V600E can be targeted with selective inhibitors, such as vemurafenib. Despite initial positive tumor responses of regression and decreased viability, both single agent or combination agent drug treatments provide a selective pressure for drug resistant evolving clones within the overall heterogeneous tumor. Also, there are evidences suggesting that sequential monotherapy is ineffective and selects for resistant and ultimately lethal tumor clones. Reconstructing both clonal and subclonal thyroid tumor heterogeneous cell clusters for somatic mutations and epigenetic profile, copy number variation, cytogenetic alterations, and non-coding RNA expression becomes increasingly critical as different clonal enrichments implicate how the tumor may respond to drug treatment and dictate its invasive, metastatic, and progressive abilities, and predict prognosis. Therefore, development of novel preclinical and clinical empirical models supported by mathematical assessment will be the tools required for estimating the parameters of clonal and subclonal evolution, and unraveling the dormant vs. non-dormant state of thyroid cancer. In sum, novel experimental models performing the reconstruction both pre- and post-drug treatment of the thyroid tumor will enhance our understanding of clonal and sub-clonal reconstruction and tumor evolution exposed to treatments during ultra-precision targeted therapies. This approach will improve drug development strategies in thyroid oncology and identification of disease-specific biomarkers.The introduction of ultra-precision targeted therapy has become a significant advancement in cancer therapeutics by creating treatments with less off target effects. Specifically with papillary thyroid carcinoma (PTC), the cancer's hallmark genetic mutation BRAF V600E mutation. Constitutive activation of the BRAF proto-oncogene  leads to activation of ERK1/2 pathway and other intracellular pathways associated with abnormal cell proliferation and growth (Papillary thyroid carcinoma (PTC) is the most frequent type of thyroid cancer, accounting for almost 80% of thyroid cancer cases. The genetic hallmark of human PTC is the somatic BRAFd growth .V600E can be targeted with selective inhibitors such as vemurafenib, the first FDA approved orally administered inhibitor  and suppression of growth signals. Part of a cell's evolution to evade these signals involves genetic mutations, which predisposes the cells to being able to survive with mutations that would otherwise not survive in non-cancerous or malignant cells. Tumorigenesis requires increased mutability in order for tumor cells to bypass regulatory and apoptotic pathways and signals. Increased mutability of cells is achieved through down regulation of genomic maintenance mechanisms, including P53 gene inactivation . The dowV600E in PTC  resistant subclones , some tumor cells will respond to the treatment and die  gene, targeted drug treatment therapy positively selected for a number of drug resistant clones and drove tumor clonal evolution  gene family mutations . In . In V600t cancer . Single Combination therapy is seen as the best treatment option for overcoming resistance to single agent targeted therapy . HoweverV600E, Tg mutations were more likely passenger mutations that are advantageous in the malignant evolution of PTC as opposed to the actual drivers of PTC. Since Tg mutations are associated with mutations in genes encoding components of the MAPK signaling pathway, it is possible that some subclones harboring both driver and maybe passenger mutations, such as RBM gene family mutations   gene were associated with poorer clinical prognosis . Additio0, RBMX) , could s0, RBMX) .Another experimental model focusing on tumor heterogeneity in breast cancers identified a subclonal genetic marker associated with CD44+ breast cancer stem cells. Previous studies had demonstrated that CD44+ cells displayed increased tumorigenesis compared to CD44– cells . Given tV600E and CDKN2A−/− mutant PTC's and for overcoming both innate/primary and secondary tumor resistance mechanisms.In the PTC experimental model, an understanding of the subclonal construction of the tumor having chromosome 5 amplifications and RBM gene family mutations, revealed potential pathways for secondary resistance. This knowledge of both the clonal and subclonal configuration of the tumor, allowed for a more effective solution to treating BRAFBeyond elucidating better understandings of potential cellular pathways and genes involved in drug therapy resistance, clonal and subclonal reconstructions of tumors can also reveal biomarkers for early detection of aggressive thyroid cancer that could dictate future tumor behavior. With regard to thyroid cancers, PTC is classified as a differentiated thyroid cancer, and other types of thyroid carcinomas, such as anaplastic thyroid carcinoma (ATC), are classified as undifferentiated thyroid cancer. The transition from PTC to undifferentiated thyroid carcinoma is still poorly understood and furthermore effective treatments of ATC represent a large unmet clinical need. Clonal and subclonal reconstructions of both heterogeneous PTC  and ATC Importantly, ATC show increased mutational burden compared to PTC. In one study examining the genetic profile of 196 ATC samples, only 41% (81 tumors) harbored BRAF mutations . If ATC In sum, some bioinformatics models have been designed and are being used to reconstruct the clonal and subclonal heterogeneity of tumors. However, we need novel experimental models performing the clonal and subclonal reconstruction both pre- and post-drug treatment(s) of the thyroid tumor for somatic mutational and epigenetic profile, copy number variation, cytogenetic alterations, and non-coding RNA expression. Clonal and subclonal evolution of tumor cell clusters is also driven by the selective pressure of targeted drug therapy, therefore the pre-treatment reconstruction and the post-treatment reconstruction would identify all clones and subclones that drug treatments positively select, those that are responsive to drug treatments and die, and clones containing passenger genetic alterations conferring secondary tumor resistance.CN: design. CN and EM: editing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Abstract Global new-born mortality has shown steady decline over the last two decades, but this decline has been slowest in Sub-Saharan Africa (SSA). Perinatal asphyxia (PA) is a major cause of new-born deaths in this region and as such SSA now contributes a disproportionate large percentage of global asphyxia-related deaths. In this paper, we examine regional challenges affecting primary, secondary and tertiary prevention of PA and proffers locally adaptable solutions to these identified challenges. Global newborn mortality has shown steady decline over the preceding two decades, but this has been slowest in Sub-Saharan Africa (SSA), where newborn deaths now accounts for 38 percent of global neonatal mortality . In thisEnding preventable newborn deaths currently feature prominently in the global health agenda and this is reflective in the Sustainable Development Goals, specifically Goal 3 . To achiIn this paper, we examine challenges faced in the prevention and management of perinatal asphyxia by countries within this region, and we suggest possible solutions to the current issues.These challenges relate to identifying and limiting the risk of pregnant women who without intervention might deliver asphyxiated babies. They hinder effective demand and supply of obstetric services within the region.In SSA, attendance of ante-natal care, which should connect the ‘at-risk pregnant woman’ with the formal health system, is poor, as under 40 percent of women attend at least four visits . Within Despite widespread regional poverty, 40 to 54 percent of people access healthcare primarily out-of-pocket which hinders health service demand . In instRegional sociocultural norms such as child marriages also negatively affect antenatal care attendance. A recent review of demographic and health survey data in 31 SSA countries documented a third of girls were married by age 18 in more than half of the studied countries . In thesThese relate to three service delivery gaps: coverage, equity and quality gaps. The coverage gap connotes insufficient manpower to address regional obstetric needs. The global health worker shortage is greatest in SSA, where the majority of countries have health worker to population densities below 2.5 per 1000 population, starkly contrasting developed country estimates which are between two and ten times this number . The ine15Additionally, existing quality gaps affect obstetric supply. In a review of data from 20 SSA countries, 71 percent of women did not have intermittent preventive treatment for malaria in pregnancy despite attending at least 4 antenatal care visits . SimilarSecondary prevention of asphyxia involves resuscitation of newborn infants with breathing problems who are at risk of developing perinatal asphyxia. One major challenge to this is the large proportion of out-of-hospital births occurring in the presence of unskilled birth attendants who lack knowledge and skill of neonatal resuscitation . More thWhen births occur in-facility, obstetric service providers frequently do not have the basic skills or equipment necessary to provide quality neonatal resuscitation . A regioTertiary prevention of asphyxia involves treating acute complications and mitigating their progression to long-term disabling morbidities. This requires functional multidisciplinary rehabilitative care teams which are lacking in SSA. Countries within the region have rehabilitative worker densities below 0.01 per 10,000 population, contrasting developed countries where these figures are almost a thousand times this number . AdditioFocusing on primary prevention within the region is most likely to have the greatest impact on asphyxia burden and this would entail stimulating a demand for obstetric services while improving supply. Infrastructural and human capacity development are key to improving regional obstetric demand. Road networks, transportation, referral, communication and information systems, all of which have direct effects on service demand would need to be upgraded . Additio8Community engagement is also fundamental to stimulating demand and should entail changing community perceptions regarding orthodox obstetric services through health education, local media and provision of holistic, culturally acceptable and easily accessible obstetric services. In these settings, the buy-in of prominent local community, traditional and religious leaders is crucial to programmatic success.From a supply perspective, an obvious solution to tackle the existing coverage gaps would be to attract skilled birth attendants through competitive remuneration. However, this is not feasible in the short term, as many SSA countries are currently economically challenged. Task-shifting, a practice which involves delegating roles and responsibilities otherwise carried out by senior health staff to lower and mid-health care workers can serve as a short term measure . Local r27Equitable distribution of obstetric human resources across geographical divides needs to be ensured through health worker tax rebates and provision of rural allowances to encourage their retention in these areas. Nigeria and Zambia have instituted rural midwives’ and rural health worker retention schemes which have shown modest successes 30. Rural31Regional governments need to increase budgetary allocations to the health sector to improve quality of obstetric care. Local services would also need to be more effectively organized by developing strong bottom-up referral systems which centralize high-risk pregnancies to tertiary obstetric health centers and those considered low-risk to primary healthcare. In addition, proper supervision and monitoring of existing obstetric facilities using methods such as perinatal audits, obstetric checklists, regular in-house staff training and drills will also improve quality of care .Despite being controversial among policy makers , traininTo improve tertiary prevention of asphyxia, capacity building for rehabilitative service providers is essential. Local health facilities would need to establish collaborative links with international agencies and centers with specialized rehabilitative care that can offer voluntary services and develop local capacity. Vital registration of all births and deaths in SSA needs to be improved for accurate data on local asphyxia burden and for managing regional government development plans.Challenges to successfully preventing perinatal asphyxia in SSA might seem herculean. The key to solving these would be the institution of pragmatic locally adapted solutions that take into cognizance existing realities in the region. These would need to target safer pregnancy and delivery outcomes with a focus on accessible quality neonatal resuscitation and human capacity development.


Here we report optimization, expression and binding of DMAbs based on anti-PD1 CPI and discuss the potential of DMAbs in checkpoint immunotherapy.Checkpoint inhibitors (CPI) have revolutionized the treatment of many solid tumors. However, difficulties in production, stability, the requirement of frequent high doses for antibody administration and long intravenous administration are recurring issues. Synthetically designed DNA-encoded monoclonal antibodies (DMAbs) are a novel delivery method for antibody therapy which could potentially address many of these issues, simplifying design and implementation of MAb-based therapies. DMAbs delivered through plasmid DNA injection and electroporation have been used in preclinical models for the treatment or prophylaxis of infectious diseases, cancer and cardiovascular disease. Our group has recently reported that immune checkpoint blockers can be optimized and delivered  Checkpoint inhibitors (CPI) have revolutionized the treatment of many solid tumors. These therapies have generated an increase in the percentage of cancer long-term survivors by ‘releasing the brakes’ of the immune system to potentiate its antitumor effect in those patients who respond . HoweverSynthetically designed DNA-encoded monoclonal antibodies (DMAbs) are a novel delivery method for antibody therapy which could potentially address many of these issues, as well as open up novel approaches for design and implementation of MAb based therapies. DMAbs represent a simple, scalable development system, with the additional benefit of higher stability and simpler storage than protein biologicals. DMAbs are administered locally by intramuscular injection and allow simple coformulation, permitting the generation of CPI with a unique profile of expression and potency, suggesting they could be considered as a new tool for study in this important therapeutic arena.DMAbs delivered through plasmid DNA injection and electroporation (EP) have been used in pre-clinical models for the treatment or prophylaxis of infectious diseases , 5, cancin vivo advancing further DMAb technology [in vivo expression for several months. These first studies in mice, while encouraging, require additional examination in other models, including additional optimization in other species to further understand the implications with an eye towards subsequent clinical evaluation. Furthermore, studies in combinations and with additional genetic modifications for functional enhancement by the Fc portion of the Ig heavy chain can be much more easily developed and studied as DMAbs than as protein biologicals to advance new CPI-like forms with improved functions resulting in improved tumor impact advancing clinical benefit. Under this concept the development of additional CPI targets as DMAbs appears important.In support, Duperret et al., recently reported that immune checkpoint blockers can be optimized and delivered chnology . In the chnology  or tremechnology . These sThe PD-1-PD-L1 signaling pathway was first discovered in 1992 and monoclonal antibodies targeting this suppressive pathway were moved towards clinical testing in 2006. These MAb have made a major positive impact in the clinic resulting in FDA approvals for treating a variety of different tumor types due to exciting clinical benefit for treatment of diverse cancer types including melanoma, non-small cell lung carcinoma, renal cell carcinoma, high microsatellite instability cancers, Hodgkin’s disease, hepatocellular carcinoma, urothelial carcinoma, bladder carcinoma, Merkel cell carcinoma and gastroesophageal junction [in vivo expression while retaining their required binding ability and functionality. These DMAbs expressed for several months and exhibited the specificity and cell binding of the parental antibodies. The recent development of DMAbs encoding anti-CTLA4 [in vivo production is likely to provide unique research and ultimately clinical benefit in the cancer arena.Accordingly, the development of forms of DMAbs encoding anti-PD-1 like antibodies are important. Engineered DMAb forms mimicking highly impactful anti-PD-1 monoclonal antibodies were studied in an effort to optimize direct DMAb ti-CTLA4  and for ti-CTLA4 , 12 or DIn summary, DMAbs are a new tool that conceptually simplifies antibody therapies and their combinations, including checkpoint blockade, which if successful would likely expand their applications bringing CPI therapies to a much larger patient population. Further translational study of the DMAb platform for impacting cancer is worthy of consideration.


Recent breakthroughs in cancer immunotherapy have led to curative efficacy and significantly prolonged survival in a subset of patients of multiple cancer types; and immunotherapy has become the newest pillar of cancer treatment in addition to surgery, chemotherapy, radiotherapy and precision targeted therapies. In the metastatic disease setting, responses to immunotherapy are heterogeneous depending on the metastatic organ sites. The tissue-specific immuno-biology in the tumor microenvironments (TMEs) contributes to the differential therapeutic responses. Herein, we review the impact of tissue-specific tumor microenvironment on the efficacy of immunotherapy, with a focus on historically under-represented central nervous system (CNS) metastasis, which was excluded from most clinical trials. Retrospective examination of patient specimens and prospective clinical studies with immune checkpoint blockade (ICB) have established that brain can harbor an “active” immune microenvironment for effective immunotherapy. Regulation by the innate immune microglial cells and remodeling of the blood–brain barrier (BBB) may contribute to immunotherapeutic responses mediated by T lymphocytes. How to convert an “inactive” (cold) brain microenvironment into an “active” (hot) brain TME should be the focus of future efforts. Thus, procurement and complete examination of clinical specimens from brain metastases as well as development of appropriate preclinical brain metastasis models susceptible to external manipulation of the TME are critical steps towards that goal. A deeper understanding of the immuno-biology in distinct organ microenvironments will help to expand the benefits of immunotherapy to more needed patients. The idea of immunotherapy was conceptualized more than 100 years ago when German pathologist Rudolf Virchow first described the involvement of immune cells in human tumors . Even thBeginning in the 1980s, therapeutic monoclonal antibodies, a bioengineered version of the naturally secreted immune molecule, emerged as a versatile platform of therapeutic agents against cancer , 5. AfteIt has long been known that CD8+ effector T cells have cytolytic capability that kills cancer cells . In-deptDifferent cancer types tend to colonize specific organ sites, as depicted by the “seed and soil” hypothesis of metastasis . Many ofA common clinical observation with advanced cancer patients is the differential responses to systemic treatments where some metastatic lesions may be less or more responsive to therapy compared to lesions located at other anatomical sites. Such frequently encountered clinical phenomenon strongly suggests that the local TME plays crucial roles in modulating therapeutic responses. For example, in a retrospective study of 371 metastatic melanoma patients treated with the first FDA-approved “modern” immunotherapy high-dose IL-2, the response rate in patients with cutaneous or subcutaneous metastasis was ~ 50% whereas with visceral metastases it was only 13%; more strikingly, in individual patients harboring both cutaneous/subcutaneous and visceral metastases, tumor regression took place only at cutaneous/subcutaneous lesions whereas visceral metastases progressed upon the same systemic IL-2 therapy . FurtherDespite the clear relevance derived from multiple clinical studies, further in-depth mechanistic investigations that require procuring clinical specimens from multiple metastatic organ sites can be logistically challenging. To that end, an exceptional case study reported a single patient with high-grade serous ovarian cancer who was treated with multiple chemotherapy regimens and exhibited regression of some metastatic lesions with concomitant progression of other lesions . After cTo broadly elucidate the underlying biological mechanisms of the organ specific TME impact on immunotherapy responses, multiple studies have used preclinical murine models harboring metastases at multiple anatomical sites and having treatments by various immunotherapy agents. For example, implanting murine 4T1 mammary cancer cells at subcutaneous or intratibial sites and FACS profiling of isolated tumor-associated immune cells revealed significant differences in the immune composition  depending on the sites of tumor growth . AdditioUnfortunately, despite fair amount of effort by the research community to compare differential anatomic responses to cancer therapies, the brain, one common metastasis organ site, has been adversely neglected , 34. WitWhile the primary regulatory and cognitive functions of the central nervous system (CNS) are conducted by neuronal circuitry, it is also essential to maintain a homeostatic environment of stable metabolism and inflammation, which tasks fall on the large number of stromal cells in the brain, including astrocytes and microglia cells . To thatIntracranial malignant neoplasms can arise either from primary brain tumors (mainly glioma) or from secondary cancers metastatic to the CNS. Lung cancer, breast cancer and melanoma are the major sources of brain metastases, which collectively outnumber primary malignant brain tumors by ~ 10:1 , 47. WhiIntriguingly, infiltration with adaptive immune T lymphocytes is highly heterogenous in brain metastasis lesions, varying from total absence to very dense infiltration , 59. A sLastly, how do adaptive immune T cells infiltrate brain metastatic lesions in the presence of blood–brain barrier (BBB)? Pharmacodynamic studies in preclinical murine models of breast cancer brain metastasis showed that BBB permeability could be compromised, and vascular leakiness became highly heterogeneous depending on the progression of brain metastatic outgrowth . FurtherBrain is conventionally regarded a major organ site of metastasis with sanctuary immune status; hence, up till recently, most clinical trials exclude patients with CNS metastases , 38. WitBased on these clinical studies showing early signals of positive intracranial activity, a landmark trial of treating melanoma brain metastasis with ICB combination of anti-PD-1 nivolumab and anti-CTLA-4 ipilimumab has been conducted  . It was Despite these promising results, the advances are still in the early stage and most patients with CNS metastases remain difficult to treat; the benefit must also be extended to brain metastases from other primary cancer types in addition to melanoma. Additionally, the underlying mechanism of resistance versus response of the intracranial tumors to systemically administered ICB remains a fundamentally unanswered question. Because immune cells are highly dynamic in response to physiological alterations, their biological functions must be tightly coupled to the cellular metabolism that provides the underlying material and energetic support. From in vitro studies, it was believed that activation of T cells shifts cellular metabolism towards glycolysis which takes place in the cytosol and produces more biological building blocks in preparation of cell proliferation and clonal expansion, and that naïve and memory T cells are more dependent on mitochondrion-dependent oxidative phosphorylation (OXPHOS) which yields more ATP to confer higher spare respiratory capacity . HoweverCurrently, immunotherapy benefits a small number of patients across multiple cancer types, and the immuno-biological microenvironments at distinct metastatic organ sites are important determinants for differences in efficacy. In particular, the local immuno-biological TME at metastatic organ sites, partly mediated by the tissue-resident innate immune cells, interacts with the systemic adaptive immune system to determine responses to immunotherapy. Therefore, the major goal of future efforts should be deepening the understanding of underlying immuno-biological mechanisms responsible for the organ-specific anti-tumor immune responses and based on such knowledge developing strategies to expand the benefits of immunotherapy to more patients with advanced metastatic cancer. To that end, it is important to analyze clinical specimens of immunotherapy treated metastases of all cancer types  to examine immune cell infiltration and composition, as well as local stromal cell alterations, which will reveal novel insight into the response mechanism of immunotherapy in distinctive metastatic TMEs. Additionally, it is necessary to perform mechanistic studies and functional validations using appropriate animal models in order to better understand the immuno-biology underlying effective immunotherapy.In the CNS, it has been convincingly established, by retrospective examinations of brain metastasis specimens and prospective clinical studies of ICB treatment of patients with brain metastases, that in some patients the brain can harbor an “active” immune microenvironment that respond to immunotherapy. Enrichment of mitochondrion mediated OXPHOS is a unique metabolic trait of brain metastasis; modulating the OXPHOS activity in the brain TME may impact efficacy of ICB treatments. To overcome the immunosuppressive TME in the CNS, future efforts should also include combining checkpoint inhibitors with other treatments . The rapid progress in clinical investigations and preclinical studies will pave the way for effective modulation of the brain metastasis tumor microenvironment that allows effective T cell-mediated responses and enables more brain metastasis patients to benefit from immunotherapy.In summary, persistent endeavor in clinical investigations and preclinical studies to explore effective ways of manipulating the local immuno-biological microenvironment will likely enhance and expand the efficacy of immunotherapy to more metastatic diseases.


The STOMP trial is a multicenter, randomized, phase II trial  that incClinicalTrials.gov: NCT02680587), comparing observation versus SBRT in oligometastatic hormone-sensitive prostate cancer, are comparable to those observed in the STOMP trial, validating the safety and efficacy of SBRT in this setting.Despite some inherent limitations such as the small patient cohort and the use of a treatment-related primary endpoint, the STOMP trial represents the first randomized study exploring the role of MDT compared to standard of care in oligorecurrent patients. Of note, preliminary results of the phase II randomized Baltimore ORIOLE trial  [It is noteworthy that the optimal treatment of oligorecurrent patients remains a challenging and open question, based mainly on, even if promising, retrospective and heterogeneous data. The possibility to treat a metastatic disease with a potentially curative intent collects an increasing interest, with expert panels considering MDT a valid treatment option for these patients . Of noteent ADT) . Some poFirst, although oligorecurrent prostate cancer with exclusive nodal involvement is a common clinical situation  and the 68Ga prostate-specific membrane antigen (PSMA) PET-CT [Second, improvements in the diagnostic procedures such as use of ) PET-CT  will surLastly, implementation in trials of translational analysis of leading-edge laboratory measuring circulating tumor cells, circulating tumor DNA, and circulating T-cell receptor repertoires will surely help to better characterize the oligomestatic status by identifying patients with potentially curable metastatic disease and evaluating the effects of MDT on disease response .ClinicalTrials.gov: NCT03569241), a randomized phase II trial for the Salvage Treatment of OligoRecurrent nodal prostate cancer Metastases, will surely help to answer some of these open questions. By randomizing patients between MDT (SBRT or sLND) versus MDT combined with WPRT (adjuvant WPRT after sLND or WPRT with boost to the positive nodes), and implementing modern imaging techniques and liquid biopsies, the study aims at finding the better treatment strategy in terms of extrapelvic metastasis-free survival as primary endpoint for this subset of patients.The recently opened Belgian-Swiss PEACE V STORM trial  and European Society for Radiotherapy and Oncology (ESTRO) OligoCare observational basket study should be encouraged.


Fructans are fructose-based oligo- and polymers that serve as reserve carbohydrates in many plant species. The biochemistry of fructan biosynthesis in dicots has been resolved, and the respective cDNAs have been cloned. Recent progress has now succeeded in elucidating the biochemistry and molecular biology of fructan biodegradation in chicory, an economically important species used for commercial inulin extraction. Unlike fructan biosynthetic genes that originated from vacuolar-type invertase, fructan exohydrolases (FEHs) seem to have evolved from a cell-wall invertase ancestor gene that later obtained a low iso-electric point and a vacuolar targeting signal. Expression analysis reveals that fructan enzymes are controlled mainly at the transcriptional level. Using chicory as a model system, northern analysis was consistent with enzymatic activity measurements and observed carbohydrate changes throughout its development.


Siphoviridae, Myoviridae and Podoviridae), where members of the same family were generally far more divergent and often not detectably homologous to each other. Analysis of the 20 currently classified prokaryotic virus families indeed split them into 70 separate clusters of tailed phages genetically equivalent to family-level assignments of eukaryotic viruses. It further divided several bacterial  and archaeal (Lipothrixviridae) families. We also found that the subfamily-level groupings of tailed phages were generally more consistent with the family assignments of eukaryotic viruses, and this supports ongoing reclassifications, including Spounavirinae and Vi1virus taxa as new virus families. The current study applied a common benchmark with which to compare taxonomies of eukaryotic and prokaryotic viruses. The findings support the planned shift away from traditional morphology-based classifications of prokaryotic viruses towards a genome-based taxonomy. They demonstrate the feasibility of a unified taxonomy of viruses into which the vast body of metagenomic viral sequences may be consistently assigned.Genome Relationship Applied to Virus Taxonomy (GRAViTy) is a genetics-based tool that computes sequence relatedness between viruses. Composite generalized Jaccard (CGJ) distances combine measures of homology between encoded viral genes and similarities in genome organizational features (gene orders and orientations). This scoring framework effectively recapitulates the current, largely morphology and phenotypic-based, family-level classification of eukaryotic viruses. Eukaryotic virus families typically formed monophyletic groups with consistent CGJ distance cut-off dividing between and within family divergence ranges. In the current study, a parallel analysis of prokaryotic virus families revealed quite different sequence relationships, particularly those of tailed phage families ( Currently, 4404 species are assigned to 735 genera, which in turn are assigned to 122 families ]. Similarly, the list of unclassified archaeal viruses with complete genomes was retrieved using the search terms . Only those from the GenBank database were collected. In total, the list comprised 576 whole genomes of unclassified bacterial viruses, and eight unclassified archaeal viruses (Table S4). The search was performed in February 2018. The genome of unclassified bacteriophages and archaeal viruses were run through the GRAViTy pipeline to identify which virus groups they might belong to. Our results (Table S5) show that 580 of the unclassified bacteriophages (573 viruses) and archaeal viruses (seven viruses) exhibit some similarity to group I dsDNA. A bootstrapped dendrogram depicting relationship among these unclassified viruses and the classified dsDNA viruses is shown in The list of unclassified bacteriophages with complete genomes was compiled from the NCBI database using the search terms [Click here for additional data file.Click here for additional data file.


Research on bile acids has increased dramatically due to recent studies demonstrating their ability to significantly impact the host, microbiome, and various disease states –3. AlthoMembers of the gastrointestinal tract (GIT) microbiota initiate bile acid metabolism via a critical first step catalyzed by bile salt hydrolases (BSHs) . These eA recent review by Dong and colleagues has reported in depth on many of the biochemical and structural features of BSHs that are summarized here . BSHs beClostridium perfringens BSH (Protein Data Bank ID 2BJF) has been captured with a hydrolyzed taurodeoxycholic acid (TDCA) substrate in its active site [Despite the conservation of their active sites and the similarity of their overall topology , BSHs haive site . Even wiLactobacillus and Bifidobacterium because these species are associated with deconjugation in the small intestine and harboring a BSH is thought to be a beneficial feature of probiotics [Clostridium and Enterococcus similarly display a high occurrence of BSH-positive strains. Recent work characterizing BSH encoding members of the Bacteroidetes phylum has begun to elucidate the phenotypes of gram-negative BSH activity [The broad distribution and abundance of BSHs in the GIT suggests that bile acid deconjugation is a selected adaptive trait of several bacterial species for symbiosis or pathogenesis within the host , 18. Theobiotics , 18, 19.activity , 21.Despite their single hydrolytic function, BSHs can be advantageous in various ways. Because some bile acids are toxic molecules due to their acidic nature and detergent-like properties , 23, BSHBrucella abortus BSH activity leads to membrane modifications resisting phagocytosis [Listeria monocytogenes exploits its BSH for survival in the bile acid-rich liver and gall bladder [Clostridioides difficile, which can use taurocholate (TCA) as a spore germinant, but vegetative cells are sensitive to most secondary bile acids [Lactobacillus johnsonii BSH activity has been shown to limit the eukaryotic pathogen Giardia duodenalis in vivo [Bacterial pathogens, like some commensals, use BSHs to persist and survive during host infection. ocytosis . Listeri bladder , 29. Altle acids . Similar in vivo . The varThe bile acid pool, influenced in part by microbial-encoded BSHs, in turn shapes the microbiome composition and function . This biDuring enterohepatic recirculation, circulating bile acids interact with BARs in all major organs to impart signals that regulate metabolic and homeostatic processes inside and outside of the gut, in which their transformations originate . The nucEscherichia coli engineered to express Lactobacillus BSHs were able to mimic these effects by modifying the bile acid pool, curbing lipid and cholesterol metabolism, and protecting mice from weight gain [Bacteroides thetaiotaomicron native BSH to modify the germfree mouse bile acid pool in a manner that reflects the BSH’s in vitro substrate preferences, further supporting the notion that these enzymes can be delivered in a targeted manner to selectively manipulate the bile acid pool [Several studies have used mouse models to bridge the gaps between weight gain and/or obesity, the microbiota, and bile acids through the FXR signaling. Mouse models of diet-induced obesity have demonstrated that both the microbiome and FXR signaling are necessary for weight gain, implicating deconjugated primary and secondary bile acids as regulators of host metabolism , 36. Furght gain . Similarcid pool .Bile acid dysregulation has also been implicated in other diseases, though the role of BSHs in their etiology is not well understood. A mouse model of nonalcoholic fatty liver disease (NAFLD) demonstrated that symptoms could be relieved by inhibiting bile acid reabsorption, leading to a reduction in conjugated bile acids, and a reduction in FXR antagonism . BSH actCan BSHs be used to alter the bile acid pool to rationally alter the gut microbiota and shape host physiology?Are BSHs required for general bacterial fitness and competition for nutrients? Is this context dependent? What happens in the face of inflammation and other disease states?Can BSHs be engineered with increased activity and substrate specificity for certain bile acids? What amino acid residues are important for determining bile acid substrate specificity?How do BSHs with different activity and substrate specificity alter the bile acid pool, microbiota, and host response in different regions of the GIT? How will BSHs be delivered to the different regions of the GIT?


Cumulative Dis/Advantage (CDA) theory concerns how societal structure influences individual developmental and health trajectory across the life span, but few studies have applied CDA in the international setting with gender comparisons. This study provides a cross-national perspective to test CDA in explaining health inequality between developing and developed countries. Cross-sectional harmonized data from the international Health Retirement Study-series  in 2013-2014 were used . Four health indicators were included: self-reported health, depressive symptoms, functional ability, and memory. Sociodemographic information and health behaviors were used as covariates. Regression models were fitted to examine the moderation roles of country and gender in health trajectory in later life. Results indicate self-reported health and mental health remained steady while functional ability and memory declined across late life span. Older Chinese and Mexican respondents had poorer health status than their British and American counterparts consistently except for memory in the Mexican data. Cumulative health gaps between developing and developed countries existed only for functional ability. Females in the four countries had poorer health than their male counterparts except their memory status. We conclude that CDA explains only the temporal decline of functional ability and its increasing gaps in later life between countries. Health inequality between countries could be attributed to the limited availability of healthcare and social resources in developing countries. However, other health status, including general health and mental health, depend more on individuals’ intrinsic capacity and human agency.


CareSearch is an Australian Government Department of Health funded repository of evidence-based palliative care information and resources. The CareSearch Allied Health Hub was developed in 2013 to support all allied health professionals working with palliative care clients in all clinical settings. This cross-sectional online survey sought to elicit allied health professionals palliative care experiences and subsequent considerations for educational and clinical practice needs. The survey was disseminated nationally via a range of organisations. Data was collected about palliative care knowledge, experience working with palliative care clients and professional development needs. Data were evaluated by profession, experience and practice setting. In total, 217 respondents answered one or more survey questions (94%). Respondents (65%) reported seeing >15 palliative care clients per month with 84% seen in hospital and community settings. Undergraduate education underprepared or partially prepared allied health professionals to work with these clients (96%) and 67% identified the need for further education. Access to postgraduate professional development was limited by available backfill and funding. Study findings support the importance of free, accessible, relevant educational and professional development resources to support clinical practice. This is particularly relevant for allied health professionals who have limited opportunities to attend formal professional development sessions. The World Health Assembly Resolution 2014) recommends palliative care be considered as a component of comprehensive care throughout the life course due to rapidly increasing numbers of people with palliative care needs [4 recommeAllied health professionals play a key role in the care of people with palliative care needs in all health care settings . They bring profession-specific knowledge and skills that can be essential in addressing the person’s individual care needs. They can provide non-pharmacological symptom control options alongside pharmacological interventions. Their care approaches enable continuing participation in essential and valued daily activities ,4. AllieAllied health professionals can make important contributions in the treatment and non-pharmacological management of symptoms, alongside improving the quality of life for palliative care patients and caregivers. Increasing numbers of allied health professionals employ a rehabilitative approach to optimise function of palliative care patients . ManagemLittle research considers the type of end-of-life care interventions being provided outside of specialist palliative care settings, the experiences of allied health professionals and their education and practice needs in these non-specialist settings. The purpose of this study was to survey allied health professionals across Australia on their understanding and views about palliative care, of its relevance to practice, their knowledge, and their clinical information education needs. The aim of this paper is to present survey results pertaining to palliative care training and continuing educational needs. Qualitative survey results presenting allied health professionals’ knowledge and views about palliative care are presented elsewhere .This study was a purpose-designed cross-sectional survey of Australian Allied Health Professionals. For the purposes of this survey, allied health professionals included were those most likely to work with palliative care clients in specialist or generalist settings. Survey functionality and face validity was determined by piloting the questions with the Executive Officer of Allied Health Professions Australia (AHPA) and representatives of the CareSearch Allied Health Hub advisory group prior to distribution (available from authors on request). The survey design and conduct were reviewed against the CHERRIES checklist . Ethics approval for this study was provided by the Flinders University Social and Behavioural Research Ethics Committee (Project 7014). Participant consent was implied through commencement of the online questionnaire. Allied health professionals were recruited to complete the survey through member newsletters of the Allied Health Professions of Australia and through social media channels such as CareSearch, LinkedIn and Twitter. Allied health professionals approached to participate in the survey included occupational therapists, physiotherapists, speech pathologists, social workers, dietitians, psychologists and music therapists. These allied health disciplines were represented in the CareSearch Allied Health Hub. It is not possible to determine how many people were offered the opportunity to participate in the survey due to the variety of approaches via member networks and social media but it is estimated that the networks alone represented more than 120,000 allied health professionals.Participants accessed the participant information sheet and the online survey through embedded hyperlinks within newsletters or social media posts. Data were collected from 1 November 2015 to 30 April 2016, and included 42 items on palliative care education and professional development, practice, and attitude.n) and proportion (%). As it was not compulsory to respond to each survey item, there are varying levels of missing data for every question. Individual n values are presented for each item to indicate completeness of responses. Differences in proportions between groups were evaluated using Chi-square statistics. Statistical analyses were conducted using IBM SPSS version 23.0 (IBM Corp) and statistically significant differences (p < 0.05) are highlighted in bold.This paper reports on demographic data and descriptive statistics. Categorical data are reported as number of respondents  were incomplete. Sociodemographic characteristics are reported in Occupational therapists, social workers, physiotherapists and dietitians comprised 86% of the sample . Fifty sOver half of allied health professionals felt their undergraduate training did not prepare (54%), or only partially prepared them (42%) to care for palliative care patients and/or their families. Many allied health professionals had previously undertaken professional development in palliative care, most frequently by reading and short in-service training sessions within their workplace. Palliative care educational opportunities appeared to be frequent, with 68% reporting their most recent opportunity was within the last year. Over one-third (39%) had completed online learning modules. While approximately 10% had specific qualifications in palliative care, 67% indicated that they needed additional education to better inform their clinical practice when working with palliative care patients. However, respondents reported barriers to accessing education, most frequently citing time (41%) and funding (33%) as primary limitations. Lack of available leave or backfill to cover clinical caseloads and limited knowledge about specialised or relevant educational opportunities also prevented access to education .There were no significant differences in palliative care qualifications or need to access palliative care education by allied health discipline. However, speech pathologists (70%) and physiotherapists (75%) felt the least prepared by undergraduate education and reported needing higher levels of postgraduate training in order to work effectively with palliative care patients (data not shown).Further training in grief and loss (56%) and symptom management (54%) were identified as priorities by the majority of disciplines . HoweverWhen asked to reflect on difficulties encountered in their most recent palliative care experience, most allied health professionals reported caseload or time demands as limiting (57%), while some reported feeling overwhelmed discussing non-medical topics (15%), and at their inability to take time out (14%). The proportion of allied health professionals who reported changing mindsets about working with palliative care patients differed by years of experience post-training. Those with the least experience reported this to be a greater problem at more than double the number of professionals overall (46% versus 23%). Additionally, the proportion citing a lack of palliative care knowledge or skills making their palliative care experiences difficult was significantly higher for those with less experience and those working outside of specialist palliative care settings. Forty-three percent of all respondents noted that access to postgraduate professional development was limited by available time, cost/funding, workload pressures and backfill. Further, allied health professionals working outside of a palliative care service were far more likely to report feeling overwhelmed discussing non-medical topics compared with medical topics than those working within this setting.A diverse allied health workforce delivers patient care in metropolitan, regional, rural, and remote settings. Each setting brings with it specific workforce issues and needs. Given lower life expectancies and high levels of chronic disease in lower socioeconomic areas, existing allied health models of care need to take into consideration ways to best support patients and caregivers at the end-of-life . For exaA recent study of occupational groups working in long-term care settings highlighted the differences in palliative care-specific educational needs and the intensity of inter-professional collaboration . UnderstOnline resources targeting context-specific needs have been found to build confidence of allied health professionals who work with palliative care patients and were accessed by survey respondents. Australian palliative care resources that specifically address the allied health context such as the Allied Health section on the CareSearch website  and the This study had some limitations. Respondents were a self-selecting sample of allied health professionals, some of whom already worked in palliative care. This may have led to under-representation of generalist clinician professional development needs. Numbers of respondents are small and not equal for all disciplines, hence their responses may not be representative of individual discipline educational needs.Allied health professionals have an active role to play in the physical, social, emotional and spiritual care of palliative care patients and their caregivers. However, in order to do this allied health professionals require access to evidence-based education to enable better support of patients and their caregivers as deterioration ensues. Allied health professionals working in rural and remote locations often take on specialist generalist roles but require adequate support to provide quality care to patients with complex palliative care needs. Generalist allied health professionals in particular require targeted post-graduate education, particularly around grief and loss and non-pharmacological symptom management. Online resources such as CareSearch and End-of-Life Essentials and clinical placements such as those offered through PEPA can support all allied health professionals in non-specialist palliative care settings to develop and sustain clinical skills through best available evidence and clinical networking.


Patients’ survival for most cancer types is slightly improving due to progress in faster diagnosis and advances in treatment. However, median period of survival time of patients with pancreatic cancer, glioblastoma, metastatic melanoma, metastatic lung tumors, high-grade serous subtype epithelial ovarian cancer, abdominal bowel and esophagus tumors treated with standard therapies is extremely low. There are several reasons for this therapeutic failure. Tumor initiating cells are resistant to drugs, have the ability of self-renewal and can be source of metastatic spread. Other additional major drawbacks of standard therapies lie in a lack of tumor specificity of anti-cancer drugs and the emergence of drug-resistant cell subpopulations after radio and/or chemotherapy. Further progress in cancer therapy  requires novel therapeutic modalities.HSV-MSC/GCV system [Physiological role of human mesenchymal/stromal stem cells (MSCs) is to regenerate damaged and used tissues in the body. MSCs possess the ability to migrate to the site of injury and secrete a variety of soluble factors and extra-cellular nanovesicles – exosomes capable of a number of functions inducing and supporting regenerative processes in the damaged tissue. MSCs recognize tumor as an injury, home in the tumor and, together with other cells, form the tumor stroma. Based on our experience with virus mediated cancer gene therapy, the tumor-specific tropism of MSCs inspired us to develop a targeted prodrug gene therapy mediated by MSCs engineered to express the yeast cytosine deaminase::uracil phosphoribosyl transferase fusion gene (yCD::UPRT), yCD::UPRT-MSC/5-FC system  and MSCsV system . Both syV system . SpecifiV system  melanomaV system  and prosV system . In all HSV-MSC/GCV system. Tumor specificity of MSC suicide gene exosomes is rather broad, but tissue origin of MSCs can influence the tumor cell targeting and augment the suicide gene therapeutic effect. Exosomes secreted by MSCs derived from placenta selectively inhibit growth of prostate cancer cells. Generally, MSC-exosomes display a unique anti-tumor effect thanks to a variety of molecular species such as micro-RNAs within their cargo and the capability to activate multiple gene pathways [The explanation came when we found release of extracellular vesicles - exosomes from yCD::UPRT gene transduced MSCs. Exosomes incorporated mRNA of suicide gene in their cargo. Such exosomes we call MSC suicide gene exosomes. Size-exclusion chromatography of the secretome released from yCD::UPRT-MSCs revealed that the biological activity was clearly localized in the exosome fractions. These exosomes migrate to tumor similarly like MSCs, internalized tumor cells, therefore they kill tumor cells by intracellular conversion of prodrug 5-FC to cytostatic drug 5-FU and to 5-FUMP . Similarpathways . Since Mpathways .Exosomes from suicide gene modified MSCs have the potential to be a new class of highly selective cancer-targeted therapeutics. Composition of exosomes released from MSCs might be purposely modified to create therapeutically interesting exosomes for cancer treatment. Recently we reported a dual action of MSCs-yCD-UPRT-MSCs exosomes possessing beside mRNA of suicide gene also iron oxide nanoparticles. These nanoparticles were able to act both as a prodrug dependent therapeutic and hyperthermia inducing factor when tumor cells were exposed to alternating magnetic field .Our present research direction is headed to development of suicide gene exosomes for metastases. Human tumor cell specific exosomes with suicide gene we found to induce tumor cell death in a similar way as MSC exosomes (article in preparation). It was reported that aggressive tumor cells release exosomes creating pre-metastatic niche in body organs. Integrins of tumor exosomes determine organotropic metastasis. Therefore suicide gene exosomes prepared from primary human tumor might be used in future as a therapeutic tool for the patient-tailored therapy of metastases. The usefulness of prodrug gene therapy for cancer mediated by MSC suicide gene exosomes is now validated by animal studies.Described findings open new exciting possibilities for cancer gene therapy of human tumors that do not respond to standard therapies such as grade IV glioblastoma multiform. MSC suicide gene exosomes carry mRNA of suicide gene protected by the plasma membrane. They can travel long distances in the body, when administered intravenously might execute their therapeutic effect at a distant location. Accumulating evidence indicates that cancer therapy using MSC exosomes has multiple advantages over cell therapy. CM or exosomes are stable after intravenous administration and exhibit a superior safety profile.To be innovative cancer therapy curative; it must differ from standard therapies. The therapy should be targeted not only to tumor mass, but also specifically to tumor cells, drugs should be able to internalize both cancer stem cells and cancer cells and act intracellular. In this way it could be possible to avoid side effects, to prevent development of resistance and even kill already resistant tumor cells . Suicide


Gorilla g. gorilla) from Dzanga Sangha Protected Areas, Central African Republic. We examined 43 fecal samples for GIPs and quantified strongylid nematodes. We characterized fecal microbiome composition through 454 pyrosequencing of the V1-V3 region of the bacterial 16S rRNA gene. Entamoeba spp. infections were associated with significant differences in abundances of bacterial taxa that likely play important roles in nutrition and metabolism for the host, besides being characteristic members of the gorilla gut microbiome. We did not observe any relationships between relative abundances of several bacterial taxa and strongylid egg counts. Based on our findings, we suggest that there is a significant relationship between fecal microbiome and Entamoeba infection in wild gorillas. This study contributes to the overall knowledge about factors involved in modulating GIM communities in great apes.Relationships between gastrointestinal parasites (GIPs) and the gastrointestinal microbiome (GIM) are widely discussed topics across mammalian species due to their possible impact on the host's health. GIPs may change the environment determining alterations in GIM composition. We evaluated the associations between GIP infections and fecal microbiome composition in two habituated and two unhabituated groups of wild western lowland gorillas ( The mammalian gastrointestinal microbiome (GIM) is essential in providing access to nutrients, regulating epithelial development, and shaping immunity Berg, . Thus, dGorilla gorilla gorilla showed that feeding behavior, geographical range and increased anthropogenic pressure may be important modulators of the gorilla GIM. Moreover, the GIMs of two gorilla species G. gorilla and G. beringei exhibit significantly different patterns, but the GIMs converge when hosts face similar dietary constraints, associated with low fruit availability in their habitats suggesting that in primates dietary constraints triggered during their adaptive radiation were potential factors behind the species-specific GIM patterns observed today  infections on the composition and activity of the GIM has received increasing attention and several studies have been conducted in humans and animals   that may change the gut environment, potentially leading to alterations in GIM composition proteins, which may function as proteases or pore-forming proteins that could affect epithelial integrity) can suppress innate and adaptive pro-inflammatory immune responses  has been hypothesized to decrease gluten sensitivity and could serve as a potential treatment for celiac disease  in Dzanga Sangha Protected Areas (DSPA), Central African Republic , which are highly prevalent in studied gorillas  Does the fecal microbial diversity differ between individuals positive and negative for particular GIP? (ii) Does the abundance of specific bacterial taxa differ between individuals positive and negative for particular GIP? (iii) Is there a relationship between fecal microbial diversity and surrogate measures of intensity of parasite strongylid infection (egg counts)? (iv) Is there a relationship between abundances of specific bacterial taxa and surrogate measures of intensity of parasite strongylid infection (egg counts)?As a part of the long-term non-invasive monitoring of GIP infections and fecal microbiome/GIM of western lowland gorillas (G. g. gorilla) were collected at two research sites: Mongambe  and Bai Hokou  in the Dzanga sector of the Dzanga-Ndoki National Park (part of the DSPA complex), Central African Republic . Samples were diluted with water up to 50 ml volume and centrifuged for 5 min at 2,000 rpm. The sediment was weighed and re-suspended to 10 ml with 4% formaldehyde. For coprological examinations, Sheather's flotation with modified sugar solution was used (specific gravity 1.33) , Hasegawa et al. (Oesophagostomum or Necator. Therefore we divided the strongylid eggs found in gorilla samples into two categories: (i) Necator/Oesophagostomum and (ii) Mammomonogamus.We reported parasite presence/absence and for strongylid nematodes, also the intensity of infection expressed as EPG. Although the number of parasite eggs shed in feces may not be linearly correlated with the intensity of infection  and 534r . Amplicon purification was done using the QIAquick PCR Purification Kit . Amplicons were multiplexed and pyrosequenced using 454 FLX-Titanium technology as described previously  according to the manufacturer's protocol. The V1-V3 region of the 16S rRNA gene was PCR amplified  using primers 27f  with Entamoeba status as a predictor variable and gorilla social group as a covariate was fitted using MASS package ; eggs of Strongyloides, Necator/Oesophagostomum, Mammomonogamus, Bertiella, and Spirurida fam. gen  and 3.13 EPG , respectively (see Table We detected: trophozoites of en Table . The medEntamoeba positive (Ent+) and Entamoeba negative (Ent-) individuals , weighted UniFrac , and unweighted UniFrac .We obtained a median sampling depth of 6,458 reads per gorilla fecal sample  after sequence quality control  with Entamoeba status as a predictor variable and gorilla social group as a covariate  reached higher levels in Ent+ individuals. At the family level, Peptostreptococcaceae reached significantly higher levels in Ent− individuals , while unknown Selenomonadales , Erysipelotrichaceae , unknown Mollicutes , and Anaeroplasmataceae  reached higher levels in Ent+ individuals. At the genus level, unknown Selenomonadales , unknown Erysipelotrichaceae , unknown Molicutes , unknown Deltaproteobacteria , Olsenella , and Dorea  reached significantly higher levels in Ent+ individuals. Three out of six indicator taxa on genus level belonged among the 26 most abundant bacterial genera . We did not find significant differences in relative abundances of any other bacterial taxa between individuals positive or negative for other detected parasites (data not shown).We detected significant differences in relative abundances of indicator taxa, detected by Species indicator analysis and Random forest classifier, in te Table . Specifia Figure . AlthougEnt+ and Ent- individuals, even though they reached higher values in Ent+ individuals . Analyses of multivariate dispersion of communities or inter-individual variation within groups also did not show differences between Ent+ and Ent- individuals  did not significantly differ between Necator/Oesophagostomum and Mammomonogamus (EPG) and overall fecal microbiome composition, as described by the first NMDS axis, NMDS1 . We found weak relationships only between relative abundances of members of phylum Verrucomicrobia, family Verrucomicrobia subdivision 5 and Necator/Oesophagostomum egg counts based on Spearman's rank correlations and linear regression models . We did not find any significant relationship between relative abundances of any bacterial taxa and Mammomonogamus egg counts using Spearmans rank correlation analyses and linear regression model (data not shown).Using linear regression models we found no relationships between egg counts of  Figures , but wheNecator/Oesophagostomum  and egg count of Entamoeba spp. is associated with the abundance of specific bacterial taxa in the gorilla gastrointestinal tract. The mechanism behind these observations is unknown, however, this may be a reflection of either direct or indirect interaction between entamoebas, the GIM, and the host immune system. The genus Entamoeba contains both pathogenic and commensal species  and taxa that seem to be a signature of the fecal microbiome of gorillas even if they belong among minor taxa   in gorillas must be tested molecularly, by specifically targeting the presence and expression of known parasite-associated virulence factors. Since large diversity of Entamoeba spp. has been observed in wild great apes  that are not reflected in the fecal microbiome composition , the host immune machinery, and the other microbiota. To gain further insight into the specific nature of these interactions, it will be necessary to apply additional molecular approaches to assess GIP diversity and function at the mucosal level to understand how the host immune system reacts to the GIPs and their virulence factors, with subsequent consequences for gut bacterial communities. Likewise, the role of diet in this interaction should be clarified from a molecular perspective in terms of metabolic impact on the GIPs and the other microbiota. For more complex analyses adding other factors affecting fecal microbiome of great apes, e.g., sex and age would be also beneficial, nevertheless, it would require studying captive or larger number of habituated animals. Moreover, future work may be directed into analyzing the evolutionary correlates of GIP infections for health and disease in humans and great apes. Our results can have implications for understanding host-microbe interactions and gorilla welfare in both wild and captive conditions. Absence of GIP in captive apes may be responsible for particular health or digestive problems (together with other factors like diet), on the other hand, it is well-known that particular GIP in captive apes can reach higher intensities than in the wild and infected animals suffer from clinical outcomes which are rarely observed in the wild.Here, we examined the associations between GIP infections and the GIM composition of wild lowland gorillas. Although we did not observe notable changes in global bacterial community profiles in connection with GIP infections, we found significant relationships between KV and AG conceived the initial project design, with inputs from KP; BP KP and AT designed the field study and collected the samples; KV, AG, MT performed the microbial community analyses; BP performed parasitological analyses; KV analyzed the data with significant contributions from AG; KP, DM, KN, BreW, BryW, CY, RS, SL provided the financial support; KV wrote the initial manuscript with significant contributions from AG and KP. All authors reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer AK and handling Editor declared their shared affiliation.


Family caregivers play a crucial role in supporting older adults through home health (HH) episodes; yet no prior research examines factors affecting the adequacy of caregiver support during HH. We use a novel dataset linking nationally-representative survey data with HH assessment data for community-dwelling older adults  to identify older adult characteristics associated with adequate caregiver support in four task categories  during a subsequent HH episode. Weighted, multivariable logistic regression is used to model the likelihood of adequate caregiver support in each category. Multiple older adult characteristics prior to the HH episode were associated with greater likelihood of adequate caregiver support during HH, including: prior caregiver assistance with mobility, self-care, and health care tasks, living with others, and cognitive impairment. These findings reveal new risk factors for consideration in risk assessment and payment adjustments related to social determinants of health.


Obesity has been linked to multiple conditions including cardiovascular disease, cancer, and metabolic syndrome. While the relationship between obesity and these diseases is well-established, the relationship between obesity and changes in cognitive function is less clear. This study examined the effects of overweight and obese status on performance in tests of executive function and memory. It was hypothesized that overweight and obese individuals would perform worse than normal weight individuals. Data from 547 individuals who participated in the Midlife in the United States Refresher cohort were used. Body mass index (BMI) and waist circumference (WC) were employed as measures of obesity. Both variables were examined continuously and categorically (from NHBLI-defined cutoffs). Z-scores were computed for each cognitive test and averaged together to create separate composite scores for executive function and memory. When measuring BMI and WC continuously, higher BMI was significantly associated with lower executive function ; no significant association between executive function and WC was found (p=.162). When measuring BMI and WC with clinical thresholds, participants with overweight or obese WC had significantly lower executive function (p=.030). No overall association between BMI-based thresholds and executive function was found (p=.682). Memory did not differ between overweight/obese participants and healthy weight controls with continuous or clinical threshold specifications. These findings suggest that: 1) obesity may relate to poorer executive function but not worse memory, and 2) the way in which obesity is measured reflects saliently in the results. Future researchers should consider conducting sensitivity analyses with different obesity criteria.


Self-neglect includes persistent inattention to personal hygiene and the conditions of one’s immediate living environment and is known to be associated with an increased risk of mortality among older adults. Although previous studies have shown that many individual factors predict self-neglect, neighborhood characteristics have received much less attention. Extant research has yet to consider connections between the conditions of one’s neighborhood and self care over time. Using nationally representative longitudinal data from the National Social Life, Health, and Aging Project (NSHAP), we consider several features of neighborhood context in later life, including self-reported perceptions of neighborhood cohesion and neighborhood danger, neighborhood disorder (measured by interviewer ratings), and concentrated neighborhood disadvantage (using census data). Adjusting for individual-level factors , results from both lagged dependent variable and cross-lagged panel models find higher levels of neighborhood disorder to be associated with higher self-neglect scores (measured by interviewer ratings) over time. Social cohesion, perceived neighborhood danger, and collective efficacy were not associated with self-neglect when controlling for neighborhood disorder. These findings suggest that improving neighborhood disorder may be an effective approach for self-neglect prevention in later life


The potential life-threatening consequences of catecholamine use for emergency circulatory support in Takotsubo cardiomyopathy-related acute heart failure is a major challenge in cardiovascular emergences. In their recent work in BMC Cardiovascular Disorders Ansari U. et al. demonstrated the harmful effects of catecholamines on the outcome of patients with Takotsubo cardiomyopathy. Concerning this matter we emphasize the usefulness of speckle-tracking-derived echocardiography for early recognition of an acute phase of a Takotsubo syndrome in order to avoid the deleterious effects of a catecholamine therapy in patients with Takotsubo-associated acute heart failure. We read with great interest the publication by Ansari U. et al. , in whicAlthough the etiopathogenesis of TTS is still under debate, the role of catecholamines appears central to the pathophysiology of TTS. There is increasing evidence that the reversible change in left ventricular (LV) shape  associated with potentially life-threatening LV dysfunction, which characterize the acute phase of TTS reflect an uncommon myocardial response to sympathetic stimulation –4 PatienCatecholamines are still the first-line therapeutics in cardiogenic shock following acute myocardial infarction (MI), but are absolutely contraindicated in TTS patients, regardless of the severity of hemodynamic compromise. The potentially life-threatening consequences of catecholamine use for emergency circulatory support if the underlying cause of acute LV dysfunction is unrecognized TTS are therefore the main problem that can derive from diagnostic errors , 4, 5.c) reached up to 7 times higher value in the apex than in basal regions [c can be high enough to oppose circumferential myocardial fiber shortening which mainly generates the visible inward movement in this region and thus could explain the visually akinetic appearance of the apical regions in spite of the unequivocal prove of myocardial viability provided by the longitudinal strain data [Transthoracic echocardiography can be useful for early distinction between TTS and acute apical MI if attention is focused on regional myocardial function using the advantages of strain imaging.In patients with life-threatening acute HF, before coronary angiography becomes possible, echocardiography including also STE can identify a highly probable acute phase of TTS and in such patients, if absolutely necessary, any administration of cathecholamines should be continuously monitored by echocardiography and immediately stopped if the signs for TTS become more evident.Clinically (including laboratory tests), electrocardiographically, and even echocardiographically using only conventional echocardiographic techniques, TTS-related acute LV disorders closely mimic acute apical MI and without coronary angiography data these two etiopathogenically different diseases are almost indistinguishable. The only helpful conventional echocardiography signs which indicate that any sympathomimetic treatment can be deleterious are the detection of mitral valve systolic anterior movement (SAM) and high LV outflow tract (LVOT) pressure gradients. However, even during acute stress-induced LV dysfunction, LVOT obstruction because of mitral valve SAM is not evident in all patients with TTS . On the  regions . Such anain data , 5. Suchain data . All the


Choir interventions confer psychological benefits for persons with dementia (PwD) and their caregivers. However, less is known about whether physiological function also exhibits improvements pursuant to such social-cognitive interventions. The present study, based upon a subsample of the Voices in Motion (ViM) project, explored whether participation in an intergenerational choir results in systematic improvements in gait velocity  for both informal caregivers  and PwD . Longitudinal burst data from the first of three cohorts spanning 4 assessments over 3.5 months was analysed using multilevel modeling. Whereas caregivers exhibited significant improvements (p<.05) in gait velocity, PwD showed no improvement. Ongoing analyses are exploring additional cohorts, and whether improvements in gait dynamically covary with reductions in comorbidities . These results underscore the potential of choir for facilitating both psychosocial and physiological function for caregivers and PwD.


Traumatic lesions of the wrist occur frequently and may give rise to underdiagnosed secondary abutment syndromes. The latter are a common cause of incapacitating pain and limited range of motion, despite minimal or even absent alterations on radiographs. Moreover, the complex wrist anatomy often results in ignorance or underappreciation of these syndromes.This paper presents a pictorial review of frequent and rare secondary abutment syndromes at the wrist joint, which – in contrast to primary abutment syndromes – are not based on anatomical variants or congenital deformations. The merit of each imaging modality is briefly mentioned. Traumatic wrist lesions occur frequently. Subsequently, secondary abutment syndromes (SAS), a common cause of incapacitating pain and limited range of motion in spite of minimal or absent alterations on radiographs, may arise. They are often underappreciated due to the complex wrist anatomy and call for a thorough analysis of all wrist components.The aim of this pictorial review is to present an overview of SAS and to highlight the role of imaging.The wrist is a complex structure of cartilaginous joints with little intrinsic stability, but mainly relies on soft tissue constraints from various ligaments. The three-dimensional motion is very susceptible to disturbances of their complex surfaces and to ligamentous lesions .Wrist fractures are frequently missed on radiographs . LigamenThe secondary repetitive bony impaction may result in contusion  with theSAS may give rise to complaints, sometimes appearing years after trauma. The predominant symptoms are restricted motion and incapacitating pain, exacerbated by activity. SAS may have a negative impact on the three-dimensional hand positioning during daily activities .Intra-articular fractures of the radius may heal with a residual step-off , seen onLunate bone impaction on its articular fossa may cause SAS. Parasagittal radial fractures Figure  need carDistal radioulnar joint (DRUJ) fractures are difficult to evaluate on radiographs, particularly coronal sigmoid notch fractures Figure  and B. BA relative ulnar shortening may appear after trauma, causing a DRUJ impingement Figure  and F. EStyloid process fractures may fail to heal, resulting into fragmentation and collision during ulnar deviation. MRI highlights neo-articulation and BMO Figure . The tri9Due to styloid process length increase, impaction with the triquetral bone may appear Figure . As in tIn secondary positive ulnar variance, the latter abuts the lunate and/or triquetral bone and eventually leads to ulnar head deformation Figure . It may Extensive destruction of extrinsic ligaments leads to a proximal-ulnar carpal shift , creatinFractures appear most frequently at the scaphoid waist . Radial Avascular necrosis – probably due to chronic microtraumata – with deformation starts at the radial side . Due to On radiographs Figure , a widenMRI may also show this ligamentous tear Figure  and the Hamatolunar abutment is related to lunate bony variants (Viegas type II). However, a posttraumatic disturbance of the carpal row alignment (Gilula)  may induQuadrangular joint traumata may result in bony carpal boss . AlthougA large variety of pathologies may cause SAS. This underscores the need for a thorough posttraumatic joint evaluation. Follow-up radiographs and MRI are mandatory in the presence of clinical symptoms. Concerns about the prognosis – certainly in expert or insurance-related files – should encourage detailed assessment, as even small lesions may be very functionally disabling.Posttraumatic SAS may interfere with a large variety of normal daily activities, as the wrist is a crucial structure in the three-dimensional positioning of the hand. Some are fairly unknown and, due the complex anatomy of the wrist, a SAS is also often ignored or underappreciated.


Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings.Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010–2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria.Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days , particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006).Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries. Variation in hospital staffing has been associated with increases in risk of patient morbidity and mortality. Mortality for both critically ill patients and those requiring emergent surgical intervention, for example, has been found to increase during nights and weekends, the so-called “weekend effect.” , 2 SimilDespite efforts to maintain high levels of quality healthcare delivery at all times, trauma centers continue to experience regular fluctuations in staffing, and the potential risks associated with those periods remains largely unclear. Multiple times each year, thousands of surgeons leave their respective institutions to travel to academic conferences. A recent study found that during national cardiology meetings, mortality decreased for high-risk patients hospitalized with heart failure and cardiac arrest. As the aIn this study, we examine the association between national surgery conferences and in-hospital trauma mortality. We also perform subgroup analysis on specific trauma populations and hospitals according to their different forms of trauma center accreditation. We hypothesize that mortality resulting from traumatic injuries increases during national surgery conferences, presumably due to fluctuations in staffing.We conducted a retrospective cohort study of trauma patients treated at hospitals participating in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP). The primThe study population consisted of patients meeting inclusion criteria for the ACS TQIP. TQIP is We included injured patients admitted to TQIP participating centers between January 2010 and December 2011. The data excludes children (age less than 16 years) and patients who lacked records for date and time of admission to the Emergency Department. We excluded patients who presented to emergency departments without signs of life, defined as an initial systolic blood pressure of zero, heart rate of zero, and Glasgow Coma Scale motor score of one. Rates ofa priori and obtained meeting dates from publicly available conference announcements. After identifying dates of each individual meeting, we created a composite “meeting” variable that consisted of all surgery conference periods combined. The control group consisted of patients admitted three weeks before and after each meeting.The primary exposure variable was hospital admission during national surgery conferences that are consistently well attended by trauma surgeons. Conferences included annual meetings of the American College of Surgeons, the Eastern Association for the Surgery of Trauma, the Western Trauma Association, and the American Association for the Surgery of Trauma. We selected these conferences When modeling the influence of conference periods on mortality, we adjusted the probability of death for patients using the ISS, the motor component of the Glasgow Coma Scale, age, gender, race, initial systolic blood pressure in the Emergency Department, mechanism of injury, inter-hospital transfer status, payer type, and hospital teaching status.We first performed descriptive statistics using chi-square and Student t tests to compare patient characteristics in both cohorts. All tests were two tailed with α = 0.05. We then performed risk adjustment of patient level factors and hospital teaching status using multivariable logistic regression models, clustering at the hospital level. We constructed the mortality model using forward selection, and the order of variable entry was determined by the c-index, a measure of the ability of a parameter to discriminate outcome. Continuous data (systolic blood pressure) exhibited a right-skewed distribution and was natural log-transformed in a manner consistent with the TQIP mortality model. We testeWe performed several sensitivity analyses. We first conducted falsification analyses to assess for potential confounding in the relationship between surgery meeting and non-meeting periods.–17 SpeciThe ACS TQIP registry included a total of 94,566 trauma patient admissions reported from 156 hospitals during the study period. Of those patients, 12,256 patients (13%) presented during national surgical conferences. Patients in both cohorts, those admitted during meeting compared with non-meeting periods, were similar with respect to their demographic and injury characteristics. The majority of patients were male and white, and falls were the most common mechanism of injury. The majority of patients in each cohort were treated at ACS level I university hospitals, and approximately one third of the patients in each cohort were transferred from other facilities, suggesting that patients were not diverted away from academic centers during surgical conferences. Patient and injury characteristics of each cohort are summarized in The study included data collected from 145 hospitals (2010–2011), with an addition ten hospitals included in 2011. The majority of participating hospitals had an ACS trauma verification level (I or II), however, a considerable number of hospitals without ACS trauma verification contributed data as well . We provided a summary of hospital characteristics in Overall risk-adjusted in-patient mortality was similar for trauma patients admitted during meetings compared with non-meeting periods (approximately 6%). Also, when we stratified patients by injury type (blunt and penetrating), patient mortality exhibited no difference between meeting and non-meeting cohorts. However, we found that when stratified by ACS trauma verification level, mortality increased significantly during meetings among trauma patients admitted to hospitals that lacked ACS trauma verification . That association was particularly pronounced at non-ACS verified trauma centers among patients with penetrating injuries, whose predicted mortality increased from 12% to 16%. We found in subgroup analysis by state verification level that the conference effect in non-ACS trauma centers was entirely driven by state verified level I trauma centers. In contrast, mortality remained unchanged during meetings compared with non-meeting periods for injured patients who presented to ACS verified trauma centers.When stratified by injury acuity (ISS≤15 and ISS>15), we found no evidence in the overall patient cohort of conference effect among low-acuity patients  and high-acuity patients . At trauma centers that lacked ACS trauma verification, we found statistically insignificant trends towards increased mortality during meetings among both low- and high-acuity patients . The association only reached statistical significance among high-acuity patients with penetrating injuries . We found no evidence of interaction effects between number of trauma surgeons and meetings, meaning the number of trauma surgeons did not contribute to mortality differences during meetings, so we did not include that variable in the final mortality model. Additionally, we found no evidence of interaction between patient characteristics  and surgery meetings with regards to mortality risk. Odds ratios and predicted probability of risk-adjusted in-patient mortality during meetings compared with non-meeting periods are summarized for each patient cohort in We tested the robustness of our model and found no evidence that unmeasured confounding contributed to differences in in-patient mortality between national surgical meetings and non-meeting periods. Risk-adjusted mortality of trauma patients was similar during national meetings for oncology and health services research when compared with the three weeks before and after those meetings. That analysis included 114,918 patients, 17,154 patients admitted during meetings and 97,764 patients admitted during non-meeting periods. Subgroup analysis, stratifying patients by hospital ACS trauma verification level and injury type, produced no difference in mortality between cohorts (meeting and non-meeting) for non-surgery conferences. Results of those tests are summarized in We found substantial increases in mortality among trauma patients admitted to hospitals that lack trauma center verification by the ACS during national surgery conferences, particularly for patients who presented with penetrating injuries. Since typical risk factors such as ISS, age, and transfer status did not differ significantly between patients admitted during meeting and non-meeting periods, it is unlikely that high-risk patients were directed to or from particular hospitals during meetings. The increased mortality during meetings is most likely attributable to the selective decline of surgeons and changes in hospital staff composition that occur, potentially leaving hospitals with decreased capacity and/or capability to effectively treat injured patients. The finding that mortality increased among patients with penetrating injuries, in particular, supports this explanation, since those patients often require surgical intervention compared with patients whose injuries result from blunt mechanisms.Study of the conference effect phenomenon is limited. Cardiology conferences have been associated with decreases in both percutaneous coronary interventions (PCI) and cardiovascular mortality, whereas we found surgery conferences were associated with increased mortality for trauma patients. These diIt is also noteworthy that we found no such association between surgery meetings and increased mortality for patients admitted to ACS verified trauma centers. This finding may be due to trauma center adherence to the ACS guidelines. The American College of Surgeons Committee on Trauma (ACS-COT) has maintained guidelines for regionalized trauma systems since 1979, and the a priori for the purposes of this study. The study does not include a comprehensive assessment of all surgery, trauma, and critical care conferences. Inclusion of both additional specialty conferences and more granular attendance data, including the clinical experience of the attendees, may clarify the relationship between fluctuations in staffing during surgery conferences and trauma patient mortality.The primary limitation of our study was the inability to establish specific mechanisms by which patients admitted during national surgery conferences to hospitals lacking ACS verification had increased risk of mortality. Further study of variation in processes of care such as resuscitation practices and procedures may explain the influence of surgical meetings on clinical outcomes. Another limitation is that we selected four surgery conferences In this study, we identified a “conference effect” for trauma patients treated at non-ACS verified trauma centers, and we identified patients with penetrating injuries as particularly at-risk of increased mortality during national surgery meetings. Staffing criteria of trauma center verification by the American College of Surgeons appears to protect against the conference effect. These findings have important implications for both how hospitals prepare for conferences with regards to staffing and, potentially, how conferences themselves are structured to allow for increased remote participation.S1 TableAppendix A and Appendix B.(DOCX)Click here for additional data file.S1 File(DTA)Click here for additional data file.


Ductal adenocarcinoma is the most common pancreatic neoplasm. A variety of pancreatic lesions mimic pancreas ductal adenocarcinoma (PDAC), such as high-grade neuroendocrine tumors, small solid pseudopapillary tumors, metastases, focal autoimmune pancreatitis, and groove pancreatitis. These occasionally look similar in images, but they have differential diagnosis points. Familiarity with the imaging features of PDAC and its mimics is paramount for correct diagnosis and management of patients. In this essay, we describe imaging findings of PDAC and its mimics for differential diagnosis. Pancreas ductal adenocarcinoma (PDAC) accounts for 85–90% of all pancreatic neoplasms and is one of the leading causes of death worldwide 2. Variou3438Computed tomography (CT) is a useful modality for detecting and staging PDACs . PDACs u12Pancreatic NETs originate from the islet cells of Langerhans and are divided into low-, intermediate-, and high-grade according to the World Health Organization classification . High-gr71417SPTs are uncommon neoplasms with low malignancy potential, occurring predominantly in young women 19. Calci202222A previous study  reported24Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis caused by an autoimmune mechanism . It is a282930Groove pancreatitis is an uncommon type of pancreatitis affecting the pancreaticoduodenal groove, defined as the potential space between the pancreatic head, common bile duct, and duodenum . This in9259Neoplastic lesions such as high-grade NETs, small SPTs, and metastases and inflammatory lesions including focal AIP and groove pancreatitis can mimic PDAC. Abrupt narrowing of a dilated pancreatic duct is a usual imaging finding of PDAC. Although some mimics occasionally accompany pancreatic duct dilatation, they have points of differential diagnosis: presence of tumor thrombus and hypervascular liver metastases, absence of adjacent vascular invasion, and delayed enhancement pattern. In addition to these imaging findings, the shape of the narrowed pancreatic duct is a key imaging feature for discrimination of PDAC from other disease entities. Familiarity with the imaging features of PDAC and its mimics is paramount for managing patients in daily practice.


Research suggests that older adults with neurodegenerative diseases are at increased risk of developing a subsequent neurodegenerative or comorbid psychiatric disorder or both. Depression and other psychiatric conditions, though prevalent, are often under-diagnosed and under-treated among those with neurodegenerative conditions potentially leading to more rapid disease progression, poorer health outcomes and increased health care use. Few population-based studies have comprehensively examined the risk and temporal ordering of common neurodegenerative and psychiatric conditions, including whether these associations differ by age or sex. Initial findings regarding the incidence of ordered pairs of neurological conditions  and psychiatric disorders  will be summarized. This population-based retrospective cohort study will provide essential data to allow policymakers, planners and providers to better anticipate the prognosis and care needs of older adults with comorbid neurodegenerative and psychiatric conditions.