Measurement-based care training curriculum in psychiatry residency programs: I: Description of the curriculum and demonstration of implementation.

BACKGROUND: Recent literature shows that most practicing psychiatrists do not receive training in measurement-based care (MBC). Among the primary barriers to MBC implementation are the lack of formal training and curriculums. We present the first comprehensive MBC curriculum for use in adult psychiatric practice, and describe how the curriculum is adapted and implemented in psychiatry residency training programs. METHODS: The Standard for Clinicians' Interview in Psychiatry (SCIP) was developed as a measurement-based care tool for clinicians' use. The SCIP is the only instrument that includes 18 reliable and validated clinician-rated scales covering most adult psychiatric disorders. The SCIP has simple, unified rules of measurement that apply to the 18 scales. The MBC curriculum includes 2 instruction manuals, 4 didactic lectures, and 12 videotaped interviews. We describe the annual learning and implementation of MBC curriculum in residency programs. RESULTS: The curriculum implementation at West Virginia University and Delaware Psychiatric Center began in 2019 and is ongoing. We present 3 case demonstrations of the implementation of MBC in clinical settings. CONCLUSIONS: Comprehensive implementation of MBC curriculum in residency programs has the potential to facilitate research and create a "culture" of MBC in future generations of psychiatrists.

Maternal and Child Health Nutrition Faculty and Trainees Work Collaboratively with Community Partners to Assess Afterschool Nutrition Environments.

Purpose The purpose of this paper is to describe a collaborative service learning experience (SLE) which was part of the degree requirements of the Public Health Nutrition Graduate Program at the University of Tennessee. The SLE was collaboratively developed by the University of Tennessee's maternal and child health (MCH) nutrition leadership education and training (NLET) Program Director and the Knox County Health Department's healthy weight program manager. Description The SLE was a semester long project that included instructional time and fieldwork. Coursework focused on development of a community nutrition needs assessment, how to interpret and analyze assessment data, and how to use assessment data for program planning and policy development. Fieldwork consisted of interacting with an interprofessional team, assessing the nutrition environment at two afterschool sites, conducting a plate waste study to determine the amount of food consumed by children at the sites' dinner meals, interpreting and analyzing data, and developing and presenting recommendations for improvement. Assessment Trainees successfully completed all aspects of the SLE. They completed a community needs assessment of the neighborhoods surrounding the two afterschool program sites, conducted nutrition environment audits, including meal observations, and measured and analyzed plate waste from dinner meals served at the sites. Using the data gathered and collected, they prepared suggestions for nutrition environment improvements and policy development for community partners. Conclusion The SLE allowed trainees to develop MCH competencies and professional skills required in public health nutrition, while providing valuable data that subsequently was used to establish nutrition-related policies and interventions.

Cochlear labyrinth volume in Krapina Neandertals.

Research with extant primate taxa suggests that cochlear labyrinth volume is functionally related to the range of audible frequencies. Specifically, cochlear volume is negatively correlated with both the high and low frequency limits of hearing so that the smaller the cochlea, the higher the normal range of audible frequencies. The close anatomical relationship between the membranous cochlea and the bony cochlear labyrinth allows for the determination of cochlear size from fossil specimens. This study compares Krapina Neandertal cochlear volumes to extant taxa cochlear volumes. Cochlear volumes were acquired from high-resolution computed tomography scans of temporal bones of Krapina Neandertals, chimpanzees, gorillas, and modern humans. We find that Krapina Neandertals' cochlear volumes are similar to modern Homo sapiens and are significantly larger than chimpanzee and gorilla cochlear volumes. The measured cochlear volume in Krapina Neandertals suggests they had a range of audible frequencies similar to the modern human range.

Physical therapists' treatment choices for non-specific low back pain in Florida: an electronic survey.

OBJECTIVES: No study has described low back pain (LBP) treatment choices among physical therapists (PTs) in the United States (US) in the new millennium. Intervention for LBP in the new millennium is largely based on evidence-based practice (EBP) recommendations. The purpose of this study was twofold: (a) to describe PTs' preferences for treating acute and subacute non-specific LBP in Florida and to compare these preferences to EBP guideline recommendations and (b) to compare outpatient musculoskeletal therapist (MSPT) choices for management of acute and subacute LBP to non-outpatient musculoskeletal therapist (NMSPT) choices. METHODS: The data were collected with an electronic survey. Study participants selected treatment choices for acute and subacute LBP clinical vignettes. RESULTS: A total of 327 PTs participated in the study, of which 128 worked in outpatient musculoskeletal settings. The most common treatment choices for acute and subacute LBP were home exercise program, exercise in the clinic, back care education, joint mobilization, ice/heat, and interferential current. The EBP adherence rate for acute LBP was 30% for MSPTs and 15% for NMSPTs. Thirty-seven percent (37%) of MSPTs and 30% of NMSPTs adhered to EBP guidelines for subacute LBP. DISCUSSION: The EBP adherence rate for management of acute and subacute LBP was low. Spinal manipulation was underutilized for management of acute LBP, and passive therapeutic procedures were overutilized for subacute LBP. Physical Therapy schools and professional associations should reemphasize the benefits of spinal manipulation to manage non-specific acute LBP and active interventional procedures to manage subacute LBP.

Brief communication: Investigation of the semicircular canal variation in the Krapina Neandertals.

Previous studies comparing bony labyrinth morphology in geographically-dispersed samples of Neandertals and modern Homo sapiens (H. sapiens) showed that Neandertals generally have smaller semicircular canals than modern H. sapiens (Hublin et al., ; Spoor et al., ; Glantz et al., ). Here we analyze the morphology of a single group of Neandertal specimens from one locale, the Krapina site, to determine the intraspecific variation in Neandertal semicircular canal sizes. Dimensions of the semicircular canals were collected from computed tomography scans of nine temporal bones. With the rare exception, the dimensions of the semicircular canals in the Krapina sample are similar to those previously reported across a geographically-dispersed sample of Neandertals, further supporting previous studies that suggest low levels of variation in the semicircular canals for Neandertals.

Overcoming language barriers in community-based research with refugee and migrant populations: options for using bilingual workers.

BACKGROUND: Although the challenges of working with culturally and linguistically diverse groups can lead to the exclusion of some communities from research studies, cost effective strategies to encourage access and promote cross-cultural linkages between researchers and ethnic minority participants are essential to ensure their views are heard and their health needs identified. Using bilingual research assistants is one means to achieve this. In a study exploring alcohol and other drug service use by migrant women in Western Australia, bilingual workers were used to assist with participant recruitment and administration of a survey to 268 women who spoke more than 40 different languages. DISCUSSION: Professional interpreters, bilingual students, bilingual overseas-trained health professionals and community sector bilingual workers were used throughout the research project. For the initial qualitative phase, professional interpreters were used to conduct interviews and focus group sessions, however scheduling conflicts, inflexibility, their inability to help with recruitment and the expense prompted exploration of alternative options for interview interpreting in the quantitative component of the study. Bilingual mature-age students on work placement and overseas-trained health professionals provided good entry into their different community networks and successfully recruited and interviewed participants, often in languages with limited interpreter access. Although both groups required training and supervision, overseas-trained health professionals often had existing research skills, as well as understanding of key issues such as confidentiality and referral processes. Strategies to minimise social desirability bias and the need to set boundaries were discussed during regular debriefing sessions. Having a number of workers recruiting participants also helped minimise the potential for selection bias. The practical and educational experience gained by the bilingual workers was regarded as capacity building and a potentially valuable community resource for future health research projects. SUMMARY: The use of bilingual workers was key to the feasibility and success of the project. The most successful outcomes occurred with students and overseas-trained health professionals who had good community networks for recruitment and the required linguistic skills. By describing the advantages and disadvantages encountered when working with bilingual workers, we offer practical insights to assist other researchers working with linguistically diverse groups.

Application of the Staged Approach for Rehabilitation Classification System and Associated Improvements in Patient-Reported Outcomes Following Rehabilitation for Shoulder Pain.

OBJECTIVE: The Staged Approach for Rehabilitation Classification for the Shoulder (STAR-Shoulder) has been proposed as a model to guide management and improve outcomes for patients with shoulder pain; however, the effect of its utilization on patient outcomes has not been established. Therefore, the primary purpose of this study was to determine whether patient outcomes were improved if care was matched to the STAR-Shoulder system compared with unmatched care. METHODS: Collected and reviewed demographic, examination, and intervention data for all patients receiving physical therapist treatment for shoulder pain during a 1-year period within a single health care system. Outcome variables included the numeric pain rating scale, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the number of visits. Clinical records from patients receiving care at the discretion of the therapist were systematically audited to determine whether care provided was considered matched or unmatched. RESULTS: A total of 692 patient records were examined. The interrater reliability of classifying care as matched or unmatched was substantial (κ = 0.6; 95% CI = 0.4 to 0.9), with 82% agreement. Changes in patient outcome scores were significantly better for those patients whose care matched the STAR-Shoulder system for pain changes (mean difference = -1.2; 95% CI = 0.8 to 1.6; effect size [d] = 0.5) and QuickDASH score (mean difference = 12.7; 95% CI = 9.9 to 15.5; d = 0.7). No difference was noted for number of visits. CONCLUSION: The STAR-Shoulder system appears to be a meaningful way to classify patients and guide intervention to improve patient outcomes. IMPACT: Application of the STAR-Shoulder system to help align physical therapist interventions more closely with tissue irritability and physical impairments appears to improve patient outcomes. These findings support this model as a promising approach to advance evidence-based practice for shoulder pain.

Changes in Acute Care Pharmacist Prescribing and Laboratory Ordering over Time: CAPLET Study.

Background: In Alberta, pharmacists may obtain additional prescribing authorization (APA) and a practice identification number (PRAC-ID) for ordering laboratory tests. Pharmacists working within Alberta Health Services were mandated by the employer to attain APA by 2018, whereas laboratory ordering has been in place since 2009. Five acute care sites within the Calgary Zone had a computerized provider order entry (CPOE) system that allowed tracking of these activities. Objectives: To describe changes in prescribing and laboratory ordering by acute care pharmacists over time and to compare these activities across hospitals, sites, and specialty teams. Methods: A retrospective, descriptive review of acute care pharmacist orders for medications and laboratory tests was completed using data from the CPOE system for the period 2018 to 2021. Results: Over the study period, the rates of prescribing and laboratory ordering by pharmacists increased by 67.5% (from 1423 to 2383 per full-time equivalent [FTE]) and by 5.5% (from 235 to 248 per FTE), respectively. Pharmacists at the 5 hospitals increased their prescribing rates during that time (by proportions ranging from 7% to 176%). Cardiology, intensive care, and mental health teams had the largest increases in prescribing rates, whereas mental health, hospitalist, and intensive care teams had the greatest increases in rates of laboratory ordering. In each year of the study, the most frequently ordered medication for adult patients was vancomycin, and the most frequently ordered laboratory test was measurement of vancomycin before dose administration. The proportion of medication orders conveyed verbally decreased from 60.0% to 47.4% over the study period. Conclusions: The application of expanded scope of practice increased among acute care pharmacists, to a greater extent for prescribing than for laboratory ordering; however, the proportion of verbal medication orders remains high, a situation that should be addressed to improve patient safety. This study showed that prescribing and laboratory ordering are complementary, given that the top medications and laboratory tests were frequently related. The results of this study can be used for practice development and as the basis for further research within an expanded CPOE system.

Contexte: En Alberta, les pharmaciens peuvent obtenir une autorisation de prescription élargie (APE) et un numéro d'identification de pratique (PRAC-ID) pour demander des analyses de laboratoire. Les pharmaciens travaillant dans les Services de santé de l'Alberta ont été sommés par leur employeur d'obtenir une APE avant 2018, alors que les demandes d'analyses de laboratoire sont en place depuis 2009. Cinq sites de soins aigus dans la zone de Calgary disposaient d'un système de saisie informatique des ordonnances médicales (CPOE) permettant de suivre ces activités. Objectifs: Décrire les changements en matière de prescription et de demande d'analyses de laboratoire par les pharmaciens de soins aigus au fil du temps et comparer ces activités entre les hôpitaux, les sites et les équipes spécialisées. Méthodologie: Un examen rétrospectif et descriptif des prescriptions de médicaments et des demandes d'analyses de laboratoire effectuées par les pharmaciens en soins aigus a été mené à l'aide des données du système de CPOE pour la période 2018 à 2021. Résultats: Au cours de la période de l'étude, les taux de prescription et de demande d'analyses de laboratoire par les pharmaciens ont augmenté respectivement de 67,5 % (de 1423 à 2383 par équivalent temps plein [ETP]) et de 5,5 % (de 235 à 248 par ETP). Le taux de prescription des pharmaciens de tous les hôpitaux a augmenté au cours de cette période (de 7 % à 176 %). Les équipes de cardiologie, de soins intensifs et de santé mentale ont enregistré les plus fortes augmentations des taux de prescription, tandis que celles de santé mentale, de soins hospitaliers et de soins intensifs ont enregistré les plus fortes augmentations des taux de demande d'analyses de laboratoire. Chaque année de l'étude, la vancomycine était le médicament le plus fréquemment prescrit pour les patients adultes et les analyses de laboratoire les plus fréquemment demandées portaient sur la mesure de la vancomycine avant l'administration de la dose. La part des prescriptions de médicament communiquées verbalement a diminué de 60,0 % à 47,4 % au cours de la période d'étude. Conclusions: L'application d'un champ de pratique élargi a augmenté chez les pharmaciens de soins aigus, dans une plus grande mesure pour la prescription que pour les demandes d'analyses de laboratoire. Cependant, la part des prescriptions de médicament communiquées verbalement demeure élevée ­ une situation qui devrait être corrigée pour améliorer la sécurité des patients. Cette étude a démontré que les prescriptions et les demandes d'analyses de laboratoire sont complémentaires, étant donné que les principaux médicaments et les principales analyses sont fréquemment liés. Les résultats de cette étude peuvent être utilisés pour le développement de la pratique et comme base pour des recherches ultérieures au sein d'un système de CPOE élargi.

Postnatal brain and skull growth in an Apert syndrome mouse model.

Craniofacial and neural tissues develop in concert throughout prenatal and postnatal growth. FGFR-related craniosynostosis syndromes, such as Apert syndrome (AS), are associated with specific phenotypes involving both the skull and the brain. We analyzed the effects of the FGFR P253R mutation for AS using the Fgfr2(+/P253R) Apert syndrome mouse to evaluate the effects of this mutation on these two tissues over the course of development from day of birth (P0) to postnatal day 2 (P2). Three-dimensional magnetic resonance microscopy and computed tomography images were acquired from Fgfr2(+/P253R) mice and unaffected littermates at P0 (N = 28) and P2 (N = 20).Three-dimensional coordinate data for 23 skull and 15 brain landmarks were statistically compared between groups. Results demonstrate that the Fgfr2(+/P253R) mice show reduced growth in the facial skeleton and the cerebrum, while the height and width of the neurocranium and caudal regions of the brain show increased growth relative to unaffected littermates. This localized correspondence of differential growth patterns in skull and brain point to their continued interaction through development and suggest that both tissues display divergent postnatal growth patterns relative to unaffected littermates. However, the change in the skull-brain relationship from P0 to P2 implies that each tissue affected by the mutation retains a degree of independence, rather than one tissue directing the development of the other.

Providing health information for culturally and linguistically diverse women: priorities and preferences of new migrants and refugees.

ISSUES ADDRESSED: Preferences for topics and means of access to health information among newly arrived, culturally and linguistically diverse women in Perth, Western Australia, were explored. METHODS: A mixed-methods approach was adopted. Qualitative material obtained from focus groups and interviews with 22 service providers and 26 migrant women was used to develop a questionnaire, which was then administered to 268 newly arrived migrant and refugee women from 50 countries. Participants' information and support priorities were ascertained from a ranking exercise conducted in a non-threatening context. Responses of migrant and refugee women were compared quantitatively. RESULTS: Women's top priorities for information and support included employment advice, as well as information regarding mental health issues, women's health, exercise and nutrition, family violence and alcohol and other drug issues. Their preferred methods for receiving information were interactive talks or presentations, with written material support. Audiovisual and Web-based material were also considered useful. There were differences between refugee women's and other migrants' preferences for means of receiving information and topics of most concern. DISCUSSION: The use of a non-threatening ranking process encouraged women to prioritise sensitive topics, such as family violence, and revealed a need for such topics to be incorporated within general health information presentations. Internet-based technologies are becoming increasingly important methods for disseminating information to migrant women. SO WHAT? Differences between migrant and refugee women's priority health issues and their preferred methods for receiving information highlight the desirability of tailoring information to particular groups. Although advice on employment pathways and mental health concerns were top priorities, the study revealed a need for more discussion on other sensitive topics, such as family violence and alcohol-related issues, and that ideally these should be incorporated into general information sessions to destigmatise attendance The increasing relevance of computer technology and social media for information dissemination was also of note.

Distinct disease mutations in DNMT3A result in a spectrum of behavioral, epigenetic, and transcriptional deficits.

Phenotypic heterogeneity is a common feature of monogenic neurodevelopmental disorders that can arise from differential severity of missense variants underlying disease, but how distinct alleles impact molecular mechanisms to drive variable disease presentation is not well understood. Here, we investigate missense mutations in the DNA methyltransferase DNMT3A associated with variable overgrowth, intellectual disability, and autism, to uncover molecular correlates of phenotypic heterogeneity in neurodevelopmental disease. We generate a DNMT3A P900L/+ mouse model mimicking a disease mutation with mild-to-moderate severity and compare phenotypic and epigenomic effects with a severe R878H mutation. We show that the P900L mutation leads to disease-relevant overgrowth, obesity, and social deficits shared across DNMT3A disorder models, while the R878H mutation causes more extensive epigenomic disruption leading to differential dysregulation of enhancers elements. We identify distinct gene sets disrupted in each mutant which may contribute to mild or severe disease, and detect shared transcriptomic disruption that likely drives common phenotypes across affected individuals. Finally, we demonstrate that core gene dysregulation detected in DNMT3A mutant mice overlaps effects in other developmental disorder models, highlighting the importance of DNMT3A-deposited methylation in neurodevelopment. Together, these findings define central drivers of DNMT3A disorders and illustrate how variable disruption of transcriptional mechanisms can drive the spectrum of phenotypes in neurodevelopmental disease.

Distinct disease mutations in DNMT3A result in a spectrum of behavioral, epigenetic, and transcriptional deficits.

Phenotypic heterogeneity in monogenic neurodevelopmental disorders can arise from differential severity of variants underlying disease, but how distinct alleles drive variable disease presentation is not well understood. Here, we investigate missense mutations in DNA methyltransferase 3A (DNMT3A), a DNA methyltransferase associated with overgrowth, intellectual disability, and autism, to uncover molecular correlates of phenotypic heterogeneity. We generate a Dnmt3aP900L/+ mouse mimicking a mutation with mild to moderate severity and compare phenotypic and epigenomic effects with a severe R878H mutation. P900L mutants exhibit core growth and behavioral phenotypes shared across models but show subtle epigenomic changes, while R878H mutants display extensive disruptions. We identify mutation-specific dysregulated genes that may contribute to variable disease severity. Shared transcriptomic disruption identified across mutations overlaps dysregulation observed in other developmental disorder models and likely drives common phenotypes. Together, our findings define central drivers of DNMT3A disorders and illustrate how variable epigenomic disruption contributes to phenotypic heterogeneity in neurodevelopmental disease.

Sampling challenges in a study examining refugee resettlement.

BACKGROUND: As almost half of all refugees currently under United Nations protection are from Afghanistan or Iraq and significant numbers have already been resettled outside the region of origin, it is likely that future research will examine their resettlement needs. A number of methodological challenges confront researchers working with culturally and linguistically diverse groups; however, few detailed articles are available to inform other studies. The aim of this paper is to outline challenges with sampling and recruitment of socially invisible refugee groups, describing the method adopted for a mixed methods exploratory study assessing mental health, subjective wellbeing and resettlement perspectives of Afghan and Kurdish refugees living in New Zealand and Australia. Sampling strategies used in previous studies with similar refugee groups were considered before determining the approach to recruitment METHODS: A snowball approach was adopted for the study, with multiple entry points into the communities being used to choose as wide a range of people as possible to provide further contacts and reduce selection bias. Census data was used to assess the representativeness of the sample. RESULTS: A sample of 193 former refugee participants was recruited in Christchurch (n = 98) and Perth (n = 95), 47% were of Afghan and 53% Kurdish ethnicity. A good gender balance (males 52%, females 48%) was achieved overall, mainly as a result of the sampling method used. Differences in the demographic composition of groups in each location were observed, especially in relation to the length of time spent in a refugee situation and time since arrival, reflecting variations in national humanitarian quota intakes. Although some measures were problematic, Census data comparison to assess reasonable representativeness of the study sample was generally reassuring. CONCLUSIONS: Snowball sampling, with multiple initiation points to reduce selection bias, was necessary to locate and identify participants, provide reassurance and break down barriers. Personal contact was critical for both recruitment and data quality, and highlighted the importance of interviewer cultural sensitivity. Cross-national comparative studies, particularly relating to refugee resettlement within different policy environments, also need to take into consideration the differing pre-migration experiences and time since arrival of refugee groups, as these can add additional layers of complexity to study design and interpretation.

Intracranial volume and whole brain volume in infants with unicoronal craniosynostosis.

OBJECTIVE: Craniosynostosis has been hypothesized to result in alterations of the brain and cerebral blood flow due to reduced intracranial volume, potentially leading to cognitive deficits. In this study we test the hypothesis that intracranial volume and whole brain volume in infants with unilateral coronal synostosis differs from those in unaffected infants. DESIGN: Our study sample consists of magnetic resonance images acquired from 7- to 72-week-old infants with right unilateral coronal synostosis prior to surgery (n  =  10) and age-matched unaffected infants (n  =  10). We used Analyze 9.0 software to collect three cranial volume measurements. We used nonparametric tests to determine whether the three measures differ between the two groups. Correlations were calculated between age and the three volume measures in each group to determine whether the growth trajectory of the measurements differ between children with right unicoronal synostosis and unaffected infants. RESULTS: Our results show that the three volume measurements are not reduced in infants with right unicoronal synostosis relative to unaffected children. Correlation analyses between age and various volume measures show similar correlations in infants with right unicoronal synostosis compared with unaffected children. CONCLUSIONS: Our results show that the relationship between brain size and intracranial size in infants with right unicoronal synostosis is similar to that in unaffected children, suggesting that reduced intracranial volume is not responsible for alterations of the brain in craniosynostosis.

Beyond the closed suture in apert syndrome mouse models: evidence of primary effects of FGFR2 signaling on facial shape at birth.

Apert syndrome is a congenital disorder caused mainly by two neighboring mutations on fibroblast growth factor receptor 2 (FGFR2). Premature closure of the coronal suture is commonly considered the identifying and primary defect triggering or preceding the additional cranial malformations of Apert phenotype. Here we use two transgenic mouse models of Apert syndrome, Fgfr2(+/S252W) and Fgfr2(+/P253R), to explore variation in cranial phenotypes in newborn (P0) mice. Results show that the facial skeleton is the most affected region of the cranium. Coronal suture patency shows marked variation that is not strongly correlated with skull dysmorphology. The craniofacial effects of the FGFR2 mutations are similar, but Fgfr2(+/S252W) mutant mice display significantly more severe dysmorphology localized to the posterior palate. Our results demonstrate that coronal suture closure is neither the primary nor the sole locus of skull dysmorphology in these mouse models for Apert syndrome, but that the face is also primarily affected.

Brain phenotypes in two FGFR2 mouse models for Apert syndrome.

Apert syndrome (AS) is one of at least nine disorders considered members of the fibroblast growth factor receptor (FGFR) -1, -2, and -3-related craniosynostosis syndromes. Nearly 100% of individuals diagnosed with AS carry one of two neighboring mutations on Fgfr2. The cranial phenotype associated with these two mutations includes coronal suture synostosis, either unilateral (unicoronal synostosis) or bilateral (bicoronal synostosis). Brain dysmorphology associated with AS is thought to be secondary to cranial vault or base alterations, but the variation in brain phenotypes within Apert syndrome is unexplained. Here, we present novel three-dimensional data on brain phenotypes of inbred mice at postnatal day 0 each carrying one of the two Fgfr2 mutations associated with AS. Our data suggest that the brain is primarily affected, rather than secondarily responding to skull dysmorphogenesis. Our hypothesis is that the skull and brain are both primarily affected in craniosynostosis and that shared phenogenetic developmental processes affect both tissues in craniosynostosis of Apert syndrome.

The effects of dry needling to the thoracolumbar junction multifidi on measures of regional and remote flexibility and pain sensitivity: A randomized controlled trial.

BACKGROUND: Dry needling (DN) has been consistently shown to decrease pain sensitivity and increase flexibility local to the site of treatment, however it is unclear whether these effects are limited to the region of treatment or can be observed remote to the area of treatment. OBJECTIVE: To determine the immediate, short-term effects of DN to the thoracolumbar junction on regional and remote flexibility, and to observe if changes in pain sensitivity can occur remote to site of treatment. DESIGN: Double-blind randomized clinical trial. METHODS: Fifty-four subjects with low back pain and decreased length in at least one hamstring were randomized to receive either DN or sham DN to the T12 and L1 multifidi. Participants underwent regional (fingertip-to-floor) and remote flexibility (passive knee extension, passive straight leg raise) and pressure pain threshold (PPT) testing of the upper and lower extremity before, immediately after and 1 day after treatment. ANCOVAs were used to analyze flexibility data, with the covariate of pre-treatment values. Paired t-tests were used for difference in remote pain sensitivity. RESULTS: Statistically larger improvements in regional flexibility, but not remote flexibility, were observed immediately post-treatment in those who received DN than in those receiving sham DN (p = .0495; adjusted difference 1.2, 95% CI 0.002-2.3). Differences between upper and lower extremity PPT were not significant. CONCLUSION: DN can potentially have immediate changes in regional flexibility, but effects are not sustained at 24-h follow-up. DN may not affect remote flexibility or segmental pain sensitivity.

Functional and epigenetic phenotypes of humans and mice with DNMT3A Overgrowth Syndrome.

Germline pathogenic variants in DNMT3A were recently described in patients with overgrowth, obesity, behavioral, and learning difficulties (DNMT3A Overgrowth Syndrome/DOS). Somatic mutations in the DNMT3A gene are also the most common cause of clonal hematopoiesis, and can initiate acute myeloid leukemia (AML). Using whole genome bisulfite sequencing, we studied DNA methylation in peripheral blood cells of 11 DOS patients and found a focal, canonical hypomethylation phenotype, which is most severe with the dominant negative DNMT3AR882H mutation. A germline mouse model expressing the homologous Dnmt3aR878H mutation phenocopies most aspects of the human DOS syndrome, including the methylation phenotype and an increased incidence of spontaneous hematopoietic malignancies, suggesting that all aspects of this syndrome are caused by this mutation.

Activation of p38 MAPK pathway in the skull abnormalities of Apert syndrome Fgfr2(+P253R) mice.

BACKGROUND: Apert syndrome is characterized by craniosynostosis and limb abnormalities and is primarily caused by FGFR2 +/P253R and +/S252W mutations. The former mutation is present in approximately one third whereas the latter mutation is present in two-thirds of the patients with this condition. We previously reported an inbred transgenic mouse model with the Fgfr2 +/S252W mutation on the C57BL/6J background for Apert syndrome. Here we present a mouse model for the Fgfr2+/P253R mutation. RESULTS: We generated inbred Fgfr2(+/P253R) mice on the same C56BL/6J genetic background and analyzed their skeletal abnormalities. 3D micro-CT scans of the skulls of the Fgfr2(+/P253R) mice revealed that the skull length was shortened with the length of the anterior cranial base significantly shorter than that of the Fgfr2(+/S252W) mice at P0. The Fgfr2(+/P253R) mice presented with synostosis of the coronal suture and proximate fronts with disorganized cellularity in sagittal and lambdoid sutures. Abnormal osteogenesis and proliferation were observed at the developing coronal suture and long bones of the Fgfr2(+/P253R) mice as in the Fgfr2(+/S252W) mice. Activation of mitogen-activated protein kinases (MAPK) was observed in the Fgfr2(+/P253R) neurocranium with an increase in phosphorylated p38 as well as ERK1/2, whereas phosphorylated AKT and PKCalpha were not obviously changed as compared to those of wild-type controls. There were localized phenotypic and molecular variations among individual embryos with different mutations and among those with the same mutation. CONCLUSIONS: Our in vivo studies demonstrated that the Fgfr2 +/P253R mutation resulted in mice with cranial features that resemble those of the Fgfr2(+/S252W) mice and human Apert syndrome. Activated p38 in addition to the ERK1/2 signaling pathways may mediate the mutant neurocranial phenotype. Though Apert syndrome is traditionally thought to be a consistent phenotype, our results suggest localized and regional variations in the phenotypes that characterize Apert syndrome.

DNMT3A Haploinsufficiency Results in Behavioral Deficits and Global Epigenomic Dysregulation Shared across Neurodevelopmental Disorders.

Mutations in DNA methyltransferase 3A (DNMT3A) have been detected in autism and related disorders, but how these mutations disrupt nervous system function is unknown. Here, we define the effects of DNMT3A mutations associated with neurodevelopmental disease. We show that diverse mutations affect different aspects of protein activity but lead to shared deficiencies in neuronal DNA methylation. Heterozygous DNMT3A knockout mice mimicking DNMT3A disruption in disease display growth and behavioral alterations consistent with human phenotypes. Strikingly, in these mice, we detect global disruption of neuron-enriched non-CG DNA methylation, a binding site for the Rett syndrome protein MeCP2. Loss of this methylation leads to enhancer and gene dysregulation that overlaps with models of Rett syndrome and autism. These findings define the effects of DNMT3A haploinsufficiency in the brain and uncover disruption of the non-CG methylation pathway as a convergence point across neurodevelopmental disorders.