Validation of a Dermatoscopy-Based Algorithm for the Diagnosis of Acral Melanoma.

INTRODUCTION: Diagnosis of acral melanocytic lesions can be challenging. The BRAAFF checklist was introduced as a tool to help differentiate between acral nevi and melanoma but has not been validated. METHODS: We asked raters with varying expertise in dermatoscopy to diagnose dermatoscopic images of 533 acral nevi and 144 melanomas via an online platform with and without use of the BRAAFF checklist. From the ratings, we calculated sensitivity, specificity, and interrater agreement. Additionally, a new simplified version of the checklist was also tested. RESULTS: We collected 6,880 ratings from 175 readers. The BRAAFF checklist achieved a sensitivity of 92.5% and a specificity of 65.0%, which was similar to diagnosis from pattern recognition (sensitivity 90.0%, specificity: 72.1%). Interrater agreement for the BRAAFF criteria ranged from fair to moderate, with lowest agreement for parallel ridge and fibrillar pattern (alpha = 0.31) and highest for asymmetry of colors and structures (alpha = 0.46). Agreement and diagnostic accuracy were higher for more experienced readers. A simplified version with only two criteria achieved similar sensitivity (95.0%) and lower specificity (60.0%) as the original BRAAFF checklist. CONCLUSION: The BRAAFF checklist is a useful tool for the diagnosis of melanocytic acral lesions with acceptable sensitivity and reasonable specificity but is not superior to pattern recognition. A simplified version of the checklist could be easier to use with equal sensitivity while exhibiting a modest reduction in specificity.

The role of S-adenosylhomocysteine hydrolase-like 1 in cancer.

This integrative review aims to highlight the importance of investigating the functional role of AHCYL1, also known as IRBIT, in cancer cells. It has recently been suggested that AHCYL1 regulates cell survival/death, stemness capacity, and the host adaptive response to the tumor microenvironment. Despite this knowledge, the role of AHCYL1 in cancer is still controversial, probably due to its ability to interact with multiple factors in a tissue-specific manner. Understanding the mechanisms regulating the functional interplay between the tumor and the tumor microenvironment that controls the expression of AHCYL1 could provide a deeper comprehension of the regulation of tumor development. Addressing how AHCYL1 modulates cellular plasticity processes in a tumoral context is potentially relevant to developing translational approaches in cancer biology.

Severe intraprosthetic aortic insufficiency immediately after implantation of a SAPIEN 3 Ultra RESILIA valve with spontaneous resolution: case report.

Background: Aortic insufficiency (AI) is often encountered in transcatheter aortic valve replacement (TAVR) but is only rarely haemodynamically significant. Even more uncommon is the occurrence of intraprosthetic AI that often leads to haemodynamic compromise requiring additional therapeutic intervention. Case summary: An 85-year-old female with severe aortic stenosis underwent elective TAVR with a size 23 mm SAPIEN 3 Ultra RESILIA (S3UR) valve. After implantation, the patient developed hypotension. Transthoracic as well as transoesophageal echocardiogram identified significant transvalvular AI. Persistence of AI led the team to consider a TAV-in-TAV strategy. Before a second valve system could be inserted, the patient's blood pressure improved and AI resolved spontaneously. The patient was discharged and recovered with no AI on follow-up imaging studies. Discussion: This is the first reported case of significant intraprosthetic AI with the new S3UR in our literature search as of writing. The new S3UR valve has several improvements from previous generations designed to increase valve area and durability as well as decreasing the incidence of paravalvular and intraprosthetic leaks. A stuck leaflet was inferred as the cause of the intraprosthetic AI, and the improved design with excessive expansion may have led to this. Unlike previous case reports, intraprosthetic AI resolved without further intervention likely due to the turbulence of flow releasing the stuck leaflet. Cautious observation prevented the need for a TAV-in-TAV for a rare and possibly catastrophic complication.

Steep right anterior oblique view of self-expandable transcatheter aortic valve to timely detect stent under-expansion or non-uniform expansion before final release: a case series.

Background: Severely calcified aortic valves are a major limitation of transcatheter aortic valve replacement, because eccentric and heavy calcification of the aortic valve occasionally inhibits self-expansion of the valve frame, resulting in stent under-expansion, including non-uniform expansion or infolding. Nevertheless, the two-dimensional nature of fluoroscopic projection imaging can limit detection of stent under-expansion prior to the final release. Case summary: We present two cases demonstrating the importance of the steep right anterior oblique (RAO) view (>50°) in detecting significant stent under-expansion of a self-expanding valve prior to the final release. In Case 1, despite enough pre-dilatation, the partially deployed transcatheter heart valve (THV) appeared to be a substantial under-expansion, which was detected only in steep RAO view. Immediately after the final release, the THV was spontaneously embolized into the ascending aorta (the so-called 'pop-up' phenomenon). Emergent implantation of balloon-expandable valve proved to be successful as a bailout. In Case 2, significant stent distortion and infolding, especially on the non-coronary cusp side, was successfully diagnosed only in a steep RAO view prior to the final release. This finding allowed THV recapture and replacement with a new THV. Discussion: Notably, the steep RAO view can visualize the THV from its short axis while eliminating parallax, allowing for accurate diagnosis of THV under-expansion particularly in patients with severe calcification in the non- or right-coronary cusp. Therefore, the steep RAO view allows timely detection of THV under-expansion before the final release, enabling THV recapture and the adoption of several management strategies.

Murf1 alters myosin replacement rates in cultured myotubes in a myosin isoform-dependent manner.

Skeletal muscle tissue increases or decreases its volume by synthesizing or degrading myofibrillar proteins. The ubiquitin-proteasome system plays a pivotal role during muscle atrophy, where muscle ring finger proteins (Murf) function as E3 ubiquitin ligases responsible for identifying and targeting substrates for degradation. Our previous study demonstrated that overexpression of Ozz, an E3 specific to embryonic myosin heavy chain (Myh3), precisely reduced the Myh3 replacement rate in the thick filaments of myotubes (E. Ichimura et al., Physiol Rep. 9:e15003, 2021). These findings strongly suggest that E3 plays a critical role in regulating myosin replacement. Here, we hypothesized that the Murf isoforms, which recognize Myhs as substrates, reduced the myosin replacement rates through the enhanced Myh degradation by Murfs. First, fluorescence recovery after a photobleaching experiment was conducted to assess whether Murf isoforms affected the GFP-Myh3 replacement. In contrast to Murf2 or Murf3 overexpression, Murf1 overexpression selectively facilitated the GFP-Myh3 myosin replacement. Next, to examine the effects of Murf1 overexpression on the replacement of myosin isoforms, Cherry-Murf1 was coexpressed with GFP-Myh1, GFP-Myh4, or GFP-Myh7 in myotubes. Intriguingly, Murf1 overexpression enhanced the myosin replacement of GFP-Myh4 but did not affect those of GFP-Myh1 or GFP-Myh7. Surprisingly, overexpression of Murf1 did not enhance the ubiquitination of proteins. These results indicate that Murf1 selectively regulated myosin replacement in a Myh isoform-dependent fashion, independent of enhanced ubiquitination. This suggests that Murf1 may have a role beyond functioning as a ubiquitin ligase E3 in thick filament myosin replacement.

Regulatory roles of dopamine D2 receptor in milk protein production and apoptosis in mammary epithelial cells.

Dopamine D2 receptors (D2Rs) play crucial roles in regulating diverse physiological functions of the central nervous system and peripheral organs. D2Rs are also expressed in mammary glands. However, which cell types express D2Rs and whether they are involved in milk production remains unclear. The present findings revealed that D2Rs are expressed in the apical regions of the lateral membranes of mammary epithelial cells (MECs) in lactating mice. We also investigated the effects of the D2R agonist bromocriptine and/or antagonist domperidone on intracellular cAMP levels, milk protein production, and apoptosis in a lactation culture model of MECs that produce major milk components like lactating MECs in vivo. We found that bromocriptine decreased intracellular cAMP levels, whereas domperidone dose-dependently neutralized this effect. Bromocriptine also inhibited casein and lactoferrin production and suppressed activities of STAT5 and glucocorticoid receptors (GRs). Domperidone neutralized the inhibition of casein production as well as STAT5 and GR inactivation induced by bromocriptine. Furthermore, D2R activation by bromocriptine induced apoptosis and inactivated ERK, a signaling molecule responsible for promoting cell proliferation and survival. Domperidone attenuated ERK inactivation and apoptosis induced by bromocriptine. These findings suggest that D2Rs play regulatory roles in milk protein production and apoptosis in MECs.

Structural Features of Connective Tissue Formed around Resin Implants Subcutaneously Embedded in Dairy Cows.

Foreign body reactions (FBRs) are inadvertently observed in invading or artificially embedded materials, triggering inflammation and subsequent fibrotic processes to occur in situ. Here, we assessed the spatiotemporal formation of connective tissue around implanted materials to establish a technique using connective tissue formed by FBRs as xenografts. An acrylic resin implant, comprising a columnar inner rod and a tubular outer cylinder (OC) with several slits, was embedded in adult dairy cows. Tissues formed in the inner rod and OC groups were histologically analyzed at weeks 2, 4, 8, and 12. Edematous tissues with non-collagenous fibers formed for 2 weeks and showed increased cellularity after 4 weeks. The weight, thickness, amounts of total protein, collagen, DNA, and quantitative scores of α-smooth muscle actin-positive myofibroblasts or elastic fibers notably increased after 8 weeks, with condensed collagen fibers showing orientation. Inflammatory cells were primarily localized in tissues close to the OC, and their numbers increased, with the count of CD204+ cells peaking at 8 weeks and declining at 12 weeks. The count of Ki67+ proliferating cells slightly increased in tissues close to the OC; however, the number and lumen of CD31+ vessels increased. These results may help understand FBR-related tissue remodeling.

Potential effects of gingerol topical application on components of the innate immunity in lactating goat mammary glands.

In the mammary glands, production of antimicrobial components and formation of less-permeable tight junctions (TJs) are important for safe milk production. Previously, we reported that local heat treatment of udders using disposable heating pad enhances the components of innate immunity in lactating goat mammary glands. Gingerol is a polyphenol present in ginger that can induce heat-like effects. However, oral administration of polyphenols causes a decrease in biological activity through conjugation and metabolic conversion. Here, we investigated the effects of gingerol on antimicrobial components and TJs by topically applying it to lactating goat udders. Gingerol application increased the somatic cell count, cathelicidin-2 concentration, and proportion of polymorphonuclear cells in the milk and interleukin-8 production. Moreover, gingerol treatment enhanced ß-defensin-1 production in milk, cultured mammary epithelial cells, and cultured somatic cells. Contrastingly, gingerol treatment did not affect the concentrations of blood-derived components (Na+, albumin, and IgG) in the milk or the TJ barrier function of cultured mammary epithelial cells. These findings suggest that the topical application of gingerol, similar to local heat treatment, to udders enhances the components of innate immunity in mammary glands. These findings may be useful for the prevention of mastitis in milk-producing animals and, hence, safe and stable dairy production.

Effects of hydrostatic compression on milk production-related signaling pathways in mouse mammary epithelial cells.

Mammary epithelial cells (MECs) secrete milk into the mammary alveolar lumen during lactation. The secreted milk accumulates in the alveolar lumen until milk ejection occurs, and excess milk accumulation downregulates milk production in alveolar MECs. Intramammary hydrostatic pressure also increases in the alveolar lumen in a manner dependent on milk accumulation. In this study, we investigated whether high hydrostatic compression directly affects lactating MECs, using a commercial compression device and a lactation culture model of MECs, which have milk production ability and less permeable tight junctions. High hydrostatic compression at 100 kPa for 8 h decreased ß-casein and increased claudin-4 levels concurrently with inactivation of STAT5 and glucocorticoid receptor signaling pathways. In addition, high hydrostatic compression for 1 h inactivated STAT5 and activated p38 MAPK signaling. Furthermore, repeated rises and falls of the hourly hydrostatic compression induced activation of positive (Akt, mTOR) and negative (STAT3, NF-κB) signaling pathways for milk production concurrently with stimulation of casein and lactoferrin production in MECs. These results indicate that milk production-related signaling pathways in MECs change in response to hydrostatic compression. Hydrostatic compression of the alveolar lumen may directly regulate milk production in the alveolar MECs of lactating mammary glands.

Netrin-4 synthesized in satellite cell-derived myoblasts stimulates autonomous fusion.

Satellite cells are indispensable for skeletal muscle regeneration and hypertrophy by forming nascent myofibers (myotubes). They synthesize multi-potent modulator netrins (secreted subtypes: netrin-1, -3, and -4), originally found as classical neural axon guidance molecules. While netrin-1 and -3 have key roles in myogenic differentiation, the physiological significance of netrin-4 is still unclear. This study examined whether netrin-4 regulates myofiber type commitment and myotube formation. Initially, the expression profiles indicated that satellite cells isolated from the extensor digitorum longus muscle (EDL muscle: fast-twitch myofiber-abundant) expressed slightly more netrin-4 than the soleus muscle (slow-type abundant) cells. As netrin-4 knockdown inhibited both slow- and fast-type myotube formation, netrin-4 may not directly regulate myofiber type commitment. However, netrin-4 knockdown in satellite cell-derived myoblasts reduced the myotube fusion index, while exogenous netrin-4 promoted myotube formation, even though netrin-4 expression level was maximum during the initiation stage of myogenic differentiation. Furthermore, netrin-4 knockdown also inhibited MyoD (a master transcriptional factor of myogenesis) and Myomixer (a myoblast fusogenic molecule) expression. These data suggest that satellite cells synthesize netrin-4 during myogenic differentiation initiation to promote their own fusion, stimulating the MyoD-Myomixer signaling axis.

Effectiveness of inactivated influenza and COVID-19 vaccines in hospitalized children in 2022/23 season in Japan - The first season of co-circulation of influenza and COVID-19.

We have analyzed the inactivated vaccine effectiveness (VE)for preventing influenza hospitalization by test-negative design in the 2022/23 season. This is the first season of co-circulation of influenza and COVID-19, and a unique period because all inpatients received COVID-19 screening. Among 536 children hospitalized with fever, none were positive for both influenza and SARS-CoV-2. The adjusted VE for preventing influenza A for all children, the 6-12-year-old group, and those with underlying diseases was 34 % (95 ％CI, -16 %-61 %, n = 474), 76 % (95 ％ CI, 21 %-92 %, n = 81), and 92 % (95 ％ CI, 30 %-99 %, n = 86), respectively. Only 1 out of 35 hospitalized cases with COVID-19, and 42 out of 429 controls, had been immunized with COVID-19 vaccine. This is the first report showing influenza VE by age group in children in this limited season. We still recommend the inactivated influenza vaccine for children based on the significant VE in subgroup analysis.

Culture Models to Investigate Mechanisms of Milk Production and Blood-Milk Barrier in Mammary Epithelial Cells: a Review and a Protocol.

Mammary epithelial cells (MECs) are the only cell type that produces milk during lactation. MECs also form less-permeable tight junctions (TJs) to prevent the leakage of milk and blood components through the paracellular pathway (blood-milk barrier). Multiple factors that include hormones, cytokines, nutrition, and temperature regulate milk production and TJ formation in MECs. Multiple intracellular signaling pathways that positively and negatively regulate milk production and TJ formation have been reported. However, their regulatory mechanisms have not been fully elucidated. In addition, unidentified components that regulate milk production in MECs likely exist in foods, for example plants. Culture models of functional MECs that recapitulate milk production and TJs are useful tools for their study. Such models enable the elimination of indirect effects via cells other than MECs and allows for more detailed experimental conditions. However, culture models of MECs with inappropriate functionality may result in unphysiological reactions that never occur in lactating mammary glands in vivo. Here, I briefly review the physiological functions of alveolar MECs during lactation in vivo and culture models of MECs that feature milk production and less-permeable TJs, together with a protocol for establishment of MEC culture with functional TJ barrier and milk production capability using cell culture inserts.

A unique case in which Kimoto-style fermentation was completed with Leuconostoc as the dominant genus without transitioning to Lactobacillus.

The Kimoto-style fermentation starter is a traditional preparation method of sake brewing. In this process, specific microbial transition patterns have been observed within nitrate-reducing bacteria and lactic acid bacteria during the production process of the fermentation starter. We have characterized phylogenetic compositions and diversity of the bacterial community in a sake brewery performing the Kimoto-style fermentation. Comparing the time-series changes with other sake breweries previously reported, we found a novel type of Kimoto-style fermentation in which the microbial transition differed significantly from other breweries during the fermentation step. Specifically, the lactic acid bacteria, Leuconostoc spp. was a predominant species in the late stage in the preparation process of fermentation starter, on the other hand, Lactobacillus spp., which plays a pivotal role in other breweries, was not detected in this analysis. The discovery of this new variation of microbiome transition in Kimoto-style fermentation has further deepened our understanding of the diversity of sake brewing.

Sweet taste receptor subunit T1R3 regulates casein secretion and phosphorylation of STAT5 in mammary epithelial cells.

During lactation, mammary epithelial cells (MECs) on the apical membrane are in contact with lactose in milk, while MECs on the basolateral membrane are in contact with glucose in blood. Both glucose and lactose are sweeteners that are sensed by a sweet taste receptor. Previously, we have shown that lactose exposure on the basolateral membrane, but not the apical membrane, inhibits casein production and phosphorylation of STAT5 in MECs. However, it remains unclear whether MECs have a sweet taste receptor. In this study, we confirmed that the sweet taste receptor subunit T1R3 existed in both the apical and basolateral membranes of MECs. Subsequently, we investigated the influence of apical and basolateral sucralose as a ligand for the sweet taste receptor using a cell culture model. In this model, upper and lower media were separated by the MEC layer with less-permeable tight junctions. The results showed in the absence of glucose, both apical and basolateral sucralose induced phosphorylation of STAT5, which is a positive transcriptional factor for milk production. In contrast, the T1R3 inhibitor basolateral lactisole reducing phosphorylated STAT5 and secreted caseins in the presence of glucose. Furthermore, exposure of the apical membrane to sucralose in the presence of glucose inhibited the phosphorylation of STAT5. Simultaneously, GLUT1 was partially translocated from the basolateral membrane to the cytoplasm in MECs. These results suggest that T1R3 functions as a sweet receptor and is closely involved in casein production in MECs.

Menthol application on healthy and inflamed goat udders changes antimicrobial components in milk.

Mammary glands with mastitis are usually treated with antibiotics in combination with anti-inflammatory drug application on the udder skin. Menthol is an anti-inflammatory drug. The aim of the present study was to investigate the effect of surface application of menthol on goat udders on the production of antimicrobial components in milk. Goats (5 Shiba and 11 Tokara goats) were subjected to menthol application to the udder under both healthy and inflammatory conditions. An intramammary infusion of lipopolysaccharides was carried out to induce inflammatory conditions in the udder. Milk samples were collected to determine somatic cell count (SCC) and sodium ion (Na+ ), antimicrobial component and cytokine concentrations. In healthy udders, menthol application increased the concentration of antimicrobial components (S100A7 and S100A8), but not in the control. In the inflamed udder, antimicrobial component (lactoferrin, S100A7, and S100A8) and inflammatory cytokine (IL-1ß) concentrations were higher in the menthol group than in the control group. These results suggest that menthol application on udders augments the antimicrobial component concentration in the mammary gland under both healthy and inflammatory conditions.

S-adenosylhomocysteine hydrolase-like protein 1 (AHCYL1) inhibits lung cancer tumorigenesis by regulating cell plasticity.

BACKGROUND: Lung cancer is one of the most frequently diagnosed cancers characterized by high mortality, metastatic potential, and recurrence. Deregulated gene expression of lung cancer, likewise in many other solid tumors, accounts for their cell heterogeneity and plasticity. S-adenosylhomocysteine hydrolase-like protein 1 (AHCYL1), also known as Inositol triphosphate (IP(3)) receptor-binding protein released with IP(3) (IRBIT), plays roles in many cellular functions, including autophagy and apoptosis but AHCYL1 role in lung cancer is largely unknown. RESULTS: Here, we analyzed the expression of AHCYL1 in Non-Small Cell Lung Cancer (NSCLC) cells from RNA-seq public data and surgical specimens, which revealed that AHCYL1 expression is downregulated in tumors and inverse correlated to proliferation marker Ki67 and the stemness signature expression. AHCYL1-silenced NSCLC cells showed enhanced stem-like properties in vitro, which correlated with higher expression levels of stem markers POU5F1 and CD133. Also, the lack of AHCYL1 enhanced tumorigenicity and angiogenesis in mouse xenograft models highlighting stemness features. CONCLUSIONS: These findings indicate that AHCYL1 is a negative regulator in NSCLC tumorigenesis by modulating cell differentiation state and highlighting AHCYL1 as a potential prognostic biomarker for lung cancer.

A dark matter in sake brewing: Origin of microbes producing a Kimoto-style fermentation starter.

Introduction: In Kimoto-style fermentation, a fermentation starter is produced before the primary brewing process to stabilize fermentation. Nitrate-reducing bacteria, mainly derived from brewing water, produce nitrite, and lactic acid bacteria such as Leuconostoc can proliferate because of their tolerance toward low temperature and their low nutritional requirements. Later, Lactobacillus becomes the dominant genus, leading to weakly acidic conditions that contribute to control yeasts and undesired bacterial contaminants. However, the sources of these microorganisms that play a pivotal role in Sake brewing have not yet been revealed. Thus, comprehensive elucidation of the microbiome is necessary. Methods: In this study, we performed 16S rRNA amplicon sequencing analysis after sampling from floor, equipment surfaces, and raw materials for making fermentation starters, including koji, and water in Tsuchida Sake brewery, Gunma, Japan. Results: Amplicon sequence variants (ASVs) between the external environments and the fermentation starter were compared, and it was verified that the microorganisms in the external environments, such as built environments, equipment surfaces, and raw materials in the sake brewery, were introduced into the fermentation starter. Furthermore, various adventitious microbes present in the fermentation starter of early days and from the external environments were detected in a nonnegligible proportion in the starter, which may impact the taste and flavor. Discussion: These findings illuminate the uncharacterized microbial dark matter of sake brewing, the sources of microbes in Kimoto-style fermentation.

Incidence, Predictors, and Clinical Impact of the Impeded-By-Stent Phenomenon After Placing Two-Linked Design New Generation Drug-Eluting Stents.

BACKGROUND: When a catheter device is delivered during percutaneous coronary intervention, its passage can be disrupted by a deployed in a coronary artery. However, the condition and details of this phenomenon, that is impeded-by-stent phenomenon (ISP), remain unclear. METHODS: We designed a prospective, open-label, single-center, observational study to clarify the incidence, predictors, and clinical impact of ISP in drug-eluting stents (DESs). Two independent operators observed and judged the occurrence of ISP, which was defined as all disturbances to a device delivery by deployed DESs. We consecutively used the Ultimaster™ (Terumo, Tokyo, Japan) DES for one month (109 patients, October 2018), followed by the Synergy™ (Boston Scientific Corporation, Marlborough, MA, USA) DES the next month (119 patients, November 2018). RESULTS: DESs (2.5-4.0 mm in diameter) were implanted in 230 de novo coronary vessels. ISPs were observed in 17 of 239 stented segments (7.1 %). Multivariate analysis showed that bifurcation lesions (adjusted odds ratio [OR], 4.2; 95 % confidence interval [CI], 1.5-12.6; p = 0.008), predilatation balloon diameter (mm) (OR, 0.2; 95 % CI, 0.1-0.9; p = 0.03), and Ultimaster™ use (OR, 6.0; 95 % CI, 1.9-27.2; p = 0.002) were independent predictors of ISPs. During the 1.5-year follow-up period, no repeat revascularization or stent thrombosis occurred in patients with ISP. CONCLUSIONS: ISP itself does not trigger notable clinical outcomes, including repeat revascularization and stent thrombosis. However, caution should be considered regarding the latent risk of procedural complications.

A Cluster of Japanese Spotted Fever Cases Associated with Cemetery Visits in Wakayama City, Japan.

Japanese spotted fever (JSF) is a tick-borne rickettsiosis caused by Rickettsia japonica. Although the number of JSF cases has been increasing, exceeding 300 per year since 2017, clusters of cases are rare. Here, we report a cluster of seven JSF cases, the first nonfamilial cluster of the disease documented in the Japanese literature, and describe the management of the outbreak through prompt investigation and control-and-prevention measures performed collaboratively by members from the clinical, laboratory, and public health fields. All seven cases in the cluster had visited a cemetery in September or October of 2019. R. japonica was detected in whole-blood and/or skin samples from six patients and in the larvae of Haemaphysalis hystricis collected in a field survey. The evidence suggested that this cluster of cases was caused by the conjunction of two circumstances within a short period of time: an increase in the number of visitors to a cemetery during a Buddhist event and an increase in the number of infectious tick larvae in the cemetery through hatching (vertical transmission from infected females). Delays in the treatment of JSF can lead to severe manifestations. Early interventions through collaborative efforts among members from the clinical, laboratory, and public health fields are important for controlling outbreaks, raising the awareness of the public, and diagnosing and treating patients.