Permissive versus restrictive temperature thresholds in critically ill children with fever and infection: a multicentre randomized clinical pilot trial.

BACKGROUND: Fever improves pathogen control at a significant metabolic cost. No randomized clinical trials (RCT) have compared fever treatment thresholds in critically ill children. We performed a pilot RCT to determine whether a definitive trial of a permissive approach to fever in comparison to current restrictive practice is feasible in critically ill children with suspected infection. METHODS: An open, parallel-group pilot RCT with embedded mixed methods perspectives study in four UK paediatric intensive care units (PICUs) and associated retrieval services. Participants were emergency PICU admissions aged > 28 days to < 16 years receiving respiratory support and supplemental oxygen. Subjects were randomly assigned to permissive (antipyretic interventions only at ≥ 39.5 °C) or restrictive groups (antipyretic interventions at ≥ 37.5 °C) whilst on respiratory support. Parents were invited to complete a questionnaire or take part in an interview. Focus groups were conducted with staff at each unit. Outcomes were measures of feasibility: recruitment rate, protocol adherence and acceptability, between group separation of temperature and safety. RESULTS: One hundred thirty-eight children met eligibility criteria of whom 100 (72%) were randomized (11.1 patients per month per site) without prior consent (RWPC). Consent to continue in the trial was obtained in 87 cases (87%). The mean maximum temperature (95% confidence interval) over the first 48 h was 38.4 °C (38.2-38.6) in the restrictive group and 38.8 °C (38.6-39.1) in the permissive group, a mean difference of 0.5 °C (0.2-0.8). Protocol deviations were observed in 6.8% (99/1438) of 6-h time periods and largely related to patient comfort in the recovery phase. Length of stay, duration of organ support and mortality were similar between groups. No pre-specified serious adverse events occurred. Staff (n = 48) and parents (n = 60) were supportive of the trial, including RWPC. Suggestions were made to only include invasively ventilated children for the duration of intubation. CONCLUSION: Uncertainty around the optimal fever threshold for antipyretic intervention is relevant to many emergency PICU admissions. A more permissive approach was associated with a modest increase in mean maximum temperature. A definitive trial should focus on the most seriously ill cases in whom antipyretics are rarely used for their analgesic effects alone. TRIAL REGISTRATION: ISRCTN16022198 . Registered on 14 August 2017.

A CRISPR/Cas-Based Method for Precise DNA Integration in Xenopus laevis Oocytes Followed by Intracytoplasmic Sperm Injection (ICSI) Fertilization.

Xenopus has long had a reputation for being a powerful model organism for use in developmental cell and biochemistry research. With the advent of gene-editing technologies, and the full genome sequencing of Xenopus genomes revealing the extent of the genetic conservation between Xenopus and humans, Xenopus has the potential to become an ideal model for human genetic disease. However, the inability to produce non-mosaic, precise DNA insertions through homology directed repair has limited the strength of Xenopus this field. Furthermore, it has prevented researchers from taking full advantage of fusion tagging, a method for directly tagging genes with either epitope or fluorescent tags, allowing the visualization, quantification, and tracking of proteins without the use of protein-specific antibodies. Here, we describe a method for precise DNA insertion into oocytes using CRISPR/Cas9, followed by in vitro maturation and fertilization by intracytoplasmic sperm injection (ICSI), culminating in the production of embryos carrying a non-mosaic, heterozygous insertion.

Confirming Antibody Specificity in Xenopus.

Verifying that a new antibody recognizes its target can be difficult. In this protocol, expression of a target protein in Xenopus embryos is either knocked down using CRISPR-Cas9 technology (for zygotic proteins) or enhanced by microinjection of a synthetic mRNA (for maternal proteins). Western blotting analysis is then performed. If the antibody recognizes the target protein, the western blot will show a relatively weak band for CRISPR-injected embryos and a relatively strong band for RNA-injected embryos. This represents a straightforward, powerful strategy for confirming antibody specificity in Xenopus.

Information Accrual From the Period Preceding Racket-Ball Contact for Tennis Ground Strokes: Inferences From Stochastic Masking.

Previous research suggests the existence of an expert anticipatory advantage, whereby skilled sportspeople are able to predict an upcoming action by utilizing cues contained in their opponent's body kinematics. This ability is often inferred from "occlusion" experiments: information is systematically removed from first-person videos of an opponent, for example, by stopping a tennis video at the point of racket-ball contact, yet performance, such as discrimination of shot direction, remains above chance. In this study, we assessed the expert anticipatory advantage for tennis ground strokes via a modified approach, known as "bubbles," in which information is randomly removed from videos in each trial. The bubbles profile is then weighted by trial outcome (i.e., a correct vs. incorrect discrimination) and combined across trials into a classification array, revealing the potential cues informing the decision. In two experiments (both with N = 34 skilled tennis players) we utilized either temporal or spatial bubbles, applying them to videos running from 0.8 to 0 s before the point of racket-ball contact (cf. Jalali et al., 2018). Results from the spatial experiment were somewhat suggestive of accrual from the torso region of the body, but were not compelling. Results from the temporal experiment, on the other hand, were clear: information was accrued mainly during the period immediately prior to racket-ball contact. This result is broadly consistent with prior work using nonstochastic approaches to video manipulation, and cannot be an artifact of temporal smear from information accrued after racket-ball contact, because no such information was present.

Different temperature thresholds for antipyretic intervention in critically ill children with fever due to infection: the FEVER feasibility RCT.

BACKGROUND: Fever accelerates host immune system control of pathogens but at a high metabolic cost. The optimal approach to fever management and the optimal temperature thresholds used for treatment in critically ill children are unknown. OBJECTIVES: To determine the feasibility of conducting a definitive randomised controlled trial (RCT) to evaluate the clinical effectiveness and cost-effectiveness of different temperature thresholds for antipyretic management. DESIGN: A mixed-methods feasibility study comprising three linked studies - (1) a qualitative study exploring parent and clinician views, (2) an observational study of the epidemiology of fever in children with infection in paediatric intensive care units (PICUs) and (3) a pilot RCT with an integrated-perspectives study. SETTING: Participants were recruited from (1) four hospitals in England via social media (for the FEVER qualitative study), (2) 22 PICUs in the UK (for the FEVER observational study) and (3) four PICUs in England (for the FEVER pilot RCT). PARTICIPANTS: (1) Parents of children with relevant experience were recruited to the FEVER qualitative study, (2) patients who were unplanned admissions to PICUs were recruited to the FEVER observational study and (3) children admitted with infection requiring mechanical ventilation were recruited to the FEVER pilot RCT. Parents of children and clinicians involved in the pilot RCT. INTERVENTIONS: The FEVER qualitative study and the FEVER observational study had no interventions. In the FEVER pilot RCT, children were randomly allocated (1 : 1) using research without prior consent (RWPC) to permissive (39.5 °C) or restrictive (37.5 °C) temperature thresholds for antipyretics during their PICU stay while mechanically ventilated. MAIN OUTCOME MEASURES: (1) The acceptability of FEVER, RWPC and potential outcomes (in the FEVER qualitative study), (2) the size of the potentially eligible population and the temperature thresholds used (in the FEVER observational study) and (3) recruitment and retention rates, protocol adherence and separation between groups and distribution of potential outcomes (in the FEVER pilot RCT). RESULTS: In the FEVER qualitative study, 25 parents were interviewed and 56 clinicians took part in focus groups. Both the parents and the clinicians found the study acceptable. Clinicians raised concerns regarding temperature thresholds and not using paracetamol for pain/discomfort. In the FEVER observational study, 1853 children with unplanned admissions and infection were admitted to 22 PICUs between March and August 2017. The recruitment rate was 10.9 per site per month. The majority of critically ill children with a maximum temperature of > 37.5 °C received antipyretics. In the FEVER pilot RCT, 100 eligible patients were randomised between September and December 2017 at a recruitment rate of 11.1 per site per month. Consent was provided for 49 out of 51 participants in the restrictive temperature group, but only for 38 out of 49 participants in the permissive temperature group. A separation of 0.5 °C (95% confidence interval 0.2 °C to 0.8 °C) between groups was achieved. A high completeness of outcome measures was achieved. Sixty parents of 57 children took part in interviews and/or completed questionnaires and 98 clinicians took part in focus groups or completed a survey. Parents and clinicians found the pilot RCT and RWPC acceptable. Concerns about children being in pain/discomfort were cited as reasons for withdrawal and non-consent by parents and non-adherence to the protocol by clinicians. LIMITATIONS: Different recruitment periods for observational and pilot studies may not fully reflect the population that is eligible for a definitive RCT. CONCLUSIONS: The results identified barriers to delivering the definitive FEVER RCT, including acceptability of the permissive temperature threshold. The findings also provided insight into how these barriers may be overcome, such as by limiting the patient inclusion criteria to invasive ventilation only and by improved site training. A definitive FEVER RCT using a modified protocol should be conducted, but further work is required to agree important outcome measures for clinical trials among critically ill children. TRIAL REGISTRATION: The FEVER observational study is registered as NCT03028818 and the FEVER pilot RCT is registered as Current Controlled Trials ISRCTN16022198. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 5. See the NIHR Journals Library website for further project information.

Classification Videos Reveal the Visual Information Driving Complex Real-World Speeded Decisions.

Humans can rapidly discriminate complex scenarios as they unfold in real time, for example during law enforcement or, more prosaically, driving and sport. Such decision-making improves with experience, as new sources of information are exploited. For example, sports experts are able to predict the outcome of their opponent's next action (e.g., a tennis stroke) based on kinematic cues "read" from preparatory body movements. Here, we explore the use of psychophysical classification-image techniques to reveal how participants interpret complex scenarios. We used sport as a test case, filming tennis players serving and hitting ground strokes, each with two possible directions. These videos were presented to novices and club-level amateurs, running from 0.8 s before to 0.2 s after racquet-ball contact. During practice, participants anticipated shot direction under a time limit targeting 90% accuracy. Participants then viewed videos through Gaussian windows ("bubbles") placed at random in the temporal, spatial or spatiotemporal domains. Comparing bubbles from correct and incorrect trials revealed how information from different regions contributed toward a correct response. Temporally, only later frames of the videos supported accurate responding (from ~0.05 s before ball contact to 0.1 s afterwards). Spatially, information was accrued from the ball's trajectory and from the opponent's head. Spatiotemporal bubbles again highlighted ball trajectory information, but seemed susceptible to an attentional cuing artifact, which may caution against their wider use. Overall, bubbles proved effective in revealing regions of information accrual, and could thus be applied to help understand choice behavior in a range of ecologically valid situations.

A Roving Dual-Presentation Simultaneity-Judgment Task to Estimate the Point of Subjective Simultaneity.

The most popular tasks with which to investigate the perception of subjective synchrony are the temporal order judgment (TOJ) and the simultaneity judgment (SJ). Here, we discuss a complementary approach-a dual-presentation (2x) SJ task-and focus on appropriate analysis methods for a theoretically desirable "roving" design. Two stimulus pairs are presented on each trial and the observer must select the most synchronous. To demonstrate this approach, in Experiment 1 we tested the 2xSJ task alongside TOJ, SJ, and simple reaction-time (RT) tasks using audiovisual stimuli. We interpret responses from each task using detection-theoretic models, which assume variable arrival times for sensory signals at critical brain structures for timing perception. All tasks provide similar estimates of the point of subjective simultaneity (PSS) on average, and PSS estimates from some tasks were correlated on an individual basis. The 2xSJ task produced lower and more stable estimates of model-based (and thus comparable) sensory/decision noise than the TOJ. In Experiment 2 we obtained similar results using RT, TOJ, ternary, and 2xSJ tasks for all combinations of auditory, visual, and tactile stimuli. In Experiment 3 we investigated attentional prior entry, using both TOJs and 2xSJs. We found that estimates of prior-entry magnitude correlated across these tasks. Overall, our study establishes the practicality of the roving dual-presentation SJ task, but also illustrates the additional complexity of the procedure. We consider ways in which this task might complement more traditional procedures, particularly when it is important to estimate both PSS and sensory/decisional noise.