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Abstract Background In the United States (US), hepatitis C virus (HCV) screening is not covered by payers in settings outside of primary care. A non-traditional, emergency department (ED)-based HCV screening program can be cost-effective and identify infection in vulnerable populations with a high HCV risk. This study examined the long-term cost-effectiveness of routine HCV screening and linkage-to-care for high-risk patients in the ED from the payer’s perspective. Methods The University of Illinois Hospital and Health Sciences System (UIH) implemented Project HEAL (HIV & HCV Screening, Education, Awareness, Linkage-to-Care). Under this initiative, patients who presented to the ED received opt-out HCV screening if they were at high risk for HCV infection (birth cohort between 1945 and 1964, persons who inject drugs, and HIV infection) with subsequent linkage-to-care if infected. Using the summary data from Project HEAL, a hybrid decision-analytic Markov model was developed based on the HCV screening procedure in the ED and the natural history of HCV. A 30-year time horizon and 1-year cycle length were used. All patients who received the ED-based HCV screening were referred for treatment with direct-acting antiviral (DAA) regardless of their fibrosis stage. Results When unscreened/untreated patients received DAA treatment at F1, F2, F3, and compensated cirrhosis stages, the incremental cost-effectiveness ratio (ICER) ranged from $6,084 to $77,063 per quality-adjusted life year (QALY) gained. When unscreened/untreated patients received DAA treatment at the decompensated cirrhosis stage, no HCV screening was dominated. Conclusion ED-based HCV screening and linkage-to-care was cost-effective at the willingness-to-pay (WTP) threshold of $100,000/QALY in all scenarios. A reduction in infected persons in the community may provide additional benefits not evaluated in this study.

Abstract Autoimmune diseases such as systemic lupus erythematosus (SLE) display a strong female bias. Although sex hormones have been associated with protecting males from autoimmunity, the molecular mechanisms are incompletely understood. Here we report that androgen receptor (AR) expressed in T cells regulates genes involved in T cell activation directly, or indirectly via controlling other transcription factors. T cell-specific deletion of AR in mice leads to T cell activation and enhanced autoimmunity in male mice. Mechanistically, Ptpn22, a phosphatase and negative regulator of T cell receptor signaling, is downregulated in AR-deficient T cells. Moreover, a conserved androgen-response element is found in the regulatory region of Ptpn22 gene, and the mutation of this transcription element in non-obese diabetic mice increases the incidence of spontaneous and inducible diabetes in male mice. Lastly, Ptpn22 deficiency increases the disease severity of male mice in a mouse model of SLE. Our results thus implicate AR-regulated genes such as PTPN22 as potential therapeutic targets for autoimmune diseases.

Abstract Microglia play a crucial role in synaptic elimination by engulfing dystrophic neurons via triggering receptors expressed on myeloid cells 2 (TREM2). They are also involved in the clearance of beta‐amyloid (Aβ) plaques in Alzheimer's disease (AD); nonetheless, the driving force behind TREM2‐mediated phagocytosis of beta‐amyloid (Aβ) plaques remains unknown. Here, using advanced 2D/3D/4D co‐culture systems with loss‐of‐function mutations in TREM2 (a frameshift mutation engineered in exon 2) brain organoids/microglia/assembloids, it is identified that the clearance of Aβ via TREM2 is accelerated by externalized phosphatidylserine (ePtdSer) generated from dystrophic neurons surrounding the Aβ plaques. Moreover, it is investigated whether microglia from both sporadic (CRISPR‐Cas9‐based APOE4 lines) and familial (APPNL‐G‐F/MAPT double knock‐in mice) AD models show reduced levels of TREM2 and lack of phagocytic activity toward ePtdSer‐positive Aβ plaques. Herein new insight is provided into TREM2‐dependent microglial phagocytosis of Aβ plaques in the context of the presence of ePtdSer during AD progression.

Abstract Background Cerebral organoids (COs) are the most advanced in vitro models that resemble the human brain. The use of COs as a model for Alzheimer’s disease (AD), as well as other brain diseases, has recently gained attention. This study aimed to develop a human AD CO model using normal human pluripotent stem cells (hPSCs) that recapitulates the pathological phenotypes of AD and to determine the usefulness of this model for drug screening. Methods We established AD hPSC lines from normal hPSCs by introducing genes that harbor familial AD mutations, and the COs were generated using these hPSC lines. The pathological features of AD, including extensive amyloid-β (Aβ) accumulation, tauopathy, and neurodegeneration, were analyzed using enzyme-linked immunosorbent assay, Amylo-Glo staining, thioflavin-S staining, immunohistochemistry, Bielschowsky’s staining, and western blot analysis. Results The AD COs exhibited extensive Aβ accumulation. The levels of paired helical filament tau and neurofibrillary tangle-like silver deposits were highly increased in the AD COs. The number of cells immunoreactive for cleaved caspase-3 was significantly increased in the AD COs. In addition, treatment of AD COs with BACE1 inhibitor IV, a β-secretase inhibitor, and compound E, a γ-secretase inhibitor, significantly attenuated the AD pathological features. Conclusion Our model effectively recapitulates AD pathology. Hence, it is a valuable platform for understanding the mechanisms underlying AD pathogenesis and can be used to test the efficacy of anti-AD drugs.

BackgroundDiets rich in minimally processed plant-based foods are recommended to breast cancer patients, and some may have an interest in whole-food, plant-based (WFPB) diets that avoid animal-based foods, added fats, and refined sugars. Within WFPB diets, the intakes of isoflavones, omega-6 polyunsaturated fatty acids (n-6 PUFAs), and omega-3 polyunsaturated FAs (n-3 PUFAs), which have been discussed in reference to breast cancer outcomes, have not been well characterized.MethodsWomen with stage IV breast cancer on stable therapy were randomized 2:1 into (1) a WFPB intervention (N = 21) or (2) usual care (N = 11) for 8 weeks. Three meals per day were provided. Outcomes presented here include dietary intake of isoflavones, n-3 and n-6- PUFAs, which were assessed using three-day food records at baseline and 8 weeks. Baseline and 8-week mean intake within groups were compared using the Wilcoxon signed-rank test and between control and intervention groups by a two-sample t-test.ResultsThe WFPB intervention participants increased their daily consumption of total isoflavones from a mean of 0.8 mg/day to 14.5 mg/day (p

This research analyzed the mechanisms of work and modified a colorimetric nanosensor to make it more cost-effective for the detection of Escherichia coli (E. coli) in water. The base nanosensors modified herein rely on a competitive binding detection mechanism, where positively charged gold nanoparticles coated with polyethyleneimine (PEI-AuNPs) preferably bind to negatively charged E. coli in the presence of β-galactosidase (β-Gal) enzymes and chlorophenol red β-d-galactopyranosides (CPRG). The positive surface charge of the nanoparticle, rather than nanoparticle composition or type of chemical coating on its surface, was hypothesized herein as the governing factor for the nanosensor functionality. Thus, positively charged nanoparticles and polymers were tested as potential alternatives for gold nanoparticles for detecting E. coli. Positively charged silver and iron oxide nanoparticles coated with branched PEI detected E. coli as low as 105 and 107 colony-forming units per milliliter (CFU/mL), respectively. Furthermore, the branched PEI polymer itself (without nanomaterial) detected E. coli at 107 CFU/mL. These findings suggest that the positive charge, rather than the nanoparticle type was likely responsible for the detection of E. coli using the competitive binding approach. Therefore, other types of recyclable and cost-effective nanomaterials and polymers can be developed for E. coli detection using this rapid colorimetric sensing technique.

Dobutamine is a weak beta-1 and a potent beta-2 adrenergic agonist commonly used to treat patients in cardiogenic shock. It enhances myocardial contractibility, increasing cardiac output. Myoclonus in patients receiving an infusion of dobutamine is rare and, although not fully understood, seems more common in patients with severe kidney failure. To our knowledge, this is the first reported case of dobutamine-induced myoclonus in a patient with kidney failure receiving peritoneal dialysis. Only 7% of the 518,749 patients of the United States requiring kidney replacement therapy receive peritoneal dialysis, with only a small unknown number of those with advanced heart failure manage with an infusion of inotropic medication. The low prevalence of combined advanced heart failure and kidney failure could partly explain this condition’s rarity. In this study, we report the case of a 64-year-old woman with kidney failure receiving peritoneal dialysis in whom myoclonus developed 3 weeks after starting a dobutamine infusion for advanced refractory heart failure. Infectious and other pharmacologic causes of myoclonus were ruled out. Initially, uremia was suspected; however, despite increasing her peritoneal dialysis dose, it was only after discontinuing the dobutamine infusion that her myoclonus resolved.

Despite recent advancements in our understanding of genetic etiology and its molecular and physiological consequences, it is not yet clear what genetic features determine the inheritance pattern of a disease. To address this issue, we conducted whole exome sequencing analysis to characterize genetic variants in 1,180 Korean patients with neurological symptoms. The diagnostic yield for definitive pathogenic variant findings was 50.8%, after including 33 cases (5.9%) additionally diagnosed by reanalysis. Of diagnosed patients, 33.4% carried inherited variants. At the genetic level, autosomal recessive-inherited genes were characterized by enrichments in metabolic process, muscle organization and metal ion homeostasis pathways. Transcriptome and interactome profiling analyses revealed less brain-centered expression and fewer protein-protein interactions for recessive genes. The majority of autosomal recessive genes were more tolerant of variation, and functional prediction scores of recessively-inherited variants tended to be lower than those of dominantly-inherited variants. Additionally, we were able to predict the rates of carriers for recessive variants. Our results showed that genes responsible for neurodevelopmental disorders harbor different molecular mechanisms and expression patterns according to their inheritance patterns. Also, calculated frequency rates for recessive variants could be utilized to pre-screen rare neurodevelopmental disorder carriers.

Abstract The inferior vena cava (IVC) is the largest vein in the body, draining blood from the abdomen, pelvis and lower extremities. This pictorial review summarises normal anatomy and embryological development of the IVC. In addition, we highlight a wide range of anatomical variants, acquired pathologies and a common pitfall in imaging of the IVC. This information is essential for clinical decision making and to reduce misdiagnosis.

Background: The longitudinal response to the COVID-19 vaccines among patients on hemodialysis with and without prior SARS-CoV-2 infection has not been well characterized. Methods: To guide vaccination strategies in patients on hemodialysis, it is critical to characterize the longevity and efficacy of the vaccine; therefore, we conducted a prospective single-center monthly antibody surveillance study between March 2021 and March 2022 to investigate the dynamic humoral response to a series of COVID-19 mRNA vaccines in patients on hemodialysis with and without prior SARS-CoV-2 infection. Monthly quantitative antibody testing was performed using the Beckman Coulter Access SARS-CoV-2 IgG Antibody Test©, which detects IgG antibodies targeting the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. Results: This cohort of 30 participants (mean age: 61 ± 3 years) predominantly self-identified as African American (97%) and male (53%). Eight participants (27%) had recovered from COVID-19 (recovered) before the vaccine initiation. All participants received two vaccine doses, and 86.6% received a 6-month booster dose. Among patients naïve to COVID-19, the antibody positivity rate (APR) was 55% post-first-dose, 91% post-second-dose, 50% pre-booster at 6 months, 100% post-booster, and 89% at 6 months post-booster. Recovered patients sustained a consistent 100% APR throughout the year. The naïve patients demonstrated lower peak antibody levels post-second-dose than the recovered patients (17.9 ± 3.2 vs. 44.7 ± 5.6, p < 0.001). The peak antibody levels post-booster showed no significant difference between both groups (27.1 ± 3.9 vs. 37.9 ± 8.2, p = 0.20). Two naïve patients contracted COVID-19 during the follow-up period. Conclusions: The patients naïve to COVID-19 exhibited an attenuated and foreshortened antibody response following two doses of the mRNA vaccines compared with the recovered patients, who maintained 100% APR before the booster dose. The 6-month booster dose counteracted declining immunity and stimulated antibody responses in the naïve patients, even in previously non-responsive patients. This observation implies that different booster vaccination strategies might be required for COVID-19-naïve and -recovered patients. Post-vaccination antibody testing may serve as a valuable tool for guiding vaccination strategies.

Introduction: There is an unmet medical need for pruritus associated with chronic kidney disease, a distressing complication characterized by generalized and persistent itch affecting 20% to 40% of patients undergoing hemodialysis. Here we report the results of a phase 2 trial evaluating the efficacy and safety of a novel peripherally restricted kappa opioid receptor agonist, difelikefalin, in adult patients undergoing hemodialysis with pruritus. Methods: In this study, 174 hemodialysis patients with moderate-to-severe pruritus were randomly assigned to receive difelikefalin (0.5, 1.0, or 1.5 μg/kg) or placebo intravenously thrice weekly after each hemodialysis session for 8 weeks in a double-blind, controlled trial. The primary endpoint was the change from baseline at week 8 in the weekly mean of the 24-hour Worst Itching Intensity Numerical Rating Scale score. The secondary efficacy endpoint was the change in itch-related quality of life measured by the Skindex-10 questionnaire. Other endpoints included safety, sleep quality, and additional measures including the 5-D itch scale. Results: A significant reduction from baseline in itch intensity scores at week 8 favored all difelikefalin doses combined versus placebo (P = 0.002). Difelikefalin also showed improvement over placebo in Skindex-10, 5-D itch, and sleep disturbance scores (P ≤ 0.005). Overall, 78% of patients receiving difelikefalin reported treatment-emergent adverse events versus 42% of patients given placebo, with diarrhea, dizziness, nausea, somnolence, and fall being the most frequent (≥5%). Conclusion: In this trial, difelikefalin effectively reduced itching intensity and improved sleep and itch-related quality of life. Keywords: chronic kidney disease, CKD-aP, CR845, hemodialysis, kappa opioid receptor agonist, uremic pruritus

Summary: A skewed tryptophan metabolism has been reported in patients with lupus. Here, we investigated the mechanisms by which it occurs in lupus-susceptible mice, and how tryptophan metabolites exacerbate T cell activation. Metabolomic analyses demonstrated that tryptophan is differentially catabolized in lupus mice compared to controls and that the microbiota played a role in this skewing. There was no evidence for differential expression of tryptophan catabolic enzymes in lupus mice, further supporting a major contribution of the microbiota to skewing. However, isolated lupus T cells processed tryptophan differently, suggesting a contribution of T cell intrinsic factors. Functionally, tryptophan and its microbial product tryptamine increased T cell metabolism and mTOR activation, while kynurenine promoted interferon gamma production, all of which have been associated with lupus. These results showed that a combination of microbial and T cell intrinsic factors promotes the production of tryptophan metabolites that enhance inflammatory phenotypes in lupus T cells.

Recent attention on ChatGPT, a prominent AI language model, highlights its potential in assisting EFL writing. Although ChatGPT's capabilities involve grammar correction, vocabulary enrichment and sentence structuring, its full potential alongside human scaffolding in EFL writing classrooms remains unexplored. This study aims to fill this gap by adopting the cognitive process model of writing as a theoretical framework. Four groups of 19 EFL learners were engaged in think-aloud sessions and interviews. The collaborative writing process with ChatGPT progressed through iterative stages of planning, translating, and reviewing, incorporating various embedded subprocesses. Guidance from the teacher and collaborative work among peers facilitated the effective use of ChatGPT for writing refinement by creating an environment of emotional reassurance and enhancing metacognitive awareness among the learners. The findings emphasise the importance of collaborative work, orchestrated by the teacher and peers in using ChatGPT in the EFL writing class.

OBJECTIVES/GOALS: To develop a two-staged convolutional neural network to identify the ovary and antral follicles within ovarian ultrasound images and determine its reliability and feasibility compared to conventional techniques in 2D and 3D ultrasonography image analysis. METHODS/STUDY POPULATION: De-identified and archived ultrasonographic images of women across the reproductive spectrum (N=500) will be used in the study. These ultrasound images will be labeled by experienced raters to train a two-staged convolutional neural network (CU-Net). CU-Net will first separate the entire ovary from the background and subsequently identify all antral follicles within the ovary. Following training, the CU-Net will evaluate a second set of independent images (N=100) to determine performance accuracy. Three specialized raters will establish the reliability and feasibility of CU-Net compared to conventional 2D and 3D ovarian ultrasound image analysis methods. RESULTS/ANTICIPATED RESULTS: The labeled training dataset of ovarian ultrasound images is expected to successfully train the CU-Net and allow for accurate identification of the ovary and the total number of antral follicles in the second testing set of ultrasound images. When compared to conventional 2D and 3D ultrasound image analysis methods, CU-Net is expected to have similar accuracy when compared to the gold-standard method (2D-Offline with Grid) and outperform other approaches, such as 2D-Real Time and 3D volume software (VOCAL and Sono-AVC). However, CU-Net is anticipated to be the fastest and most reliable method across users, supporting its clinical feasibility. DISCUSSION/SIGNIFICANCE: This study will immediately translate to providing a standardized platform that can improve the accuracy, reliability, and time demand required for the evaluation of ovarian ultrasounds across users and clinical and research settings.

Introduction Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit (ICU). Probiotics are defined as live microorganisms that may confer health benefits when ingested. Prior randomised trials suggest that probiotics may prevent infections such as VAP and Clostridioides difficile–associated diarrhoea (CDAD). PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial) is a multicentre, double-blinded, randomised controlled trial comparing the efficacy of the probiotic Lactobacillus rhamnosus GG with usual care versus usual care without probiotics in preventing VAP and other clinically important outcomes in critically ill patients admitted to the ICU.Methods and analysis The objective of E-PROSPECT is to determine the incremental cost-effectiveness of L. rhamnosus GG plus usual care versus usual care without probiotics in critically ill patients. E-PROSPECT will be performed from the public healthcare payer’s perspective over a time horizon from ICU admission to hospital discharge.We will determine probabilities of in-ICU and in-hospital events from all patients alongside PROSPECT. We will retrieve unit costs for each resource use item using jurisdiction-specific public databases, supplemented by individual site unit costs if such databases are unavailable. Direct costs will include medications, personnel costs, radiology/laboratory testing, operative/non-operative procedures and per-day hospital ‘hoteling’ costs not otherwise encompassed. The primary outcome is the incremental cost per VAP prevented between the two treatment groups. Other clinical events such as CDAD, antibiotic-associated diarrhoea and in-hospital mortality will be included as secondary outcomes. We will perform pre-specified subgroup analyses (medical/surgical/trauma; age; frailty status; antibiotic use; prevalent vs no prevalent pneumonia) and probabilistic sensitivity analyses for VAP, then generate confidence intervals using the non-parametric bootstrapping approach.Ethics and dissemination Study approval for E-PROSPECT was granted by the Hamilton Integrated Research Ethics Board of McMaster University on 29 July 2019. Informed consent was obtained from the patient or substitute decision-maker in PROSPECT. The findings of this study will be published in peer-reviewed journals.Trial registration number NCT01782755; Pre-results.

The implications of germline de novo variants (DNVs) in diseases are well documented. Despite extensive research, inconsistencies between studies remain a challenge, and the distribution and genetic characteristics of DNVs need to be precisely evaluated. To address this issue at the whole-genome scale, a large number of DNVs identified from the whole-genome sequencing of 1,902 healthy trios (i.e., parents and progeny) from the Simons Foundation for Autism Research Initiative study and 20 healthy Korean trios were analyzed. These apparently nonpathogenic DNVs were enriched in functional elements of the genome but relatively depleted in regions of common copy number variants, implying their potential function as triggers of evolution even in healthy groups. No strong mutational hotspots were identified. The pathogenicity of the DNVs was not strongly elevated, reflecting the health status of the cohort. The mutational signatures were consistent with previous studies. This study will serve as a reference for future DNV studies.

Federal land managers in the United States are tasked with managing a vast array of resources for current and future generations. However, coordinating action among multiple stakeholders across diverse landscapes is challenging given that the organizations and institutions set up to govern federal lands are often unable to overcome scale-related challenges. Unconventional oil and gas development is often a contentious issue on federal lands. Identifying how to bridge scale mismatches in this sector is critical for achieving management objectives. To gain a deeper understanding of the institutional landscape governing oil and gas, we took an in-depth case study approach and examined a case in the western United States where communities worked with federal land managers to cancel 25 existing oil and gas leases. We identified the most relevant scale mismatches pertaining to unconventional oil and gas development and assessed the role of community-based organizations in bridging scale mismatches to increase institutional fit. Our results demonstrate the importance of community-based organizations that can function as bridging organizations to engage a broad set of actors across scales. Our results also highlight the importance of creating shared visions across diverse stakeholder groups to foster collaboration. We conclude that overcoming scale mismatches requires a focus on shared values and the creation and maintenance of flexible governance networks.

There are limited approaches available that enable researchers and practitioners to conduct multiple case study comparisons of complex cases of collaboration in natural resource management and conservation. The absence of such tools is felt despite the fact that over the past several years a great deal of literature has reviewed the state of the science regarding collaboration. Much of this work is based on case studies of collaboration and highlights the importance of contextual variables, further complicating efforts to compare outcomes across case-study areas and the likely failure of approaches based on one size fits all generalizations. We expand on the standard overview of the field by identifying some of the challenges associated with managing complex systems with multiple resources, multiple stakeholder groups with diverse knowledges/understandings, and multiple objectives across multiple scales, i.e., multifaceted collaborative initiatives. We then elucidate how a realist methodology, within a critical realist framing, can support efforts to compare multiple case studies of such multifaceted initiatives. The methodology we propose considers the importance and impact of context for the origins, purpose, and success of multifaceted collaborative natural resource management and conservation initiatives in social-ecological systems.