Search

Autistic people experience significant health disparities and reduced life expectancy. Barriers to accessing healthcare are associated with adverse health outcomes. Autism training and healthcare professionals' knowledge about autism is variable, and heterogeneity among autistic people leads to additional educational and clinical complexities. Autism remains nebulous for many practitioners, who are unclear about communication differences, access needs or life experiences common to autistic people. Healthcare environments can be challenging for all patients but autistic people may require specific accommodations to allow equitable access. The authors have developed a simple framework which may facilitate equitable clinical services at all points of access and care, using the acronym ‘SPACE’. This encompasses five core autistic needs: Sensory needs, Predictability, Acceptance, Communication and Empathy. Three additional domains are represented by physical space, processing space and emotional space. This simple yet memorable framework encompasses commonalities shared by autistic people.

The Lancet Commission on the Future of Care and Clinical Research in Autism recently published their recommendations for what should be done in the next 5 years to address the current needs of autistic individuals and families. Although the Commission includes many prominent clinicians and researchers from around the world, as well as some autistic advocates and parents of autistic people, there have been widespread expressions of dissatisfaction among autistic people and communities regarding these recommendations.\ud \ud We, the Global Autistic Task Force on Autism Research are a group of autistic professionals and representatives of organizations run by and for autistic people. We are autistic clinicians, therapists, educators and researchers, parents, and family members of autistic people of all ages and with all types of support needs, as well as individuals with high support needs. Among us are also autistic people of color, autistic people from the Global South and Asia, autistic women, and autistic people belonging to gender minorities.\ud \ud Despite aiming at bringing together different stakeholders, representation within the Lancet Commission was limited in these respects. We hope to bring more voices to the discourse. We previously wrote an open letter to the Commission to draw attention to our main concerns. In this editorial, we offer a more detailed discussion of the Commission's report, as well as our own recommendations for future directions in autism research and care.

The list of talks, speaker names, and their affiliations.

Recognition of autism and the associated co-occurring physical and mental health issues has increased over recent years. However, undergraduate and postgraduate curricula take time to adapt and to impact on what is delivered in training so healthcare professionals, including doctors, report little training on these topics. Doctors need to know when someone might be autistic in order to respond to them appropriately. This article sets out the reasons why recognition of autism is important and the positive impacts of recognising and understanding autism on health outcomes, service delivery and patient experience. The negative consequences of not recognising autism or understanding the impact of autistic traits on the person are also explored. A companion article then covers how practice can be made more appropriate for autistic people to improve outcomes.

Rates of autism diagnosis have increased over the past 20 years,1 reflecting increased awareness and recognition both by patients and by GPs. Indeed, many GPs are discovering autistic traits in themselves2 mirroring the shift towards increased diagnosis among those without co-occurring intellectual disability. While a fall in referrals for autism assessment occurred early in the pandemic, high profile celebrity revelations, media coverage, and perhaps the pandemic itself, continue to track with climbing numbers of referrals (Table 1).3 In fact, the number of referrals in the first quarter of 2021/2022 were more than double that of the corresponding period in 2019/2020.

Autistic psychiatrists bring strengths and values to the workforce and ask to be acknowledged and supported as part of the Royal College of Psychiatrists' CIRCLE values and

To assess the acute toxicity and quality of life (QOL) of hypofractionation compared with conventional fractionation for whole breast irradiation (WBI) after breast-conserving surgery.Women with node-negative breast cancer who had undergone breast-conserving surgery with clear margins were randomly assigned to conventional WBI of 5000 cGy in 25 fractions over 35 days or hypofractionated WBI of 4256 cGy in 16 fractions over 22 days. Acute skin toxicity and QOL were assessed at baseline and 2, 4, 6, and 8 weeks from the start of treatment for a subgroup of patients. QOL was assessed at baseline and 4 weeks posttreatment for all patients. In the acute toxicity substudy, repeated measures modeling was used to investigate treatment by time interactions over the 8-week period for acute toxicity and QOL mean change score. QOL mean change score from baseline to 4 weeks posttreatment was compared for all patients.In the acute toxicity substudy, 161 patients participated. In the main trial, 1152 patients participated. Acute skin toxicity was initially similar between groups but was less with hypofractionation compared with conventional fractionation toward the end of the 8-week period (P.001). QOL at 6 weeks from the start of treatment was improved with hypofractionation for the skin side effects, breast side effects, fatigue, attractiveness, and convenience domains (all P.05). In the main trial, hypofractionation resulted in improved overall QOL and QOL attributed to skin side effects, breast side effects, and attractiveness (all P.01).Hypofractionated WBI compared with conventional WBI resulted in less acute toxicity and improved QOL. This further supports the benefits of hypofractionation.

Patients with anal squamous cell carcinoma (SCC) are treated with sphincter-preserving radiation therapy and concurrent chemotherapy, achieving excellent oncologic outcomes. Patients, however, may experience treatment-related morbidity including sexual dysfunction. The objective of this systematic review was to review the literature on sexual dysfunction in female patients treated for anal cancer and to identify knowledge gaps.This systematic review was registered in PROSPERO prior to initiation. Databases searched included MEDLINE, Embase, PubMed, Cochrane, and Google Scholar. There were no restrictions on the study time period. Studies were limited to English. All study designs were included except review articles, letters to the editor, and case reports with less than ten patients.In total, 1801 studies were retrieved and 19 met the inclusion criteria, including: 13 cross-sectional surveys, 3 prospective studies, 1 longitudinal intervention study, 1 retrospective chart review, 1 case control study. Sexual function was assessed using the female sexual functioning index (FSFI), EORTC-QLQ-CR30 and -CR38; response rates were low (50 % in most studies). Sexual dysfunction was reported by up to 85 % of women; the most common symptoms being dyspareunia (17-65 %), vaginal dryness (22-88 %), and loss of libido (38-95 %). Gastrointestinal issues, such as bowel problems, and body image concerns additionally affected sexual function and quality of life.Sexual dysfunction is a common issue affecting most female patients treated for anal cancer and there is a paucity of evidence on the management of this important survivorship issue. There is additionally a lack of ethnic, economic, and educational diversity and there are no studies addressing the unique needs of LGBTQ individuals - future studies should make a concerted effort to include a diverse patient population.

BACKGROUND There is little evidence to guide management of patients with acute leukemia and intracranial hemorrhage (ICH). Predictors of long-term outcome following ICH are unknown. STUDY DESIGN AND METHODS This study included adult patients with acute leukemia and ICH over an 8-year period. The primary outcome was data regarding 90-day mortality. Secondary outcomes included data related to the proportion of patients receiving post-remission therapy and predictors of 90-day mortality. RESULTS ICH occurred in 101 patients; 12 patients died within 72 hours. For the 89 others, 90-day mortality was 40%. Of 43 patients who received induction, 30 achieved remission and 26 received post-remission therapy. Older age (p = 0.03) and higher white count (p = 0.02) at the time of ICH were predictive of inferior survival. During 90-day follow-up, median platelet count was 37 x 109 /L (0-1526 x 109 /L). Lower platelet count during follow-up was predictive of 90-day mortality (p =

AimsWe aim to raise awareness of the existence and value of autistic doctors in psychiatry and to also signpost psychiatrists who are or suspect they might be autistic towards peer support.MethodAutism refers to a lifelong difference in how people communicate and interact with the world. These differences lead to strengths and challenges with individual profiles which include special interests, hyper-focus, and often sensory differences and anxiety. Autism has an estimated prevalence of 1-2%, which is likely an underestimate. It was noted that there was little in the way of advocacy for autistic doctors around the world. Anecdotal evidence also suggested possible issues of misunderstanding and stigmatisation of autistic doctors. As such, there was a need to tackle this to promote positive change. MD founded the group Autistic Doctors International (ADI) in 2019 to foster camaraderie, advocacy and support. ADI has flourished with 250+ members currently. In a recent member poll, 24 of 180 respondents identified themselves as psychiatrists – second only to general practice (n = 54). Several other consultant psychiatrists are known to self-identify as autistic but have not formally joined due to the fear of disclosure. The group has additionally supported multiple doctors to tackle prejudice and discrimination in the workplace / training environment. It has also brought together autistic doctors with academic interests and has generated multiple academic outputs in the form of publications, research grants and conference posters/papers regarding autism.ResultPsychiatrists, and doctors in general, are a self-selecting group for many autistic strengths such as hyper-focus, curiosity, self-motivation, a desire to study social communication, attention to detail, pattern recognition, problem solving and empathy, which, contrary to prevailing stereotypes, can be marked in autism. The increasing numbers of doctors joining ADI supports the assumption that autistic individuals are safe and effective clinicians. It is worth noting that many members are not ‘doctors in difficulty’. Those who have been able to achieve suitable accommodations, often without realising why they were needed, have flourished. Such accommodations and outcomes are in line with the neurodiversity movement, which promotes a view of autism as difference, rather than pure disability or disorder. This aims to challenge stereotypes and the tragedy narrative surrounding autism.ConclusionAutism awareness is increasing amongst doctors but more open discussion is still needed in order to facilitate appropriate peer and workplace support. This is likely to improve mental wellbeing and resilience for autistic psychiatrists.

BackgroundThe global COVID-19 pandemic has had an unprecedented impact on European health and social care systems, with demands on testing, hospital and intensive care capacity exceeding available resources in many regions. This has led to concerns that some vulnerable groups, including autistic people, may be excluded from services.MethodsWe reviewed policies from 15 European member states, published in March–July 2020, pertaining to (1) access to COVID-19 tests; (2) provisions for treatment, hospitalisation and intensive care units (ICUs); and (3) changes to standard health and social care. In parallel, we analysed survey data on the lived experiences of 1301 autistic people and caregivers.ResultsAutistic people experienced significant barriers when accessing COVID-19 services. First, despite being at elevated risk of severe illness due to co-occurring health conditions, there was a lack of accessibility of COVID-19 testing. Second, many COVID-19 outpatient and inpatient treatment services were reported to be inaccessible, predominantly resulting from individual differences in communication needs. Third, ICU triage protocols in many European countries (directly or indirectly) resulted in discriminatory exclusion from lifesaving treatments. Finally, interruptions to standard health and social care left over 70% of autistic people without everyday support.ConclusionsThe COVID-19 pandemic has further exacerbated existing healthcare inequalities for autistic people, probably contributing to disproportionate increases in morbidity and mortality, mental health and behavioural difficulties, and reduced quality of life. An urgent need exists for policies and guidelines on accessibility of COVID-19 services to be updated to prevent the widespread exclusion of autistic people from services, which represents a violation of international human rights law.

ObjectivesAutistic people experience poor physical and mental health along with reduced life expectancy compared with non-autistic people. Our aim was to identify self-reported barriers to primary care access by autistic adults compared with non-autistic adults and to link these barriers to self-reported adverse health consequences.DesignFollowing consultation with the autistic community at an autistic conference, Autscape, we developed a self-report survey, which we administered online through social media platforms.SettingA 52-item, international, online survey.Participants507 autistic adults and 157 non-autistic adults.Primary and secondary outcome measuresSelf-reported barriers to accessing healthcare and associated adverse health outcomes.ResultsEighty per cent of autistic adults and 37% of non-autistic respondents reported difficulty visiting a general practitioner (GP). The highest-rated barriers by autistic adults were deciding if symptoms warrant a GP visit (72%), difficulty making appointments by telephone (62%), not feeling understood (56%), difficulty communicating with their doctor (53%) and the waiting room environment (51%). Autistic adults reported a preference for online or text-based appointment booking, facility to email in advance the reason for consultation, the first or last clinic appointment and a quiet place to wait. Self-reported adverse health outcomes experienced by autistic adults were associated with barriers to accessing healthcare. Adverse outcomes included untreated physical and mental health conditions, not attending specialist referral or screening programmes, requiring more extensive treatment or surgery due to late presentations and untreated potentially life-threatening conditions. There were no significant differences in difficulty attending, barriers experienced or adverse outcomes between formally diagnosed and self-identified autistic respondents.ConclusionsReduction of healthcare inequalities for autistic people requires that healthcare providers understand autistic perspectives, communication needs and sensory sensitivities. Adjustments for autism-specific needs are as necessary as ramps for wheelchair users.

From 2014 to 2017 autism was championed by the Royal College of General Practitioners (RCGP). A suite of resources were developed to support GPs in their care of autistic patients.1 Engagement on this topic allowed the RCGP and GPs to be represented in national policy and guideline development. The RCGP continues to promote proper care of autistic patients, their families, and carers. In its position statement on the subject in June 20162 it recognised the essential role general practice plays in caring for this community, their families, and carers. It committed to promoting evidence-based training on autism, and to sign-posting resources that enable equitable access by this group to primary health care. The Core Capabilities Framework for Supporting Autistic People3 and Reasonable Adjustments ‘flag’ on patient records mark out some of the significant progress that has been made. Much remains to be done, and although sensitivities to the needs of autistic patients have improved, the experience and needs of autistic doctors have gone, largely, unrecognised. Recent prevalence data indicates 1.1% of the UK population is autistic,4 although this is widely held to be an underestimate. While we do not yet have prevalence rates for autistic doctors, 1% of GP responders surveyed on this topic by the RCGP clinical priority group5 indicated that they were themselves autistic, so informing their care of autistic patients. Public awareness campaigns,6 medical literature,7 or the diagnosis of a family member are prompting a ‘lost generation’ of autistic …

BackgroundAutistic people experience significantly poorer physical and mental health along with reduced life expectancy.AimTo identify self-reported barriers to primary care by autistic adults compared to parents of autistic children and non-autistic adults and link these barriers to self-reported adverse health consequences.Design and SettingFollowing consultation with the autistic community at an autistic conference, Autscape, a quantitative and qualitative survey was developed.MethodThe self-report survey was administered online through social media platforms.ResultsThe 57-item online survey was completed by 507 autistic adults, 196 parents of autistic children and 157 control subjects. 79.7% of autistic adults, 52.8% of parents and 36.5% of controls reported difficulty visiting a GP. The highest-rated barriers by autistic adults were deciding if symptoms warrant a GP visit (72.2%), difficulty making appointments by telephone (61.9%), not feeling understood (55.8%), difficulty communicating with their doctor (53.1%) and the waiting room environment (50.5%).Autistic adults reported a preference for online or text based appointment booking, facility to email in advance the reason for consultation, first or last clinic appointment and a quiet place to wait.Increased adverse health outcomes reported by autistic adults correlated with difficulty attending, including untreated physical and mental health conditions, not attending specialist referral or screening programmes, requiring more extensive treatment or surgery due to late presentations, and untreated potentially life threatening conditions.ConclusionReduction of healthcare inequalities for autistic people requires that healthcare providers understand autistic perspectives and communication needs. Adjustments for autism specific needs are as necessary as ramps for wheelchair users.How this fits inAdverse health outcomes are common among autistic people and so it is important to understand how we can promote access to primary care.This cross sectional study indicates that 79.7% of autistic patients (compared to 36.5% of controls) reported difficulty visiting a GP.Common barriers were: deciding if symptoms warrant a GP visit, difficulty using the telephone to book appointments, not feeling understood and difficulty communicating with their doctor.Common suggestions to promote access included: online or text based appointment booking facility, emailing in advance the reason for consultation, providing first or last clinic appointment and having a quiet place to wait.

This study was conducted to elucidate patients with early breast cancer preference for standard whole breast irradiation (WBI) or partial breast irradiation (PBI) following lumpectomy, as well as identify important factors for patients when making their treatment decisions. Based on relevant literature and ASTRO consensus statement guidelines, an educational tool and questionnaire were developed. Consenting, eligible women reviewed the educational tool and completed the trade-off questionnaire. Descriptive statistics were calculated, as well as chi-squares and a logistic regression model. Of the 90 patients who completed the study, 62 % preferred WBI, 30 % preferred PBI, 4 % required more information, and 3 % had no preferences. Of the patients who chose WBI, 58 % preferred hypofractionated RT, whereas 25 % preferred the conventional RT regimen. The majority of patients rated recurrence rate [WBI = 55/55 (100 %), PBI = 26/26 (100 %)] and survival [WBI = 54/55 (98 %), PBI = 26/26 (100 %)] as important factors contributing to their choice of treatment preference. Financial factors [WBI = 21/55 (38 %), PBI = 14/26 (53 %)] and convenience [WBI = 36/54 (67 %), PBI = 18/26 (69 %)] were rated as important less frequently. Significantly, more patients who preferred WBI also rated standard method of treatment as important when compared to patients who preferred PBI [WBI = 52/54 (96 %), PBI = 16/26 (61 %), χ 2 = 16.63, p = 0.001]. The majority of patients with early breast cancer who were surveyed for this study preferred WBI as an adjuvant treatment post lumpectomy, yet there was a sizeable minority who preferred PBI. This was associated with the importance patients place on standard treatment. These results will help medical professionals treat patients according to patient values.

Background The standard regimen of radiotherapy following lumpectomy consists of whole breast irradiation (WBI) to the entire breast including the lumpectomy cavity and all the surrounding normal breast tissue. Recently, there has been increased interest in partial breast irradiation (PBI) as an alternative to WBI. However, the preferences of patients with early breast cancer as to what type of radiotherapy regimen post lumpectomy they would prefer and why is unclear in the literature. This study was conducted to determine whether patients with early stage breast cancer would prefer PBI or WBI and to identify important factors for patients when making their treatment decision. Methods Based on our previous study of early stage breast cancer patient information needs, the relevant literature and the ASTRO consensus statement guidelines, an educational tool and questionnaire were developed. New patients with early breast cancer who were referred for adjuvant radiotherapy at the large academic cancer center were invited to participate. Women >40 years of age with a new histological diagnosis of ductal carcinoma in-situ or invasive breast carcinoma treated with breast conserving surgery showing clear margins for non-invasive and invasive disease and negative axillary nodes were eligible. Descriptive statistics were calculated for all variables of interest. Survey question responses were compared between those preferring WBI or PBI using chi-square analyses or Fisher's exact tests. Results Ninety /126 patients who were approached about this study completed the survey, 27(30%) preferred PBI and 55(62%) preferred WBI. Four patients (4%) required more information to choose between WBIvsPBI, and 3 patients (3%) had no preferences. From patients who choose WBI,32(58%)patients preferred hypofractionated RTvs 14 (25%)conventional RTregimen,Factors rated as important by patients in making their decision included convenience [PBI=18/26(69%), WBI=36/54(67%)], financial factors [PBI=14/26(53%), WBI=21/55(38%)], radiation dose to the breast [PBI=20/26(80%), WBI=46/55(83%)], invasiveness [PBI=18/26(69%), WBI=43/53(81%),, recurrence rate [PBI=26/26(100%), WBI=55/55(100%)], survival [PBI=26/26(100%),WBI=54/55(98%)], side effects PBI 21/26 (81%) WBI 47/55(85%) effectiveness [PBI=25/26(96%),WBI=54/54(100%)], standard method of treatment [PBI=16/26(61%), WBI=52/54(96%), p=0.001] and radiation dose to surrounding organs [PBI=23/26(88%), WBI=52/54(95%)]. Conclusions Our study shows that patients with early breast cancer prefer WBI as an adjuvant treatment post lumpectomy. There is significant association between preference of treatment and importance of standard treatment. Patients preferring WBRT were more likely to consider standard treatment as more important than those preferring PBI.There was a marginally significant association between marital status and preference of radiotherapy(p=0.0773) and employment (p=0.0667).Those currently not employed were marginally more likely to prefer WBI than those currently employed. A detailed analysis of all decisional preferences between WBI and PBI will be presented at the meeting. Citation Format: Szumacher EF, McGuffin M, Presutti R, Pignol IP, Harth T, Mesci A, Feldman-Stewart D, Chow E, DiProspero L, Vesprini D, Rakovitch E, Lee J, Doherty M, Soliman H, Ackerman I, Cao X, Kiss A. Breast cancer patients' preferences for adjuvant radiotherapy post-lumpectomy: Whole breast irradiation versus partial breast irradiation-single institutional study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-11-10.

Spatial and temporal patterns in microbial biodiversity across the Amazon river-ocean continuum were investigated along ∼675 km of the lower Amazon River mainstem, in the Tapajós River tributary, and in the plume and coastal ocean during low and high river discharge using amplicon sequencing of 16S rRNA genes in whole water and size-fractionated samples (0.2–2.0 μm and >2.0 μm). River communities varied among tributaries, but mainstem communities were spatially homogeneous and tracked seasonal changes in river discharge and co-varying factors. Co-occurrence network analysis identified strongly interconnected river assemblages during high (May) and low (December) discharge periods, and weakly interconnected transitional assemblages in September, suggesting that this system supports two seasonal microbial communities linked to river discharge. In contrast, plume communities showed little seasonal differences and instead varied spatially tracking salinity. However, salinity explained only a small fraction of community variability, and plume communities in blooms of diatom-diazotroph assemblages were strikingly different than those in other high salinity plume samples. This suggests that while salinity physically structures plumes through buoyancy and mixing, the composition of plume-specific communities is controlled by other factors including nutrients, phytoplankton community composition, and dissolved organic matter chemistry. Co-occurrence networks identified interconnected assemblages associated with the highly productive low salinity near-shore region, diatom-diazotroph blooms, and the plume edge region, and weakly interconnected assemblages in high salinity regions. This suggests that the plume supports a transitional community influenced by immigration of ocean bacteria from the plume edge, and by species sorting as these communities adapt to local environmental conditions. Few studies have explored patterns of microbial diversity in tropical rivers and coastal oceans. Comparison of Amazon continuum microbial communities to those from temperate and arctic systems suggest that river discharge and salinity are master variables structuring a range of environmental conditions that control bacterial communities across the river-ocean continuum.

This chapter concerns balance, gait function, exercise, and current rehabilitation options for older adults with Parkinson’s disease (PD) and stroke, within the context of normal aging. We outline the primary balance and gait deficits and their impact on fall rates for PD and stroke, with discussion regarding impairment in dual tasking and cognitive disturbances. We consider current options in physical therapy and exercise-based therapy for PD and stroke, particularly for interlimb coordination and gait function. Crossover approaches in rehabilitative techniques from PD/stroke to normal aging motor impairments often go underutilized in the clinic. Therefore, implications for older adults without movement disorders, who often have purely aging-related symptoms similar to those of PD, are discussed. Currently, research is especially engaged in investigating novel approaches to multimodal exercise, which have emerged as promising therapies for balance impairments including aerobic exercise, tai chi, and dance. Efficacy of such interventions is presented with respect to new research showing cognitive effects. We conclude the chapter by discussing hypotheses regarding mechanisms underlying deficit and recovery in these populations. Understanding the mechanisms for rehabilitative gains is crucial for developing targeted and efficient therapy for PD and stroke populations.

To assess the effects of seasonal oxygen transition on microbial metabolism, we measured spatiotemporal changes in total dissolved inorganic carbon, respiratory products, and geochemical constituents in the mesohaline region of Chesapeake Bay from May to October 2010. Vertical redox zonation was examined, and a spatial transect survey was also conducted from the southern to northern limit of the mesohaline region in July providing an alternative approach for assessing the temporal dynamics of oxygen transition. The transitions from oxic to hypoxic to anoxic and back to oxic were illustrated by the pattern of nitrogen redox species. Respiration, measured from changes in total dissolved inorganic carbon (∆DIC) and dissolved oxygen (∆DO) during incubations, had an average respiratory quotient (∆DIC/∆DO) of 1.04 ± 0.06 under oxic conditions and 1.58 ± 0.48 under hypoxic conditions. The difference in the respiratory quotients suggested that oxygen-based respiration measurements would underestimate community respiration rates in hypoxic conditions. In the present study, we observed within the surface-mixed layer three- to sevenfold differences in temporal and vertical variation of community respiration, while net respiration across oxyclines and anaerobic respiration in deep waters had lower rates and variability. In some anoxic samples, there was a net decrease in dissolved inorganic carbon that was exacerbated with experimental augmentation of terminal electron acceptors. Potential carbon fixation rates of chemoautotrophs within and below oxyclines were estimated and ranged from 0.63 to 116.9 mg C m−2 day−1 depending on growth conditions. These results indicate that anaerobic metabolism during the seasonal anoxic transition and at oxic/anoxic interface can play an important role in the estuarine carbon cycle.

We used metatranscriptomics to study the gene transcription patterns of microbial plankton (0.2 to 64 μm) at a mesohaline station in the Chesapeake Bay under transitions from oxic to anoxic waters in spring and from anoxic to oxic waters in autumn. Samples were collected from surface (i.e., above pycnocline) waters (3 m) and from waters beneath the pycnocline (16 to 22 m) in both 2010 and 2011. Metatranscriptome profiles based on function and potential phylogeny were different between 2010 and 2011 and strongly variable in 2011. This difference in variability corresponded with a highly variable ratio of eukaryotic to bacterial sequences (0.3 to 5.5), reflecting transient algal blooms in 2011 that were absent in 2010. The similarity between metatranscriptomes changed at a lower rate during the transition from oxic to anoxic waters than after the return to oxic conditions. Transcripts related to photosynthesis and low-affinity cytochrome oxidases were significantly higher in shallow than in deep waters, while in deep water genes involved in anaerobic metabolism, particularly sulfate reduction, succinyl coenzyme A (succinyl-CoA)-to-propionyl-CoA conversion, and menaquinone synthesis, were enriched relative to in shallow waters. Expected transitions in metabolism between oxic and anoxic deep waters were reflected in elevated levels of anaerobic respiratory reductases and utilization of propenediol and acetoin. The percentage of archaeal transcripts increased in both years in late summer (from 0.1 to 4.4% of all transcripts in 2010 and from 0.1 to 6.2% in 2011). Denitrification-related genes were expressed in a predicted pattern during the oxic-anoxic transition. Overall, our data suggest that Chesapeake Bay microbial assemblages express gene suites differently in shallow and deep waters and that differences in deep waters reflect variable redox states.

The nature and extent of microbial biodiversity remain controversial with persistent debates over patterns of distributions (i.e. cosmopolitanism versus endemism) and the processes that structure these patterns (neutrality versus selection). We used culture-independent approaches to address these issues focusing on two groups of ciliates, the Oligotrichia (Spirotrichea) and Choreotrichia (Spirotrichea) across an environmental gradient. We assessed SSU rDNA diversity in ciliate communities at six stations in Long Island Sound spanning the frontal region that separates the fresher Connecticut River outflow plume from the open Sound. As in previous studies, we find one abundant cosmopolitan species (Strombidium biarmatum), a few moderately abundant sequences, and a long list of rare sequences. Furthermore, neither ciliate diversity nor species composition showed any clear relationship to measured environmental parameters (temperature, salinity, accessory pigment composition and chorophyll). Overall, we observed that diversity decreased moving from nearshore to offshore. We also conducted analyses to detect clustering among the sampled communities using the software Unifrac. This approach revealed three significant clusters grouping samples from nearshore, surface and deep/well mixed stations. We find no strong fit of our communities to log series, geometric or log normal distributions, though one of the 3 clusters is most consistent with a log series distribution. However, when we remove the abundant cosmopolitan species S. biarmatum, all three clusters fit to a log series distribution. These analyses suggest that, with the exception of one cosmopolitan species, the oligotrich and choreotrich communities at these stations may be distributed in a neutral manner.

A choroidal metastasis usually presents as blurred vision or decreased visual acuity and is usually an indicator of poor outcome. The authors describe the case of a 57-year-old woman with a history of breast cancer that presented with distorted vision and decreased visual acuity in her left eye. The authors discuss the use of radiation and hormonal therapy to manage this case of choroidal metastasis from breast carcinoma. Background A 57-year-old woman presented with distorted vision and decreased visual acuity (finger count only) in her left eye, 6 years after she had undergone a lumpectomy, lymph-node dissection, and radiation therapy for a 1.1 cm infiltrating ductal carcinoma of her right breast. A year before this presentation, she had completed 5 years of adjuvant tamoxifen therapy. Investigations Physical examination, including a thorough ophthalmologic evaluation; laboratory investigations, ocular fluorescein angiography, ocular ultrasonography, head CT, chest X-ray, abdominal ultrasonography, bone scan, and bilateral mammography. Diagnosis Choroidal metastasis from breast carcinoma, with no other evidence of disease recurrence. Management Radiation therapy to the left eye followed by ongoing hormonal therapy with oral letrozole 2.5 mg daily for the past 9.5 years.

Planktonic ciliates within the subclasses Choreotrichia and Oligotrichia play critical roles in food webs in the world's oceans. To assess the diversity of these ciliates, we designed primers specific to small subunit ribosomal DNA (SSU rDNA) of ciliates within these clades and sampled at 3 coastal sites in the northwest Atlantic in October 2004 and May 2005. We also preserved and ana- lyzed samples using standard ecological methods to compare observations from light microscopy with our molecular results. We found that (1) estimates of diversity based on molecular markers were similar to estimates from morphological observations for choreotrich ciliates, but much greater for oligotrich ciliates; (2) while similar levels of diversity were found at each site, each collection had its own distinct assemblage of rare and abundant ciliate haplotypes; (3) genealogical analyses of our samples combined with published sequences from identified morphospecies revealed that haplotype diversity at these sites is greatest within the genus Strombidium, in the Oligotrichia. The results from this ciliate-specific analysis are consistent with previous molecular studies on microbial diver- sity in marine systems in that they reveal high diversity and shifting assemblages within microbial communities.

We developed a method to extract environmental DNA and amplify target portions of the internal transcribed spacer region (ITS) of the ribosomal gene (ITS1-5.8S-ITS2) from individual species of oligotrich and choreotrich ciliate microzooplankton. To date, we have lab- and field-tested primers specific to the tintinnid Favella ehrenbergii, the oligotrich Laboea strobila, and the choreotrich Strombidinopsis sp. For all three species, the primers were both species-specific (not producing PCR product from non-target DNA) and comprehensive (able to amplify from different populations of the target species). The method is both time-efficient and sensitive, compared with microscopy. In seawater samples amended with both target and non-target DNA, we were able to detect the targets at < 1 cell L−1. Some difficulties we encountered resulted from PCR-inhibitory compounds that co-extracted with the environmental DNA, and the rarity of the target DNA within natural plankton assemblages. Comparisons with microscopic counts were qualitatively similar to PCR (presence/absence of the species in different amounts of extract). We are evaluating ways to make the method fully quantitative by investigating the degree to which copy number for this gene may vary among individuals.

The Amazon River has the largest discharge of all rivers on Earth, and its complex plume system fuels a wide array of biogeochemical processes, across a large area of the western tropical North Atlantic. The plume thus stimulates microbial processes affecting carbon sequestration and nutrient cycles at a global scale. Chromosomal gene expression patterns of the 2.0 to 156 μm size-fraction eukaryotic microbial community were investigated in the Amazon River Plume, generating a robust dataset (more than 100 million mRNA sequences) that depicts the metabolic capabilities and interactions among the eukaryotic microbes. Combining classical oceanographic field measurements with metatranscriptomics yielded characterization of the hydrographic conditions simultaneous with a quantification of transcriptional activity and identity of the community. We highlight the patterns of eukaryotic gene expression for 31 biogeochemically significant gene targets hypothesized to be valuable within forecasting models. An advantage to this targeted approach is that the database of reference sequences used to identify the target genes was selectively constructed and highly curated optimizing taxonomic coverage, throughput, and the accuracy of annotations. A coastal diatom bloom highly expressed nitrate transporters and carbonic anhydrase presumably to support high growth rates and enhance uptake of low levels of dissolved nitrate and CO2. Diatom-diazotroph association (DDA: diatoms with nitrogen fixing symbionts) blooms were common when surface salinity was mesohaline and dissolved nitrate concentrations were below detection, and hence did not show evidence of nitrate utilization, suggesting they relied on ammonium transporters to aquire recently fixed nitrogen. These DDA blooms in the outer plume had rapid turnover of the photosystem D1 protein presumably caused by photodegradation under increased light penetration in clearer waters, and increased expression of silicon transporters as silicon became limiting. Expression of these genes, including carbonic anhydrase and transporters for nitrate and phosphate, were found to reflect the physiological status and biogeochemistry of river plume environments. These relatively stable patterns of eukaryotic transcript abundance occurred over modest spatiotemporal scales, with similarity observed in sample duplicates collected up to 2.45 km in space and 120 minutes in time. These results confirm the use of metatranscriptomics as a valuable tool to understand and predict microbial community function., Gordon and Betty Moore Foundation (River Ocean Continuum of the Amazon Project. Grants GBMF 2293 and 2928), National Science Foundation (U.S.) (Grant NSF-OCE 0934095)

International audience; Since ciliates rarely possess structures that easily fossilize, we are limited in our ability to use paleontological studies to reconstruct the early evolution of this large and ecologically important clade of protists. Tintinnids, a group of loricate (house-forming) planktonic ciliates, are the only group that has a significant fossil record. Putative tintinnid fossils from rocks older than Jurassic, however, possess few to no characters that can be found in extant ciliates; these fossils are best described as `incertae sedis eukaryotes'. Here, we review the Devonian fossil Nassacysta reticulata and propose that it is likewise another `incertae sedis eukaryote due to the lack of any unambiguous ciliate characters. Future tintinnid fossil descriptions would be most helpful if: (i) neutral terminology is used in the descriptions but ciliate-specific terminology in the interpretations; (ii) the current ciliate classification is used, although fossil data may expand or modify classifications based on modem forms; (iii) close collaboration with specialists studying extant ciliates is done; and (iv) editors include an expert of extant ciliates in the review process. (C) 2015 Elsevier B.V. All rights reserved.