iPSC-Based Modeling of Variable Clinical Presentation in Hypertrophic Cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disease and a frequent cause of heart failure and sudden cardiac death. Our understanding of the genetic bases and pathogenic mechanisms underlying HCM has improved significantly in the recent past, but the combined effect of various pathogenic gene variants and the influence of genetic modifiers in disease manifestation are very poorly understood. Here, we set out to investigate genotype-phenotype relationships in 2 siblings with an extensive family history of HCM, both carrying a pathogenic truncating variant in the MYBPC3 gene (p.Lys600Asnfs*2), but who exhibited highly divergent clinical manifestations. METHODS: We used a combination of induced pluripotent stem cell (iPSC)-based disease modeling and CRISPR (clustered regularly interspersed short palindromic repeats)/Cas9 (CRISPR-associated protein 9)-mediated genome editing to generate patient-specific cardiomyocytes (iPSC-CMs) and isogenic controls lacking the pathogenic MYBPC3 variant. RESULTS: Mutant iPSC-CMs developed impaired mitochondrial bioenergetics, which was dependent on the presence of the mutation. Moreover, we could detect altered excitation-contraction coupling in iPSC-CMs from the severely affected individual. The pathogenic MYBPC3 variant was found to be necessary, but not sufficient, to induce iPSC-CM hyperexcitability, suggesting the presence of additional genetic modifiers. Whole-exome sequencing of the mutant carriers identified a variant of unknown significance in the MYH7 gene (p.Ile1927Phe) uniquely present in the individual with severe HCM. We finally assessed the pathogenicity of this variant of unknown significance by functionally evaluating iPSC-CMs after editing the variant. CONCLUSIONS: Our results indicate that the p.Ile1927Phe variant of unknown significance in MYH7 can be considered as a modifier of HCM expressivity when found in combination with truncating variants in MYBPC3. Overall, our studies show that iPSC-based modeling of clinically discordant subjects provides a unique platform to functionally assess the effect of genetic modifiers.

Intermediate-effect size p.Arg637Gln in FHOD3 increases risk of HCM and is associated with an aggressive phenotype in homozygous carriers.

Formin homology 2 domain-containing 3 (FHOD3) gene has emerged as one of the main non-sarcomeric genes associated with hypertrophic cardiomyopathy (HCM), but no cases of biallelic variants associated with disease have been described to date. From 2014 until 2021, FHOD3 was evaluated in our center by next-generation sequencing in 22 806 consecutive unrelated probands. The p.Arg637Gln variant in FHOD3 was enriched in our HCM cohort (284 of 9668 probands; 2.94%) compared with internal controls (64 of 11 480; 0.59%) and gnomAD controls (373 of 64 409; 0.58%), with ORs of 5.40 (95% CI: 4.11 to 7.09) and 5.19 (95% CI: 4.44 to 6.07). The variant affects a highly conserved residue localised in a supercoiled alpha helix considered a clustering site for HCM variants, and in heterozygosis can act as a predisposing factor (intermediate-effect variant) for HCM, with an estimated penetrance of around 1%. Additionally, seven homozygous carriers of p.Arg637Gln in FHOD3 were identified. All but one (unaffected) showed an early presentation and a severe HCM phenotype. All this information suggest that p.Arg637Gln variant in FHOD3 is a low-penetrant variant, with an intermediate effect, that contributes to the development of HCM in simple heterozygosis, being associated with a more severe phenotype in homozygous carriers.

Natural variation in Arabidopsis responses to Plasmodiophora brassicae reveals an essential role for Resistance to Plasmodiophora brasssicae 1 (RPB1).

Despite the identification of clubroot resistance genes in various Brassica crops our understanding of the genetic basis of immunity to Plasmodiophora brassicae infection in the model plant Arabidopsis thaliana remains limited. To address this issue, we performed a screen of 142 natural accessions and identified 11 clubroot-resistant Arabidopsis lines. Genome-wide association analysis identified several genetic loci significantly linked with resistance. Three genes from two of these loci were targeted for deletion by CRISPR/Cas9 mutation in resistant accessions Est-1 and Uod-1. Deletion of Resistance to Plasmodiophora brassicae 1 (RPB1) rendered both lines susceptible to the P. brassicae pathotype P1+. Further analysis of rpb1 knock-out Est-1 and Uod-1 lines showed that the RPB1 protein is required for activation of downstream defence responses, such as the expression of phytoalexin biosynthesis gene CYP71A13. RPB1 has recently been shown to encode a cation channel localised in the endoplasmic reticulum. The clubroot susceptible Arabidopsis accession Col-0 lacks a functional RPB1 gene; when Col-0 is transformed with RPB1 expression driven by its native promoter it is capable of activating RPB1 transcription in response to infection, but this is not sufficient to confer resistance. Transient expression of RPB1 in Nicotiana tabacum induced programmed cell death in leaves. We conclude that RPB1 is a critical component of the defence response to P. brassicae infection in Arabidopsis, acting downstream of pathogen recognition but required for the elaboration of effective resistance.

Double somatic mosaicism in Marfan syndrome.

Marfan syndrome (MFS) is a hereditary systemic connective tissue disorder with great clinical variability. It is caused by heterozygous pathogenic variants in the FBN1 gene. Cardinal manifestations involve the cardiovascular, ocular, and skeletal systems. Clinical diagnosis is based on the revised Ghent nosology. We present the case of a child with a Marfan systemic score of 9 whose genetic study revealed two pathogenic mosaic frameshift variants in the FBN1 gene. Mosaicism is very rare in patients diagnosed with MFS, and this is the first description of a patient with two pathogenic mosaic variants in the FBN1 gene. Both variants are present in cells derived from ectodermal (buccal swab) and mesodermal (leukocyte) tissues, suggesting a mutation prior to gastrulation. We propose a defective repair of the de novo variant in the complementary strand as the mechanism that led this individual to be a carrier of two different populations of mutant cells carrying adjacent variants.

EBUS-TBNA for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer clinically staged with PET/CT.

BACKGROUND AND OBJECTIVE: To evaluate the diagnostic accuracy and clinical usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer (NSCLC) clinically staged with positron emission tomography/computed tomography (PET/CT). METHODS: We conducted a study that included patients with centrally located T1N0M0 NSCLC, clinically staged with PET/CT who underwent EBUS-TBNA for mediastinal staging. Patients with negative EBUS-TBNA underwent mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy (VAMLA) and/or lung resection with systematic nodal dissection, that were considered the gold standard. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), overall accuracy of EBUS-TBNA for diagnosing mediastinal metastases (N2 disease) and the number needed to treat (NNT: number of patients needed to undergo EBUS-TBNA to avoid a case of pathologic N2 disease after resection) were calculated. RESULTS: One-hundred eighteen patients were included. EBUS-TBNA proved N2 disease in four patients. In the remaining 114 patients who underwent mediastinoscopy, VAMLA and/or resection there were two cases of N2 (N2 prevalence 5.1%). The sensitivity, specificity, NPV, PPV and overall accuracy for diagnosing mediastinal metastases (N2 disease) were of 66%, 100%, 98%, 100% and 98%, respectively. The NNT was 31 (95% CI: 15-119). CONCLUSION: EBUS-TBNA in patients with central clinically staged T1N0M0 NSCLC presents a good diagnostic accuracy for mediastinal staging, even in a population with low prevalence of N2 disease. Therefore, its indication should be considered in the management of even these early lung cancers.

Altered amino acid profile in patients with SARS-CoV-2 infection.

Low plasma arginine bioavailability has been implicated in endothelial dysfunction and immune dysregulation. The role of arginine in COVID-19 is unknown, but could contribute to cellular damage if low. Our objective was to determine arginine bioavailability in adults and children with COVID-19 vs. healthy controls. We hypothesized that arginine bioavailability would be low in patients with COVID-19 and multisystem inflammatory syndrome in children (MIS-C). We conducted a prospective observational study of three patient cohorts; arginine bioavailability was determined in asymptomatic healthy controls, adults hospitalized with COVID-19, and hospitalized children/adolescents <21 y old with COVID-19, MIS-C, or asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection identified on admission screen. Mean patient plasma amino acids were compared to controls using the Student's t test. Arginine-to-ornithine ratio, a biomarker of arginase activity, and global arginine bioavailability ratio (GABR, arginine/[ornithine+citrulline]) were assessed in all three groups. A total of 80 patients were included (28 controls, 32 adults with COVID-19, and 20 pediatric patients with COVID-19/MIS-C). Mean plasma arginine and arginine bioavailability ratios were lower among adult and pediatric patients with COVID-19/MIS-C compared to controls. There was no difference between arginine bioavailability in children with COVID-19 vs. MIS-C. Adults and children with COVID-19 and MIS-C in our cohort had low arginine bioavailability compared to healthy adult controls. This may contribute to immune dysregulation and endothelial dysfunction in COVID-19. Low arginine-to-ornithine ratio in patients with COVID-19 or MIS-C suggests an elevation of arginase activity. Further study is merited to explore the role of arginine dysregulation in COVID-19.

Cardiac myosin binding protein-C variants in paediatric-onset hypertrophic cardiomyopathy: natural history and clinical outcomes.

BACKGROUND: Variants in the cardiac myosin-binding protein C gene (MYBPC3) are a common cause of hypertrophic cardiomyopathy (HCM) in adults and have been associated with late-onset disease, but there are limited data on their role in paediatric-onset HCM. The objective of this study was to describe natural history and clinical outcomes in a large cohort of children with HCM and pathogenic/likely pathogenic (P/LP) MYBPC3 variants. METHODS AND RESULTS: Longitudinal data from 62 consecutive patients diagnosed with HCM under 18 years of age and carrying at least one P/LP MYBPC3 variant were collected from a single specialist referral centre. The primary patient outcome was a major adverse cardiac event (MACE). Median age at diagnosis was 10 (IQR: 2-14) years, with 12 patients (19.4%) diagnosed in infancy. Forty-seven (75%) were boy and 31 (50%) were probands. Median length of follow-up was 3.1 (IQR: 1.6-6.9) years. Nine patients (14.5%) experienced an MACE during follow-up and five (8%) died. Twenty patients (32.3%) had evidence of ventricular arrhythmia, including 6 patients (9.7%) presenting with out-of-hospital cardiac arrest. Five-year freedom from MACE for those with a single or two MYBPC3 variants was 95.2% (95% CI: 78.6% to 98.5%) and 68.4% (95% CI: 40.6% to 88.9%), respectively (HR 4.65, 95% CI: 1.16 to 18.66, p=0.03). CONCLUSIONS: MYBPC3 variants can cause childhood-onset disease, which is frequently associated with life-threatening ventricular arrhythmia. Clinical outcomes in this cohort vary substantially from aetiologically and genetically mixed paediatric HCM cohorts described previously, highlighting the importance of identifying specific genetic subtypes for clinical management of childhood HCM.

RXam2, a NLR from cassava (Manihot esculenta) contributes partially to the quantitative resistance to Xanthomonas phaseoli pv. manihotis.

KEY MESSAGE: The overexpression of RXam2, a cassava NLR (nucleotide-binding leucine-rich repeat) gene, by stable transformation and gene expression induction mediated by dTALEs, reduce cassava bacterial blight symptoms. Cassava (Manihot esculenta) is a tropical root crop affected by different pathogens including Xanthomonas phaseoli pv. manihotis (Xpm), the causal agent of cassava bacterial blight (CBB). Previous studies have reported resistance to CBB as a quantitative and polygenic character. This study sought to validate the functional role of a NLR (nucleotide-binding leucine-rich repeat) associated with a QTL to Xpm strain CIO151 called RXam2. Transgenic cassava plants overexpressing RXam2 were generated and analyzed. Plants overexpressing RXam2 showed a reduction in bacterial growth to Xpm strains CIO151, 232 and 226. In addition, designer TALEs (dTALEs) were developed to specifically bind to the RXam2 promoter region. The Xpm strain transformed with dTALEs allowed the induction of the RXam2 gene expression after inoculation in cassava plants and was associated with a diminution in CBB symptoms. These findings suggest that RXam2 contributes to the understanding of the molecular basis of quantitative disease resistance.

Alpha-protein kinase 3 (ALPK3) truncating variants are a cause of autosomal dominant hypertrophic cardiomyopathy.

AIMS: The aim of this study was to determine the frequency of heterozygous truncating ALPK3 variants (ALPK3tv) in patients with hypertrophic cardiomyopathy (HCM) and confirm their pathogenicity using burden testing in independent cohorts and family co-segregation studies. METHODS AND RESULTS: In a discovery cohort of 770 index patients with HCM, 12 (1.56%) were heterozygous for ALPK3tv [odds ratio(OR) 16.11, 95% confidence interval (CI) 7.94-30.02, P = 8.05e-11] compared to the Genome Aggregation Database (gnomAD) population. In a validation cohort of 2047 HCM probands, 32 (1.56%) carried heterozygous ALPK3tv (OR 16.17, 95% CI 10.31-24.87, P < 2.2e-16, compared to gnomAD). Combined logarithm of odds score in seven families with ALPK3tv was 2.99. In comparison with a cohort of genotyped patients with HCM (n = 1679) with and without pathogenic sarcomere gene variants (SP+ and SP-), ALPK3tv carriers had a higher prevalence of apical/concentric patterns of hypertrophy (60%, P < 0.001) and of a short PR interval (10%, P = 0.009). Age at diagnosis and maximum left ventricular wall thickness were similar to SP- and left ventricular systolic impairment (6%) and non-sustained ventricular tachycardia (31%) at baseline similar to SP+. After 5.3 ± 5.7 years, 4 (9%) patients with ALPK3tv died of heart failure or had cardiac transplantation (log-rank P = 0.012 vs. SP- and P = 0.425 vs. SP+). Imaging and histopathology showed extensive myocardial fibrosis and myocyte vacuolation. CONCLUSIONS: Heterozygous ALPK3tv are pathogenic and segregate with a characteristic HCM phenotype.

Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infection can cause alterations in the coagulation mechanism conditioning thrombotic phenomena such as acute limb ischemia (ALI) as the only manifestation of the infection. The aim of the study was to describe clinical and surgical characteristics of a group of patients infected with severe acute respiratory syndrome coronavirus 2 who presented ALI in the context of the COVID-19 pandemic at Lima, Peru. METHODS: A multicenter, observational, and retrospective study was performed in six general hospitals, from March to July 2020. The variables considered were the pathological history and associated habits, laboratory tests, the severity of COVID-19 infection and ALI, the anatomic location of the lesion, treatment, evolution, and discharge conditions. RESULTS: Thirty patients with ALI infected with COVID-19 were evaluated. Their mean age was 60 ± 15 years, the condition being more frequent in men (76.6%). The main comorbidities were arterial hypertension (33.3%), obesity (33.3%), and diabetes mellitus 2 (26.6%). There were 23.3% asymptomatic patients, and their only manifestation was ALI. Rutherford IIA and IIB stage included 93.2% of patients. The most frequent location of the thrombosis was the lower limbs (73.3% vs. 26.6%). Thrombectomy was performed in 76.6% of the patients, and amputation (primary and secondary) was performed in 30% of the patients. The mortality rate was 23.3%, all of it because of acute respiratory distress syndrome. CONCLUSIONS: ALI is a vascular pathology associated with embolic and thrombotic processes. COVID-19 infection can cause severe alterations in coagulation mechanisms, leading some patients to present severe acute arterial complications such as thrombosis, as the only associated manifestation. We report a younger cohort than those described in other studies and with a high frequency of amputations despite adequate surgical treatment.

Medical recommender systems based on continuous-valued logic and multi-criteria decision operators, using interpretable neural networks.

BACKGROUND: Out of the pressure of Digital Transformation, the major industrial domains are using advanced and efficient digital technologies to implement processes that are applied on a daily basis. Unfortunately, this still does not happen in the same way in the medical domain. For this reason, doctors usually do not have the time or knowledge to evaluate all alternative treatment options for each patient accurately and individually. However, physicians can reduce their workload by using recommender systems, still having every decision under control. In this way, they also get an insight into how other physicians make treatment decisions in each situation. In this work, we report the development of a novel recommender system that uses predicted outcomes based on continuous-valued logic and multi-criteria decision operators. The advantage of this methodology is that it is transparent, since the model outcomes emulate logical decision processes based on the hierarchy of relevant physiological parameters, and second, it is safer against adversarial attacks than conventional deep learning methods since it drastically reduces the number of trainable parameters. METHODS: We test our methodology in a patient population with diabetes and heart insufficiency that becomes a therapy (beta-blockers, ACE or Aspirin). The original database (Pakistan database) is publicly available and accessible via the internet. However, to explore methods to protect the patient's identity and guarantee data privacy we implemented a methodology on a variable-by-variable basis by fitting a sequence of regression models and drawing synthetic values from the corresponding predictive distributions using linear regressions and norm rank. Furthermore, we implemented a deep-learning model based on logical gates modeled by perceptrons with fixed weights and biases. While a first trainable layer automatically recognizes a meaningful parameter hierarchy, the implemented Logic-Operator Neuronal Network (LONN) simulates cognitive processes like a rational, logical thinking process, considering that this logic is joined by fuzziness, i.e., logical operations are not exact but essentially fuzzy due to the implemented continuous-valued operators. The predicted outcomes of the model (kind of therapy-ACE, Aspirin or beta-blocker- and expected therapy time of the patient) are then implemented in a recommender system that compares two different models: model 1 trained on a population excluding negative outcomes (patient group 1, with no patient dead and long therapy times) and a model 2 trained on the whole patient population (patient group 2). In this way, we provide a recommendation of the best possible therapy based on the outcome of the model and the confidence of this recommendation when the outcome of model 1 is compared with the outcome of model 2. RESULTS: With the applied method for data synthetization, we obtained an error of about 1% for all the relevant parameters. Furthermore, we demonstrate that the LONN models reach an accuracy of about 75%. After comparing the LONN models against conventional deep-learning models we observe that our implemented models are less accurate (accuracy loss of about 8%). However, the loss of accuracy is compensated by the fact that LONN models are transparent and safe because the freezing of training parameters makes them less prone to adversarial attacks. Finally, we predict the best therapy as well as the expected therapy time. We were able to predict individualized therapies, which were classified as optimal (binary value) when the prediction fully matched predictions made with models 1 and 2. The results provided by the recommender system are displayed using a graphical interface. The current is a proof of concept to improve the quality of the disease management, while the methods are continuously visualized to preserve transparency for the customers. CONCLUSIONS: This work contributes to simplify administrative functions and boost the quality of management of patients improving the quality of healthcare with models that are both transparent and safe. Our methodology can be extended to different clinical scenarios where recommender systems can be applied. The acceptance and further development of the app is one of the next important steps and still requires further development depending on specific requirements of the health management, the physicians or health professionals, and the patent population.

Yield of Clinical Screening for Hypertrophic Cardiomyopathy in Child First-Degree Relatives.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is a heritable myocardial disease with age-related penetrance. Current guidelines recommend clinical screening of relatives beginning at 10 years of age, but the clinical value of this approach has not been systematically evaluated. METHODS: Anonymized clinical data were collected from children referred for family screening between 1994 and 2017 after diagnosis of HCM in a first-degree relative. RESULTS: Of 1198 consecutive children (≤18 years of age) from 594 families who underwent serial evaluation (median, 3.5 years; interquartile range, 1.2-7), 32 individuals met diagnostic criteria at baseline (median maximal left ventricular wall thickness, 13 mm; interquartile range, 8-21 mm), and 25 additional patients developed HCM during follow-up. Median age at diagnosis was 10 years (interquartile range, 4-13 years); 44 (72%) were ≤12 years of age. Median age of affected patients at the last follow-up was 14 years (interquartile range, 9.5-18.2 years). A family history of childhood HCM was more common in those patients diagnosed with HCM (n=32 [56%] versus n=257 [23%]; P<0.001). Eighteen patients (32%) were started on medication for symptoms; 2 (4%) underwent a septal myectomy; 14 (25%) received an implantable cardioverter-defibrillator; 1 underwent cardiac transplantation; 2 had a resuscitated cardiac arrest; and 1 died after a cerebrovascular accident. CONCLUSIONS: Almost 5% of first-degree child relatives undergoing screening meet diagnostic criteria for HCM at first or subsequent evaluations, with the majority presenting as preadolescents; a diagnosis in a child first-degree relative is made in 8% of families screened. The phenotype of familial HCM in childhood is varied and includes severe disease, suggesting that clinical screening should begin at a younger age.

Comparison of immediate colposcopy, repeat conventional cytology and hrHPV testing for the clinical management of ASC-US cytology in routine health services of Medellin, Colombia: The ASCUS-COL Trial.

In the context of opportunistic cervical cancer screening settings of low-and-middle-income countries, little is known about the benefits of high-risk human papillomavirus (hrHPV) testing on high-grade cervical abnormality detection among women with atypical squamous cells of undetermined significance (ASC-US) cytology in routine clinical practice. We compared the effectiveness of immediate colposcopy (IC), conventional cytology at 6 and 12 months (colposcopy if ≥ASC-US) (RC), and hrHPV testing (colposcopy if hrHPV-positive) (HPV) to detect cervical intraepithelial neoplasia grade 2 or more severe diagnoses (CIN2+) among women aged 20-69 years with ASC-US in routine care. Participants (n=2,661) were evenly randomized into three arms (n=882 IC, n=890 RC, n=889 HPV) to receive services by routine healthcare providers and invited to an exit visit 24 months after recruitment. Histopathology was blindly reviewed by a quality-control external panel (QC). The primary endpoint was the first QC-diagnosed CIN2+ or CIN3+ detected during three periods: enrolment (≤6 months for IC and HPV, ≤12 months for RC), follow-up (between enrolment and exit visit), and exit visit. The trial is completed. Colposcopy was done on 88%, 42%, and 52% of participants in IC, RC, and HPV. Overall, 212 CIN2+ and 52 CIN3+ cases were diagnosed. No differences were observed for CIN2+ detection (p=0.821). However, compared to IC, only HPV significantly reduced CIN3+ cases that providers were unable to detect during the 2-year routine follow-up (relative proportion 0.35, 95% CI 0.09-0.87). In this context, hrHPV testing was the most effective and efficient management strategy for women with ASC-US cytology.

Deletions of specific exons of FHOD3 detected by next-generation sequencing are associated with hypertrophic cardiomyopathy.

Despite new strategies, such as evaluating deep intronic variants and new genes in whole-genome-sequencing studies, the diagnostic yield of genetic testing in hypertrophic cardiomyopathy (HCM) is still around 50%. FHOD3 has emerged as a novel disease-causing gene for this phenotype, but the relevance and clinical implication of copy-number variations (CNVs) have not been determined. In this study, CNVs were evaluated using a comparative depth-of-coverage strategy by next-generation sequencing (NGS) in 5493 HCM probands and 2973 disease-controls. We detected three symmetrical deletions in FHOD3 that involved exons 15 and 16 in three HCM families (no CNVs were detected in the control group). These exons are part of the diaphanous inhibitory domain of FHOD3 protein, considered a cluster of mutations for HCM. The clinical characteristics of the affected carriers were consistent with those reported in FHOD3 in previous studies. This study highlights the importance of performing CNV analysis systematically in NGS genetic testing panels for HCM, and reinforces the relevance of the FHOD3 gene in the disease.

Pharyngeal dysesthesias as aura in epilepsy localized to the non-dominant frontal operculum misdiagnosed as non-epileptic seizures.

The diagnosis of atypical paroxysmal events represents a significant challenge for clinicians when differentiating epileptic from nonepileptic events. The ictal manifestations of pharyngeal dysesthesias are often misdiagnosed and difficult to distinguish clinically, given their subtle features such as pharyngeal discomfort with and without autonomic symptomology. We report a rare case of isolated ictal pharyngeal dysesthesias localizing to the non-dominant frontal operculum lobe misdiagnosed as psychogenic and later confirmed by continuous video-EEG monitoring.

Behavioral implications of temporal lobe epilepsy on social contingency.

OBJECTIVE: Temporal lobe epilepsy (TLE) is a chronic condition classically characterized by recurrent unprovoked episodes of involuntary violent motion and behavior whose degree and nature often overshadow the more subtle interictal neuropsychiatric symptoms. The purpose of this research was to investigate further the nature of cognitive impairment seen in social interaction within the population with TLE. METHODS: We recorded the dynamics of real-time sensorimotor interaction in 10 pairs of control participants and ten pairs of participants with drug-resistantTLE using a minimalistic human-computer interface paradigm known as "perceptual crossing." We investigated whether TLE is associated with impaired detection of social contingency, i.e.,reduced sensitivity to their teammate's responsiveness to their behavior. RESULTS: Our analysis reveals that using a simplified, computer-mediated, embodied form of social interaction, people with TLE demonstrated a statistically significant decrease in identification accuracy ratio (p-value is 0.00084,p < 0.05), a decrease in turn-taking (p-value is 0.03216,p < 0.05), decrease in player-object discrimination specificity (p-value is 0.00695,p < 0.05), and a decrease time spend in contact both in absolute terms (p-value is 0.00181, p < 0.05) and as a percentage of time after first contact (p-value is 0.0268, p < 0.05) when compared with age-gender-matched controls. DISCUSSION: We found that coregulated interactions differed significantly between subjects with drug-resistantTLE and age-gender-matched controls consistent with prior meta-analysis observations regarding social cognition impairment in TLE. This is the first study to demonstrate social contingency impairment through dyadic interaction in the population with TLE.

Drinking water improvements and rates of urinary and gastrointestinal infections in Galápagos, Ecuador: Assessing household and community factors.

OBJECTIVES: The Galápagos provides an important setting to investigate the health impacts of a new drinking water treatment plant (DWTP) in a limited resource environment. We examine how household perceptions and practices affect the relationship between water quality and infections before and after DWTP. METHODS: Ethnographic data and self-reported infections were collected from 121 mothers and 168 children ages 2 to 10 from Isla San Cristóbal. Household tap water samples were tested for levels of fecal contamination. Community level infection rates were estimated using discharge records from the Ministry of Public Health. The effects of the new DWTP and fecal contamination levels on infections were tested using logistic and Poisson models. RESULTS: Perceptions of water quality and household practices influenced exposures to contaminated tap water. We found minimal change in drinking water sources with 85% of mothers sampled before the DWTP and 83% sampled after using bottled water, while >85% from the pooled sample used tap water for cooking and hygiene practices. The DWTP opening was associated with lower odds of fecal contamination in tap water, reported urinary infections, and community level rates of urinary and gastrointestinal infections. The household practice of recently washing the cistern contributed to higher contamination levels after the DWTP opened. CONCLUSIONS: To ensure access to clean water, public health works need to consider how household perceptions and practices influence tap water use and quality, in addition to infrastructure improvements. Exposures to contaminated tap water contribute to the burden of infectious disease in environments with inadequate water infrastructure.

First detection of leaf blight and stem canker caused by Phytophthora ramorum on Brisbane box in the United States.

Brisbane box,Lophostemon confertus (Myrtaceae) is a frost tender evergreen tree planted for its upright form, large ovate leaves and attractive white flowers which bloom in the spring. In June of 2017, the Plant Pest Diagnostics Center lab received a call from an arborist who described Brisbane box street trees dying in central Sausalito, Marin Co., California. Trees ranged from containing 10% to nearly 80% dead hanging leaves. Six trees along the same street were affected. Wilted brown leaves remained attached to branchlets covered in black cankers. Some healthy branchlets had leaves with angular spots which crossed the veins and were surrounded by yellow halos. Isolations were made onto CMA-PARP (Jeffers and Martin, 1986) from the canker and leaf spot margins. A Phytophthora species resemblingPhytophthora ramorum grew on CMA-PARP media with coralloid coenocytic hyphae, chlamydospores, and ellipsoidal semi-papillate sporangia. The internal transcribed spacer region (ITS) of rDNA was amplified and sequenced using primers PHY.OO.18F and PHY.OO.28SR (Rooney-Latham, et al. 2019). BLAST analysis of 770 base pairs of the sequenced amplicon (GenBank MK993541) showed 100% identity with the ITS sequence of the P. ramorum ex-type (MG865581). A portion of the cox2 gene was amplified and sequenced (Hudspeth et al. 2000) (GenBank MK994528) and 530 base pairs matched with 100% identity GU222130. Pathogenicity was confirmed by inoculating 3, initially 1.8-meter-tall trees in 18.9-liter pots. Prior to inoculations, trees were cut so they would fit into 122 cm high dew and growth chambers. For each tree, 3 lower branchlets measuring from 4 to10 mm in diameter were inoculated by wounding with a 6 mm punch, placing a colonized agar plugs in the wound, then wrapping with Parafilm. Lower branches were covered in plastic to protect them from subsequent zoospore inoculation. Branchlet inoculum was prepared by growing P. ramorum on V8 juice agar (V8) for 4 days at 22°C. Zoospores were prepared for leaf inoculation by taking 6 mm agar plugs from the margin of 6-day old cultures and flooding plugs in soil water for four days. Zoospores were released by transferring plugs to sterile distilled water at 4°C for 1.5 h. Leaves on the same three trees that were inoculated with the plugs were sprayed with 350 mL of zoospores (2 × 105 zoospores/mL), and placed in a dew chamber at 23°C for 48 h. Afterwards, they were transferred to a growth chamber (23°C, 12-h diurnal cycle) where the plastic was removed from the lower branches after leaves had dried. A single control tree was treated similarly with uncolonized V8 plugs, followed by a water spray. Leaf spots were visible 4 days later, with inoculated leaves turning necrotic and abscising after 3 weeks. Cankers from inoculated branchlets measured from 12 to 60 mm long after 60 days. Phytophthora ramorum was isolated from the margin of every inoculated canker and leaf spot. No P. ramorum was isolated from the control tree. To our knowledge, this is the first report of P. ramorum on L. confertus, in the world. Natural inoculum presumably came from infected Umbellularia californica trees located less than 800 m west of the trees in Sausalito. This detection will further limit the planting choices of arborists and landscapers in P. ramorum infected locations.

Predicting state transitions in brain dynamics through spectral difference of phase-space graphs.

Networks are naturally occurring phenomena that are studied across many disciplines. The topological features of a network can provide insight into the dynamics of a system as it evolves, and can be used to predict changes in state. The brain is a complex network whose temporal and spatial behavior can be measured using electroencephalography (EEG). This data can be reconstructed to form a family of graphs that represent the state of the brain over time, and the evolution of these graphs can be used to predict changes in brain states, such as the transition from preictal to ictal in patients with epilepsy. This research proposes objective indications of seizure onset observed from minimally invasive scalp EEG. The approach considers the brain as a complex nonlinear dynamical system whose state can be derived through time-delay embedding of the EEG data and characterized to determine change in brain dynamics related to the preictal state. This method targets phase-space graph spectra as biomarkers for seizure prediction, correlates historical degrees of change in spectra, and makes accurate prediction of seizure onset. A significant trend of normalized dissimilarity over time indicates a departure from the norm, and thus a change in state. Our methods show high sensitivity (90-100%) and specificity (90%) on 241 h of scalp EEG training data, and sensitivity and specificity of 70%-90% on test data. Moreover, the algorithm was capable of processing 12.7 min of data per second on an Intel Core i3 CPU in Matlab, showing that real-time analysis is viable.