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Mucus fishing syndrome is a chronic inflammatory ocular surface condition characterised by repetitive self-extraction of mucous strands from the eye.A man in his 30s presented with bilateral ocular redness, itch, irritation, tearing and sticky mucoid discharge for 3 months. Examination disclosed bilateral bulbar and tarsal conjunctival injection. Fluorescein staining disclosed a well-circumscribed area of tarsal conjunctival epithelial defect near the inferior lacrimal punctum in both eyes. The patient admitted to a habit of mechanically removing mucus from his eyes several times a day. Demonstration of the mucus extraction process disclosed direct contact of his fingers with the excoriated tarsal conjunctiva in each eye. He was diagnosed with mucus fishing syndrome and his condition resolved within a month after he stopped fishing mucus from his eyes and had a course of topical antibiotics and steroids.Mucus fishing syndrome is an important diagnostic consideration in patients with chronic conjunctivitis.

We conducted a prospective environmental surveillance study to investigate the air, surface, dust, and water contamination of a room occupied by a patient infected with mpox virus (MPXV) at various stages of the illness. The patient tested positive for MPXV from a throat swab and skin lesions. Environmental sampling was conducted in a negative pressure room with 12 unidirectional high efficiency particulate air filter (HEPA) air changes per hour and daily cleaning of the surfaces. A total of 179 environmental samples were collected on days 7, 8, 13, and 21 of illness. Among the days of sampling, air, surface, and dust contamination showed the highest contamination rates on day 7 and 8 of illness, with a gradual decline to the lowest contamination level by day 21. Viable MPXV was isolated from surfaces and dust samples and no viable virus was isolated from the air and water samples. Ministry of Health (MOH) National Environmental Agency (NEA) National Medical Research Council (NMRC) Published version This research is supported by the Singapore Ministry of Health’s (MOH) National Medical Research Council (NMRC) under its NMRC Collaborative Grant: Collaborative Solutions Targeting Antimicrobial Resistance Threats in Health Systems (CoSTAR-HS) (CG21APR2005), NMRC Clinician Scientist Award (MOH-000276), and NMRC Clinician Scientist Individual Research Grant (MOH-CIRG18Nov-0034). The study is also internally funded by the National Environment Agency.

BACKGROUND: Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe disease. During the coronavirus disease 2019 (COVID-19) pandemic, numerous reports of AP have been published, with most authors concluding a causal relationship between COVID-19 and AP. Retrospective case reports or small case series are unable to accurately determine the cause-effect relationship between COVID-19 and AP. AIM: To establish whether COVID-19 is a cause of AP using the modified Naranjo scoring system. METHODS: A systematic review was conducted on PubMed, World of Science and Embase for articles reporting COVID-19 and AP from inception to August 2021. Exclusion criteria were cases of AP which were not reported to be due to COVID-19 infection, age < 18 years old, review articles and retrospective cohort studies. The original 10-item Naranjo scoring system (total score 13) was devised to approximate the likelihood of a clinical presentation to be secondary to an adverse drug reaction. We modified the original scoring system into a 8-item modified Naranjo scoring system (total score 9) to determine the cause-effect relationship between COVID-19 and AP. A cumulative score was decided for each case presented in the included articles. Interpretation of the modified Naranjo scoring system is as follows: ≤ 3: Doubtful, 4-6: Possible, ≥ 7: Probable cause. RESULTS: The initial search resulted in 909 articles, with 740 articles after removal of duplicates. A total of 67 articles were included in the final analysis, with 76 patients which had AP reported to be due to COVID-19. The mean age was 47.8 (range 18-94) years. Majority of patients (73.3%) had ≤ 7 d between onset of COVID-19 infection and diagnosis of AP. There were only 45 (59.2%) patients who had adequate investigations to rule out common aetiologies (gallstones, choledocholithiasis, alcohol, hypertriglyceridemia, hypercalcemia and trauma) of AP. Immunoglobulin G4 testing was conducted in 9 (13.5%) patients to rule out autoimmune AP. Only 5 (6.6%) patients underwent endoscopic ultrasound and/or magnetic resonance cholangiopancreatogram to rule out occult microlithiasis, pancreatic malignancy and pancreas divisum. None of the patients had other recently diagnosed viral infections apart from COVID-19 infection, or underwent genetic testing to rule out hereditary AP. There were 32 (42.1%), 39 (51.3%) and 5 (6.6%) patients with doubtful, possible, and probable cause-effect relationship respectively between COVID-19 and AP. CONCLUSION: Current evidence is weak to establish a strong link between COVID-19 and AP. Investigations should be performed to rule out other causes of AP before establishing COVID-19 as an aetiology. Published version

Precision medicine promises to transform healthcare for groups and individuals through early disease detection, refining diagnoses and tailoring treatments. Analysis of large-scale genomic-phenotypic databases is a critical enabler of precision medicine. Although Asia is home to 60% of the world's population, many Asian ancestries are under-represented in existing databases, leading to missed opportunities for new discoveries, particularly for diseases most relevant for these populations. The Singapore National Precision Medicine initiative is a whole-of-government 10-year initiative aiming to generate precision medicine data of up to one million individuals, integrating genomic, lifestyle, health, social and environmental data. Beyond technologies, routine adoption of precision medicine in clinical practice requires social, ethical, legal and regulatory barriers to be addressed. Identifying driver use cases in which precision medicine results in standardized changes to clinical workflows or improvements in population health, coupled with health economic analysis to demonstrate value-based healthcare, is a vital prerequisite for responsible health system adoption. Agency for Science, Technology and Research (A*STAR) Ministry of Health (MOH) National Medical Research Council (NMRC) National Research Foundation (NRF) We thank all investigators, staf members and study participants of the contributing cohorts and studies: (1) the HELIOS study at the Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; (2) the GUSTO study jointly hosted by the National University Hospital, KK Women’s and Children’s Hospital, the National University of Singapore and the Singapore Institute for Clinical Sciences, the Agency for Science Technology and Research (A*STAR); (3) the SEED cohort at the Singapore Eye Research Institute; (4) the MEC, National University of Singapore; (5) the PRISM cohort; and (6) the TTSH Personalised Medicine Normal Controls cohort. We also thank the National Supercomputing Centre, Singapore (https://www.ncss.sg) for computation resources. The SG10K_Health project is funded by the Industry Alignment Fund (Pre-Positioning) (IAF-PP, H17/01/a0/007); the project made use of participating study cohorts supported by the following funding sources: (1) the HELIOS study by grants from a Strategic Initiative at Lee Kong Chian School of Medicine, the Singapore MOH under its Singapore Translational Research Investigator Award (NMRC/STaR/0028/2017) and the IAF-PP (H18/01/a0/016); (2) the GUSTO study by the Singapore National Research Foundation under its Translational and Clinical Research Flagship Program and administered by the Singapore MOH’s National Medical Research Council Singapore (NMRC/TCR/004-NUS/2008, NMRC/ TCR/012-NUHS/2014) with additional funding support available through the A*STAR and the IAF-PP (H17/01/a0/005); (3) the SEED study by NMRC/CIRG/1417/2015, NMRC/CIRG/1488/2018 and NMRC/OFLCG/004/2018; (4) the MEC by individual research and clinical scientist award schemes from the Singapore National Medical Research Council (including MOH-000271-00) and the Singapore Biomedical Research Council, the Singapore MOH, the National University of Singapore and the Singapore National University Health System; (5) the PRISM cohort study by NMRC/CG/ M006/2017_NHCS, NMRC/STaR/0011/2012, NMRC/STaR/0026/2015, the Lee Foundation and the Tanoto Foundation; and (6) the TTSH cohort study by NMRC/CG12AUG2017 and CGAug16M012. This research is also supported by the National Research Foundation Singapore under its NPM program Phase II funding (MOH-000588) and administered by the Singapore MOH’s National Medical Research Council.

Blood tests are considered as standard clinical procedures to screen for markers of diseases and health conditions. However, the complex cellular background (>99.9% RBCs) and biomolecular composition often pose significant technical challenges for accurate blood analysis. An emerging approach for point-of-care blood diagnostics is utilizing "label-free" microfluidic technologies that rely on intrinsic cell properties for blood fractionation and disease detection without any antibody binding. A growing body of clinical evidence has also reported that cellular dysfunction and their biophysical phenotypes are complementary to standard hematoanalyzer analysis (complete blood count) and can provide a more comprehensive health profiling. In this review, we will summarize recent advances in microfluidic label-free separation of different blood cell components including circulating tumor cells, leukocytes, platelets and nanoscale extracellular vesicles. Label-free single cell analysis of intrinsic cell morphology, spectrochemical properties, dielectric parameters and biophysical characteristics as novel blood-based biomarkers will also be presented. Next, we will highlight research efforts that combine label-free microfluidics with machine learning approaches to enhance detection sensitivity and specificity in clinical studies, as well as innovative microfluidic solutions which are capable of fully integrated and label-free blood cell sorting and analysis. Lastly, we will envisage the current challenges and future outlook of label-free microfluidics platforms for high throughput multi-dimensional blood cell analysis to identify non-traditional circulating biomarkers for clinical diagnostics. Ministry of Education (MOE) Published version The authors would like to acknowledge support from Singapore Ministry of Education Academic Research Fund (MOE AcRF) Tier 2 (MOE-T2EP30120-0004) and under the RIE2020 Industry Alignment Fund – Industry Collaboration Projects (IAF-ICP) Funding Initiative, as well as cash and in kind contributions from the industry partner, HP Inc., through the HP-NTU Digital Manufacturing Corporate Lab.

Pseudomonas aeruginosa is a leading cause of hospital-acquired infections. Treatment of P. aeruginosa infections is difficult given its multiple virulence mechanisms, intrinsic antibiotic resistance mechanisms, and biofilm-forming ability. Auranofin, an approved oral gold compound for rheumatoid arthritis treatment, was recently reported to inhibit the growth of multiple bacterial species. Here, we identify P. aeruginosa's global virulence factor regulator Vfr as one target of auranofin. We report the mechanistic insights into the inhibitory mechanism of auranofin and gold(I) analogues to Vfr through structural, biophysical, and phenotypic inhibition studies. This work suggests that auranofin and gold(I) analogues have potential to be developed as anti-virulence drugs against P. aeruginosa. Ministry of Education (MOE) Published version This research is supported by the Singapore Ministry of Education under its Singapore Ministry of Education Academic Research Fund Tier 1 (2018-T1-002-010) and Tier 2 (2016-T2-2-097) to D.L.; Nanyang Presidential Graduate Scholarship to B.L.A.C.; the Guangdong Natural Science Foundation for Distinguished Young Scholar [2020B1515020003]; the National Key Research and Development Program of China (2022YFC2304700); the National Natural Science Foundation of China (32270196 and 32200155); the Guangdong Basic and Applied Basic Research Foundation [2019A1515110640]; and the Shenzhen Overseas High-level Talent Team (KQTD20200909113758004).

Monoallelic or biallelic RAD51C germline mutations results in chromosome instability disorders such as fanconi anemia (FA) and cancers. The bona fide function of RAD51C is to assist RAD51 nucleoprotein filament onto single strand DNA to complete Homologous Recombination (HR) repair. In addition to HR repair, the role of RAD51C in DNA replication is emerging when replication forks are transiently or irreversibly stalled. We identified novel RAD51C variants of uncertain significance (VUS) from breast, ovarian, pancreatic, and gastric cancer patients and functionally characterized the effect of these variants in replication fork protection and double-strand breaks (DSB's) repair. In RAD51C deficient chinese hamster CL-V4B cells, expression of RAD51C F164S, A87E, L134S and E49K variants heightened sensitivity to mitomycin C (MMC), etoposide and PARP inhibition. Differently, expression of a subset RAD51C variants R24L, R24W, and R212H displayed mild sensitivity to MMC, etoposide and PARP inhibition. Further functional characterization of a subset of variants revealed that Rad51C F164S, A87E, L134S and E49K variants displayed reduced RAD51 foci formation and increased overall nuclear single strand DNA levels in the presence of replication stress. Additionally, DNA fiber assay revealed that RAD51C F164S, A87E, L134S and E49K variants displayed defective replication fork protection upon prolonged fork stalling. Investigations using patient-derived lymphoblastoid cell line carrying heterozygous RAD51C L134S variant showed an impairment in RAD51 chromatin association and replication fork protection, suggestive of deleteriousness of this VUS variant. Overall, our findings provide more insights into molecular roles of RAD51C in replication fork integrity maintenance and in DSB repair. Disclosure Summary The authors report no relevant conflicts of interest in this work. Ministry of Education (MOE) National Medical Research Council (NMRC) Singapore Ministry of Education (MOE) under its Academic Research Fund ( AcRF) Tier 1 [2019-T1-001-018]; National Cancer Centre Research Fund Terry Fox Grant [NCCRF-YR2018-NOV-1]; National Medical Research Council (NMRC) Clinician Scientist Award [MOH-000654].

Background Bazex–Dupré–Christol syndrome (BDCS; MIM301845) is a rare X-linked dominant genodermatosis characterized by follicular atrophoderma, congenital hypotrichosis and multiple basal cell carcinomas (BCCs). Previous studies have linked BDCS to an 11·4-Mb interval on chromosome Xq25-q27.1. However, the genetic mechanism of BDCS remains an open question. Objectives To investigate the genetic aetiology and molecular mechanisms underlying BDCS. Methods We ascertained multiple individuals from eight unrelated families affected with BDCS (F1–F8). Whole-exome (F1 and F2) and genome sequencing (F3) were performed to identify putative disease-causing variants within the linkage region. Array comparative genomic hybridization and quantitative polymerase chain reaction (PCR) were used to explore copy number variations, followed by long-range gap PCR and Sanger sequencing to amplify the duplication junctions and to define the head–tail junctions. Hi-C was performed on dermal fibroblasts from two affected individuals with BDCS and one control. Public datasets and tools were used to identify regulatory elements and transcription factor binding sites within the minimal duplicated region. Immunofluorescence was performed in hair follicles, BCCs and trichoepitheliomas from patients with BDCS and sporadic BCCs. The ACTRT1 variant c.547dup (p.Met183Asnfs*17), previously proposed to cause BDCS, was evaluated with t allele frequency calculator. Results In eight families with BDCS, we identified overlapping 18–135-kb duplications (six inherited and two de novo) at Xq26.1, flanked by ARHGAP36 and IGSF1. Hi-C showed that the duplications did not affect the topologically associated domain, but may alter the interactions between flanking genes and putative enhancers located in the minimal duplicated region. We detected ARHGAP36 expression near the control hair follicular stem cell compartment, and found increased ARHGAP36 levels in hair follicles in telogen, in BCCs and in trichoepitheliomas from patients with BDCS. ARHGAP36 was also detected in sporadic BCCs from individuals without BDCS. Our modelling showed the predicted maximum tolerated minor allele frequency of ACTRT1 variants in control populations to be orders of magnitude higher than expected for a high-penetrant ultra-rare disorder, suggesting loss of function of ACTRT1 variants to be an unlikely cause for BDCS. Conclusions Noncoding Xq26.1 duplications cause BDCS. The BDCS duplications most likely lead to dysregulation of ARHGAP36. ARHGAP36 is a potential therapeutic target for both inherited and sporadic BCCs. What is already known about this topic? Bazex–Dupré–Christol syndrome (BDCS) is a rare X-linked basal cell carcinoma susceptibility syndrome linked to an 11·4-Mb interval on chromosome Xq25-q27.1.Loss-of-function variants in ACTRT1 and its regulatory elements were suggested to cause BDCS. What does this study add? BDCS is caused by small tandem noncoding intergenic duplications at chromosome Xq26.1.The Xq26.1 BDCS duplications likely dysregulate ARHGAP36, the flanking centromeric gene.ACTRT1 loss-of-function variants are unlikely to cause BDCS. What is the translational message? This study provides the basis for accurate genetic testing for BDCS, which will aid precise diagnosis and appropriate surveillance and clinical management.ARHGAP36 may be a novel therapeutic target for all forms of sporadic basal cell carcinomas.

The role of biological augmentation in arthroscopic rotator cuff repair surgery has increased over the years. It has shown favorable healing rates and functional outcomes. Patch augmentation is commonly applied in repairs of massively retracted cuff tears, full-thickness tears, revision repair, or open cuff surgery. There is a paucity of literature on the use of patch augmentation when dealing with a chronic degenerate tendon associated with small-sized cuff tears. In recent years, the resorbable bioinductive bovine collagen implant has gained popularity for its application in partial-thickness tears via an isolated bioinductive repair fashion, without traditional rotator cuff repair. These bioinductive implants, albeit promising in their biological properties for tendon repair, lack structural strength and do not confer similar biomechanical advantages as human dermal allograft. We share our surgical technique for an arthroscopic patch augmentation involving human dermal allograft, using a single-lateral row surgical fixation, to address a degenerate cuff tendon with small-sized rotator cuff tear. We believe that our use of a human dermal patch augmentation conferred increased biomechanical advantage and reduced costs while delivering favorable outcomes for patients in our value-driven care. Published version

Abnormal lipid homeostasis has been observed in the brain of Parkinson's disease (PD) patients and experimental models, although the mechanism underlying this phenomenon is unclear. Notably, previous studies have reported that the PD-linked protein Parkin functionally interacts with important lipid regulators, including Sterol Regulatory Element-Binding Proteins (SREBPs) and cluster of differentiation 36 (CD36). Here, we demonstrate a functional relationship between Parkin and lipoprotein lipase (LPL), a triglyceride lipase that is widely expressed in the brain. Using a human neuroblastoma cell line and a Parkin knockout mouse model, we demonstrate that Parkin expression level positively correlates with neuronal LPL protein level and activity. Importantly, our study identified SREBP2, a major regulator of sterol and fatty acid synthesis, as a potential mediator between Parkin and LPL. Supporting this, SREBP2 genetic ablation abolished Parkin effect on LPL expression. We further demonstrate that Parkin-LPL pathway regulates the formation of intracellular lipid droplets, and that this pathway is upregulated upon exposure to PD-linked oxidative stress induced by rotenone. Finally, we show that inhibition of either LPL or SREBP2 exacerbates rotenone-induced cell death. Taken together, our findings reveal a novel pathway linking Parkin, SREBP2 and LPL in neuronal lipid homeostasis that may be relevant to the pathogenesis of PD. Ministry of Education (MOE) Ministry of Health (MOH) National Medical Research Council (NMRC) Published version Singapore Ministry of Health Open Fund-Large Collaborative Grant (MOH-OFLCG18May-0002), Lee Kong Chian School of Medicine Start Up Grant from Singapore Ministry of Education (#002642-00001), and National Medical Research CouncilTranslational and Clinical Research (NMRC/TCR/013-NNI/2014) awarded to K.L.L. and Khoo Pilot Award (Duke/Duke-NUS/RECA (Pilot)/2016/0023) awarded to K.L.L. and T.P.Y.

Bacterial infections and multidrug-resistant bacteria are major health burdens in wound care. Biocompatible antimicrobial agents, e.g., ε-polylysine (ε-PL), provide a broad spectrum of antibacterial properties and support dermal cell growth. Here, ε-PL was incorporated into polycaprolactone (PCL)/gelatin electrospun scaffolds collected at varying rotation speeds. Then, the samples were crosslinked using dopamine hydrochloride to provide highly proliferative dressings with broad antimicrobial activity. The morphological study showed that the electrospun wound dressings were smooth, continuous, and bead-free, with a mean diameter ranging from 267 ± 7 to 331 ± 8 nm for all random and aligned nanofibers. The fiber alignment of the electrospun PCL/gelatin scaffolds improved their tensile strength and modulus. Moreover, nanofiber mats are highly hydrophilic, which is crucial for an efficient wound dressing. The samples also demonstrated high antimicrobial properties against common wound bacterial strains, including methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus aureus (SA), Escherichia coli (EC), Acinetobacter baumannii (AB), and Pseudomonas aeruginosa (PA). Mammalian cell proliferation and morphology assays involving primary human dermal fibroblasts (hDFs) and immortalized keratinocytes (HaCaT) showed excellent biocompatibility of the electrospun mats and remarkably aligned mats. Furthermore, aligned mats showed more cell migration than randomly oriented mats, which is desirable for more efficient wound healing. Therefore, it can be concluded that aligned PCL/gelatin mats containing ε-PL are promising for potential use in wound dressings. Graphical Abstract: [Figure not available: see fulltext.]. Agency for Science, Technology and Research (A*STAR) Ministry of Education (MOE) Nanyang Technological University E.R.G. acknowledges the financial support from the Singapore International Graduate Award (SINGA). R.L. thanks funding support from the Duke-NUS Khoo Bridge Funding Award (Duke-NUS-KBrFA/2021/0044). N.K.V. acknowledges funding support from the Singapore Ministry of Education (MOE) under its MOE Academic Research Fund (AcRF) Tier 1 Grant (RG26/20) and the Agency for Science, Technology and Research (A*STAR) under its Wound Care Innovation for the Tropics (WCIT) Industry Alignment Fund Pre-Positioning (IAF-PP) Grant (H17/01/a0/0K9). B.H.S.W. and Z.S.P. were provided Ph.D. fellowships by HealthTech NTU and Lee Kong Chian School of Medicine, Nanyang Technological University Singapore.

Pressure injuries and ulcers result in high morbidity and healthcare burden and contribute to burnout of caregivers. The Smart Automated Body-Pressure Redistributor (SABR) is a mattress device designed to sense body pressure and automatically redistribute the air pressures in the underlying air bladders supporting the body. This technical study demonstrated that the SABR mattress device is able to reliably detect and alleviate high pressure and provide sustained avoidance of high pressures underlying the body. This device can potentially be used for the prevention and management of pressure injuries and when scaled-up and can possibly contribute to the reduction of healthcare burden in the ageing population. National Medical Research Council (NMRC) Submitted/Accepted version HL Tey is supported by the Clinician Scientist Award (NMRC/CSAINV20nov-0003) from the National Medical Research Council, Ministry of Health of Singapore.

A cost-minimization analysis was conducted for Klebsiella pneumoniae liver abscess (KLA) patients enrolled in a randomized controlled trial which found oral ciprofloxacin to be non-inferior to intravenous (IV) ceftriaxone in terms of clinical outcomes. Healthcare service utilization and cost data were obtained from medical records and estimated from self-reported patient surveys in a non-inferiority trial of oral ciprofloxacin versus IV ceftriaxone administered to 152 hospitalized adults with KLA in Singapore between November 2013 and October 2017. Total costs were evaluated by category and payer, and compared between oral and IV antibiotic groups over the trial period of 12 weeks. Among the subset of 139 patients for whom cost data were collected, average total cost over 12 weeks was $16,378 (95% CI, $14,620-$18,136) for the oral ciprofloxacin group and $20,569 (95% CI, $18,296-$22,842) for the IV ceftriaxone group, largely driven by lower average outpatient costs, as the average number of outpatient visits was halved for the oral ciprofloxacin group. There were no other statistically significant differences, either in inpatient costs or in other informal healthcare costs. Oral ciprofloxacin is less costly than IV ceftriaxone in the treatment of Klebsiella liver abscess, largely driven by reduced outpatient service costs.Trial registration: ClinicalTrials.gov Identifier NCT01723150 (7/11/2012). National Medical Research Council (NMRC) Singapore Infectious Diseases Initiative - National Medical Research Council Published version This work was supported by Singapore National Medical Research Council [NMRC/CNIG/1101/2013] and Singapore Infectious Diseases Initiative [SIDI/2013/006].

Since it was first identified in early November 2021, the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread quickly and replaced the B.1.617.2 (delta) variant as the dominant variant in many countries. Data on the real-world effectiveness of vaccines against the omicron variant in children are lacking.In a study conducted from January 21, 2022, through April 8, 2022, when the omicron variant was spreading rapidly, we analyzed data on children in Singapore who were 5 to 11 years of age. We assessed the incidences of all reported SARS-CoV-2 infections (confirmed on polymerase-chain-reaction [PCR] assay, rapid antigen testing, or both), SARS-CoV-2 infections confirmed on PCR assay, and coronavirus disease 2019 (Covid-19)-related hospitalizations among unvaccinated, partially vaccinated (≥1 day after the first dose of vaccine and up to 6 days after the second dose), and fully vaccinated children (≥7 days after the second dose). Poisson regression was used to estimate vaccine effectiveness from the incidence rate ratio of outcomes.A total of 255,936 children were included in the analysis. Among unvaccinated children, the crude incidence rates of all reported SARS-CoV-2 infections, PCR-confirmed SARS-CoV-2 infections, and Covid-19-related hospitalizations were 3303.5, 473.8, and 30.0 per 1 million person-days, respectively. Among partially vaccinated children, vaccine effectiveness was 13.6% (95% confidence interval [CI], 11.7 to 15.5) against all SARS-CoV-2 infections, 24.3% (95% CI, 19.5 to 28.9) against PCR-confirmed SARS-CoV-2 infection, and 42.3% (95% CI, 24.9 to 55.7) against Covid-19-related hospitalization; in fully vaccinated children, vaccine effectiveness was 36.8% (95% CI, 35.3 to 38.2), 65.3% (95% CI, 62.0 to 68.3), and 82.7% (95% CI, 74.8 to 88.2), respectively.During a period when the omicron variant was predominant, BNT162b2 vaccination reduced the risks of SARS-CoV-2 infection and Covid-19-related hospitalization among children 5 to 11 years of age.

Thyroid hormones (TH), adiponectin and brown adipose tissue (BAT) are regulators of energy homoeostasis. Influence of BAT activity on the relationship between TH and adiponectin remains unexplored. The aim of the study was to identify the relationship between TH and adiponectin and to clarify the impact of active BAT on the metabolic effects of adiponectin before and after the correction of thyrotoxicosis. Twenty-one patients with newly diagnosed hyperthyroidism from Graves' disease were recruited. A titration dosing regimen of thionamide anti-thyroid drug (ATD) was used to establish euthyroidism over 12-24 weeks. Anthropometric, biochemical and adipocytokine parameters were measured before and after control of hyperthyroidism. BAT activity was quantified by fusion 18 F-fluorodeoxyglucose (18 F-FDG) PET/MR imaging, and patients were grouped based on BAT status. Plasma adiponectin level was significantly increased following correction of hyperthyroidism in the overall sample. Free thyroxine (FT4) was also identified as a predictor of adiponectin level in thyroid dysfunction. However, significant changes in adiponectin level and correlations involving adiponectin were absent in BAT-positive patients but maintained in BAT-negative patients. BAT activity diminishes the correlative relationship with body composition and abolishes TH and adiponectin relationships when transitioning from a hyperthyroid to euthyroid state. Agency for Science, Technology and Research (A*STAR) Published version The study was supported by the Singapore Ministry of Health’s National Medical Research Council (NMRC) Clinician Scientist Award. (grant ID NMRC/CSA-INV /0003/2015) and the Agency for Science, Technology and Research (A *STAR) awarded to A/Prof. Melvin Leow.

Mutations in the DNA mismatch repair gene MSH2 are causative of microsatellite instability (MSI) in multiple cancers. Here, we discovered that besides its well-established role in DNA repair, MSH2 exerts a novel epigenomic function in gastric cancer. Unbiased CRISPR-based mass spectrometry combined with genome-wide CRISPR functional screening revealed that in early-stage gastric cancer MSH2 genomic binding is not randomly distributed but rather is associated specifically with tumor-associated super-enhancers controlling the expression of cell adhesion genes. At these loci, MSH2 genomic binding was required for chromatin rewiring, de novo enhancer-promoter interactions, maintenance of histone acetylation levels, and regulation of cell adhesion pathway expression. The chromatin function of MSH2 was independent of its DNA repair catalytic activity but required MSH6, another DNA repair gene, and recruitment to gene loci by the SWI/SNF chromatin remodeler SMARCA4/BRG1. Loss of MSH2 in advanced gastric cancers was accompanied by deficient cell adhesion pathway expression, epithelial-mesenchymal transition, and enhanced tumorigenesis in vitro and in vivo. However, MSH2-deficient gastric cancers also displayed addiction to BAZ1B, a bromodomain-containing family member, and consequent synthetic lethality to bromodomain and extraterminal motif (BET) inhibition. Our results reveal a role for MSH2 in gastric cancer epigenomic regulation and identify BET inhibition as a potential therapy in MSH2-deficient gastric malignancies. Agency for Science, Technology and Research (A*STAR) Ministry of Education (MOE) National Medical Research Council (NMRC) National Research Foundation (NRF) This study was supported by National Medical Research Council grants NMRC/STaR/0026/2015, MOH-000967-00 and OFLCG18May-0003, and A*ccelerate GAP fund ETPL/15-R15 GAP-0021 (to P. Tan) and MOE tier 2 grant (MOE2017-T2-1-105) and NMRC CS-IRG grant (NMRC/CIRG/1481/2017 to S. Li) and SCISSOR (A*STAR IAF-PP) H18/01/a0/020. Funding was also provided by Cancer Science Institute of Singapore, NUS, under the National Research Foundation Singapore and the Singapore Ministry of Education under its Research Centers of Excellence initiative, and block funding from Duke-NUS Medical School. A.M. Nargund is also supported by St. Baldrick's Foundation Research Award. R. Sundar is supported by a National Medical Research Council (NMRC) Fellowship, Singapore. M.J. Fullwood is supported by the RNA Biology Center at the Cancer Science Institute of Singapore, NUS, as part of funding under the Singapore Ministry of Education Academic Research Fund Tier 3 awarded to Daniel Tenen (MOE2014-T3-1-006) and the National Research Foundation Singapore and the Singapore Ministry of Education under its Research Centers of Excellence initiative.

White matter hyperintensities (WMH) and β-amyloid (Aβ) accumulation have both been linked to neurodegeneration in Alzheimer's disease (AD). However, the independent effects of global WMH and regional Aβ on the corresponding regional cortical thickness have not been investigated. Here, we evaluated 280 cognitively normal (CN), 450 mild cognitive impairment (MCI), and 63 individuals with AD dementia separately. In CN individuals, only WMH was associated with lower cortical thickness in fronto-temporal regions, independent of regional Aβ deposition in the corresponding cortical regions. In MCI individuals, the spatial pattern of independent WMH associations was predominantly in temporal and cingulate regions, while independent regional Aβ associations were now evident in temporal regions. No regional interactions were found. In non-demented individuals and MCI individuals alone, we found that global WMH, composite regional Aβ burden and cortical thickness in AD-associated regions all independently predicted progression to AD dementia. Our findings suggest that the independent effects of global WMH and regional Aβ on regional cortical thickness are spatially different, converging in temporal regions in MCI individuals. Ministry of Education (MOE) Nanyang Technological University This study was supported by Nanyang Technological University, Singapore Start-Up Grant M40824100 (CHT) and MOE AcRF Tier 1 M4012193 (CHT). Data collection and sharing for this project was funded by the Alzheimer’s Disease Neuroimaging Initiative (ADNI) (National Institutes of Health Grant U01 AG024904) and DOD ADNI (Department of Defense award number W81XWH-12-2-0012). ADNI is funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through generous contributions from the following: AbbVie, Alzheimer’s Association; Alzheimer’s Drug Discovery Foundation; Araclon Biotech; BioClinica, Inc.; Biogen; Bristol-Myers Squibb Company; CereSpir, Inc.; Cogstate; Eisai Inc.; Elan Pharmaceuticals, Inc.; Eli Lilly and Company; EuroImmun; F. Hoffmann-La Roche Ltd and its affiliated company Genentech, Inc.; Fujirebio; GE Healthcare; IXICO Ltd.;Janssen Alzheimer Immunotherapy Research & Development, LLC.; Johnson & Johnson Pharmaceutical Research & Development LLC.; Lumosity; Lundbeck; Merck & Co., Inc.; Meso Scale Diagnostics, LLC.; NeuroRx Research; Neurotrack Technolo gies; Novartis Pharmaceuticals Corporation; Pfizer Inc.; Piramal Imaging; Servier; Takeda Pharmaceutical Company; and Transition Therapeutics. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. Private sector contributions are facilitated by the Foundation for the National Institutes of Health (www.fnih.org). The grantee organization is the Northern California Institute for Research and Education.

Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018-2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it's difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.

Core outcome sets are critically important outcomes that should be measured in clinical trials. Their absence in atopic dermatitis is a form of research waste and impedes combining evidence to inform patient care. Here, we articulate the rationale for core outcome sets in atopic dermatitis and review the work of the international Harmonising Outcome Measures for Eczema group from its inception in Munich, 2010. We describe core domain determination (what should be measured), to instrument selection (how domains should be measured), culminating in the complete core outcome measurement set in Tokyo, 2019. Using a "road map," Harmonising Outcome Measures for Eczema includes diverse research methods including Delphi and nominal group techniques informed by systematic reviews of properties of candidate instruments. The 4 domains and recommended instruments for including in all clinical trials of atopic dermatitis are patient symptoms, measured by Patient-Oriented Eczema Measure and peak Numerical Rating Scale 11 for itch intensity over 24 hours, clinical signs measured using the Eczema Area and Severity Index, quality of life measured by the Dermatology Life Quality Index series for adults, children, and infants, and long-term control measured by either Recap of atopic eczema or Atopic Dermatitis Control Tool. Published version Details of funding for each of the consensus meetings is outlined in the published meeting reports. The following additional funding sources contributed to facilitating the HOME COS development: National Institute for Health and Care Research Senior Investigator award to Prof Hywel Williams (RE 2374) funded travel costs to enable UK patients to participate in HOME meetings; National Institute for Health and Care Research Programme Grant for Applied Research RP-PG-0407-10177 ‘‘Setting Priorities and Reducing Uncertainties for the Prevention and Treatment of Skin Disease (SPRUSD)’’ was used to support completion of the some of the systematic reviews, the cost of meetings and patient and public involvement (Prof Kim Thomas); NIH NIAMS A Community-based Assessment of Skin Care, Allergies, and Eczema: The CASCADE Trial grant number 5 R01 AR071057-05 and Oregon Clinical and Translational Research Institute (OCTRI) assisted with outcome evaluations and associated travel costs (Prof Eric Simpson); Laura Howells received a PhD studentship from the British Skin Foundation (Ref: 8016) for studies that informed this work.

Neurodegenerative diseases (NDDs) such as Alzheimer's disease (AD) and Parkinson's disease (PD) are a heterogeneous group of disorders characterized by progressive degeneration of neurons. NDDs threaten the lives of millions of people worldwide and regretfully remain incurable. It is well accepted that dysfunction of mitochondria underlies the pathogenesis of NDDs. Dysfunction of mitochondria results in energy depletion, oxidative stress, calcium overloading, caspases activation, which dominates the neuronal death of NDDs. Therefore, mitochondria are the preferred target for intervention of NDDs. So far various mitochondria-targeting drugs have been developed and delightfully some of them demonstrate promising outcome, though there are still some obstacles such as targeting specificity, delivery capacity hindering the drugs development. In present review, we will elaborately address 1) the strategy to design mitochondria targeting drugs, 2) the rescue mechanism of respective mitochondria targeting drugs, 3) how to evaluate the therapeutic effect. Hopefully this review will provide comprehensive knowledge for understanding how to develop more effective drugs for the treatment of NDDs. Published version This study was supported by the National Key R&D Program of China (2020YFA0709900), the National Natural Science Foundation of China (22077101), China-Sweden Joint Mobility Project (51811530018, China) and Postdoctoral Research Funding Schemes of Jiangsu Province (2021, China).

Hand eczema is a common inflammatory condition of the skin that has been linked to hand hygiene. This systematic review and meta-analysis aims to determine the risks of hand eczema associated with hand hygiene, including frequency of hand washing, wet work and use of alcohol hand rub. A comprehensive search of MEDLINE, EMBASE and Cochrane Library was performed for cohort, case-control or cross-sectional studies that analysed the association between hand hygiene and risk of hand eczema. Results of individual studies were presented in respective forest plots and pooled summary relative risks were estimated using a random-effects model. Forty-five studies were included in the analysis. Hand washing at least 8-10 times daily significantly increased risk of hand eczema (relative risk [RR] 1.51; 95% confidence interval [CI]: 1.35-1.68; p

Musculoskeletal injuries are common in humans. The cascade of cellular and molecular events following such injuries results either in healing with functional recovery or scar formation. While fibrotic scar tissue serves to bridge between injured planes, it undermines functional integrity. Hence, faithful regeneration is the most desired outcome; however, the potential to regenerate is limited in humans. In contrast, various non-mammalian vertebrates have fascinating capabilities of regenerating even an entire appendage following amputation. Among them, zebrafish is an important and accessible laboratory model organism, sharing striking similarities with mammalian embryonic musculoskeletal development. Moreover, clinically relevant muscle and skeletal injury zebrafish models recapitulate mammalian regeneration. Upon muscle injury, quiescent stem cells - known as satellite cells - become activated, proliferate, differentiate and fuse to form new myofibres, while bone fracture results in a phased response involving hematoma formation, inflammation, fibrocartilaginous callus formation, bony callus formation and remodelling. These models are well suited to testing gene- or pharmaco-therapy for the benefit of conditions like muscle tears and fractures. Insights from further studies on whole body part regeneration, a hallmark of the zebrafish model, have the potential to complement regenerative strategies to achieve faster and desired healing following injuries without any scar formation and, in the longer run, drive progress towards the realisation of large-scale regeneration in mammals. Here, we provide an overview of the basic mechanisms of musculoskeletal regeneration, highlight the key features of zebrafish as a regenerative model and outline the relevant studies that have contributed to the advancement of this field. AKKP is supported by a Nanyang Technological University (Lee Kong Chian School of Medicine) Research Scholarship. PWI is supported by the Toh Kian Chui Foundation.

Increasing evidence links metabolism, protein synthesis, and growth signaling to impairments in the function of hematopoietic stem and progenitor cells (HSPCs) during aging. The Lin28b/Hmga2 pathway controls tissue development, and the postnatal downregulation of this pathway limits the self-renewal of adult vs fetal hematopoietic stem cells (HSCs). Igf2bp2 is an RNA binding protein downstream of Lin28b/Hmga2, which regulates messenger RNA stability and translation. The role of Igf2bp2 in HSC aging is unknown. In this study, an analysis of wild-type and Igf2bp2 knockout mice showed that Igf2bp2 regulates oxidative metabolism in HSPCs and the expression of metabolism, protein synthesis, and stemness-related genes in HSCs of young mice. Interestingly, Igf2bp2 expression and function strongly declined in aging HSCs. In young mice, Igf2bp2 deletion mimicked aging-related changes in HSCs, including changes in Igf2bp2 target gene expression and impairment of colony formation and repopulation capacity. In aged mice, Igf2bp2 gene status had no effect on these parameters in HSCs. Unexpectedly, Igf2bp2-deficient mice exhibited an amelioration of the aging-associated increase in HSCs and myeloid-skewed differentiation. The results suggest that Igf2bp2 controls mitochondrial metabolism, protein synthesis, growth, and stemness of young HSCs, which is necessary for full HSC function during young adult age. However, Igf2bp2 gene function is lost during aging, and it appears to contribute to HSC aging in 2 ways: the aging-related loss of Igf2bp2 gene function impairs the growth and repopulation capacity of aging HSCs, and the activity of Igf2bp2 at a young age contributes to aging-associated HSC expansion and myeloid skewing. Ministry of Education (MOE) Funding support for this article was provided by the the German Research Foundation (DFG) within the collaborative research center “PolyTarget” (to K.L.R.) and by an Ong Tiong Tat Professorship financed by Ministry of Education, Singapore (to B.O.B.). SFB1278, project ID: 316213987.

There is increasing interest in the use of ethnography as a qualitative research approach to explore, in depth, issues of culture in health professions education (HPE). Our specific focus in this article is incorporating the digital into ethnography. Digital technologies are pervasively and increasingly shaping the way we interact, behave, think, and communicate as health professions educators and learners. Understanding the contemporary culture(s) of HPE thus means paying attention to what goes on in digital spaces. In this paper, we critically consider some of the potential issues when the field of ethnography exists outside the space time continuum, including the need to engage with theory in research about technology and digital spaces in HPE. After a very brief review of the few HPE studies that have used digital ethnography, we scrutinize what can be gained when ethnography encompasses the digital world, particularly in relation to untangling sociomaterial aspects of HPE. We chart the shifts inherent in conducting ethnographic research within the digital landscape, specifically those related to research field, the role of the researcher and ethical issues. We then use two examples to illustrate possible HPE research questions and potential strategies for using digital ethnography to answer those questions: using digital tools in the conduct of an ethnographic study and how to conduct an ethnography of a digital space. We conclude that acknowledging the pervasiveness of technologies in the design, delivery and experiences of HPE opens up new research questions which can be addressed by embracing the digital in ethnography.

There is a scarcity of population-level data of pediatric COVID-19 infection from Southeast Asia. This study aims to describe and compare epidemiological, clinical, laboratory and outcome data among pediatric COVID-19 cases versus controls in two neighboring countries, Singapore and Malaysia. We used a test-negative case-control study design recruiting all suspected COVID-19 cases (defined by either clinical or epidemiological criteria) from January 2020 to March 2021 admitted to two main pediatric centers in Singapore and Malaysia. Data were collected using a standardized registry (Pediatric Acute and Critical Care COVID-19 Registry of Asia). The primary outcome was laboratory-confirmed COVID-19. Univariate and multivariable logistic regression analysis was used to determine factors associated with COVID-19. This study included 923 children with median age of 4 (interquartile range 2-9) years. Of these, 35.3% were COVID-19 cases. Children with COVID-19 were more likely to be asymptomatic compared with controls (49.4 versus 18.6%; P < 0.0001). They were also less likely to develop respiratory complications, such as bronchitis or pneumonia, or organ dysfunction. Four (1.2%) of our COVID-19 patients required respiratory support compared with 14.2% of controls needing respiratory support. COVID-19 cases tended to have lower neutrophil count but higher hemoglobin compared with controls. There were no reported deaths of COVID-19 infection; in contrast, 0.7% of the control group died. In the multivariable analysis, older age, travel history, and close contact with an infected household member were associated with COVID-19 infection. This study shows that the majority of pediatric COVID-19 cases were of lesser severity compared with other community acquired respiratory infections. Published version This study was funded by the SingHealth Duke- NUS Global Health Institute Pilot Research Grant, project no. Duke- NUS/SDGHI_RGA(Khoo)/2020/0006 (principal investigator: J. J. M. W.). The Singapore Clinical Research Institute supported this study in kind by providing database development and maintenance services. C. F. Y. is supported by the SingHealth Duke-NUS Academic Medicine COVID-19 Rapid Response Research Grant, AM/COV001/ 2020 (SRDUKAMC2001).

With the global COVID-19 pandemic, governments from many countries in the world implemented various restrictions to prevent the SARS-Cov-2 virus's spread, including social distancing measures, quarantine, in-home lockdown, and the closure of services and public spaces. This led to an in-creased use of social media platforms to make people feel more connected, but also to maintain physical activity while self-isolating. Concerns about physical appearance and the desire to keep or reach a muscular and toned ideal body, might have further reinforced the engagement in fitness-related social media activities, like sharing progresses in training achievements or following more fitness contents on popular profiles. To better understand the underlying relation among these factors, the present study investigates 729 responses to the Exercise Addiction Inventory (EAI), the Appearance Anxiety Inventory (AAI), the Self-Compassion Scale (SCS) and their association to social media usage and compares the results cross-culturally in five countries (Spain, Lithuania, United Kingdom, Japan, and Hungary). Findings highlight significant differences between males and females, espe-cially in regard to the time spent online (U = 477.5, p = 0.036). Greater levels of appearance anxiety were associated with the exposure to fitness-related contents on social media. These results strongly confirm the previously highlighted association between fitspiration media and body image anxiety predominantly in females. Clinical implications and future considerations in terms of prevention and treatment in a situation of global emergency are also discussed. Published version This publication is based upon work from the European Network for Problematic Usage of the Internet, supported by COST (European Cooperation in Science and Technology; CA16207). This research was also supported by Fundaç ̃ao para a Ciˆencia e Tecnologia (FCT) through R&D Units funding (UIDB/05210/2020). ZD’s contribution was supported by the Hungarian National Research, Development, and Innovation Office (KKP126835; K134807; ELTE Thematic Excellence Programme, 2020; KP2020-IKA-05). HF’s contribution was supported by “Grant-in-Aid” by the Smoking Research Foundation.

Aims/hypothesis Although targeted in extrapancreatic tissues by several drugs used to treat type 2 diabetes, the role of AMP-activated protein kinase (AMPK) in the control of insulin secretion is still debatable. Previous studies have used pharmacological activators of limited selectivity and specificity, and none has examined in primary pancreatic beta cells the actions of the latest generation of highly potent and specific activators that act via the allosteric drug and metabolite (ADaM) site. Methods AMPK was activated acutely in islets isolated from C57BL6/J mice, and in an EndoC-βH3 cell line, using three structurally distinct ADaM site activators (991, PF-06409577 and RA089), with varying selectivity for β1- vs β2-containing complexes. Mouse lines expressing a gain-of-function mutation in the γ1 AMPK subunit (D316a) were generated to examine the effects of chronic AMPK stimulation in the whole body, or selectively in the beta cell. Results Acute (1.5 h) treatment of wild-type mouse islets with 991, PF-06409577 or RA089 robustly stimulated insulin secretion at high glucose concentrations (ppp2+ dynamics in response to 991 (AUC, ppppp Conclusions/interpretation AMPK activation exerts complex, time-dependent effects on insulin secretion. These observations should inform the design and future clinical use of AMPK modulators. Graphical abstract

Although there are a variety of psychological and therapeutic approaches to coping Autism Spectrum Disorder, people with autism still face some challenges in a "normal" therapy setting. Some therapy organizations and services have proposed an alternative therapy approach, Animal-assisted therapy (AAT). The aim of this phenomenological study was to gain a better understanding of the therapists and parents of individuals who choose the alternative approach, AAT. Data were collected through structured interviews with a group of three therapists and four parents. An analysis of the data revealed three main themes; the first theme named the perceived benefits of AAT with three subthemes consisting of physical benefits, sensory benefits and emotional benefits. The second theme is named the way AAT works with subthemes of client-centred therapy and mixed models, and the third theme is potential limitations of AAT. Limitations and suggestions for future research are discussed.

Backgrounds The COVID-19 pandemic has resulted in not only significant mortalities in Vietnam but has had an impact on its economy. Previous studies have highlighted how the pandemic has had a marginal impact on Vietnamese healthcare workers working at the frontlines. To date, there have been several other studies examining the impact of COVID-19 on intentions to transition between jobs among healthcare professionals, but this has yet to be explored amongst Vietnamese healthcare workers. Methods To achieve the study’s objectives an online cross-sectional study was conducted between September to November 2021. Snowball sampling methodology was adopted for the recruitment of participants. The questionnaire that was used for this study comprised of the following sections: (a) socio-demographic information; (b) impact of COVID-19 on work; (c) risk of exposure to COVID-19; (d) career choices/intentions to change job, and (e) motivation at work. Results There were 5727 completed the entire survey. 17.2% of the respondents have had increased job satisfaction, 26.4% reported increased motivation to work, and 40.9% reported decreased motivation to work. Whilst there were changes in the daily work intensity and the level of work-related stress, more than 60% of respondents we sampled did not intend to switch careers. Demographic variables like gender, whether one was a student or an existing healthcare worker, and income related to work motivation. The community’s stigma was a negative factor that declined intrinsic motivation as well as decreased work retention. Conclusions Our study is instrumental in identifying the impact of COVID-19 on career choices amongst Vietnamese healthcare workers. The factors identified have clear implications for policymaking.

The development of paired appendages was a key innovation during evolution and facilitated the aquatic to terrestrial transition of vertebrates. Largely derived from the lateral plate mesoderm (LPM), one hypothesis for the evolution of paired fins invokes derivation from unpaired median fins via a pair of lateral fin folds located between pectoral and pelvic fin territories1. Whilst unpaired and paired fins exhibit similar structural and molecular characteristics, no definitive evidence exists for paired lateral fin folds in larvae or adults of any extant or extinct species. As unpaired fin core components are regarded as exclusively derived from paraxial mesoderm, any transition presumes both co-option of a fin developmental programme to the LPM and bilateral duplication2. Here, we identify that the larval zebrafish unpaired pre-anal fin fold (PAFF) is derived from the LPM and thus may represent a developmental intermediate between median and paired fins. We trace the contribution of LPM to the PAFF in both cyclostomes and gnathostomes, supporting the notion that this is an ancient trait of vertebrates. Finally, we observe that the PAFF can be bifurcated by increasing bone morphogenetic protein signalling, generating LPM-derived paired fin folds. Our work provides evidence that lateral fin folds may have existed as embryonic anlage for elaboration to paired fins. Agency for Science, Technology and Research (A*STAR) Ministry of Education (MOE) Published version This work was funded by the Industry Aligned Fund (IAF) Agency for Science, Technology and Research (grant to T.J.C. and K.-W.T.); Ministry of Education (MoE) Tier 3 (grant 2016-T3-1-005 to T.J.C., C.W. and H.M.); Ministry of Education (MoE) Tier 1 (grant 2016-T1-001-055 to T.J.C. and C.Z.); Ministry of Education (MoE) Tier 2 (grant MOE-T2EP30221-0008 to C.W.); the Company of Biologists (travelling fellowship to M.J.T.); the National Science Foundation (grants IOS-1853949 to M.C.D. and 2203311 to C.M.); the Swiss National Science Foundation Sinergia (grant CRSII5_180345 to C.M.); the Swiss Bridge Foundation (C.M.); Additional Ventures Single Ventricle Research Fund (SVRF) (grant 1048003 to C.M.); the University of Colorado School of Medicine Anschutz Medical Campus and the Children’s Hospital Colorado Foundation (C.M.); the National Institutes of Health (NIH), National Institute of General Medical Sciences (grants 1T32GM141742-01 to H.R.M. and 3T32GM121742-02S1 to H.R.M.); Australian Research Council (discovery grant DP200103219 to F.J.T. and P.D.C); National Health and Medical Research Council (senior principal research fellow APP1136567 to P.D.C.); and the NIH (grant R35NS111564 to J.S. and M.E.B.).

Photorealistic 3D models (PR3DM) have great potential to supplement anatomy education; however, there is evidence that realism can increase cognitive load and negatively impact anatomy learning, particularly in students with decreased spatial ability. These differing viewpoints have resulted in difficulty in incorporating PR3DM when designing anatomy courses. To determine the effects of spatial ability on anatomy learning and reported intrinsic cognitive load using a drawing assessment, and of PR3DM versus an Artistic colour-coded 3D model (A3DM) on extraneous cognitive load and learning performance. First-year medical students participated in a cross-sectional (Study 1) and a double-blind randomised control trial (Study 2). Pre-tests analysed participants' knowledge of anatomy of the heart (Study 1, N = 50) and liver (Study 2, N = 46). In Study 1, subjects were first divided equally using a mental rotations test (MRT) into low and high spatial ability groups. Participants memorised a 2D-labeled heart valve diagram and sketched it rotated 180°, before self-reporting their intrinsic cognitive load (ICL). For Study 2, participants studied a liver PR3DM or its corresponding A3DM with texture-homogenisation, followed by a liver anatomy post-test, and reported extraneous cognitive load (ECL). All participants reported no prior anatomy experience. Participants with low spatial ability (N = 25) had significantly lower heart drawing scores (p = 0.001) than those with high spatial ability (N = 25), despite no significant differences in reported ICL (p = 0.110). Males had significantly higher MRT scores than females (p = 0.011). Participants who studied the liver A3DM (N = 22) had significantly higher post-test scores than those who studied the liver PR3DM (N = 24) (p = 0.042), despite no significant differences in reported ECL (p = 0.720). This investigation demonstrated that increased spatial ability and colour-coding of 3D models are associated with improved anatomy performance without significant increase in cognitive load. The findings are important and provide useful insight into the influence of spatial ability and photorealistic and artistic 3D models on anatomy education, and their applicability to instructional and assessment design in anatomy.

Serious games may resolve problems relating to low motivation in complex medical topics such as anatomy. However, they remain relatively novel introductions to the science of learning, and further research is required to ascertain their benefits. This study describes the overall development and testing of a digital serious boardgame designed to facilitate the rehearsal of musculoskeletal anatomy based on self-determination theory with considerations for the psychological state of Flow. It was hypothesized that students assigned to the intervention game condition would attain higher Flow scores, a measure of engagement and intrinsic motivation, than students assigned to the game-free control, and that the intervention condition would report either superior or non-superior, but not inferior, scores on a surprise recall test. A total of 36 second-year undergraduate medical students participated in the quasi-randomized controlled trial, where the intervention groups went first and randomly drew questions that were mirrored into the control groups. All students were administered an identical 10-question baseline assessment before their interventions, the Short Flow Scale immediately after, and a surprise test four-to-six weeks later. Independent samples t-tests indicated that students of both conditions were of similar baseline knowledge (t = 0.7, p = 0.47), significantly higher Flow scores in the game condition (t = 2.99, p = 0.01), and no significant differences between surprise test scores (t = -0.3, p = 0.75). The game appears to be an appropriate game-based tool for student rehearsal of anatomical education, stemming from a strong theoretical base that facilitates high engagement and intrinsic motivation. Nanyang Technological University Published version This project was supported by the Special Project Grant from the Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine.

We evaluated the incidence of intraforaminal and extraforaminal variations of the vertebral artery (VA) in the Omani population using computed tomography angiography (CTA). CTA results of 579 consecutive Omani patients (1158 VAs) were reviewed retrospectively for the analysis of unusual entrance transverse foramen (UE-V2), midline migration (MM), persistent first intersegmental artery (PFIA), and paracondylar process (PP) variations of VA. The anomalous origin and VA dominance were also determined. The sex and side differences in the incidence of these variations were analyzed using the Chi-square test. The incidence of UE-V2 was observed in 10.44% (121 out of 1158) of cases. The incidence of UE-V2 at different vertebral levels was observed in the sequence of C5 (71%) > C4 (20.7%) > C7 (7.43%) > C3 (0.8%). The incidence of MM variation was 1.29%. PFIA and PP variations were found in 0.17% and 0.60% of cases, respectively. Left-dominant VA was identified in 44.7% (259 out of 579) of subjects. The incidence of VA variations was not significantly associated with either sex or side. Anomalous VA origin from arch aorta (3.5%) and right common carotid artery (CCA) (0.08%) was identified. The incidence of UE-V2 in Omani subjects is comparatively higher than that reported in other Asian populations. A rare case of VA originating from the right CCA was also identified.

O'nyongnyong virus (ONNV) is a re-emerging alphavirus previously known to be transmitted by main malaria vectors, thus suggesting the possibility of coinfections with arboviruses in co-endemic areas. However, the pathological outcomes of such infections remain unknown. Using murine coinfection models, we demonstrated that a preexisting blood-stage Plasmodium infection suppresses ONNV-induced pathologies. We further showed that suppression of viremia and virus dissemination are dependent on Plasmodium-induced IFNγ and are associated with reduced infection of CD45- cells at the site of virus inoculation. We further proved that treatment with IFNγ or plasma samples from Plasmodium vivax-infected patients containing IFNγ are able to restrict ONNV infection in human fibroblast, synoviocyte, skeletal muscle, and endothelial cell lines. Mechanistically, the role of IFNγ in restricting ONNV infection was confirmed in in vitro infection assays through the generation of an IFNγ receptor 1 α chain (IFNγR1)-deficient cell line. Agency for Science, Technology and Research (A*STAR) Published version The study was supported by a core research grant provided to A*STAR Infectious Diseases Labs and Singapore Immunology Network by the Biomedical Research Council (BMRC) from the Agency for Science, Technology and Research (A*STAR). A Torres-Ruesta is supported by the A*STAR Singapore International Graduate Award (SINGA) scholarship. Flow cytometry platform is supported by the Health and Biomedical Sciences (HBMS) Open Fund Shared Infrastructure Support Grant under the Immunomonitoring Service Platform project (NRF2017_SISFP09). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Post-pandemic economic recovery relies on border control for safe cross-border movement. Following the COVID-19 pandemic, we investigate whether effective strategies generalize across diseases and variants. For four SARS-CoV-2 variants and influenza A-H1N1, we simulated 21 strategy families of varying test types and frequencies, quantifying expected transmission risk, relative to no control, by strategy family and quarantine length. We also determined minimum quarantine lengths to suppress relative risk below given thresholds. SARS-CoV-2 variants showed similar relative risk across strategy families and quarantine lengths, with at most 2 days' between-variant difference in minimum quarantine lengths. ART-based and PCR-based strategies showed comparable effectiveness, with regular testing strategies requiring at most 9 days. For influenza A-H1N1, ART-based strategies were ineffective. Daily ART testing reduced relative risk only 9% faster than without regular testing. PCR-based strategies were moderately effective, with daily PCR (0-day delay) testing requiring 16 days for the second-most stringent threshold. Viruses with high typical viral loads and low transmission risk given low viral loads, such as SARS-CoV-2, are effectively controlled with moderate-sensitivity tests (ARTs) and modest quarantine periods. Viruses with low typical viral loads and substantial transmission risk at low viral loads, such as influenza A-H1N1, require high-sensitivity tests (PCR) and longer quarantine periods. Published version This work was supported by the National University of Singapore (NUS)’s Reimagine Research Fund (no grant number) and the NUS Saw Swee Hock School of Public Health’s Start Up Fund (22-5118-A0001).

Wai Kitt Chee,1 Vivien Cherng Hui Yip,1 Ivan O’Neill Tecson,1 Chun Hau Chua,1 Bryan Chin Hou Ang,1 Ae Ra Kee,1 Jeremy Youwei Hu,1 Tsia-Chuen John Kan,1 Leonard Wei Leon Yip1,2 1Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore; 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, SingaporeCorrespondence: Vivien Cherng Hui Yip, Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore, Tel +65 62566011, Email vyip82@yahoo.co.ukAim: This study aims to compare the efficacy and safety of combined phacoemulsification with iStent inject (Phaco-iStent) and Hydrus microstent (Phaco-Hydrus).Methods: This was a retrospective comparative study of patients who underwent Phaco-iStent from April 2019 to August 2020 and Phaco-Hydrus from August 2019 to December 2020 at a tertiary eye centre in Singapore. Sixty-nine Phaco-iStent eyes and 49 Phaco-Hydrus eyes were included in this study. Complete surgical success was defined as freedom from second glaucoma surgery, Intraocular pressure (IOP) of 18 mmHg or less, and discontinuation of all antiglaucoma medications.Results: At 12 months, both Phaco-iStent and Phaco-Hydrus groups had comparable surgical success rate (68.1% vs 51%, p=0.061), reduction in antiglaucoma medication use (− 1.3 ± 0.1 vs − 1.4 ± 0.10, p=0.880) and intraocular pressure reduction (− 1.1 ± 0.5 mmHg vs – 1.6 ± 0.9 mmHg, p=0.323). Overall intraoperative and postoperative complications rate were similar in both groups, though hyphema was more commonly seen in early postoperative period in the Phaco-Hydrus compared to the Phaco-iStent group (8% vs 0%, p=0.028), with majority of cases resolving without any need for surgical intervention. Device obstruction was also more common in the Phaco-Hydrus group compared to the Phaco-iStent group (14% vs 4.3%, p=0.04).Conclusion: Phaco-iStent and Phaco-Hydrus have similar surgical efficacy and safety profiles at 12 months.Keywords: glaucoma, phacoemulsification, cataract extraction, iStent inject, Hydrus microstent

Background: Physical activity is essential to improve health and reduce the risk of recurrence of stroke or transient ischemic attack (TIA). Still, people post stroke or TIA are often physically inactive and the availability of physical activity promotion services are often limited. This study builds on an existing Australian telehealth-delivered programme (i-REBOUND– Let’s get moving) which provides support for home-based physical activity for people post stroke or TIA. The aim of this study is to test the feasibility, acceptability, and preliminary effects of a mobile Health (mHealth) version of the i-REBOUND programme for the promotion of physical activity in people post stroke or TIA living in Sweden. Methods: One hundred and twenty participants with stroke or TIA will be recruited via advertisement. A parallel-group feasibility randomised controlled trial design with a 1:1 allocation ratio to 1) i-REBOUND programme receiving physical exercise and support for sustained engagement in physical activity through behavioural change techniques, or 2) behavioural change techniques for physical activity. Both interventions will proceed for six months and be delivered digitally through a mobile app. The feasibility outcomes (i.e., reach, adherence, safety and fidelity) will be monitored throughout the study. Acceptability will be assessed using the Telehealth Usability Questionnaire and further explored through qualitative interviews with a subset of both study participants and the physiotherapists delivering the intervention. Clinical outcomes on preliminary effects of the intervention will include blood pressure, engagement in physical activity, self-perceived exercise self-efficacy, fatigue, depression, anxiety, stress and health-related quality of life and will be measured at baseline and at 3, 6 and 12 months after the baseline assessments. Discussion: We hypothesise that the mHealth delivery of the i-REBOUND programme will be feasible and acceptable in people post stroke/TIA living in rural and urban regions of Sweden. The results of this feasibility trial will inform the development of full-scale and appropriately powered trial to test the effects and costs of mHealth delivered physical activity for people after stroke or TIA. Published version Open access funding provided by Karolinska Institute. This project is supported by the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare (FORTE), Center for Innovative Medicine (CIMED), Stockholm Region, Research School in Health Science at Karolinska Institutet, Strategic Research Area Health Care Science at Karolinska Institutet, Loo & Hans Osterman Foundation for Medical Research at Karolinska Institutet, Foundation for Geriatric diseases at Karolinska Institutet, the Swedish Stroke Association, NEURO Sweden and VINNOVA/MedTech4Health Innovators in health and care.

Diabetes mellitus (DM) is a serious threat to global health and diabetic foot ulcers (DFU) remains one of the most common complications of DM1 affecting around 20 million people annually.2 DFUs are complex to treat, take months or years to heal, and the recurrence rates remain high up to 40% within 1 year of healing.3 People with DFUs are at risk of prolonged healing times and hospitalisation, reduced quality of life4, 5 and higher five-year mortality rates.3 Moreover, DFU is a causal factor for up to 85% of patients with diabetes who subsequently undergo lower extremity amputation3, 6 and is a leading cause of global disability.2 Singapore has the highest rate of diabetic lower extremity amputation (DLEA) in the world7 because of DFU and the trend is increasing.8 Additionally, DFU is a substantial clinical and economic burden to health systems in Singapore with escalating healthcare costs corresponding to more proximal amputation levels and high re-admission rates.9 Thus, understanding barriers to managing DFU is vital for improving patient care. Nanyang Technological University Published version Centre for Primary Health Care Research and Innovation,a partnership between the Lee Kong Chian School ofMedicine, Nanyang Technological University Singapore,and the National Healthcare Group Singapore, Grant/Award Number: Ref No. 7.1/008.

Background IgG4-related disease (IgG4-RD) is a heterogeneous autoimmune disorder characterised by inflammatory lesions. Diagnostic imaging, such as 2-[18F]FDG PET/CT, is critical in evaluation of the disease, especially for potentially lethal cardiovascular manifestations. This retrospective study examines the usefulness of semi-quantitative parameters of 2-[18F]FDG PET/CT in monitoring IgG4-RD in patients with and without cardiovascular manifestations. Methods Patients diagnosed with IgG4-RD who underwent a 2-[18F]FDG PET/CT scan were identified and classified based on presence or absence of cardiovascular disease. Clinical and laboratory data were extracted and compared to three 2-[18F]FDG PET/CT semi-quantitative parameters: maximum standardised uptake value (SUVmax), metabolic tumour volume (MTV), and total lesion glycolysis (TLG). Tissue-to-background blood (TBR) values were also evaluated for cardiovascular manifestations. These data were also compared in patients before and after receiving immunosuppressive therapy. Results Forty-six patients identified were divided into an eight member subgroup of patients with cardiovascular manifestations, and a thirty-eight member subgroup of patients without. Patients with cardiovascular lesions were most frequently identified incidentally on imaging evaluation for other diseases (37.5%), with none presenting with chest pain or other cardiovascular symptoms. Ten patients with pre-treatment and post-treatment 2-[18F]FDG PET/CT scans demonstrated significant decreases in all semi-quantitative parameters, with no significant decrease in total IgG or ESR. The decrease in SUVmax, MTV, TLG following therapy was replicated in patients with and without cardiovascular manifestations. Conclusion 2-[18F]FDG PET/CT is an important investigation to determine all sites of involvement in this multisystemic disease and to rule out life-threatening cardiovascular manifestations even in the absence of symptoms. Semi-quantitative parameters such as SUVmax, MTV, TLG, and TBR are useful in assessing treatment response in patients. There are no serological substitutes that can quantify the extent of disease involvement like 2-[18F]FDG PET/CT.

Objective: Abnormal liver tests have been associated with worse clinical outcomes in patients infected with COVID-19. This retrospective observational study from Singapore aims to elucidate simple clinical predictors of abnormal alanine aminotransferase (ALT) in COVID-19 infections. Design: 717 patients hospitalised with COVID-19 at the National Centre for Infectious Diseases (NCID), Singapore, from 23 January–15 April 2020 were screened, of which 163 patients with baseline normal alanine transferase (ALT) and at least two subsequent ALTs performed were included in the final analysis. Information on baseline demographics, clinical characteristics and biochemical laboratory tests were collected. Results: 30.7% of patients developed abnormal ALT. They were more likely to be older (60 vs. 55, p = 0.022) and have comorbidities of hyperlipidaemia and hypertension. The multivariate logistic regression showed that R-factor ≥1 on admission (adjusted odds ratio (aOR) 3.13, 95% Confidence Interval (CI) 1.41–6.95) and hypoxia (aOR 3.54, 95% CI 1.29–9.69) were independent risk factors for developing abnormal ALT. The patients who developed abnormal ALT also ran a more severe course of illness with a greater proportion needing supplementary oxygen (58% vs. 18.6%, p < 0.0005), admission to the Intensive Care Unit (ICU)/High Dependency Unit (HDU) (32% vs. 11.5%, p = 0.003) and intubation (20% vs. 2.7%, p < 0.0005). There was no difference in death rate between the two groups. Conclusions: Liver injury is associated with poor clinical outcomes in patients with COVID-19. R-factor ≥1 on admission and hypoxia are independent simple clinical predictors for developing abnormal ALT in COVID-19.

The rare SLC30A8 mutation encoding a truncating p.Arg138* variant (R138X) in zinc transporter 8 (ZnT8) is associated with a 65% reduced risk for type 2 diabetes. To determine whether ZnT8 is required for beta cell development and function, we derived human pluripotent stem cells carrying the R138X mutation and differentiated them into insulin-producing cells. We found that human pluripotent stem cells with homozygous or heterozygous R138X mutation and the null (KO) mutation have normal efficiency of differentiation towards insulin-producing cells, but these cells show diffuse granules that lack crystalline zinc-containing insulin granules. Insulin secretion is not compromised in vitro by KO or R138X mutations in human embryonic stem cell-derived beta cells (sc-beta cells). Likewise, the ability of sc-beta cells to secrete insulin and maintain glucose homeostasis after transplantation into mice was comparable across different genotypes. Interestingly, sc-beta cells with the SLC30A8 KO mutation showed increased cytoplasmic zinc, and cells with either KO or R138X mutation were resistant to apoptosis when extracellular zinc was limiting. These findings are consistent with a protective role of zinc in cell death and with the protective role of zinc in T2D. Published version This research was funded by American Diabetes Association 1-16-ICTS-029, by NIDDK UC4 DK104207, NIH P30 DK26687-36, R01 DK 057846-16 (to Kevan Herold), by NIH P30 DK0636- 08 funding to the Columbia University flow core, the Weezie family foundation to D.E., and by a Columbia University Diabetes Research Center Pilot and Feasibility award to L.S., G.A.R. was supported by a Wellcome Trust Investigator Award (WT212625/Z/18/Z), an MRC Programme grant (MR/R022259/1), a start-up grant from the Université de Montréal, and a John R. Evans Leaders Award from Innovation Canada.

Arl13b, an ARF/Arl-family GTPase, is highly enriched in the cilium. Recent studies have established Arl13b as one of the most crucial regulators for ciliary organization, trafficking, and signaling. The ciliary localization of Arl13b is known to require the RVEP motif. However, its cognitive ciliary transport adaptor has been elusive. Here, by imaging the ciliary localization of truncation and point mutations, we defined the ciliary targeting sequence (CTS) of Arl13b as a C-terminal stretch of 17 amino acids containing the RVEP motif. We found Rab8-GDP, but not Rab8-GTP, and TNPO1 simultaneously and directly bind to the CTS of Arl13b in pull-down assays using cell lysates or purified recombinant proteins. Furthermore, Rab8-GDP substantially enhances the interaction between TNPO1 and CTS. Additionally, we determined that the RVEP motif is an essential element as its mutation abolishes the interaction of the CTS with Rab8-GDP and TNPO1 in pull-down and TurboID-based proximity ligation assays. Finally, knockdown of endogenous Rab8 or TNPO1 decreases the ciliary localization of endogenous Arl13b. Therefore, our results suggest Rab8 and TNPO1 might function together as a ciliary transport adaptor for Arl13b by interacting with its RVEP-containing CTS. Submitted/Accepted version

BackgroundTraumatic brain injury (TBI) adversely affects both young and old and is a growing public health issue. A number of recent trends in managing TBI, such as recommending sub-threshold aerobic activity, tailoring multi-modal treatment strategies, and studying the possible role of low-grade inflammation in those with persistent symptoms, all suggest that the physical and cognitive exercise of tai chi/qigong could have benefit.MethodDesigned in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the following databases will be searched: MEDLINE, CINAHL, Cochrane Library, Embase, China National Knowledge Infrastructure Database, Wanfang Database, Chinese Scientific Journal Database, and Chinese Biomedical Literature Database. All clinical trials on mild, moderate and/or severe TBI with tai chi and/or qigong as the treatment group and any comparison group, in any setting will be included. Four reviewers will independently select studies; two reviewers for the English and two for the Chinese databases. Cochrane-based risk of bias assessments will be conducted on all included studies. An analysis will then be conducted with the grading of recommendation, assessment, development, and evaluation (GRADE) instrument.ResultsThis review will summarize the clinical trial evidence on tai chi/qigong for TBI including type of TBI, age/sex of participants, type and length of intervention and comparator, outcome measures, and any adverse events. The risk of bias will be considered, and the strengths and weaknesses of each trial will be analyzed.DiscussionThe results of this review will be considered with respect to whether there is enough evidence of benefit to merit a more definitive randomized controlled trial.Systematic Review Registration: PROSPERO [CRD42022364385].

A recent mutation analysis suggested that Non-Structural Protein 6 (NSP6) of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a key determinant of the viral pathogenicity. Here, by transcriptome analysis, we demonstrated that the inflammasome-related NOD-like receptor signaling was activated in SARS-CoV-2-infected lung epithelial cells and Coronavirus Disease 2019 (COVID-19) patients' lung tissues. The induction of inflammasomes/pyroptosis in patients with severe COVID-19 was confirmed by serological markers. Overexpression of NSP6 triggered NLRP3/ASC-dependent caspase-1 activation, interleukin-1β/18 maturation, and pyroptosis of lung epithelial cells. Upstream, NSP6 impaired lysosome acidification to inhibit autophagic flux, whose restoration by 1α,25-dihydroxyvitamin D3, metformin or polydatin abrogated NSP6-induced pyroptosis. NSP6 directly interacted with ATP6AP1, a vacuolar ATPase proton pump component, and inhibited its cleavage-mediated activation. L37F NSP6 variant, which was associated with asymptomatic COVID-19, exhibited reduced binding to ATP6AP1 and weakened ability to impair lysosome acidification to induce pyroptosis. Consistently, infection of cultured lung epithelial cells with live SARS-CoV-2 resulted in autophagic flux stagnation, inflammasome activation, and pyroptosis. Overall, this work supports that NSP6 of SARS-CoV-2 could induce inflammatory cell death in lung epithelial cells, through which pharmacological rectification of autophagic flux might be therapeutically exploited. Published version This work was supported by The TUYF Charitable Trust and Shenzhen Science and Technology Programme (JCYJ20180508161604382).

Clostridioides difficile infection (CDI) is a common cause of nosocomial diarrhea. TcdB is a major C. difficile exotoxin that activates macrophages to promote inflammation and epithelial damage. Lysosome impairment is a known trigger for inflammation. Herein, we hypothesize that TcdB could impair macrophage lysosomal function to mediate inflammation during CDI. Effects of TcdB on lysosomal function and the downstream pro-inflammatory SQSTM1/p62-NFKB (nuclear factor kappa B) signaling were assessed in cultured macrophages and in a murine CDI model. Protective effects of two lysosome activators (i.e., vitamin D3 and carbamazepine) were assessed. Results showed that TcdB inhibited CTNNB1/β-catenin activity to downregulate MITF (melanocyte inducing transcription factor) and its direct target genes encoding components of lysosomal membrane vacuolar-type ATPase, thereby suppressing lysosome acidification in macrophages. The resulting lysosomal dysfunction then impaired autophagic flux and activated SQSTM1-NFKB signaling to drive the expression of IL1B/IL-1β (interleukin 1 beta), IL8 and CXCL2 (chemokine (C-X-C motif) ligand 2). Restoring MITF function by enforced MITF expression or restoring lysosome acidification with 1α,25-dihydroxyvitamin D3 or carbamazepine suppressed pro-inflammatory cytokine expression in vitro. In mice, gavage with TcdB-hyperproducing C. difficile or injection of TcdB into ligated colon segments caused prominent MITF downregulation in macrophages. Vitamin D3 and carbamazepine lessened TcdB-induced lysosomal dysfunction, inflammation and histological damage. In conclusion, TcdB inhibits the CTNNB1-MITF axis to suppress lysosome acidification and activates the downstream SQSTM1-NFKB signaling in macrophages during CDI. Vitamin D3 and carbamazepine protect against CDI by restoring MITF expression and lysosomal function in mice. Abbreviations: ATP6V0B: ATPase H+ transporting V0 subunit b; ATP6V0C: ATPase H+ transporting V0 subunit c; ATP6V0E1: ATPase H+ transporting V0 subunit e1; ATP6V1H: ATPase H+ transporting V1 subunit H; CBZ: carbamazepine; CDI: C. difficile infection; CXCL: chemokine C-X-X motif ligand; IL: interleukin; LAMP1: lysosomal-associated membrane protein 1; LC3: microtubule-associated protein 1 light chain 3; LEF: lymphoid enhancer binding factor 1; MITF: melanocyte inducing transcription factor; NFKB: nuclear factor kappa B; PMA: phorbol 12-myristate 13-acetate; TcdA: Clostridial toxin A; TcdB: Clostridial toxin B; TFE3: transcription factor E3; TFEB: transcription factor EB. Published version This work was supported by the National Natural Science Foundation of China [82070576] and the Hong Kong Food and Health Bureau (FHB) Commissioned Health and Medical Research Fund [CID-CUHK-C].

The outbreak of COVID-19 has caused widespread emotional distress. The current study sought to ascertain the impact of COVID stress syndrome on quality of life and gratitude. The COVID-19 Stress Scale, COVID-19 Quality of Life Scale, and Gratitude Resentment and Appreciation Scale were administered to 199 Singaporeans. Data were collected online using convenience sampling between December 2020 and March 2021. Pearson correlations and hierarchical regression analyses were used to test the research hypotheses. The results showed that fear of spreading SARSCoV2 by foreigners was the most stressful fear among Singaporeans (M = 2.59), while traumatic stress by COVID-19 was the least stressful fear (M = 0.16). COVID stress syndrome was positively correlated with negative quality of life (r ranged from .25 to .66) and negatively correlated with gratitude (r ranged from -.29 to -.14). Xenophobia was also found to be the most influential factor in reducing quality of life (β = .52) and gratitude (β = -.37) during the pandemic. Study findings demonstrate how COVID-19 increases Singaporeans' xenophobic attitudes towards foreigners, making them more vulnerable to the pandemic.

Objective: Vascular dementia (VaD) is the second most common cause of dementia worldwide. The increasing contribution of lifestyle-associated risk factors to VaD has pointed towards gene-environment interactions (i.e. epigenetics). This study thus aims to investigate the DNA methylation landscape in a chronic cerebral hypoperfusion (CCH) mouse model of VaD. As a nexus between the gene-environment interaction, intermittent fasting (IF) was introduced as a prophylactic intervention. Methods: Bilateral common carotid artery stenosis (BCAS) was used to induce CCH by placing micro-coils of 0.18 mm in each common carotid artery of the mice. The coils were left in the mice for 7, 15 and 30 days to study temporal differences. IF was introduced for 16 h daily for 4 months prior to BCAS. Reduced Representation Bisulfite Sequencing (RRBS) was used to study the DNA methylation landscape. Cognitive impairment was measured using Barnes Maze Test. White matter lesions (WML) and neuronal loss were measured using Luxol fast blue staining and cresyl violet staining respectively. Results: IF mice subjected to CCH displayed significantly better cognitive learning ability and memory, improved neuropathological alterations with reduced WMLs and neuronal loss. Modulation of DNA methylation patterns in the cortex of AL CCH mice was re-modelled and signs of reversal was observed in IF CCH mice across all three timepoints. Conclusions: These findings provide an understanding of how IF may protect the brain against damage caused by CCH and show promise in offering potential beneficial effects in mitigating the neuropathology and cognitive deficits in VaD. Ministry of Education (MOE) National Medical Research Council (NMRC) Published version This work was supported by the National Medical Research Council Research Grants (NMRC-CBRG-0102/2016; NMRC/CSA-SI/007/2016 and NMRC/OFIRG/ 0036/2017), Singapore and the Ministry of Education (MOE2017-T3-1-002), Singapore and La Trobe University, Australia.

Improving the long-term prognosis of ulcerative colitis (UC) requires sustained deep mucosal colonic healing with histologic remission, making the study of colonic tissue regeneration essential. In experimental colitis models, lipid metabolites are recognized as pivotal components of this process. This study aimed to describe the kinetics of wound healing and lipid metabolites engaged in regeneration in the normal colonic mucosa and how they are affected in UC to reveal new therapeutic targets. Experimental colonic wounds were created endoscopically in quiescent UC (n=21) and controls (n=9), and the healing process was surveilled by serial endoscopies and cross-sectional wound biopsies post-wounding. Biopsies were analyzed by liquid chromatography coupled with mass spectrometry. Endoscopic wound scores were significantly higher in UC at day two (p=0.001) and seven (p

Background Prior studies show that signature phenotypes of diabetic human induced pluripotent stem cells derived endothelial cells (dia-hiPSC-ECs) are disrupted glycine homeostasis, increased senescence, impaired mitochondrial function and angiogenic potential as compared with healthy hiPSC-ECs. In the current study, we aimed to assess the role of thymosin β-4 (Tb-4) on endothelial function using dia-hiPSC-ECs as disease model of endothelial dysfunction. Methods and results Using dia-hiPSC-ECs as models of endothelial dysfunction, we determined the effect of Tb-4 on cell proliferation, senescence, cyto-protection, protein expression of intercellular adhesion molecule-1 (ICAM-1), secretion of endothelin-1 and MMP-1, mitochondrial membrane potential, and cyto-protection in vitro and angiogenic potential for treatment of ischemic limb disease in a mouse model of type 2 diabetes mellitus (T2DM) in vivo. We found that 600 ng/mL Tb4 significantly up-regulated AKT activity and Bcl-XL protein expression, enhanced dia-hiPSC-EC viability and proliferation, limited senescence, reduced endothelin-1 and MMP-1 secretion, and improved reparative potency of dia-hiPSC-ECs for treatment of ischemic limb disease in mice with T2DM. However, Tb4 had no effect on improving mitochondrial membrane potential and glycine homeostasis and reducing intercellular adhesion molecule-1 protein expression in dia-hiPSC-ECs. Conclusions Tb-4 improves endothelial dysfunction through enhancing hiPSC-EC viability, reducing senescence and endothelin-1 production, and improves angiogenic potency in diabetes.

Currently, there is no effective method to prevent the formation of hypertrophic scars and keloids, which can cause severe physical and psychological burdens to patients. Secreted protein acidic and cysteine-rich (SPARC) is involved in wound fibrosis by modulating fibroblast functions, causing excessive collagen deposition during wound healing. Thus, the reduction in SPARC gene expression after wounding can contribute to the downstream reduction in collagen production at the wound site and prevent scar formation. In this study, a dissolvable and biocompatible hyaluronic acid (HA) microneedle patch loaded with nanoplexes containing tyramine-modified gelatin and siRNA for SPARC (siSPARC/Gtn-Tyr) was investigated for topical scar prevention. Tyramine-modified gelatin (Gtn-Tyr) provides electrostatic protection and enhances cell internalization for siSPARC. In vitro studies using human dermal fibroblasts showed that both siSPARC/Gtn-Tyr nanoplexes and siSPARC/Gtn-Tyr-loaded microneedle patches can significantly reduce SPARC gene expression (P < 0.05) and do not cause discernable cytotoxic effects. Further studies using a mouse wound model demonstrate that the siSPARC/Gtn-Tyr-loaded microneedle patch can reduce collagen production during wound healing without triggering an immune response. When Gtn-Tyr-siSPARC is administered transdermally at the wound site, effective collagen reduction is achieved through silencing of the matricellular SPARC protein, thus promising the reduction of scar formation. Overall, the siSPARC/Gtn-Tyr loaded microneedle patch can potentially provide an effective transdermal anti-fibrotic treatment. Ministry of Education (MOE) Ministry of Health (MOH) National Medical Research Council (NMRC) The authors gratefully acknowledge the support by Singapore Ministry of Education under its NTUitive Gap Fund grant scheme (NGF-2019-07-004) and Singapore Ministry of Health’s National Medical Research Council under its Clinician Scientist Award (CSAINV20nov-0003).