ConclusionImplementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.

BACKGROUND:The Victorian legislation prohibits sex workers from working when they have visible anogenital herpes or warts. The aim of this study was to determine the proportion of asymptomatic female sex workers (FSW) diagnosed with anogenital herpes or warts by genital examination. METHODS:We analysed all computerised medical records of consultations with FSW at the Melbourne Sexual Health Centre (MSHC) in 2018. All asymptomatic sex workers were offered screening sexually transmitted infections (STIs) and a genital examination to identify visible anogenital herpes or warts at MSHC. FSW consultations were categorised into either 'asymptomatic' or 'symptomatic' based on the presence of symptoms reported by the FSW to the triage nurse. The proportion of asymptomatic FSW diagnosed with visible anogenital herpes or warts during a routine screening examination was calculated. RESULTS:In 2018, 4055 consultations were provided to 1979 FSW. 3406 of these consultations were asymptomatic and all were examined by an experienced clinician for signs of STIs. Of these 3406 asymptomatic consultations, seven FSW (0.21%, 95% CI: 0.08% to 0.42%) were diagnosed with visible anogenital herpes and/or warts following a genital examination. Four were diagnosed with warts (0.12%, 95% CI: 0.03% to 0.30%), two with herpes (0.06%, 95% CI: 0.01% to 0.21%) and one with both herpes and warts (0.03%, 95% CI: 0.001% to 0.16%). CONCLUSION:Based on these data, approximately 500 asymptomatic FSW would need to be examined to identify one case of anogenital herpes or warts. Genital examinations consume considerable clinical resources, increase the duration of consultations and provide essentially no significant benefit to the mandated testing for gonorrhoea, chlamydia, HIV and syphilis. Our clinic will use self-collected samples and no longer examine FSW who are asymptomatic.

BACKGROUND:Health systems routinely implement changes to the design of electronic health records (EHRs). Physician behavior may vary in response and methods to identify this variation could help to inform future interventions. The objective of this study was to phenotype primary care physician practice patterns and evaluate associations with response to an EHR nudge for influenza vaccination. METHODS AND FINDINGS:During the 2016-2017 influenza season, 3 primary care practices at Penn Medicine implemented an active choice intervention in the EHR that prompted medical assistants to template influenza vaccination orders for physicians to review during the visit. We used latent class analysis to identify physician phenotypes based on 9 demographic, training, and practice pattern variables, which were obtained from the EHR and publicly available sources. A quasi-experimental approach was used to evaluate response to the intervention relative to control practices over time in each of the physician phenotype groups. For each physician latent class, a generalized linear model with logit link was fit to the binary outcome of influenza vaccination at the patient visit level. The sample comprised 45,410 patients with a mean (SD) age of 58.7 (16.3) years, 67.1% were white, and 22.1% were black. The sample comprised 56 physicians with mean (SD) of 24.6 (10.2) years of experience and 53.6% were male. The model segmented physicians into groups that had higher (n = 41) and lower (n = 15) clinical workloads. Physicians in the higher clinical workload group had a mean (SD) of 818.8 (429.1) patient encounters, 11.6 (4.7) patient appointments per day, and 4.0 (1.1) days per week in clinic. Physicians in the lower clinical workload group had a mean (SD) of 343.7 (129.0) patient encounters, 8.0 (2.8) patient appointments per day, and 3.1 (1.2) days per week in clinic. Among the higher clinical workload group, the EHR nudge was associated with a significant increase in influenza vaccination (adjusted difference-in-difference in percentage points, 7.9; 95% CI, 0.4-9.0; P = .01). Among the lower clinical workload group, the EHR nudge was not associated with a significant difference in influenza vaccination rates (adjusted difference-in-difference in percentage points, -1.0; 95% CI, -5.3-5.8; P = .90). CONCLUSIONS:A model-based approach categorized physician practice patterns into higher and lower clinical workload groups. The higher clinical workload group was associated with a significant response to an EHR nudge for influenza vaccination.

BackgroundVentricular septal perforation and left ventricular aneurysm are examples of potentially fatal complications of myocardial infarction. While various artificial materials are used in the repair of these issues, the possibility of associated infection and calcification is non-negligible. Cell-seeded biodegradable tissue-engineered patches may be a potential solution. This study evaluated the feasibility of a new left ventricular patch rat model to study neotissue formation in biodegradable cardiac patches.MethodsHuman induced pluripotent stem cell-derived cardiac progenitor cells (hiPS-CPCs) were cultured onto biodegradable patches composed of polyglycolic acid and a 50:50 poly (l-lactide-co-ε-caprolactone) copolymer for one week. After culturing, patches were implanted into left ventricular walls of male athymic rats. Unseeded controls were also used (n = 10/group). Heart conditions were followed by echocardiography and patches were subsequently explanted at 1, 2, 6, and 9 months post-implantation for histological evaluation.ResultThroughout the study, no patches ruptured demonstrating the ability to withstand the high pressure left ventricular system. One month after transplantation, the seeded patch did not stain positive for human nuclei. However, many new blood vessels formed within patches with significantly greater vessels in the seeded group at the 6 month time point. Echocardiography showed no significant difference in left ventricular contraction rate between the two groups. Calcification was found inside patches after 6 months, but there was no significant difference between groups.ConclusionWe have developed a surgical method to implant a bioabsorbable scaffold into the left ventricular environment of rats with a high survival rate. Seeded hiPS-CPCs did not differentiate into cardiomyocytes, but the greater number of new blood vessels in seeded patches suggests the presence of cell seeding early in the remodeling process might provide a prolonged effect on neotissue formation. This experiment will contribute to the development of a treatment model for left ventricular failure using iPS cells in the future.

Asian-born gay, bisexual and other men who have sex with men (gbMSM) who are newly arrived in Australia are at a higher risk of acquiring HIV than Australian-born gbMSM. We used a social constructionist framework to explore HIV knowledge and prevention strategies used by newly-arrived Asian-born gbMSM. Twenty four Asian-born gbMSM, aged 20-34 years, attending Melbourne Sexual Health Centre, who arrived in Australia in the preceding five years, participated in semi-structured, face-to-face interviews. Interviews were recorded, transcribed verbatim and analysed thematically. Participants described hiding their sexual identities in their country of origin, particularly from family members, due to fear of judgement and discrimination resulting from exposure to sexual identity and HIV related stigma in their countries of origin, although some were open to friends. Despite feeling more sexual freedom and acceptance in Australia, many were still not forthcoming with their sexual identity due to internalised feelings of stigma and shame. Exposure to stigma in their country of origin led many to report anxiety around HIV testing in Australia due to a fear of testing positive. Some described experiencing racism and lack of acceptance in the gay community in Australia, particularly on dating apps. Fear of discrimination and judgement about their sexual identity can have a significant impact on Asian-born gbMSM living in Australia, particularly in terms of social connectedness. Additionally, HIV-related stigma can contribute to anxieties around HIV testing. Our data highlights the potential discrimination Asian-born gbMSM face in Australia, which has implications for social connectedness, particularly with regard to LGBTQI communities and HIV testing practices. Future studies should determine effective strategies to reduce sexual identity and HIV-related stigma in newly-arrived Asian-born gbMSM.

BACKGROUND:Our primary study aimed to explore the experiences of men who have sex with men (MSM) recently diagnosed with HIV and their partner notification practices. Themes relating to acceptance, and disclosure of, their HIV status strongly emerged during analysis in our larger study and are reported separately here. METHOD:Fifteen MSM participated in semi-structured interviews by phone or face to face about their experience of a recent HIV diagnosis. In this paper we report on how they received and accepted the diagnosis, who they disclosed their diagnosis to and what is needed to improve support for MSM recently diagnosed with HIV. RESULTS:MSM's reactions to their HIV diagnosis ranged from shock, devastation and anger to a calm acceptance and feeling HIV would not have a significant impact on their lives. MSM who reported strong social support networks, or knew others with HIV, seemed better able to cope with and accept their diagnosis than those with fewer support networks. Due to prevailing stigma around HIV, most MSM were very selective about who they disclosed their status to, often only telling partners perceived to be at risk but no, or only few, close friends. Regardless of how well men accepted their diagnosis, most did not disclose their status to family members for fear of rejection or causing distress due to ideologies based on outdated information about HIV. CONCLUSION:The prevailing stigma around HIV can have a significant impact on MSM's acceptance of, and willingness to disclose their HIV serostatus to others, and consequently the levels of professional and social support they receive. HIV-related stigma needs to be addressed through community campaigns which better educate the wider population about the current state of HIV prognosis and treatment.

Under the new kidney allocation system (KAS), implemented in 2014, the distribution of the best quality donor kidney grafts shifted between age groups, but it is unclear whether this change translates to meaningful differences in post-transplant outcomes. We conducted a retrospective cohort study of 20,345 deceased donor kidney transplant recipients before and 4,605 recipients after implementation of the KAS using data from the United Network of Organ Sharing. Overall, two-year mortality was greater among recipients in the post-KAS era compared with the pre-KAS era (6.31% vs 5.91% respectively, [p = 0.01]), and two-year graft loss was not significantly different between eras (9.95% and 9.65%, respectively [p = 0.13]). In analysis stratified by age group (18-45, 46-55, 56-65, and ≥66 years), relative risk of mortality was 1.48 (95% confidence interval [CI] 1.09-1.98) among recipients 46-55 years old and 1.47 (95% CI 1.18-1.81) among recipients 56-65 years old. Relative risk of all-cause graft loss was 1.43 (95% CI 1.20-1.70) among recipients 56-65 years old. There were no significant differences in relative risk of mortality or graft loss associated with the KAS era among other age groups. After adjustment for recipient characteristics and characteristics of the changing donor pool, relative risk of two-year mortality and graft loss associated with the post-KAS era was attenuated for recipients aged 46-55 and 56-65 years, but remained statistically significant. In this early analysis after implementation of the KAS, there is suggestion that increased risk of mortality and graft loss may be disproportionately borne by middle-aged recipients, which is only partially accounted for by changes in recipient and donor characteristics. These findings signal a need to continue to monitor the effects of the KAS to ensure that allocation practices both maximize utility of the kidney graft pool and respect fairness between age groups.

Recurrence following recommended treatment for bacterial vaginosis is unacceptably high. While the pathogenesis of recurrence is not well understood, recent evidence indicates re-infection from sexual partners is likely to play a role. The aim of this study was to assess the acceptability and tolerability of topical and oral antimicrobial therapy in male partners of women with bacterial vaginosis (BV), and to investigate the impact of dual-partner treatment on the vaginal and penile microbiota.Women with symptomatic BV (Nugent Score of 4-10 and ≥3 Amsel criteria) and their regular male sexual partner were recruited from Melbourne Sexual Health Centre, Melbourne, Australia. Women received oral metronidazole 400mg twice daily (or intra-vaginal 2% clindamycin cream, if contraindicated) for 7-days. Male partners received oral metronidazole 400mg twice daily and 2% clindamycin cream topically to the penile skin twice daily for 7-days. Couples provided self-collected genital specimens and completed questionnaires at enrolment and then weekly for 4-weeks. Genital microbiota composition was determined by 16S rRNA gene sequencing. Changes in genital microbiota composition were assessed by Bray-Curtis index. Bacterial diversity was measured by the Shannon Diversity Index.Twenty-two couples were recruited. Sixteen couples (76%) completed all study procedures. Adherence was high; most participants took >90% of prescribed medication. Medication, and particularly topical clindamycin in males, was well tolerated. Dual-partner treatment had an immediate and sustained effect on the composition of vaginal microbiota (median Bray-Curtis score day 0 versus day 8 = 0.03 [IQR 0-0.15], day 0 vs day 28 = 0.03 [0.02-0.11]). We observed a reduction in bacterial diversity of the vaginal microbiota and a decrease in the prevalence and abundance of BV-associated bacteria following treatment. Treatment had an immediate effect on the composition of the cutaneous penile microbiota (median Bray-Curtis score day 0 vs day 8 = 0.09 [0.04-0.17]), however this was not as pronounced at day 28 (median Bray-Curtis score day 0 vs day 28 = 0.38 [0.11-0.59]). A decrease in the prevalence and abundance of BV-associated bacteria in the cutaneous penile microbiota was observed immediately following treatment at day 8.Combined oral and topical treatment of male partners of women with BV is acceptable and well tolerated. The combined acceptability and microbiological data presented in this paper supports the need for larger studies with longer follow up to characterize the sustained effect of dual partner treatment on the genital microbiota of couples and assess the impact on BV recurrence.

The University of British Columbia Nepal Expedition took place over several months in the fall of 2016 and was comprised of an international team of 37 researchers. This paper describes the objectives, study characteristics, organization and management of this expedition, and presents novel blood gas data during acclimatization in both lowlanders and Sherpa. An overview and framework for the forthcoming publications is provided. The expedition conducted 17 major studies with two principal goals-to identify physiological differences in: 1) acclimatization; and 2) responses to sustained high-altitude exposure between lowland natives and people of Tibetan descent. We performed observational cohort studies of human responses to progressive hypobaric hypoxia (during ascent), and to sustained exposure to 5050 m over 3 weeks comparing lowlander adults (n = 30) with Sherpa adults (n = 24). Sherpa were tested both with (n = 12) and without (n = 12) descent to Kathmandu. Data collected from lowlander children (n = 30) in Canada were compared with those collected from Sherpa children (n = 57; 3400-3900m). Studies were conducted in Canada (344m) and the following locations in Nepal: Kathmandu (1400m), Namche Bazaar (3440m), Kunde Hospital (3480m), Pheriche (4371m) and the Ev-K2-CNR Research Pyramid Laboratory (5050m). The core studies focused on the mechanisms of cerebral blood flow regulation, the role of iron in cardiopulmonary regulation, pulmonary pressures, intra-ocular pressures, cardiac function, neuromuscular fatigue and function, blood volume regulation, autonomic control, and micro and macro vascular function. A total of 335 study sessions were conducted over three weeks at 5050m. In addition to an overview of this expedition and arterial blood gas data from Sherpa, suggestions for scientists aiming to perform field-based altitude research are also presented. Together, these findings will contribute to our understanding of human acclimatization and adaptation to the stress of residence at high-altitude.

Mouse models have been essential to generate supporting data for the research of infectious diseases. Burkholderia pseudomallei, the etiological agent of melioidosis, has been studied using mouse models to investigate pathogenesis and efficacy of novel medical countermeasures to include both vaccines and therapeutics. Previous characterization of mouse models of melioidosis have demonstrated that BALB/c mice present with an acute infection, whereas C57BL/6 mice have shown a tendency to be more resistant to infection and may model chronic disease. In this study, either BALB/c or C57BL/6 mice were exposed to aerosolized human clinical isolates of B. pseudomallei. The bacterial strains included HBPUB10134a (virulent isolate from Thailand), MSHR5855 (virulent isolate from Australia), and 1106a (relatively attenuated isolate from Thailand). The LD50 values were calculated and serial sample collections were performed in order to examine the bacterial burdens in tissues, histopathological features of disease, and the immune response mounted by the mice after exposure to aerosolized B. pseudomallei. These data will be important when utilizing these models for testing novel medical countermeasures. Additionally, by comparing highly virulent strains with attenuated isolates, we hope to better understand the complex disease pathogenesis associated with this bacterium.

LInkers of Nucleoskeleton and Cytoskeleton (LINC) complexes, composed of SUN and KASH-domain proteins, span the nuclear envelope and physically connect the nuclear interior to cytoskeletal elements. Most human cells contain two SUN proteins, Sun1 and Sun2, and several KASH-proteins suggesting that multiple functionally distinct LINC complexes co-exist in the nuclear envelope. We show here, however, that while Sun1 and Sun2 in HeLa cells are each able to bind KASH-domains, Sun1 is more efficiently incorporated into LINC complexes under normal growth conditions. Furthermore, the balance of Sun1 and Sun2 incorporated into LINC complexes is cell type-specific and is correlated with SRF/Mkl1-dependent gene expression. In addition, we found that Sun1 has a LINC complex-independent role in transcriptional control, possibly by regulating the SRF/Mkl1 pathway. Together, these data reveal novel insights into the mechanisms of LINC complex regulation and demonstrate that Sun1 modulates gene expression independently of its incorporation into LINC complexes.

BackgroundNon-consensual removal of condoms, colloquially referred to as 'stealthing', is the removal of a condom during sex by a sexual partner when consent has been given for sex with a condom only.MethodsWe conducted a cross-sectional survey to determine how commonly women and men who have sex with men (MSM) attending Melbourne Sexual Health Centre had experienced stealthing, and analysed situational factors associated with the event. Responses were linked to demographic information extracted from patient files.Results1189 of 2883 women (41.2%), and 1063 of 3439 MSM (30.9%) attending the clinic during the study period completed the survey. Thirty-two percent of women (95% CI: 29%,35%) and 19% of MSM (95% CI: 17%,22%) reported having ever experienced stealthing. Women who had been stealthed were more likely to be a current sex worker (Adjusted Odds Ratio [AOR] 2.87, 95% CI: 2.01,4.11, p ConclusionsA high proportion of women and MSM attending a sexual health service reported having experienced stealthing. While further investigation is needed into the prevalence of stealthing in the general community, clinicians should be aware of this practice and consider integrating this question into their sexual health consultation. Understanding situational factors would assist in the development of preventive strategies, particularly female sex workers and MSM.

We aimed to describe patterns in the usage of antivirals to treat influenza virus infection in hospitals in Hong Kong from 2000 through 2015.We analyzed centralized electronic health records that included dispensation information and diagnosis codes. Information collected on admissions included patient age, sex, admission year and month, and medications dispensed, and were matched with the first 15 discharge diagnosis codes. We divided monthly admission episodes by relevant population denominators to obtain admission rates, and stratified analyses by drug type, age group, and diagnosis codes.Amantadine was used for influenza treatment in the early 2000s but changed with recommendations to avoid its use in 2006, and is now mainly used to treat Parkinson's disease. Oseltamivir usage increased substantially in 2009 and is now commonly used, with almost 40,000 hospitalizations treated with oseltamivir in the years 2012 through 2015, 66% of which was in persons ≥65 years of age. During the entire study period, of the 98,253 admission episodes in which oseltamivir was dispensed, 40,698 (41%) included a diagnosis code for influenza, and 80,283 (82%) included any diagnosis code for respiratory illness.The amount of oseltamivir used from 2012-15 was comparable to a separate ecological estimate of around 13,000 influenza-associated hospitalizations per year on average. We did not have access to individual patient laboratory testing data.

Chlamydia is the most common bacterial sexually transmitted infection among men who have sex with men. Repeat infection following treatment with 1g azithromycin is common and treatment failure of up to 22% has been reported. This study measured the pharmacokinetics of azithromycin in rectal tissue in men following a single 1g dose to assess whether azithromycin reaches the rectal site in adequate concentrations to kill chlamydia. Ten healthy men took a single oral dose of 1g azithromycin and provided nine self-collected swabs and one blood sample over 14 days. Participant demographics, medications, sexual behaviour, treatment side effects, lubricant use and douching practices were recorded with each swab. Drug concentration over time was determined using liquid chromatography-mass spectrometry and total exposure (AUC0-∞) was estimated from the concentration-time profiles. Following 1g of azithromycin, rectal concentrations peaked after a median of 24 hours (median 133mcg/g) and remained above the minimum inhibitory concentration for chlamydia (0.125mcg/mL) for at least 14 days in all men. AUC0-∞ was the highest ever reported in human tissue (13103((mcg/g).hr)). Tissue concentrations were not associated with weight (mg/kg), but data suggest that increased gastric pH could increase azithromycin levels and diarrhoea or use of water-based lubricants could decrease concentrations. High and sustained concentrations of azithromycin were found in rectal tissue following a single 1g dose suggesting that inadequate concentrations are unlikely to cause treatment failure. Factors effecting absorption (pH and diarrhoea) or drug depletion (douching and water-based lubricants) may be more important determinants of concentrations in situ.

The assessment of gait variability using stochastic signal processing techniques such as detrended fluctuation analysis (DFA) has been shown to be a sensitive tool for evaluation of gait alterations due to aging and neuromuscular disease. However, previous studies have suggested that the application of DFA requires relatively long recordings (600 strides), which is difficult when working with clinical populations or older adults. In this paper we propose a model for predicting DFA variance in experimental data and conduct a Monte Carlo simulation to estimate the sample size and number of trials required to detect a change in DFA scaling exponent. We illustrate the model in a simulation to detect a difference of 0.1 (medium effect) between two groups of subjects when using short gait time series (100 to 200 strides) in the context of between- and within-subject designs. We assumed that the variance of DFA scaling exponent arises due to individual differences, time series length, and experimental error. Results showed that sample sizes required to achieve acceptable power of 80% are practically feasible, especially when using within-subject designs. For example, to detect a group difference in the DFA scaling exponent of 0.1, it would require either 25 subjects and 2 trials per subject or 12 subjects and 4 trials per subject using a within-subject design. We then compared plausibility of such power predictions to the empirically observed power from a study that required subjects to synchronize with a persistent fractal metronome. The results showed that the model adequately predicted the empirical pattern of results. Our power simulations could be used in conjunction with previous design guidelines in the literature when planning new gait variability experiments.

PurposeTo identify Myo/Nog cells in the adult retina and test their role in protecting retinal photoreceptors from light damage.MethodsLight damage was induced by exposing albino rats raised in dim cyclic light to 1000 lux light for 24 hours. In one group of rats, Myo/Nog cells were purified from rat brain tissue by magnetic cell sorting following binding of the G8 monoclonal antibody (mAb). These cells were injected into the vitreous humour of the eye within 2 hours following bright light exposure. Retinal function was assessed using full-field, flash electroretinogram (ERG) before and after treatment. The numbers of Myo/Nog cells, apoptotic photoreceptors, and the expression of glial fibrillary acidic protein (GFAP) in Muller cells were assessed by immunohistochemistry.ResultsMyo/Nog cells were present in the undamaged retina in low numbers. Light induced damage increased their numbers, particularly in the choroid, ganglion cell layer and outer plexiform layer. Intravitreal injection of G8-positive (G8+) cells harvested from brain mitigated all the effects of light damage examined, i.e. loss of retinal function (ERG), death of photoreceptors and the stress-induced expression of GFAP in Muller cells. Some of the transplanted G8+ cells were integrated into the retina from the vitreous.ConclusionsMyo/Nog cells are a subpopulation of cells that are present in the adult retina. They increase in number in response to light induced stress. Intravitreal injection of Myo/Nog cells was protective to the retina, in part, by reducing retinal stress as measured by the Muller cell response. These results suggest that Myo/Nog cells, or the factors they produce, are neuroprotective and may be therapeutic in neurodegenerative retinal diseases.

Erythropoiesis-stimulating agents (ESAs) are recommended for treating anemia in patients with chronic kidney disease and end-stage renal disease. However, misappropriate and over-use of these agents can be costly and unnecessary in some settings.The primary aim was to identify predictors of adherence to a newly approved ESA inpatient ordering policy. The secondary aims were to evaluate the impact of a 5-day delay in the initiation of ESA therapy on ESA usage, hemoglobin (Hb) levels, and costs.This retrospective observational record review included a sample of adult patients admitted to four tertiary care hospitals from November 1, 2013 to August 31, 2014. Multivariable logistic and linear regression analyses were used to calculate the odds of adherence to the new ESA inpatient ordering policy and the impact of this policy on discharge Hb level, respectively.A total of 242 patients were included. The majority of the prescribers (77%) adhered to the new ESA ordering policy. Hemoglobin (OR = 1.306; 95% CI: 1.03-1.65) and ferritin (OR = 3.91; 95% CI: 1.23-12.51) levels at admission and length of hospital stay were positively correlated with the odds of patients receiving ESAs after day 5 (OR = 1.12; 95% CI:1.05-1.20). Furthermore, adherence to the new policy did not have a significant impact on discharge Hb level (β = 0.02349; P = 0.895).Prescribers were adherent to a 5-day delay in the initiation of ESA therapy policy which resulted in a reduction in ESA usage, did not impact the discharge Hb levels, and was proven to be cost effective.

BACKGROUND:Bacterial vaginosis (BV) affects a third of women of reproductive age in the US and there is increasing evidence to suggest it may be sexually transmitted. This study aimed to extend and validate the findings of our earlier smaller qualitative study by exploring in detail women's views and experiences of the triggering factors associated with BV onset and recurrence. METHODS:Women aged 20-49, who had experienced one or more symptomatic episode of BV within 6 months, were opportunistically recruited to complete a 38-item questionnaire on their experience of BV. RESULTS:103 women completed the questionnaire. Women were significantly more likely to report sexual than lifestyle factors triggered BV onset and recurrence (p

The breadth of diagnostic procedures that utilize cell free DNA (cfDNA) from human plasma has increased dramatically in recent years. Here, we confirm that tumor-derived cfDNA fragments are similar in size distribution to cfDNA derived from normal tissues. Therefore, collection procedures optimized with healthy donor specimens are likely to be applicable to the diagnosis and monitoring of many different cancer types. We verify that the distribution and DNA sequences of fragmentation sites in cfDNA from both normal-germline and tumor-derived cfDNA are non-random. A broad survey of cfDNA from healthy donors suggests that average individuals possess ~6 ng of cfDNA per mL of plasma. Importantly, the cfDNA present in plasma samples that were initially collected as whole blood in K2-EDTA tubes and subsequently processed by centrifugation is stable for several days at ambient temperatures. This observation has the potential to significantly reduce the cost and logistical complexity of shipping clinical samples from the site of collection to centers proficient in diagnostic analysis. Finally, plasma samples collected with high-volume plasma collection devices possess abundant quantities of cfDNA. Since the quantity of analyzed cfDNA is directly proportional to sensitivity of diagnostic assays, this method of plasma collection, where available, could enable highly sensitive post-treatment disease monitoring and early detection of cancer in at-risk individuals.

Burkholderia pseudomallei, the etiologic agent of melioidosis, is a Gram negative bacterium designated as a Tier 1 threat. This bacterium is known to be endemic in Southeast Asia and Northern Australia and can infect humans and animals by several routes. Inhalational melioidosis has been associated with monsoonal rains in endemic areas and is also a significant concern in the biodefense community. There are currently no effective vaccines for B. pseudomallei and antibiotic treatment can be hampered by non-specific symptomology and also the high rate of naturally occurring antibiotic resistant strains. Well-characterized animal models will be essential when selecting novel medical countermeasures for evaluation prior to human clinical trials. Here, we further characterize differences between the responses of BALB/c and C57BL/6 mice when challenged with low doses of a low-passage and well-defined stock of B. pseudomallei K96243 via either intraperitoneal or aerosol routes of exposure. Before challenge, mice were implanted with a transponder to collect body temperature readings, and daily body weights were also recorded. Mice were euthanized on select days for pathological analyses and determination of the bacterial burden in selected tissues (blood, lungs, liver, and spleen). Additionally, spleen homogenate and sera samples were analyzed to better characterize the host immune response after infection with aerosolized bacteria. These clinical, pathological, and immunological data highlighted and confirmed important similarities and differences between these murine models and exposure routes.

We introduce a novel method called Prophetic Granger Causality (PGC) for inferring gene regulatory networks (GRNs) from protein-level time series data. The method uses an L1-penalized regression adaptation of Granger Causality to model protein levels as a function of time, stimuli, and other perturbations. When combined with a data-independent network prior, the framework outperformed all other methods submitted to the HPN-DREAM 8 breast cancer network inference challenge. Our investigations reveal that PGC provides complementary information to other approaches, raising the performance of ensemble learners, while on its own achieves moderate performance. Thus, PGC serves as a valuable new tool in the bioinformatics toolkit for analyzing temporal datasets. We investigate the general and cell-specific interactions predicted by our method and find several novel interactions, demonstrating the utility of the approach in charting new tumor wiring.

The HIV care cascade is increasingly used to evaluate HIV treatment programs at the population level. However, the cascade indicators lack the ability to show changes over time, which reduces their utility to guide health policy. Alternatives have been proposed but are complex or result in a delay in results. We propose a new indicator of ART uptake, the time from HIV diagnosis to commencement of ART, and compare it to the existing cascade indicator of proportion of patients on treatment and the WHO proposed cohort cascade indicator of proportion of patients on treatment within one year of diagnosis.Records from patients from the two largest HIV treatment centres in the state of Victoria, Australia (Melbourne Sexual Health Centre and The Alfred Hospital Department of Infectious Diseases) from 2011 to 2015 were extracted. The intervals between date of diagnosis, entry into care and initiation of ART were compared.From 2011 to 2015 the proportion of in-care patients who were on ART rose from 87% to 93% (p

Azithromycin is recommended for the treatment of uncomplicated urogenital chlamydia infection although the standard 1gram dose sometimes fails to eradicate the infection (treatment failure). One hypothesis proposed for treatment failure has been insufficient levels of the antibiotic at the site of infection. We developed an assay using liquid chromatography and tandem mass spectrometry (LC-MS/MS) to measure azithromycin concentration in high-vaginal swabs and monitor how concentration changes over time following routine azithromycin treatment.Azithromycin concentrations were measured in two groups of women either within the first 24h of taking a 1g dose (N = 11) or over 9 days (N = 10). Azithromycin concentrations were normalised to an internal standard (leucine enkephalin), and the bulk lipid species phosphatidylcholine [PC(34:1)], using an Agilent 6490 triple quadrupole instrument in positive ionisation mode. The abundances of azithromycin, PC(34:1), and leu-enkephalin were determined by multiple reaction monitoring and absolute levels of azithromycin estimated using standard curves prepared on vaginal specimens.Vaginal azithromycin concentrations of women were rapidly obtained after 5h post-treatment (mean concentration = 1031mcg/mg of lipid, range = 173-2693mcg/mg). In women followed for 9 days, peak concentrations were highest after day 2 (mean concentration = 2206mcg/mg, range = 721-5791mcg/mg), and remained high for at least 9 days with a mean concentration of 384mcg/mg (range = 139-1024mcg/mg) on day 9.Our study confirmed that a single 1g dose of azithromycin is rapidly absorbed and remains in the vagina at relatively high levels for at least a week, suggesting that poor antibiotic absorption is unlikely to be an explanation for treatment failure.

Francisella tularensis, a gram-negative facultative intracellular bacterial pathogen, is the causative agent of tularemia and able to infect many mammalian species, including humans. Because of its ability to cause a lethal infection, low infectious dose, and aerosolizable nature, F. tularensis subspecies tularensis is considered a potential biowarfare agent. Due to its in vitro efficacy, ciprofloxacin is one of the antibiotics recommended for post-exposure prophylaxis of tularemia. In order to identify therapeutics that will be efficacious against infections caused by drug resistant select-agents and to better understand the threat, we sought to characterize an existing ciprofloxacin resistant (CipR) mutant in the Schu S4 strain of F. tularensis by determining its phenotypic characteristics and sequencing the chromosome to identify additional genetic alterations that may have occurred during the selection process. In addition to the previously described genetic alterations, the sequence of the CipR mutant strain revealed several additional mutations. Of particular interest was a frameshift mutation within kdsD which encodes for an enzyme necessary for the production of 3-Deoxy-D-manno-Octulosonic Acid (KDO), an integral component of the lipopolysaccharide (LPS). A kdsD mutant was constructed in the Schu S4 strain. Although it was not resistant to ciprofloxacin, the kdsD mutant shared many phenotypic characteristics with the CipR mutant, including growth defects under different conditions, sensitivity to hydrophobic agents, altered LPS profiles, and attenuation in multiple models of murine tularemia. This study demonstrates that the KdsD enzyme is essential for Francisella virulence and may be an attractive therapeutic target for developing novel medical countermeasures.

To examine the influence of sexual activity on the composition and consistency of the vaginal microbiota over time, and distribution of Gardnerella vaginalis clades in young women.Fifty-two participants from a university cohort were selected. Vaginal swabs were self-collected every 3-months for up to 12 months with 184 specimens analysed. The vaginal microbiota was characterised using Roche 454 V3/4 region 16S rRNA sequencing, and G.vaginalis clade typing by qPCR.A Lactobacillus crispatus dominated vaginal microbiota was associated with Caucasian ethnicity (adjusted relative risk ratio[ARRR] = 7.28, 95%CI:1.37,38.57,p = 0.020). An L.iners (ARRR = 17.51, 95%CI:2.18,140.33,p = 0.007) or G.vaginalis (ARRR = 14.03, 95%CI:1.22,160.69, p = 0.034) dominated microbiota was associated with engaging in penile-vaginal sex. Microbiota dominated by L.crispatus, L.iners or other lactobacilli exhibited greater longitudinal consistency of the bacterial communities present compared to ones dominated by heterogeneous non-lactobacilli (p

Acute traumatic coagulopathy has been associated with shock and tissue injury, and may be mediated via activation of the protein C pathway. Patients with acute traumatic coagulopathy have prolonged PT and PTT, and decreased activity of factors V and VIII; they are also hypocoagulable by thromboelastometry (ROTEM) and other viscoelastic assays. To test the etiology of this phenomenon, we hypothesized that such coagulopathy could be induced in vitro in healthy human blood with the addition of activated protein C (aPC).Whole blood was collected from 20 healthy human subjects, and was "spiked" with increasing concentrations of purified human aPC (control, 75, 300, 2000 ng/mL). PT/PTT, factor activity assays, and ROTEM were performed on each sample. Mixed effect regression modeling was performed to assess the association of aPC concentration with PT/PTT, factor activity, and ROTEM parameters.In all subjects, increasing concentrations of aPC produced ROTEM tracings consistent with traumatic coagulopathy. ROTEM EXTEM parameters differed significantly by aPC concentration, with stepwise prolongation of clotting time (CT) and clot formation time (CFT), decreased alpha angle (α), impaired early clot formation (a10 and a20), and reduced maximum clot firmness (MCF). PT and PTT were significantly prolonged at higher aPC concentrations, with corresponding significant decreases in factor V and VIII activity.A phenotype of acute traumatic coagulopathy can be induced in healthy blood by the in vitro addition of aPC alone, as evidenced by viscoelastic measures and confirmed by conventional coagulation assays and factor activity. This may lend further mechanistic insight to the etiology of coagulation abnormalities in trauma, supporting the central role of the protein C pathway. Our findings also represent a model for future investigations in the diagnosis and treatment of acute traumatic coagulopathy.

Tissue engineered vascular grafts (TEVGs) have the potential to overcome the issues faced by existing small diameter prosthetic grafts by providing a biodegradable scaffold where the patient's own cells can engraft and form functional neotissue. However, applying classical approaches to create arterial TEVGs using slow degrading materials with supraphysiological mechanical properties, typically results in limited host cell infiltration, poor remodeling, stenosis, and calcification. The purpose of this study is to evaluate the feasibility of novel small diameter arterial TEVGs created using fast degrading material. A 1.0mm and 5.0mm diameter TEVGs were fabricated with electrospun polycaprolactone (PCL) and chitosan (CS) blend nanofibers. The 1.0mm TEVGs were implanted in mice (n = 3) as an unseeded infrarenal abdominal aorta interposition conduit., The 5.0mm TEVGs were implanted in sheep (n = 6) as an unseeded carotid artery (CA) interposition conduit. Mice were followed with ultrasound and sacrificed at 6 months. All 1.0mm TEVGs remained patent without evidence of thrombosis or aneurysm formation. Based on small animal outcomes, sheep were followed with ultrasound and sacrificed at 6 months for histological and mechanical analysis. There was no aneurysm formation or calcification in the TEVGs. 4 out of 6 grafts (67%) were patent. After 6 months in vivo, 9.1 ± 5.4% remained of the original scaffold. Histological analysis of patent grafts demonstrated deposition of extracellular matrix constituents including elastin and collagen production, as well as endothelialization and organized contractile smooth muscle cells, similar to that of native CA. The mechanical properties of TEVGs were comparable to native CA. There was a significant positive correlation between TEVG wall thickness and CD68+ macrophage infiltration into the scaffold (R2 = 0.95, p = 0.001). The fast degradation of CS in our novel TEVG promoted excellent cellular infiltration and neotissue formation without calcification or aneurysm. Modulating host macrophage infiltration into the scaffold is a key to reducing excessive neotissue formation and stenosis.

BACKGROUND:The pharynx is a common site of gonorrhoea among men who have sex with men (MSM) and may serve as a reservoir for infection, with saliva implicated in transmission possibly through oral sex, kissing, and rimming. Reducing sexual activities involving saliva may reduce pharyngeal gonorrhoea. This study aimed to explore MSM's views and knowledge of pharyngeal gonorrhoea and their willingness to change saliva transmitting sexual practices. MSM were also asked their views on using alcohol-containing mouthwash to potentially reduce transmission. METHODS:Using a qualitative descriptive approach, 30 MSM who were part of a larger study (GONE) conducted at the Melbourne Sexual Health Centre agreed to take part in semi-structured interviews between 14th May and 8th September 2015. The 10 interviews conducted face to face and 20 by telephone, lasted between 20-45 minutes. Data were analysed using qualitative content analysis. RESULTS:Most men considered pharyngeal gonorrhoea to be a non-serious sexually transmitted infection and attributed transmission primarily to oral sex. Almost all men reported they would not stop kissing, oral sex, or consider using condoms for oral sex to reduce their risk of pharyngeal gonorrhoea. Kissing and oral sex were commonly practised and considered enjoyable low risk sexual activities. Men were more likely to consider stopping sexual activities they did not enjoy or practice often, in particular insertive rimming. If proven effective, the majority of men reported they would use alcohol-containing mouthwash to reduce or prevent their risk of pharyngeal gonorrhoea. CONCLUSION:Findings from this study suggest MSM are unlikely to stop saliva transmitting sexual practices they enjoy and consider low risk. Men would, however, consider using alcohol-containing mouthwash if found to be effective, highlighting the importance of exploring innovative strategies to reduce pharyngeal gonorrhoea.