bluuebunny/crossref_metadata_2025 huggingface dataset:
Ubiquitin E3 ligase SPOP is a host negative regulator of enterovirus 71-encoded 2A protease
Authors: Zang Lichao , Yang Xinyu , Chen Yan , Huang Fan , Yuan Yukang , Chen Xiangjie , Zuo Yibo , Miao Ying , Gu Jin , Guo Hui , Xia Wenxin , Peng Yang , Tang Mengyuan , Huang Ziwei , Wang Yangyang , Ma Jinhong , Jiang Jingting , Zhou Wei , Zheng Hui , Shi Weifeng
Published: October 2023

The 2A protease (2A
pro
) encoded by enterovirus 71 (EV71) serves as an accessory protein with significant involvement in the regulation of EV71 infection and viral replication. EV71-2A
pro
exhibits the ability to suppress various host factors, thereby disrupting the cellular antiviral immune response. However, whether host factors downregulate EV71-2A
pro
remains largely unknown. Here, we discovered that the speckle-type POZ protein (SPOP), functioning as a host E3 ubiquitin ligase, triggers ubiquitination modifications and subsequent degradation of EV71-2A
pro
. SPOP interacts with EV71-2A
pro
and exhibits a dose-dependent downregulation of EV71-2A
pro
levels. Conversely, knockdown of endogenous SPOP upregulated EV71-2A
pro
levels. Subsequent investigations revealed that the SPOP facilitates the lysosome-dependent degradation of EV71-2A
pro
by inducing K48-linked polyubiquitination of EV71-2A
pro
, which ultimately restricts EV71 replication. These findings shed light on the ubiquitination and lysosome-dependent regulation of the crucial EV71-encoded protease, offering a potential therapeutic target for the treatment of EV71 infection.

IMPORTANCE

EV71 poses a significant health threat to children aged 5 and below. The process of EV71 infection and replication is predominantly influenced by ubiquitination modifications. Our previous findings indicate that EV71 prompts the activation of host deubiquitinating enzymes, thereby impeding the host interferon signaling pathway as a means of evading the immune response. Nevertheless, the precise mechanisms by which the host employs ubiquitination modifications to hinder EV71 infection remain unclear. The present study demonstrated that the nonstructural protein 2A
pro
, which is encoded by EV71, exhibits ubiquitination and degradation mediated by the host E3 ubiquitin ligase SPOP. In addition, it is the first report, to our knowledge, that SPOP is involved in the host antiviral response.
Kaposi’s sarcoma-associated herpesvirus glycoprotein K8.1 is critical for infection in a cell-specific manner and functions at the attachment step on keratinocytes
Authors: Liu Shanchuan , Großkopf Anna K. , Yang Xiaoliang , Mannheim Maximilian E. , Backovic Marija , Scribano Stefano , Schlagowski Sarah , Ensser Armin , Hahn Alexander S.
Published: October 2023

Kaposi’s sarcoma-associated herpesvirus (KSHV) is associated with Kaposi’s sarcoma and B cell malignancies. K8.1, the major antigenic component of the KSHV virion, has been reported to play a critical role in the infection of B cells, but otherwise its function remains enigmatic. We created a K8.1 knockout virus (KSHVΔK8.1) in the BAC16 genetic background and analyzed its infectivity on a range of adherent cells. We observed a strong defect on several epithelial cells, such as the HaCaT keratinocyte cell line, human embryonic kidney (HEK) 293T, and A549 lung epithelial cells. However, we did not observe such a defect in other cells, including lymphatic and blood endothelial cells. Mechanistically, we found that reduced infectivity of the K8.1 knockout virus correlated with reduced attachment to HaCaT cells. The defect in infectivity of KSHVΔK8.1 could be rescued by complementation through expression of K8.1 in KSHVΔK8.1 producing cells by means of a lentiviral vector. In a coculture infection model with iSLK producer cells, KSHVΔK8.1 was highly efficient at infecting the BJAB B cell line but was significantly impaired at infecting the MC116 B cell line, in line with a previous report. In fusion assays together with the gH/gL glycoprotein complex and gB, the components of the conserved herpesviral core fusion machinery, we did not observe activation of membrane fusion by K8.1 or its R8.1 homolog of the rhesus monkey rhadinovirus. In summary, we found K8.1 to function in a highly cell-specific manner during KSHV entry at the attachment step, playing an important role in the infection of epithelial cells.

IMPORTANCE

Kaposi’s sarcoma-associated herpesvirus (KSHV) is the causative agent of several B cell malignancies and Kaposi’s sarcoma. We analyzed the function of K8.1, the major antigenic component of the KSHV virion in the infection of different cells. To do this, we deleted K8.1 from the viral genome. It was found that K8.1 is critical for the infection of certain epithelial cells, e.g., a skin model cell line but not for infection of many other cells. K8.1 was found to mediate attachment of the virus to cells where it plays a role in infection. In contrast, we did not find K8.1 or a related protein from a closely related monkey virus to activate fusion of the viral and cellular membranes, at least not under the conditions tested. These findings suggest that K8.1 functions in a highly cell-specific manner during KSHV entry, playing a crucial role in the attachment of KSHV to, e.g., skin epithelial cells.
Differential adenine methylation analysis reveals increased variability in 6mA in the absence of methyl-directed mismatch repair
Authors: Stone Carl J. , Boyer Gwyneth F. , Behringer Megan G.
Published: October 2023

Methylated DNA adenines (6mA) are a critical epigenetic modification in bacteria that affect cell processes like replication, stress response, and pathogenesis. While much work has been done characterizing the influence of 6mA on specific loci, very few studies have examined the evolutionary dynamics of 6mA over long time scales. We used third-generation sequencing technology to analyze 6mA methylation across the
Escherichia coli
K-12 substr. MG1655 genome. 6mA levels were consistently high across GATC sites; however, we identified regions where 6mA is decreased, particularly in intergenic regions, especially around the −35 promoter element, and within cryptic prophages and IS elements. We further examined 6mA in WT and methyl-directed mismatch repair-deficient (MMR-) populations after 2,400 generations of experimental evolution. We find that, after evolution, MMR- populations acquire significantly more epimutations resulting in a genome-wide decrease in 6mA methylation. Here, clones from evolved MMR- populations display non-deterministic sets of epimutations, consistent with reduced selection on these modifications. Thus, we show that characterization of 6mA in bacterial populations is complementary to genetic sequencing and informative for molecular evolution.

IMPORTANCE

Methylation greatly influences the bacterial genome by guiding DNA repair and regulating pathogenic and stress-response phenotypes. But, the rate of epigenetic changes and their consequences on molecular phenotypes are underexplored. Through a detailed characterization of genome-wide adenine methylation in a commonly used laboratory strain of
Escherichia coli
, we reveal that mismatch repair deficient populations experience an increase in epimutations resulting in a genome-wide reduction of 6mA methylation in a manner consistent with genetic drift. Our findings highlight how methylation patterns evolve and the constraints on epigenetic evolution due to post-replicative DNA repair, contributing to a deeper understanding of bacterial genome evolution and how epimutations may introduce semi-permanent variation that can influence adaptation.
Clinical
Staphylococcus aureus
inhibits human T-cell activity through interaction with the PD-1 receptor
Authors: Mellergaard Maiken , Skovbakke Sarah Line , Jepsen Stine Dam , Panagiotopoulou Nafsika , Hansen Amalie Bøge Rud , Tian Weihua , Lund Astrid , Høgh Rikke Illum , Møller Sofie Hedlund , Guérillot Romain , Hayes Ashleigh S. , Erikstrup Lise Tornvig , Andresen Lars , Peleg Anton Y. , Larsen Anders Rhod , Stinear Timothy P. , Handberg Aase , Erikstrup Christian , Howden Benjamin P. , Goletz Steffen , Frees Dorte , Skov Søren
Published: October 2023

Staphylococcus aureus
(
S. aureus
) represents a major clinical challenge due to its explicit capacity to select mutations that increase antibiotic resistance and immune evasion. However, the molecular mechanisms are poorly defined, especially for adaptive immunity. Cancer immunotherapy targeting programmed cell death protein 1 (PD-1) enhances T-cell activity and is emerging for the treatment of certain viral infections, while its potential against bacterial infections remains elusive. We show that an
S. aureus clpP
mutant, selected during clinical antibiotic therapy, inhibits T-cell activity by directly interacting with PD-1 on human T cells. Specificity of the interaction was confirmed using recombinant PD-1, as well as PD-1 overexpressing and knock out cells. Moreover, the PD-1-binding
S. aureus
inhibited intracellular calcium mobilization, T-cell proliferation, CD25 expression, and IL-2 secretion, while the key effects were alleviated by antibody-mediated PD-1 blockade using an engineered IgG1-based anti-PD-1 antibody. Our results suggest that
clpP
mutant
S. aureus
directly targets PD-1 to evade immune activation and that therapeutic targeting of PD-1 may be used against certain staphylococcal infections.

IMPORTANCE

Therapies that target and aid the host immune defense to repel cancer cells or invading pathogens are rapidly emerging. Antibiotic resistance is among the largest threats to human health globally.
Staphylococcus aureus
(
S. aureus
) is the most common bacterial infection, and it poses a challenge to the healthcare system due to its significant ability to develop resistance toward current available therapies. In long-term infections,
S. aureus
further adapt to avoid clearance by the host immune defense. In this study, we discover a new interaction that allows
S. aureus
to avoid elimination by the immune system, which likely supports its persistence in the host. Moreover, we find that blocking the specific receptor (PD-1) using antibodies significantly relieves the
S. aureus
-imposed inhibition. Our findings suggest that therapeutically targeting PD-1 is a possible future strategy for treating certain antibiotic-resistant staphylococcal infections.
Staphylococcus aureus
delta toxin modulates both extracellular membrane vesicle biogenesis and amyloid formation
Authors: Wang Xiaogang , Uppu Divakara SSM , Dickey Seth W. , Burgin Dylan J. , Otto Michael , Lee Jean C.
Published: October 2023

Staphylococcus aureus
secretes phenol-soluble modulins (PSMs), a family of small, amphipathic, secreted peptides with multiple biologic activities. Community-acquired
S. aureus
strains produce high levels of PSMs in planktonic cultures, and PSM alpha peptides have been shown to augment the release of extracellular membrane vesicles (MVs). We observed that amyloids, aggregates of proteins characterized by a fibrillar morphology and stained with specific dyes, co-purified with MVs harvested from cell-free culture supernatants of community-acquired
S. aureus
strains. δ-toxin was a major component of amyloid fibrils that co-purified with strain LAC MVs, and δ-toxin promoted the production of MVs and amyloid fibrils in a dose-dependent manner. To determine whether MVs and amyloid fibrils were generated under
in vivo
conditions, we inoculated mice with
S. aureus
harvested from planktonic cultures. Bacterial MVs were isolated and purified from lavage fluids recovered from infected animals. Although δ-toxin was the most abundant PSM in lavage fluids, amyloid fibrils could not be detected in these samples. Our findings expand our understanding of amyloid fibril formation in
S. aureus
cultures, reveal the important roles of δ-toxin in amyloid fibril formation and MV biogenesis, and demonstrate that MVs are generated
in vivo
in a staphylococcal infection model.

IMPORTANCE

Extracellular membrane vesicles (MVs) produced by
Staphylococcus aureus
in planktonic cultures encapsulate a diverse cargo of bacterial proteins, nucleic acids, and glycopolymers that are protected from destruction by external factors. δ-toxin, a member of the phenol soluble modulin family, was shown to be critical for MV biogenesis. Amyloid fibrils co-purified with MVs generated by virulent, community-acquired
S. aureus
strains, and fibril formation was dependent on expression of the
S. aureus
δ-toxin gene (
hld
). Mass spectrometry data confirmed that the amyloid fibrils were comprised of δ-toxin. Although
S. aureus
MVs were produced
in vivo
in a localized murine infection model, amyloid fibrils were not observed in the
in vivo
setting. Our findings provide critical insights into staphylococcal factors involved in MV biogenesis and amyloid formation.
Lactate promotes
Salmonella
intracellular replication and systemic infection via driving macrophage M2 polarization
Authors: Wang Xinyue , Yang Bin , Ma Shuangshuang , Yan Xiaolin , Ma Shuai , Sun Hongmin , Sun Yuyang , Jiang Lingyan
Published: October 2023

Salmonella
is one of the most important enteric pathogens worldwide, which is able to cause lethal systemic infection via survival and replication in host macrophages. Lactate, a byproduct of anaerobic or aerobic glycolysis, can induce macrophage M2 polarization, but the relationship between lactate-mediated macrophage M2 polarization and bacterial infection is poorly understood. Here, we evaluated the role of lactate and lactate-mediated macrophage M2 polarization in the pathogenicity of
Salmonella
. We found that lactate levels were significantly increased in
Salmonella
-infected macrophages, and the increased lactate was derived from the host. Macrophage and mouse infection assays showed that the addition of lactate enhanced
Salmonella
replication within macrophages and the colonization of mouse systemic loci, while pharmacological or genetic inhibition of host lactate production impaired
Salmonella
intracellular replication and its virulence in mice. Further analysis revealed that lactate promotes M2 polarization of
Salmonella
-infected macrophages, and the induction of macrophage M2 polarization by lactate is responsible for lactate-mediated
Salmonella
growth promotion. Moreover, we showed that macrophage-derived lactate induces the
Salmonella
pathogenicity island (SPI)-2 type III secretion system, leading to increased translocation of the SPI-2 effector SteE, which is responsible for driving M2 polarization. Overall, these findings suggest that lactate promotes
Salmonella
intracellular replication and systemic infection via driving macrophage M2 polarization and highlight the complex interactions between
Salmonella
and macrophages.

IMPORTANCE

The important enteropathogen
Salmonella
can cause lethal systemic infection
via
survival and replication in host macrophages. Lactate represents an abundant intracellular metabolite during bacterial infection, which can also induce macrophage M2 polarization. In this study, we found that macrophage-derived lactate promotes the intracellular replication and systemic infection of
Salmonella
. During
Salmonella
infection, lactate
via
the
Salmonella
type III secretion system effector SteE promotes macrophage M2 polarization, and the induction of macrophage M2 polarization by lactate is responsible for lactate-mediated
Salmonella
growth promotion. This study highlights the complex interactions between
Salmonella
and macrophages and provides an additional perspective on host-pathogen crosstalk at the metabolic interface.
Design of a novel affinity probe using the cell wall-binding domain of a
Listeria monocytogenes
autolysin for pathogen detection
Authors: Lin Min , Dan Hanhong
Published: October 2023

Rapid identification of foods and food-processing environments contaminated with
Listeria monocytogenes
is crucial for controlling human listeriosis, a leading cause of fatality related to foodborne illnesses. The
L. monocytogenes
autolysin IspC anchors to the bacterial surface non-covalently via its C-terminal cell wall-binding domain (CWBD), which contains conserved Gly-Trp (GW) dipeptides. This study explored the binding property of CWBD
IspC
to design an affinity probe for detecting
L. monocytogenes
. Immunogold electron microscopy analysis of a ∆
ispC
mutant and its wild type (WT) revealed that exogenously added CWBD
IspC
bound to surface ligands that were evenly distributed and remained mostly unoccupied in the wild type. CWBD
IspC
detected, via recognizing the cell wall component lipoteichoic acid,
L. monocytogenes
strains primarily belonging to the serotype 4 group, as well as
Listeria innocua
, and
Listeria welshimeri
but did not detect three other
Listeria
spp. (
Listeria seeligeri
,
Listeria ivanovii,
and
Listeria grayi
) nor any non-
Listeria
spp. tested. CWBD
IspC
, when tagged with the enhanced green fluorescent protein, was capable of detecting
L. monocytogenes
by fluorescence microscopy, a colony lift filter assay, and a microtube binding assay. CWBD
IspC
, when covalently attached to magnetic beads, showed the ability to separate
L. monocytogenes
cells with a maximum capture rate of 90 to nearly 100% from 1 × 10
3
to 1 × 10
5
target cells. This study demonstrated for the first time that the CWBD derived from a GW surface protein IspC is a novel antibody alternative for the rapid detection and isolation of
L. monocytogenes
despite binding to two other
Listeria
species.

IMPORTANCE

Human listeriosis is caused by consuming foods contaminated with the bacterial pathogen
Listeria monocytogenes
, leading to the development of a severe and life-threatening foodborne illness. Detection of
L. monocytogenes
present in food and food processing environments is crucial for preventing
Listeria
infection. The
L. monocytogenes
peptidoglycan hydrolase IspC anchors non-covalently to the bacterial surface through its C-terminal cell wall-binding domain (CWBD), CWBD
IspC
. This study explored the surface binding property of CWBD
IspC
to design, construct, characterize, and assess an affinity molecular probe for detecting
L. monocytogenes
. CWBD
IspC
recognized a cell wall ligand lipoteichoic acid that remains evenly displayed and mostly unoccupied on the bacterial surface for interaction with the exogenously added CWBD
IspC
. CWBD
IspC
, when fused to the enhanced green fluorescent protein reporter or covalently conjugated onto magnetic beads, exhibited the functionality as an antibody alternative for rapid detection and efficient separation of the pathogen.
Relationships between fluvial dune cross-set thickness, planview width, and trough geometry
Authors: Cardenas Benjamin T. , Stacey Kaitlyn , Baran Zachary J.
Published: October 2023

Sedimentary structures provide critical information for the reconstruction of ancient environments of Earth and other planets. Fluvial dune cross sets, structures that record dune migration via the filling of leading troughs along ancient riverbeds, are particularly useful. Most quantitative methods for interpreting cross sets require thickness measurements, but the growth of planview imaging of sedimentary rocks on Earth and Mars has introduced a need for methods to interpret planview exposures of cross sets. Here, we measured 359 cross-set widths exposed along ancient channel belts of the Cretaceous Cedar Mountain Formation exposed in Utah, USA, and compared these widths to published thicknesses (n = 350). We found that the mean cross-set width was 1.29 m, 9.3 times the mean thickness. The normalized distributions of widths and thicknesses were statistically similar and thus contained similar paleoenvironmental information. Numerical experiments representing a series of trough cut-and-fill structures show that cross-set reworking is equally important in setting width as thickness and that the observed cross-set widths could be explained by a gamma-distributed range of trough widths with a mean of 2.96 ± 0.25 m, ~2.3 times cross-set width. Given the similarity of dune-field geometries across depositional settings and planetary boundary conditions, we suggest this cross-set width-to-thickness relationship could be useful for interpreting other cross sets exposed in planview.
Seizures in hospitalised paediatric patients with SARS-CoV-2 and comparison of severity with seizures in hospitalised paediatric patients with other respiratory viruses during the COVID-19 pandemic: a population-based cohort study
Authors: Anastasopoulou Stavroula , Svensson Eva , Wickström Ronny , Hertting Olof , Rinder Malin Ryd , Bennet Rutger , Eriksson Margareta
Published: October 2023

Objective

To study seizures in patients hospitalised due to SARS-CoV-2 infection, and compare their severity with seizures in patients hospitalised due to other viral respiratory tract infections (RTIs).

Design

Observational population-based cohort study.

Setting

Northern Stockholm.

Patients

Patients aged 1 month–18 years hospitalised due to SARS-CoV-2 with and without seizures, and patients of the same age hospitalised due to other viral RTIs with seizures, between 1 March 2020 and 30 June 2022.

Main outcome measures

The prevalence of seizures in hospitalised patients due to SARS-CoV-2, the evaluation of assumed predictors of seizures and the comparison of severity markers in patients with SARS-CoV-2 versus other RTIs.

Results

32 of 239 included patients (13.4%) admitted due to SARS-CoV-2 infection had seizures. Central nervous system (CNS) disease and the omicron period had significantly increased OR for seizures (OR: 5.12; CI: 2.06 to 12.72 and OR: 3.01; CI: 1.15 to 7.88, respectively). Seizures in patients with SARS-CoV-2 were more common in children older than 5 years (p=0.001), even in the absence of fever (p=0.007), as compared with other viral RTIs. The duration of hospitalisation was longer in patients with seizures due to other viral RTIs (p=0.023). There was no significant difference regarding severity markers of seizures between the two groups.

Conclusions

CNS disease and the omicron period were risk factors for seizures in patients with SARS-CoV-2, who were older than patients with other RTIs. The severity of seizures was comparable between the two groups; hospitalisation was however longer in patients with other RTIs.
Bilateral trochlear subchondral insufficieny fracture of the knee in a professional cyclist
Authors: Kraai Tijmen , Aldershof Camiel , olde Heuvel Judith , Hoogeslag Roy
Published: October 2023

This case report presents a rare case of subsequent ipsilateral and contralateral subchondral insufficiency fracture of the knee (SIFK) in the trochlea of the femur within months, manifested in a professional cyclist. SIFKs in the trochlea have not yet been reported in the literature; however, their appearance in a professional cyclist might be explained by the amount of repetitive pressure on the patellofemoral joint when cycling. In both instances, atraumatic anterior knee pain occurred, resolving after conservative treatment for 6–9 weeks. The patient reached their previous activity level. The authors believe SIFK in the younger population may be more common than currently perceived due to its self-limiting behaviour and a lack of performing immediate MRIs in this younger group whenever an overload injury is suspected.
Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy
Authors: Harrison Nicholas L , Santoro Giovanni , Ellerby Nicolas , Samad Ajai
Published: October 2023

A male patient in his 30s, with myotonic dystrophy (DM), presented to the emergency department with abdominal pain and vomiting. CT imaging revealed a soft tissue lesion in the terminal ileum causing small bowel obstruction (SBO). The patient underwent diagnostic laparoscopy which allowed identification and removal of the obstructing lesion. This was in the form of an intact, undigested potato, a phytobezoar. Bezoars are collections of undigested material found in the gastrointestinal (GI) tract, a phytobezoar is composed of plant material and is the most common form of bezoar. DM is a multisystem disorder characterised by skeletal muscle weakness, however it often presents with GI symptoms and the muscles of mastication are often affected. DM is a known risk factor for bezoar formation and should be considered as an important differential in DM patients presenting with SBO.
Identifying, synthesising and appraising existing evidence relating to myalgic encephalomyelitis/chronic fatigue syndrome and pregnancy: a mixed-methods systematic review
Authors: Slack Emma , Pears Katrina Anne , Rankin Judith , Newton Julia L , Pearce Mark
Published: October 2023

Objectives

To identify, synthesise and appraise evidence relating to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and pregnancy.

Design

Mixed-methods systematic review, using convergent segregated design.

Data sources

MEDLINE, EMBASE, Scopus, PsycINFO, CINAHL, MedRxiv, PROSPERO and grey literature sources through 6 August 2023.

Eligibility criteria

We included original research studies, expert opinion and grey literature reporting on ME/CFS and pregnancy/post partum (up to 2 years), risk of pregnancy outcomes with ME/CFS or experiences during pregnancy for mother, partner or health and social care professionals following ME/CFS during pregnancy, all where the evidence was relevant to a confirmed ME/CFS diagnosis prior to pregnancy.

Data extraction and synthesis

Three independent reviewers completed all screening, data extraction and quality assessment. Risk of bias was assessed using the mixed-methods appraisal tool V.2018. Qualitative and quantitative literature was analysed separately using thematic and descriptive syntheses. Findings were integrated through configuration.

Results

Searches identified 3675 articles, 16 met the inclusion criteria: 4 quantitative (1 grey), 11 qualitative (9 grey) and 1 grey mixed-methods study. Of the four quantitative studies that reported on ME/CFS severity during pregnancy, two suggested pregnancy negatively impacted on ME/CFS, one found most women had no change in ME/CFS symptoms and one found ME/CFS improved; this difference in symptom severity across studies was supported by the qualitative evidence. The qualitative literature also highlighted the importance of individualised care throughout pregnancy and birth, and the need for additional support during family planning, pregnancy and with childcare. Only one quantitative study reported on pregnancy outcomes, finding decreased vaginal births and higher rates of spontaneous abortions and developmental and learning delays associated with pregnancies in those with ME/CFS.

Conclusions

Current evidence on ME/CFS in pregnancy is limited and findings inconclusive. More high-quality research is urgently needed to support the development of evidence-based guidelines on ME/CFS and pregnancy.
Content or context? A study protocol for a three-arm parallel randomised controlled trial of Re-PROGRAM, a brief internet-based intervention for patients with functional seizures
Authors: Higson Lana , O'Brien Terence J , Rayner Genevieve , Alpitsis Rubina , Winton-Brown Toby
Published: October 2023

Introduction

Functional seizures (FS) mimic epilepsy but are not caused by epileptic electrical activity in the brain and are believed to have a psychological origin. There is a well-documented gap between the needs of patients with FS and available therapeutic resources. While there is potential for reducing seizure burden in patients via psychosocial intervention, there is no evidence-based care pathway or consistent availability of treatment and no effective pharmacological treatment. The objective of this study is to investigate the clinical efficacy and tolerability of a novel internet-based intervention in reducing seizure frequency.

Methods and analysis

A 3-arm parallel randomised controlled trial will compare the efficacy of brief guided internet-based therapy to unguided internet-based therapy and to standard care. Approximately 100 participants with FS will be recruited, with diagnostic criteria based on gold standard video-electroencephalogram (v-EEG) monitoring; patients will be randomly assigned to one of the three study arms. The primary study outcome will be FS frequency at 6 weeks and at follow-up (6 and 12 months) compared with baseline. Seizure frequency will be modelled using Poisson regression. Secondary outcomes include psychosocial functioning, healthcare resource usage, anxiety, depression, somatisation and life impact. Between-group differences will be evaluated using analysis of variance. Analysis of covariance will estimate within-group changes on secondary outcomes. Cognitive and psychological factors will be used as predictors of seizure reduction in exploratory analyses. A qualitative survey using a semi-structured interview will use thematic analyses to explore participants’ treatment experiences, their impressions of FS management and perceived mechanisms for change.

Ethics and dissemination

The study was approved by the Human Research and Ethics Committee of the Alfred Hospital Human Research Ethics Committee as part of the Australian Multisite Ethics approval system. Results of the study will be presented at national and international conferences and published in peer-reviewed journals.

Trial registration number

ACTRN12622000262707.
Prognostic models based on lymph node density for primary gastrointestinal melanoma: a SEER population-based analysis
Authors: Zeng Jiaqi , Zhu Lin , Zhou Guanzhou , Pan Fei , Yang Yunsheng
Published: October 2023

Objective

This study aimed to construct prognostic models to predict the overall survival (OS) and cancer-specific survival (CSS) of patients with primary gastrointestinal melanoma (PGIM).

Design

An observational and retrospective study.

Setting

Data were obtained from the Surveillance, Epidemiology and End Results (SEER) programme database, encompassing a broad geographical and demographic spectrum of patients across the USA.

Participants

A total of 991 patients diagnosed with PGIM were included in this study.

Methods

A total of 991 patients with PGIM were selected from the SEER database. They were further divided into a training cohort and a validation cohort. Independent prognostic factors were identified by Cox regression analysis. Two prognostic models were constructed based on the results of multivariable Cox regression analysis. The concordance index (C-index) and area under the time-dependent receiver operating characteristic curve (time-dependent AUC) were used to evaluate the discriminative ability. Calibration curves were plotted to evaluate the agreement between the probability as predicted by the models and the actual probability. Risk stratification was developed given the model.

Results

By the multivariable Cox regression analysis, we identified four independent risk factors (age, stage, lymph node density and surgery) for OS, and three independent risk factors (stage, lymph node density and surgery) for CSS, which were used to construct prognostic models. C-index, time-dependent AUC, calibration curves and Kaplan-Meier curves of risk stratification indicated that these two models had good discriminative ability, predictive ability as well as clinical value.

Conclusions

The prognostic models of OS and CSS had satisfactory accuracy and were of clinical value in evaluating the prognosis of patients with PGIM.
Randomised controlled trial of preconception lifestyle intervention on maternal and offspring health in people with increased risk of gestational diabetes: study protocol for the BEFORE THE BEGINNING trial
Authors: Sujan Md Abu Jafar , Skarstad Hanna Margrethe Storheil , Rosvold Guro , Fougner Stine Lyngvi , Nyrnes Siri Ann , Iversen Ann-Charlotte , Follestad Turid , Salvesen Kjell Å , Moholdt Trine
Published: October 2023

Introduction

Gestational diabetes mellitus (GDM) is associated with increased risk for type 2 diabetes in the mother and cardiometabolic diseases in the child. The preconception period is an optimal window to adapt the lifestyle for improved outcomes for both mother and child. Our aim is to determine the effect of a lifestyle intervention, initiated before and continued throughout pregnancy, on maternal glucose tolerance and other maternal and infant cardiometabolic outcomes.

Methods and analysis

This ongoing randomised controlled trial has included 167 females aged 18–39 years old at increased risk for GDM who are contemplating pregnancy. The participants were randomly allocated 1:1 to an intervention or control group. The intervention consists of exercise (volume is set by a heart rate-based app and corresponds to ≥ 1 hour of weekly exercise at ≥ 80% of individual heart rate maximum), and time-restricted eating (≤ 10 hours/day window of energy intake). The primary outcome measure is glucose tolerance in gestational week 28. Maternal and offspring outcomes are measured before and during pregnancy, at delivery, and at 6–8 weeks post partum. Primary and secondary continuous outcome measures will be compared between groups based on the ‘intention to treat’ principle using linear mixed models.

Ethics and dissemination

The Regional Committees for Medical and Health Research Ethics in Norway has approved the study (REK 143756). The anonymised results will be submitted for publication and posted in a publicly accessible database of clinical study results.

Trial registration number

Clinical trial govNCT04585581.
Efficacy and safety of lenvatinib–transcatheter arterial chemoembolisation sequential therapy followed by surgical resection for intermediate-stage hepatocellular carcinoma beyond Up-to-7 criteria: a study protocol for a multicentre, single-arm, prospective study
Authors: Oshita Ko , Kobayashi Tsuyoshi , Namba Yosuke , Fukuhara Sotaro , Matsubara Keiso , Takei Daisuke , Nakano Ryosuke , Okamoto Wataru , Sakai Hiroshi , Tanimine Naoki , Nakahara Takashi , Kuroda Shintaro , Tahara Hiroyuki , Ohira Masahiro , Kawaoka Tomokazu , Ide Kentaro , Imamura Michio , Aikata Hiroshi , Ohdan Hideki
Published: October 2023

Introduction

The feasibility and efficacy of surgical resection following systemic therapy for intermediate-stage hepatocellular carcinoma (HCC) beyond the Up-to-7 criteria is unclear. The combination of lenvatinib (LEN) and transcatheter arterial chemoembolisation (TACE), termed LEN–TACE sequential therapy, has shown a high response rate and survival benefit in patients with intermediate-stage HCC. This trial aims to evaluate the efficacy and safety of LEN–TACE sequential therapy and the feasibility of surgical resection for intermediate-stage HCC beyond the Up-to-7 criteria.

Methods and analysis

This is a multicentre, single-arm, prospective clinical trial. Thirty patients with intermediate-stage HCC beyond the Up-to-7 criteria will be enrolled. Patients eligible for this study will undergo LEN–TACE sequential therapy in which LEN is administered for 4 weeks, followed by TACE, and then further LEN for another 4 weeks. Patients will be assessed for efficacy of LEN–TACE sequential therapy and resectability, and surgical resection will be performed if the HCC is considered radically resectable. The primary outcome of this study is the resection rate after LEN–TACE sequential therapy. The secondary outcomes are the objective response rate of LEN–TACE sequential therapy, safety, curative resection rate, overall survival and recurrence-free survival.

Ethics and dissemination

This trial was approved by the Institutional Review Board of Hiroshima University, Japan (approval no. CRB210003), and has been registered with the Japan Registry of Clinical Trials (jRCTs061220007). The results of this study will be submitted for publication in a peer-reviewed journal and shared with the scientific community at international conferences.

Trial registration number

jRCTs061220007 (https://jrct.niph.go.jp/latest-detail/jRCTs061220007).
What information sources do Dutch medical specialists use in medical decision-making: a qualitative interview study
Authors: Weller Floris S. , Hamming Jaap F. , Repping Sjoerd , van Bodegom-Vos Leti
Published: October 2023

Objective

To explore what information sources medical specialists currently use to inform their medical decision-making.

Design

Qualitative, semistructured interviews.

Setting and participants

A total of 20 semistructured interviews were conducted with 10 surgeons and 10 internal medicine specialists who work in academic and/or regional hospitals in the Netherlands.

Results

Medical specialists reported that they primarily rely on their general knowledge and experience, rather than actively using information sources. The sources they use to update their knowledge can be categorised into ‘scientific publications’, ‘guidelines or protocols’, and ‘presentations and meetings’. When medical specialists feel their general knowledge and experience are insufficient, they use three different approaches to find answers in response to clinical questions: consulting a colleague, actively searching the literature and asking someone else to search the literature.

Conclusion

Medical specialists use information sources to update their general knowledge and to find answers to specific clinical questions when they feel their general knowledge and experience are insufficient. An important finding is that medical specialists prefer accessible information sources (eg, consulting colleagues) over existing evidence-based medicine tools.
Malaria vaccine-related adverse events among children under 5 in sub-Saharan Africa: systematic review and meta-analysis protocol
Authors: Ohene-Adjei Kennedy , Asante Kwaku Poku , Akuffo Kwadwo Owusu , Tounaikok Narcisse , Asiamah Morrison , Owiredu David , Manu Alexander Ansah , Danso-Appiah Anthony
Published: October 2023

Introduction

The RTS,S vaccine has been approved for use in children under 5 living in moderate to high malaria transmission areas. However, clinically important adverse events have been reported in countries in sub-Saharan Africa. This systematic review aims to assess the frequency, severity and clinical importance of vaccine-related adverse events.

Methods and analysis

This systematic review protocol has been prepared following robust methods and reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses for protocols guidelines. We will search PubMed, CINAHL, LILACS, Google Scholar, SCOPUS, WEB OF SCIENCE, Cochrane library, HINARI,African Journals Online, Trip Pro and TOXNET from 2000 to 30 September 2023, without language restrictions. We will also search conference proceedings, dissertations, World Bank Open Knowledge Repository, and WHO, PATH, UNICEF, Food and Drugs Authorities and European Medicines Agency databases, preprint repositories and reference lists of relevant studies for additional studies. Experts in the field will be contacted for unpublished or published studies missed by our searches. At least two reviewers will independently select studies and extract data using pretested tools and assess risk of bias in the included studies using the Cochrane risk of bias tool. Any disagreements will be resolved through discussion between the reviewers. Heterogeneity will be explored graphically, and statistically using the I2statistic. We will conduct random-effects meta-analysis when heterogeneity is appreciable, and express dichotomous outcomes (serious adverse events, cerebral malaria and febrile convulsion) as risk ratio (RR) with their 95% CI. We will perform subgroup analysis to assess the impact of heterogeneity and sensitivity analyses to test the robustness of the effect estimates. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.

Ethics and dissemination

Ethical approval is not required for a systematic review. The findings of this study will be disseminated through stakeholder forums, conferences and peer-review publications.

PROSPERO registration number

CRD42021275155.
Building lean improvement skills at scale: an evaluation of a massive open online course in the English NHS
Authors: Smith Iain M
Published: October 2023

Background

Internationally, healthcare systems face challenges from population demographics and rising care costs. Systematic methods of quality improvement (QI) are considered key to delivering needed transformation and change. Large-scale training in QI skills is required.

Massive open online courses (MOOCs) are an inexpensive strategy for QI training across large regions and countries. TheLean FundamentalsMOOC was developed in the English NHS to train health and care staff in Lean QI methods. It supported participants to learn and apply process improvement skills through a free-to-access, practical, learning-in-action approach.

Methods

Lean Fundamentals’cost-effectiveness and its impact on participants’ knowledge and confidence to apply Lean to improve processes were assessed. Using the Kirkpatrick framework, participant reaction, knowledge and confidence change, results and overall return-on-investment (ROI) were evaluated. Quantitative data were collected via pre and postcourse surveys to analyse participants’ knowledge and confidence change using the Wilcoxon signed rank test. Qualitative learning platform and postcourse survey data demonstrated participants’ results from application.

Results

Over 18 months,Lean Fundamentalsattracted 6617 enrolments and supported 3462 active participants. 97.6% (n=829) of participants completing the postcourse survey indicatedLean Fundamentalsmet their expectations and 97.2% (n=823) indicated they would recommend it. Self-reported changes in knowledge and confidence to apply Lean showed significant differences (p<0.001). Learning was applied to operational healthcare priorities (such as post-COVID recovery of services) and participants shared 511 project improvement reports.

Conclusion

Lean Fundamentalshelped large numbers of participants to develop Lean process improvement skills—avoiding costs associated with commercial Lean training in the range £1.7 m to £3.4 m and generating ROI of between £11 and £23 per every pound spent on delivery. This demonstrates that massive online is an effective and efficient method for building improvement knowledge and skills at scale.
Safety culture survey among medical residents in Japan: a nationwide cross-sectional study
Authors: Watari Takashi , Kurihara Masaru , Nishizaki Yuji , Tokuda Yasuharu , Nagao Yoshimasa
Published: October 2023

Purpose

This study aimed to examine safety culture among Japanese medical residents through a comparative analysis of university and community hospitals and an investigation of the factors related to safety culture.

Method

This nationwide cross-sectional study used a survey to assess first and second-year medical residents’ perception of safety culture. We adapted nine key items from the Safety Awareness Questionnaire to the Japanese training environment and healthcare system. Additionally, we explored specific factors relevant to safety culture, such as gender, year of graduation, age, number of emergency room duties per month, average number of admissions per day, incident experience, incident reporting experience, barriers to incident reporting and safety culture. We analysed the data using descriptive statistics and multivariate logistic regression analysis.

Results

We included 5289 residents (88.6%) from community training hospitals and 679 residents (11.4%) from university hospitals. A comparative analysis of safety culture between the two groups on nine representative questions revealed that the percentage of residents who reported a positive atmosphere at their institution was significantly lower at university hospitals (81.7%) than at community hospitals (87.8%) (p<0.001). The other items were also significantly lower for university hospital residents. After adjusting for multivariate logistic analysis, university hospital training remained significantly and negatively associated with all nine safety culture items. Furthermore, we also found that university hospital residents perceived a significantly lower level of safety culture than community hospital residents.

Implications

Further research and discussion on medical professionals’ perception of safety culture in their institutions as well as other healthcare professionals’ experiences are necessary to identify possible explanations for our findings and develop strategies for improvement.
Changing prevalence of chronic hepatitis B virus infection in China between 1973 and 2021: a systematic literature review and meta-analysis of 3740 studies and 231 million people
Authors: Liu Zhenqiu , Lin Chunqing , Mao Xianhua , Guo Chengnan , Suo Chen , Zhu Dongliang , Jiang Wei , Li Yi , Fan Jiahui , Song Ci , Zhang Tiejun , Jin Li , De Martel Catherine , Clifford Gary M , Chen Xingdong
Published: October 2023

Objective

China concentrates a large part of the global burden of HBV infection, playing a pivotal role in achieving the WHO 2030 global hepatitis elimination target.

Methods

We searched for studies reporting HBV surface antigen (HBsAg) seroprevalence in five databases until January 2023. Eligible data were pooled using a generalised linear mixed model with random effects to obtain summary HBsAg seroprevalence. Linear regression was used to estimate annual percentage change (APC) and HBsAg prevalence in 2021.

Results

3740 studies, including 231 million subjects, were meta-analysed. HBsAg seroprevalence for the general population decreased from 9.6% (95% CI 8.4 to 10.9%) in 1973–1984 to 3.0% (95% CI 2.1 to 3.9%) in 2021 (APC=−3.77; p<0.0001). Decreases were more pronounced in children <5 years (APC=−7.72; p<0.0001) and 5–18 years (−7.58; p<0.0001), than in people aged 19–59 years (−2.44; p<0.0001), whereas HBsAg seroprevalence increased in persons ≥60 years (2.84; p=0.0007). Significant decreases were observed in all six major Chinese regions, in both men (APC=−3.90; p<0.0001) and women (−1.82; p<0.0001) and in high-risk populations. An estimated 43.3 million (95% uncertainty interval 30.7–55.9) persons remained infected with HBV in China in 2021 (3.0%), with notable heterogeneity by region (<1.5% in North China to>6% in Taiwan and Hong Kong) and age (0.3%, 1.0%, 4.7% and 5.6% for <5 years, 5–18 years, 19–59 years and≥60 years, respectively).

Conclusions

China has experienced remarkable decreases in HBV infection over the last four decades, but variations in HBsAg prevalence persist in subpopulations. Ongoing prevention of HBV transmission is needed to meet HBV elimination targets by 2030.

Trial registration number

PROSPERO (CRD42021284217)
Whole exome sequencing of 491 individuals with inherited retinal diseases reveals a large spectrum of variants and identification of novel candidate genes
Authors: Hayman Tamar , Millo Talya , Hendler Karen , Chowers Itay , Gross Menachem , Banin Eyal , Sharon Dror
Published: October 2023

Background

Inherited retinal diseases (IRDs) include a range of vision loss conditions caused by variants in different genes. The clinical and genetic heterogeneity make identification of the genetic cause challenging. Here, a cohort of 491 unsolved cases from our cohort of Israeli and Palestinian families with IRDs underwent whole exome sequencing (WES), including detection of CNVs as well as single nucleotide variants (SNVs).

Methods

All participants underwent clinical examinations. Following WES on DNA samples by 3 billion, initial SNV analysis was performed by 3 billion and SNV and CNV analysis by Franklin Genoox. The CNVs indicated by the programme were confirmed by PCR followed by gel electrophoresis.

Results

WES of 491 IRD cases revealed the genetic cause of disease in 51% of cases, of which 11% were due wholly or in part to CNVs. In two cases, we clarified previously incorrect or unclear clinical diagnoses. This analysis also identified
ESRRB
and
DNM1
as potential novel genes.

Conclusion

This analysis is the most extensive one to include CNVs to examine IRD causing genes in the Israeli and Palestinian populations. It has allowed us to identify the causative variant of many patients with IRDs including ones with unclear diagnoses and potential novel genes.