bluuebunny/crossref_metadata_2025 huggingface dataset:
Small GTPase Immunity-Associated Proteins Mediate Resistance to Toxoplasma gondii Infection in Lewis Rat
Authors: Kim Chi Yong , Zhang Xuejin , Witola William H.
Published: January 2018

Rats vary in their susceptibilities toToxoplasma gondiiinfection depending on the rat strain. Compared to theT. gondii-susceptible Brown Norway (BN) rat, the Lewis (LEW) rat is extremely resistant toT. gondii. Thus, these two rat strains are ideal models for elucidating host mechanisms that are important for host resistance toT. gondiiinfection. Therefore, in our efforts to unravel molecular factors directing the protective early innate immune response in the LEW rat, we performed RNA sequencing analysis of the LEW versus BN rat with or withoutT. gondiiinfection. We identified three candidate smallGTPaseimmunity-associatedproteins (GIMAPs) that were upregulated (false discovery rate, 0.05) in the LEW rat in response toT. gondiiinfection. Subsequently, we engineeredT. gondii-susceptible NR8383 rat macrophage cells for overexpression of LEW rat-derived candidate GIMAP 4, 5, and 6. By immunofluorescence analysis we observed that GIMAP 4, 5, and 6 inT. gondii-infected NR8383 cells each colocalized with GRA5, a parasite parasitophorous vacuole membrane (PVM) marker protein, suggesting their translocation to the PVM. Interestingly, overexpression of each candidate GIMAP inT. gondii-infected NR8383 cells induced translocation of LAMP1, a lysosome marker protein, to theT. gondiisurface membrane. Importantly, overexpression of GIMAP 4, 5, or 6 individually inhibited intracellularT. gondiigrowth, with GIMAP 4 having the highest inhibitory effect. Together, our findings indicate that upregulation of GIMAP 4, 5, and 6 contributes to the robust refractoriness of the LEW rat toT. gondiithrough induction of lysosomal fusion to the otherwise nonfusogenic PVM.
Shining the Light on Cyclic di-GMP Dark Matter
Authors: Waters Christopher M.
Published: January 2018

Bacterial cyclic di-GMP signaling networks often consist of dozens of components, and the majority of these components have no observable function. Dahlstrom et al. (J. Bacteriol. 200:e00703-17, 2018,
https://doi.org/10.1128/JB.00703-17
) explored the function of every component of the
Pseudomonas fluorescens
cyclic di-GMP network under 188 different growth conditions and identified activities for 80% of the network. They further demonstrated that multiple mechanisms function in tandem to control the activity of the network in different environments.
Survival of Anaerobic Fe
2+
Stress Requires the ClpXP Protease
Authors: Bennett Brittany D. , Redford Kaitlyn E. , Gralnick Jeffrey A.
Published: January 2018

Shewanella oneidensis
strain MR-1 is a versatile bacterium capable of respiring extracellular, insoluble ferric oxide minerals under anaerobic conditions. The respiration of iron minerals results in the production of soluble ferrous ions, which at high concentrations are toxic to living organisms. It is not fully understood how Fe
2+
is toxic to cells anaerobically, nor is it fully understood how
S. oneidensis
is able to resist high levels of Fe
2+
. Here we describe the results of a transposon mutant screen and subsequent deletion of the genes
clpX
and
clpP
in
S. oneidensis
, which demonstrate that the protease ClpXP is required for anaerobic Fe
2+
resistance. Many cellular processes are known to be regulated by ClpXP, including entry into stationary phase, envelope stress response, and turnover of stalled ribosomes. However, none of these processes appears to be responsible for mediating anaerobic Fe
2+
resistance in
S. oneidensis
. Protein trapping studies were performed to identify ClpXP targets in
S. oneidensis
under Fe
2+
stress, implicating a wide variety of protein targets.
Escherichia coli
strains lacking
clpX
or
clpP
also display increased sensitivity to Fe
2+
anaerobically, indicating Fe
2+
resistance may be a conserved role for the ClpXP protease system. Hypotheses regarding the potential role(s) of ClpXP during periods of high Fe
2+
are discussed. We speculate that metal-containing proteins are misfolded under conditions of high Fe
2+
and that the ClpXP protease system is necessary for their turnover.

IMPORTANCE
Prior to the evolution of cyanobacteria and oxygenic photosynthesis, life arose and flourished in iron-rich oceans. Today, aqueous iron-rich environments are less common, constrained to low-pH conditions and anaerobic systems such as stratified lakes and seas, digestive tracts, subsurface environments, and sediments. The latter two ecosystems often favor dissimilatory metal reduction, a process that produces soluble Fe
2+
from iron oxide minerals. Dissimilatory metal-reducing bacteria must therefore have mechanisms to tolerate anaerobic Fe
2+
stress, and studying resistance in these organisms may help elucidate the basis of toxicity.
Shewanella oneidensis
is a model dissimilatory metal-reducing bacterium isolated from metal-rich sediments. Here we demonstrate a role for ClpXP, a protease system widely conserved in bacteria, in anaerobic Fe
2+
resistance in both
S. oneidensis
and
Escherichia coli
.
HilE Regulates HilD by Blocking DNA Binding in Salmonella enterica Serovar Typhimurium
Authors: Grenz Jesse R. , Cott Chubiz Jessica E. , Thaprawat Pariyamon , Slauch James M.
Published: January 2018

The
Salmonella
type three secretion system (T3SS), encoded in the
Salmonella
pathogenicity island 1 (SPI1) locus, mediates the invasion of the host intestinal epithelium. SPI1 expression is dependent upon three AraC-like regulators: HilD, HilC, and RtsA. These regulators act in a complex feed-forward loop to activate each other and
hilA
, which encodes the activator of the T3SS structural genes. HilD has been shown to be the major integration point of most signals known to activate the expression of the SPI1 T3SS, acting as a switch to control induction of the system. HilE is a negative regulator that acts upon HilD. Here we provide genetic and biochemical data showing that HilE specifically binds to HilD but not to HilC or RtsA. This protein-protein interaction blocks the ability of HilD to bind DNA as shown by both an
in vivo
reporter system and an
in vitro
gel shift assay. HilE does not affect HilD dimerization, nor does it control the stability of the HilD protein. We also investigated the role of HilE during the infection of mice using competition assays. Although deletion of
hilE
does not confer a phenotype, the
hilE
mutation does suppress the invasion defect conferred by loss of FliZ, which acts as a positive signal controlling HilD protein activity. Together, these data suggest that HilE functions to restrict low-level HilD activity, preventing premature activation of SPI1 until positive inputs reach a threshold required to fully induce the system.

IMPORTANCE
Salmonella
is a leading cause of gastrointestinal and systemic disease throughout the world. The SPI1 T3SS is required for
Salmonella
to induce inflammatory diarrhea and to gain access to underlying tissue. A complex regulatory network controls expression of SPI1 in response to numerous physiological inputs. Most of these signals impinge primarily on HilD translation or activity. The system is triggered when HilD activity crosses a threshold that allows efficient activation of its own promoter. This threshold is set by HilE, which binds to HilD to prevent the inevitable minor fluctuations in HilD activity from inappropriately activating the system. The circuit also serves as a paradigm for systems that must integrate numerous environmental parameters to control regulatory output.
PhoPR Positively Regulates
whiB3
Expression in Response to Low pH in Pathogenic Mycobacteria
Authors: Feng Lipeng , Chen Shiyun , Hu Yangbo
Published: January 2018

During infection,
Mycobacterium tuberculosis
colonizes macrophages or necrotic granulomas, in which low pH is one of the major challenges. The PhoPR two-component regulatory system and the cytosolic redox sensor WhiB3 both play important roles in the response to low pH by
M. tuberculosis
. However, whether close association exists between PhoPR and WhiB3 remains unclear. In this study, the positive regulation of
whiB3
by PhoPR in mycobacteria was characterized. We observed that the expression patterns of the
whiB3
gene under acidic conditions are different among mycobacterial species, suggesting that the regulation of
whiB3
differs among mycobacteria. A sequence analysis of the
whiB3
promoters (
whiB3p
) from
M. tuberculosis
and two closely related species, namely,
M. marinum
and
M. smegmatis
, showed that the
whiB3p
regions from
M. tuberculosis
and
M. marinum
contain a new type of PhoP box that is absent in the
M. smegmatis
whiB3p
. Direct binding of PhoP to
whiB3p
from
M. tuberculosis
and
M. marinum
but not that from
M. smegmatis
was validated by
in vitro
protein-DNA binding assays. The direct activation of
whiB3
by PhoPR under acidic conditions was further verified by reverse transcription-quantitative PCR (qRT-PCR) analysis in
M. marinum
. Moreover, mutating the residues important for the phosphorylation pathway of PhoPR in
M. marinum
abolished the activation of
whiB3
expression by PhoPR under acidic conditions, suggesting that low pH triggers the phosphorylation of PhoPR, which in turn activates the transcription of
whiB3
. Since the PhoP box was only identified in
whiB3p
of pathogenic mycobacteria, we suggest that the PhoPR-
whiB3
regulatory pathway may have evolved to facilitate mycobacterial infection.

IMPORTANCE
The low pH in macrophages is an important barrier for infection by microbes. The PhoPR two-component regulatory system is required for the response to low pH and plays a role in redox homeostasis in
Mycobacterium tuberculosis
. WhiB3, a cytosolic redox-sensing transcriptional regulator, is also involved in these processes. However, there is no direct evidence to demonstrate the regulation of WhiB3 by PhoPR. In this study, we found that PhoPR directly activates
whiB3
expression in response to low pH. An atypical PhoP box in the
whiB3
promoters has been identified and is only found in pathogenic mycobacteria, which suggests that the PhoPR-
whiB3
regulatory pathway may facilitate mycobacterial infection. This study provides novel information for further characterization of the PhoPR regulon.
NS1 Protein of 2009 Pandemic Influenza A Virus Inhibits Porcine NLRP3 Inflammasome-Mediated Interleukin-1 Beta Production by Suppressing ASC Ubiquitination
Authors: Park Hong-Su , Liu GuanQun , Thulasi Raman Sathya N. , Landreth Shelby L. , Liu Qiang , Zhou Yan
Published: January 2018

The inflammasome represents a molecular platform for innate immune regulation and controls proinflammatory cytokine production. The NLRP3 inflammasome is comprised of NLRP3, ASC, and procaspase-1. When the NLRP3 inflammasome is activated, it causes ASC speck formation and caspase-1 activation, resulting in the maturation of interleukin-1β (IL-1β). The NLRP3 inflammasome is regulated at multiple levels, with one level being posttranslational modification. Interestingly, ubiquitination of ASC has been reported to be indispensable for the activation of the NLRP3 inflammasome. Influenza A virus (IAV) infection induces NLRP3 inflammasome-dependent IL-1β secretion, which contributes to the host antiviral defense. However, IAVs have evolved multiple antagonizing mechanisms, one of which is executed by viral NS1 protein to suppress the NLRP3 inflammasome. In this study, we compared IL-1β production in porcine alveolar macrophages in response to IAV infection and found that the 2009 pandemic H1N1 induced less IL-1β than swine influenza viruses (SIVs). Further study revealed that the NS1 C terminus of pandemic H1N1 but not that of SIV was able to significantly inhibit NLRP3 inflammasome-mediated IL-1β production. This inhibitory function was attributed to impaired ASC speck formation and suppression of ASC ubiquitination. Moreover, we identified two target lysine residues, K110 and K140, which are essential for both porcine ASC ubiquitination and NLRP3 inflammasome-mediated IL-1β production. These results revealed a novel mechanism by which the NS1 protein of the 2009 pandemic H1N1 suppresses NLRP3 inflammasome activation.

IMPORTANCE
Influenza A virus (IAV) infection activates the NLRP3 inflammasome, resulting in the production of IL-1β, which contributes to the host innate immune response. ASC, an adaptor protein of NLRP3, forms specks that are critical for inflammasome activation. Here, we report that the NS1 C terminus of the 2009 pandemic H1N1 has functions to suppress porcine IL-1β production by inhibiting ASC speck formation and ASC ubiquitination. Furthermore, the ubiquitination sites on porcine ASC were identified. The information gained here may contribute to an in-depth understanding of porcine inflammasome activation and regulation in response to different IAVs, helping to further enhance our knowledge of innate immune responses to influenza virus infection in pigs.
α4β7+CD4+Effector/Effector Memory T Cells Differentiate into Productively and Latently Infected Central Memory T Cells by Transforming Growth Factor β1 during HIV-1 Infection
Authors: Cheung Ka-Wai , Wu Tongjin , Ho Sai Fan , Wong Yik Chun , Liu Li , Wang Hui , Chen Zhiwei
Published: January 2018

HIV-1 transmission occurs mainly through mucosal tissues. During mucosal transmission, HIV-1 preferentially infects α4β7+gut-homing CCR7−CD4+effector/effector memory T cells (TEM) and results in massive depletion of these cells and other subsets of TEMin gut-associated lymphoid tissues. However, besides being eliminated by HIV-1, the role of TEMduring the early stage of infection remains inconclusive. Here, usingin vitro-induced α4β7+gut-homing TEM(α4β7+TEM), we found that α4β7+TEMdifferentiated into CCR7+CD4+central memory T cells (TCM). This differentiation was HIV-1 independent but was inhibited by SB431542, a specific transforming growth factor β (TGF-β) receptor I kinase inhibitor. Consistently, TEM-to-TCMdifferentiation was observed in α4β7+TEMstimulated with TGF-β1 (TGF-β). The TCMproperties of the TGF-β-induced TEM-derived TCM(α4β7+TCM) were confirmed by their enhanced CCL19 chemotaxis and the downregulation of surface CCR7 upon T cell activationin vitro. Importantly, the effect of TGF-β on TCMdifferentiation also held in TEMdirectly isolated from peripheral blood. To investigate the significance of the TGF-β-dependent TEM-to-TCMdifferentiation in HIV/AIDS pathogenesis, we observed that both productively and latently infected α4β7+TCMcould differentiate from α4β7+TEMin the presence of TGF-β during HIV-1 infection. Collectively, this study not only provides a new insight for the plasticity of TEMbut also suggests that the TGF-β-dependent TEM-to-TCMdifferentiation is a previously unrecognized mechanism for the formation of latently infected TCMafter HIV-1 infection.

IMPORTANCEHIV-1 is the causative agent of HIV/AIDS, which has led to millions of deaths in the past 30 years. Although the implementation of highly active antiretroviral therapy has remarkably reduced the HIV-1-related morbidity and mortality, HIV-1 is not eradicated in treated patients due to the presence of latent reservoirs. Besides, the pathogenesis in CD4 T cells early after infection still remains elusive. Immediately after HIV-1 mucosal infection, CD4 T cells are preferentially infected and depleted. However, in addition to being depleted, the other roles of the CD4 T cells, especially the effector/effector memory T cells (TEM), in disease progression are not completely understood. The significance of this study is in revealing a novel mechanism for the formation of latently HIV-1-infected central memory CD4 T cells, a major latent reservoir from CD4 TEMafter infection. Our findings suggest previously unrecognized roles of CD4 TEMin HIV-1 pathogenesis.
HIV-1 Envelope Glycoproteins from Diverse Clades Differentiate Antibody Responses and Durability among Vaccinees
Authors: Yates Nicole L. , deCamp Allan C. , Korber Bette T. , Liao Hua-Xin , Irene Carmela , Pinter Abraham , Peacock James , Harris Linda J. , Sawant Sheetal , Hraber Peter , Shen Xiaoying , Rerks-Ngarm Supachai , Pitisuttithum Punnee , Nitayapan Sorachai , Berman Phillip W. , Robb Merlin L. , Pantaleo Giuseppe , Zolla-Pazner Susan , Haynes Barton F. , Alam S. Munir , Montefiori David C. , Tomaras Georgia D.
Published: January 2018

Induction of broadly cross-reactive antiviral humoral responses with the capacity to target globally diverse circulating strains is a key goal for HIV-1 immunogen design. A major gap in the field is the identification of diverse HIV-1 envelope antigens to evaluate vaccine regimens for binding antibody breadth. In this study, we define unique antigen panels to map HIV-1 vaccine-elicited antibody breadth and durability. Diverse HIV-1 envelope glycoproteins were selected based on genetic and geographic diversity to cover the global epidemic, with a focus on sexually acquired transmitted/founder viruses with a tier 2 neutralization phenotype. Unique antigenicity was determined by nonredundancy (Spearman correlation), and antigens were clustered using partitioning around medoids (PAM) to identify antigen diversity. Cross-validation demonstrated that the PAM method was better than selection by reactivity and random selection. Analysis of vaccine-elicited V1V2 binding antibody in longitudinal samples from the RV144 clinical trial revealed the striking heterogeneity among individual vaccinees in maintaining durable responses. These data support the idea that a major goal for vaccine development is to improve antibody levels, breadth, and durability at the population level. Elucidating the level and durability of vaccine-elicited binding antibody breadth needed for protection is critical for the development of a globally efficacious HIV vaccine.

IMPORTANCEThe path toward an efficacious HIV-1 vaccine will require characterization of vaccine-induced immunity that can recognize and target the highly genetically diverse virus envelope glycoproteins. Antibodies that target the envelope glycoproteins, including diverse sequences within the first and second hypervariable regions (V1V2) of gp120, were identified as correlates of risk for the one partially efficacious HIV-1 vaccine. To build upon this discovery, we experimentally and computationally evaluated humoral responses to define envelope glycoproteins representative of the antigenic diversity of HIV globally. These diverse envelope antigens distinguished binding antibody breadth and durability among vaccine candidates, thus providing insights for advancing the most promising HIV-1 vaccine candidates.
Respiratory Syncytial Virus Replication Is Promoted by Autophagy-Mediated Inhibition of Apoptosis
Authors: Li Miao , Li Jian , Zeng Ruihong , Yang Jianling , Liu Jianguo , Zhang Zhengzheng , Song Xiaotian , Yao Zhiyan , Ma Cuiqing , Li Wenjian , Wang Kai , Wei Lin
Published: January 2018

Respiratory syncytial virus (RSV) is the main cause of acute lower respiratory tract infection (ALRI) in children worldwide. Virus-host interactions affect the progression and prognosis of the infection. Autophagy plays important roles in virus-host interactions. Respiratory epithelial cells serve as the front line of host defense during RSV infection, However, it is still unclear how they interact with RSV. In this study, we found that RSV induced autophagy that favored RSV replication and exacerbated lung pathology
in vivo
. Mechanistically, RSV induced complete autophagy flux through reactive oxygen species (ROS) generation and activation of the AMP-activated protein kinase/mammalian target of rapamycin (AMPK-MTOR) signaling pathway in HEp-2 cells. Furthermore, we evaluated the functions of autophagy in RSV replication and found that RSV replication was increased in HEp-2 cells treated with rapamycin but decreased remarkably in cells treated with 3-methylademine (3-MA) or wortmannin. Knockdown key molecules in the autophagy pathway with short hairpinp RNA (shRNA) against autophagy-related gene 5 (
ATG5
), autophagy-related gene 7 (
ATG7
), or
BECN1/Beclin 1
or treatment with ROS scavenger N-acetyl-
l
-cysteine (NAC) and AMPK inhibitor (compound C) suppressed RSV replication. 3-MA or sh
ATG5/BECN1
significantly decreased cell viability and increased cell apoptosis at 48 hours postinfection (hpi). Blocking apoptosis with Z-VAD-FMK partially restored virus replication at 48 hpi. Those results provide strong evidence that autophagy may function as a proviral mechanism in a cell-intrinsic manner during RSV infection.

IMPORTANCE
An understanding of the mechanisms that respiratory syncytial virus utilizes to interact with respiratory epithelial cells is critical to the development of novel antiviral strategies. In this study, we found that RSV induces autophagy through a ROS-AMPK signaling axis, which in turn promotes viral infection. Autophagy favors RSV replication through blocking cell apoptosis at 48 hpi. Mechanistically, RSV induces mitophagy, which maintains mitochondrial homeostasis and therefore decreases cytochrome
c
release and apoptosis induction. This study provides a novel insight into this virus-host interaction, which may help to exploit new antiviral treatments targeting autophagy processes.
Modifications to the Foot-and-Mouth Disease Virus 2A Peptide: Influence on Polyprotein Processing and Virus Replication
Authors: Kjær Jonas , Belsham Graham J.
Published: January 2018

Foot-and-mouth disease virus (FMDV) has a positive-sense single-stranded RNA (ssRNA) genome that includes a single, large open reading frame encoding a polyprotein. The cotranslational “cleavage” of this polyprotein at the 2A/2B junction is mediated by the 2A peptide (18 residues in length) using a nonproteolytic mechanism termed “ribosome skipping” or “StopGo.” Multiple variants of the 2A polypeptide with this property among the picornaviruses share a conserved C-terminal motif [D(V/I)E(S/T)NPG↓P]. The impact of 2A modifications within this motif on FMDV protein synthesis, polyprotein processing, and virus viability were investigated. Amino acid substitutions are tolerated at residues E
14
, S
15
, and N
16
within the 2A sequences of infectious FMDVs despite their reported “cleavage” efficiencies at the 2A/2B junction of only ca. 30 to 50% compared to that of the wild type (wt). In contrast, no viruses containing substitutions at residue P
17
, G
18
, or P
19
, which displayed little or no “cleavage” activity
in vitro
, were rescued, but wt revertants were obtained. The 2A substitutions impaired the replication of an FMDV replicon. Using transient-expression assays, it was shown that certain amino acid substitutions at residues E
14
, S
15
, N
16
, and P
19
resulted in partial “cleavage” of a protease-free polyprotein, indicating that these specific residues are not essential for cotranslational “cleavage.” Immunofluorescence studies, using full-length FMDV RNA transcripts encoding mutant 2A peptides, indicated that the 2A peptide remained attached to adjacent proteins, presumably 2B. These results show that efficient “cleavage” at the 2A/2B junction is required for optimal virus replication. However, maximal StopGo activity does not appear to be essential for the viability of FMDV.

IMPORTANCE
Foot-and-mouth disease virus (FMDV) causes one of the most economically important diseases of farm animals. Cotranslational “cleavage” of the FMDV polyprotein precursor at the 2A/2B junction, termed StopGo, is mediated by the short 2A peptide through a nonproteolytic mechanism which leads to release of the nascent protein and continued translation of the downstream sequence. Improved understanding of this process will not only give a better insight into how this peptide influences the FMDV replication cycle but may also assist the application of this sequence in biotechnology for the production of multiple proteins from a single mRNA. Our data show that single amino acid substitutions in the 2A peptide can have a major influence on viral protein synthesis, virus viability, and polyprotein processing. They also indicate that efficient “cleavage” at the 2A/2B junction is required for optimal virus replication. However, maximal StopGo activity is not essential for the viability of FMDV.
Morbidity and mortality with early pulmonary haemorrhage in preterm neonates
Authors: Ahmad Kaashif Aqeeb , Bennett Monica Michelle , Ahmad Samiya Fatima , Clark Reese Hunter , Tolia Veeral Nalin
Published: January 2018

Objective

There are no large studies evaluating pulmonary haemorrhage (PH) in premature infants. We sought to quantify the clinical characteristics, morbidities and mortality associated with early PH.

Design

Data were abstracted from the Pediatrix Clinical Data Warehouse, a large de-identified data set. For incidence calculations, we included infants from 340 Pediatrix United States Neonatal Intensive Care Units from 2005 to 2014 without congenital anomalies. Infants <28 weeks’ gestation with PH within 7 days of birth were then matched with two controls for birth weight, gestational age, gender, antenatal steroid exposure, day of life 0 or 1 intubation and multiple gestation.

Results

From 596 411 total infants, we identified 2799 with a diagnosis of PH. Peak incidence was 86.9 cases per 1000 admissions for neonates born at 24 weeks’ gestation. We then identified 1476 infants <28 weeks’ gestation with an early PH diagnosis at ≤7 days of age of which 1363 (92.3%) were successfully matched. Patients with early PH had significantly higher exposure to poractant alfa (35.4% vs 28%), diagnosis of shock (63.7% vs 51%) and grade IV intraventricular haemorrhage (20.8% vs 6%). Patients with PH also had significantly higher mortality rates at 7 days of age (40.6% vs 18.9%), 30 days of age (54% vs 28.8%) and prior to discharge (56.9% vs 33.7).

Conclusion

In this large cohort of premature infants, we found PH to be common among the most premature babies. Early PH was associated with significant morbidity and mortality in excess of 50%. A renewed focus on the underlying pathophysiology and prevention of PH is warranted.
Severity and burden of hand, foot and mouth disease in Asia: a modelling study
Authors: Koh Wee Ming , Badaruddin Hishamuddin , La Hanh , Chen Mark I-Cheng , Cook Alex R
Published: January 2018

Background

Hand, foot and mouth disease (HFMD) affects millions of children across Asia annually, leading to an increase in implemented control policies such as surveillance, isolation and social distancing in affected jurisdictions. However, limited knowledge of disease burden and severity causes difficulty in policy optimisation as the associated economic cost cannot be easily estimated. We use a data synthesis approach to provide a comprehensive picture of HFMD disease burden, estimating infection risk, symptomatic rates, the risk of complications and death, and overall disability-adjusted life-year (DALY) losses, along with associated uncertainties.

Methods

Complementary data from a variety of sources were synthesised with mathematical models to obtain estimates of severity of HFMD. This includes serological and other data extracted through a systematic review of HFMD epidemiology previously published by the authors, and laboratory investigations and sentinel reports from Singapore’s surveillance system.

Results

HFMD is estimated to cause 96 900 (95% CI 40 600 to 259 000) age-weighted DALYs per annum in eight high-burden countries in East and Southeast Asia, with the majority of DALYs attributed to years of life lost. The symptomatic case hospitalisation rate of HFMD is 6% (2.8%–14.9%), of which 18.7% (6.7%–31.5%) are expected to develop complications. 5% (2.9%–7.4%) of such cases are fatal, bringing the overall case fatality ratio to be 52.3 (24.4–92.7) per 100 000 symptomatic infections. In contrast, the EV-A71 case fatality ratio is estimated to be at least 229.7 (75.4–672.1) per 100 000 symptomatic cases. Asymptomatic rate for EV-A71 is 71.4% (68.3%–74.3%) for ages 1–4, the years of greatest incidence.

Conclusion

Despite the high incidence rate of HFMD, total DALY due to HFMD is limited in comparison to other endemic diseases in the region, such as dengue and upper respiratory tract infection. With the majority of DALY caused by years of life lost, it is possible to mitigate most with increased EV-A71 vaccine coverage.
Thread embedding acupuncture for musculoskeletal pain: a systematic review and meta-analysis protocol
Authors: Cho Yeeun , Lee Seunghoon , Kim Jihye , Kang Jung Won , Lee Jae-Dong
Published: January 2018

Introduction

Thread embedding acupuncture (TEA) is a special type of acupuncture that inserts certain medical threads (eg, catgut or polydioxanone) into subcutaneous tissue or muscles at specific points. Although TEA has been widely used for the treatment of musculoskeletal pain in Korea, China and Taiwan, evidence regarding its efficacy is lacking. The aim of this protocol is to evaluate the effectiveness and safety of TEA in the treatment of musculoskeletal pain, by conducting a systematic review and meta-analysis.

Methods and analysis

The following 16 databases will be searched from their inception to 14 May 2017: MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, three Chinese database (China National Knowledge Infrastructure, the Chongqing VIP Chinese Science and Technology Periodical Database and the Wanfang database) and eight Korean databases (Korean Medical Database, Korean Association of Medical Journal Editors, Korean Studies Information Service System, Korean National Assembly Digital Library, National Digital Science Library, Oriental Medicine Advanced Searching Integrated System, ’Database Periodical Information Academic and Korean Traditional Knowledge Portal'). The WHO International Clinical Trials Registry Platform will also be searched to retrieve the recently completed studies.

All randomised controlled studies in which TEA was used on specific points for the treatment of musculoskeletal pain will be included and no restrictions on language will be applied. The risk of bias of each study will be evaluated by the Cochrane risk of bias tool.

Mean difference or standardised mean difference for continuous data and risk ratio for dichotomous data will be calculated with 95% CIs using a random effects model or a fixed effects model. Additional subgroup and sensitivity analyses will be conducted according to a predefined protocol.

Ethics and dissemination

No ethical issues are predicted. The systematic review will be published in a peer-reviewed journal or conference presentation. These findings will summarise the current evidence of TEA for the treatment of musculoskeletal pain and may provide guidance for clinicians and patients to select TEA for musculoskeletal pain.

PROSPERO registration number

CRD42015019046.
Impact of hepatitis C virus infection on long-term mortality after acute myocardial infarction: a nationwide population-based, propensity-matched cohort study in Taiwan
Authors: Kuo Shu-Hung , Hung Wang-Ting , Tang Pei-Ling , Huang Wei-Chun , Yang Jin-Shiou , Lin Hsiao-Chin , Mar Guang-Yuan , Chang Hong-Tai , Liu Chun-Peng
Published: January 2018

Introduction

The influence of hepatitis C virus (HCV) infection on long-term outcomes of patients with acute myocardial infarction (AMI) is unclear. Therefore, this study aimed to analyse the impact of HCV infection on 12-year mortality rates after AMI using data from the Taiwan National Health Insurance Research Database (NHIRD).

Methods

NHIRD data for approximately 23 000 000 patients between January 2000 and December 2012 were analysed. A total of 186 112 cases of first AMI admission were identified. A total of 4659 patients with HCV infection not receiving interferon therapy were enrolled and divided into those with (n=107) or without (n=4552) cirrhosis. Using one-to-one matching, 4552 matched controls were included in the final analysis.

Results

The 12-year mortality rate was significantly higher in patients with AMI with HCV infection and cirrhosis than in those with HCV infection but without cirrhosis (P<0.0001) or controls (P<0.0001). Patients with HCV infection but without cirrhosis had significantly higher long-term mortality rates than the matched controls (P<0.0001). The HR for mortality was higher in patients with HCV infection (HR 1.12; 95% CI 1.06 to 1.18). HCV influenced outcomes among the subgroups of patients who were male (HR 1.15) and those who had hypertension (HR 1.14).

Conclusions

HCV infection influenced the 12-year mortality rates of patients with AMI, especially those who were male and those who had hypertension. Cirrhosis further increased the long-term mortality rates of patients with AMI with HCV infection.
Multicentre validation of a sepsis prediction algorithm using only vital sign data in the emergency department, general ward and ICU
Authors: Mao Qingqing , Jay Melissa , Hoffman Jana L , Calvert Jacob , Barton Christopher , Shimabukuro David , Shieh Lisa , Chettipally Uli , Fletcher Grant , Kerem Yaniv , Zhou Yifan , Das Ritankar
Published: January 2018

Objectives

We validate a machine learning-based sepsis-prediction algorithm (InSight) for the detection and prediction of three sepsis-related gold standards, using only six vital signs. We evaluate robustness to missing data, customisation to site-specific data using transfer learning and generalisability to new settings.

Design

A machine-learning algorithm with gradient tree boosting. Features for prediction were created from combinations of six vital sign measurements and their changes over time.

Setting

A mixed-ward retrospective dataset from the University of California, San Francisco (UCSF) Medical Center (San Francisco, California, USA) as the primary source, an intensive care unit dataset from the Beth Israel Deaconess Medical Center (Boston, Massachusetts, USA) as a transfer-learning source and four additional institutions’ datasets to evaluate generalisability.

Participants

684 443 total encounters, with 90 353 encounters from June 2011 to March 2016 at UCSF.

Interventions

None.

Primary and secondary outcome measures

Area under the receiver operating characteristic (AUROC) curve for detection and prediction of sepsis, severe sepsis and septic shock.

Results

For detection of sepsis and severe sepsis,InSightachieves an AUROC curve of 0.92 (95% CI 0.90 to 0.93) and 0.87 (95% CI 0.86 to 0.88), respectively. Four hours before onset,InSightpredicts septic shock with an AUROC of 0.96 (95% CI 0.94 to 0.98) and severe sepsis with an AUROC of 0.85 (95% CI 0.79 to 0.91).

Conclusions

InSightoutperforms existing sepsis scoring systems in identifying and predicting sepsis, severe sepsis and septic shock. This is the first sepsis screening system to exceed an AUROC of 0.90 using only vital sign inputs.InSightis robust to missing data, can be customised to novel hospital data using a small fraction of site data and retains strong discrimination across all institutions.
Evaluating sickness absence duration by musculoskeletal and mental health issues: a retrospective cohort study of Scottish healthcare workers
Authors: Demou Evangelia , Smith Shanley , Bhaskar Abita , Mackay Daniel F , Brown Judith , Hunt Kate , Vargas-Prada Sergio , Macdonald Ewan B
Published: January 2018

Objectives

Sickness absence (SA) among healthcare workers is associated with occupational and non-occupational risk factors and impacts employee health, healthcare delivery and patient health. At the same time, healthcare is one of the employment sectors with the highest rates of work-related ill health in the UK. Musculoskeletal (MSK) and mental health (MH) issues are leading causes of SA, but there is a lack of research on how certain MSK/MH conditions impact on SA duration. The study aim is to determine differences in SA duration by MH and MSK disorders in healthcare employees.

Methods

Survival analyses were used to estimate SA duration due to MSK and MH problems over 6 years, and Cox’s proportional hazards models to determine the HRs of returning to work, using a bespoke Scottish health board database with over 53 000 SA events. SA duration and time to return-to-work (RTW) were estimated for employees by age, gender, job and health conditions.

Results

MSK and MH conditions accounted for 27% and 6% of all SA events and 23.7% and 19.5% of all days lost, respectively. Average SA duration was 43.5 days for MSK and 53.9 days for MH conditions. For MSK conditions, employees with low back or neck pain had the fastest RTW (median P50: 7 days), whereas employees absent due to depression took the longest (P50: 54 days). The most influential sociodemographic variables affecting RTW were age, gender and job category.

Conclusions

Using a unique and rich database, we found significant differences in SA duration by presenting condition in healthcare workers. MH conditions, and depression specifically, accounted for the most working days’ absence. Significant variations in duration were also observed for MSK conditions. Our findings can inform public health practitioners and healthcare managers of the most significant factors impacting MSK-related and MH-related SA to develop and implement tailored and targeted workplace interventions.
Cross-sectional study assessing the addition of contrast sensitivity to visual acuity when testing for fitness to drive
Authors: Spreng Lucie , Favrat Bernard , Borruat François-Xavier , Vaucher Paul
Published: January 2018

Objectives

The aim of this study is to quantify the importance of loss of contrast sensitivity (CS) and its relationship to loss of visual acuity (VA), driving restrictions and daytime, on-road driving evaluations in drivers aged 70+.

Design

A predictive cross-sectional study.

Setting

Volunteer participants to a drivers’ refresher course for adults aged 70+ delivered by the Swiss Automobile Club in western Switzerland from 2011 to 2013.

Participants

162 drivers, male and female, aged 70 years or older.

Clinical predictors

We used a vision screener to estimate VA and the The Mars Letter Contrast Sensitivity Test to test CS.

Outcomes

We asked drivers to report whether they found five driving restrictions useful for their condition; restrict driving to known roads, avoid driving on highways, avoid driving in the dark, avoid driving in dense traffic and avoid driving in fog. All participants also underwent a standardised on-road evaluation carried out by a driving instructor.

Results

Moderate to severe loss of CS for at least one eye was frequent (21.0% (95% CI 15.0% to 28.1%)) and often isolated from a loss of VA (11/162 cases had a VA ≥0.8 decimal and a CS of ≤1.5 log(CS); 6.8% (95% CI 3.4% to 11.8%)). Drivers were more likely (R2=0.116, P=0.004) to report a belief that self-imposed driving restrictions would be useful if they had reduced CS in at least one eye. Daytime evaluation of driving performance seems limited in its ability to correctly identify difficulties related to CS loss (VA: R2=0.004, P=0.454; CS: R2=0.006, P=0.332).

Conclusion

CS loss is common for older drivers. Screening CS and referring for cataract surgery even in the absence of VA loss could help maintain mobility. Reduced CS and moderate reduction of VA were both poor predictors of daytime on-road driving performances in this research study.
Students’ satisfaction and perceived impact on knowledge, attitudes and skills after a 2-day course in scientific writing: a prospective longitudinal study in Spain
Authors: Fernández Esteve , García Ana M , Serés Elisabet , Bosch Fèlix
Published: January 2018

Objectives

This study aimed to determine students’ satisfaction with a 2-day course on scientific writing in health sciences and to assess their perceptions of the long-term impact on their knowledge, attitudes and skills.

Setting

27 iterations of a 2-day course on writing and publishing scientific articles in health sciences.

Participants

741 students attending the 27 courses.

Design

Prospective longitudinal study.

Primary and secondary outcome measures

Immediately after each course, students completed a first questionnaire, rating their satisfaction with different aspects of the classroom sessions on a Likert scale (0–5). Approximately 2 years after the course, students completed a follow-up questionnaire, using a Likert scale (0–4) to rate their knowledge, skills and attitudes in relation to scientific writing before and after attending the course.

Results

741 students (70% women) participated in the 27 iterations of the course; 568 (76.8%) completed the first questionnaire and 182 (24.6%) completed the follow-up questionnaire. The first questionnaire reflected high overall satisfaction (mean score, 4.6). In the second questionnaire, students reported that the course had improved their knowledge (mean improvement: 1.6; 95% CI 1.6 to 1.7), attitudes (mean improvement: 1.3; 95% CI 1.2 to 1.4) and skills (mean improvement: 1.4; 95% CI 1.3 to 1.4) related to writing and publishing scientific papers. Most respondents (n=145, 79.7%) had participated in drafting a scientific paper after the course; in this subgroup, all the specific writing skills assessed in the second questionnaire significantly improved.

Conclusions

Students were satisfied with the format and the contents of the course, and those who responded to the follow-up survey considered that the course had improved their knowledge, attitudes and skills in relation to scientific writing and publishing. Courses are particularly important in countries without strong traditions in scientific publication.
Needs of informal caregivers across the caregiving course in amyotrophic lateral sclerosis: a qualitative analysis
Authors: Galvin Miriam , Carney Sile , Corr Bernie , Mays Iain , Pender Niall , Hardiman Orla
Published: January 2018

Objectives

Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND), is a debilitating terminal condition. Informal caregivers are key figures in ALS care provision. The physical, psychological and emotional impact of providing care in the home requires appropriate assistance and support. The objective of this analysis is to explore the needs of informal ALS caregivers across the caregiving course.

Design

In an open-ended question as part of a semistructured interview, caregivers were asked what would help them in their role. Interviews took place on three occasions at 4-month to 6-month intervals. Demographic, burden and quality of life data were collected, in addition to the open-ended responses. We carried out descriptive statistical analysis and thematic analysis of qualitative data.

Setting and participants

Home interviews at baseline (n=81) and on two further occasions (n=56, n=41) with informal caregivers of people with ALS attending the National ALS/MND Clinic at Beaumont Hospital, Dublin, Ireland.

Results

The majority of caregivers were family members. Hours of care provided and caregiver burden increased across the interview series. Thematic analysis identified what would help them in their role, and needs related to external support and services, psychological-emotional factors, patient-related behaviours, a cure and ‘nothing’. Themes were interconnected and their prevalence varied across the interview time points.

Conclusion

This study has shown the consistency and adaptation in what caregivers identified as helpful in their role, across 12–18 months of a caregiving journey. Support needs are clearly defined, and change with time and the course of caregiving. Caregivers need support from family, friends and healthcare professionals in managing their tasks and the emotional demands of caregiving. Identifying the specific needs of informal caregivers should enable health professionals to provide tailored supportive interventions.
Quality of life, sleep and rheumatoid arthritis (QUASAR): a protocol for a prospective UK mHealth study to investigate the relationship between sleep and quality of life in adults with rheumatoid arthritis
Authors: Druce Katie L , Cordingley Lis , Short Vicky , Moore Susan , Hellman Bruce , James Ben , Lunt Mark , Kyle Simon D , Dixon Will G , McBeth John
Published: January 2018

Introduction

People with rheumatoid arthritis (RA) frequently report reduced health-related quality of life (HRQoL), the impact one’s health has on physical, emotional and social well-being. There are likely numerous causes for poor HRQoL, but people with RA have identified sleep disturbances as a key contributor to their well-being. This study will identify sleep/wake rhythm-associated parameters that predict HRQoL in patients with RA.

Methods and analysis

This prospective cohort study will recruit 350 people with RA, aged 18 years or older. Following completion of a paper-based baseline questionnaire, participants will record data on 10 symptoms including pain, fatigue and mood two times a day for 30 days using a study-specific mobile application (app). A triaxial accelerometer will continuously record daytime activity and estimate evening sleep parameters over the 30 days. Every 10 days following study initiation, participants will complete a questionnaire that measures disease specific (Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF)) and generic (WHOQOL-BREF) quality of life. A final questionnaire will be completed at 60 days after entering the study. The primary outcomes are the AIMS2-SF and WHOQOL-BREF. Structural equation modelling and latent trajectory models will be used to examine the relationship between sleep/wake rhythm-associated parameters and HRQoL, over time.

Ethics and dissemination

Results from this study will be disseminated at regional and international conferences, in peer-reviewed journals and Patient and Public Engagement events, as appropriate.
CARE CR-Cardiovascular and cardiorespiratory Adaptations to Routine Exercise-based Cardiac Rehabilitation: a study protocol for a community-based controlled study with criterion methods
Authors: Nichols Simon , Nation Fiona , Goodman Toni , Clark Andrew L , Carroll Sean , Ingle Lee
Published: January 2018

Introduction

Cardiac rehabilitation (CR) reduces all-cause and cardiovascular mortality in patients with coronary heart disease (CHD). Much of this improvement has been attributed to the beneficial effects of structured exercise training. However, UK-based studies have not confirmed this. Improvements in survival and cardiovascular health are associated with concurrent improvements in cardiorespiratory fitness (CRF). It is therefore concerning that estimated CRF improvements resulting from UK-based CR are approximately one-third of those reported in international literature. Modest improvements in CRF suggest that UK CR exercise training programmes may require optimisation if long-term survival is to be improved. However, contemporary UK studies lack control data or use estimates of CRF change. Cardiovascular and cardiorespiratory Adaptations to Routine Exercise-based CR is a longitudinal, observational, controlled study designed to assess the short-term and long-term effect of CR on CRF, as well cardiovascular and cardiometabolic health.

Methods and analysis

Patients will be recruited following referral to their local CR programme and will either participate in a routine, low-to-moderate intensity, 8-week (16 sessions) exercise-based CR programme or freely abstain from supervised exercise. Initial assessment will be conducted prior to exercise training, or approximately 2 weeks after referral to CR if exercise training is declined. Reassessment will coincide with completion of exercise training or 10 weeks after initial assessment for control participants. Participants will receive a final follow-up 12 months after recruitment. The primary outcome will be peak oxygen consumption determined using maximal cardiopulmonary exercise testing. Secondary outcomes will include changes in subclinical atherosclerosis (carotid intima–media thickness and plaque characteristics), body composition (dual X-ray absorptiometry) and cardiometabolic biomarkers.

Ethics and dissemination

Ethical approval for this non-randomised controlled study has been obtained from the Humber Bridge NHS Research Ethics Committee—Yorkshire and the Humber on the 27th September 2013, (12/YH/0278). Results will be presented at national conferences and published in peer-reviewed journals.