Hotter and drier climate made the Mediterranean Europe and Northern Africa region a shrubbier landscape.

A shift to higher temperatures has left the Mediterranean Europe and Northern Africa (MENA) region more vulnerable to drought and land degradation. We used MODIS LAI (leaf area index) and GPP (gross primary production) deficits, the differences between actual and historical-maximum values, to describe vegetation structural and functional changes and consequential landcover change in response to changing climate conditions during 2001-2019 in the area (20° W-45° E, 20° N-45° N). We found that 1) the vegetation responses varied significantly among eight landcover types with the decreasing importance: forests, savannas, a mosaic of cropland and natural vegetation (CNV), croplands, permanent wetlands, urban land, grasslands, and shrublands, each with distinctive yet overlapping signatures over the ranges of the climate conditions considered. 2) Forests, occupying the coolest and wettest niche, showed the strongest response to severe drought with a lag of 1-3 years and a legacy effect for 10 years. Shrubs, occupying the hottest and driest niche, were the most resilient under a hotter and drier climate. 3) The total areas of savannas and CNV increased by 394,994 and 404,592 km2, respectively, while that of forests decreased by 33,091 km2. Shrublands extended by 287,134 km2 while grasslands and croplands retreated by 490,644 and 225,263 km2. The area of wetlands increased by 49,192 km2, and that of urban land increased by 39,570 km2. A total of 57,649 km2 of barren land became vegetated over the years. Along with higher temperature and more extended period of drought, MENA has evolved towards a shrubbier landscape.

Early outcomes of magnetic intramedullary compression nailing for humeral fractures.

PURPOSE: The optimal treatment protocol for humeral shaft fractures at risk for nonunions is controversial. Here, we aim to describe magnetic intramedullary compression nailing as an option for these challenging scenarios and to evaluate its clinical and radiographic outcomes. METHODS: This retrospective case series was performed at an urban university-based level-1 trauma center. Patients aged 18-65 who underwent fixation of their at-risk humerus shaft fracture using the PRECICE nail were included in this investigation. These fractures are characterized by a persistent distraction gap, minimal callous formation, or malalignment greater than 20 degrees. The study data were collected through a retrospective chart review and review of the radiographic studies. Primary outcome measure was radiographic union. Secondary outcome measures included mechanical failure, nonunion, malunion, medical, and surgical complications. Functional outcome was determined by range of motion and restoration of rotator cuff strength. RESULTS: A total of six patients were included who underwent treatment of their humeral shaft fracture with a NuVasive PRECICE nail after failure of conservative management. After nail placement along with our compression protocol, all patients achieved bony union and experienced favorable outcomes with return to their previous working status. Two complications included a superficial incisional infection treated with antibiotics and a backing out of proximal screw which did not cause discomfort. No other mechanical failures, surgical complications, or medical complications occurred. CONCLUSIONS: Early results of controlled compression nailing for humeral shaft fracture demonstrated favorable clinical outcomes. This technique may be utilized for these challenging situations.

Rebound Self-tonometry Acquisition Time and Ease of Use Evaluated by Newly Trained Optometry Students and Optometrists.

SIGNIFICANCE: Peak IOP and IOP fluctuations have been implicated as risk factors for glaucoma progression. Peak 24-hour IOP can be significantly higher than in-office measurements. Icare HOME could be a useful adjunct in glaucoma management if positively appraised by individuals familiar with eye care. PURPOSE: The purpose of this study was to measure the time needed for a nonclinical convenience sample of optometry students and optometrists to self-measure IOP using Icare HOME and to determine their perceptions of rebound self-tonometry. METHODS: A total of 234 subjects were enrolled, with 226 (97%) having a complete data set. Self-measurement was performed on the study eye using Icare HOME while seated and without contact lenses. Examiners self-measured IOP while subjects observed; examiners then measured subjects' IOP. Subjects then completed self-measurement while timed. Only one attempt was allowed. Time and study eye were recorded, and subjects completed a short survey. Descriptive statistics were conducted. RESULTS: Mean ± standard deviation age was 34.6 ± 13.3 years (58.3% female, 52.3% contact lens wearers). Test time ranged from 3 to 366 seconds, with 38% able to self-measure in 10 seconds or less, 74% in 60 seconds or less, and 92.8% in 120 seconds or less; 5.8% were unable to self-measure IOP. There was no significant correlation between test time and age (r = -0.03, P = .67). The device was reported to be easy or very easy to use by 69.7% of subjects and comfortable or very comfortable by 90.4% of subjects. After the study, 89.1% of subjects perceived that rebound self-tonometry has a role in the management of patients with glaucoma and suspicion of glaucoma. CONCLUSIONS: The majority of neophyte subjects perceived self-measurement of IOP as having a role in the management of glaucoma and suspicion of glaucoma. They rated Icare HOME as comfortable and easy to use and were able to self-measure IOP on the first attempt.

Development of an Efficient Enzyme Production and Structure-Based Discovery Platform for BACE1 Inhibitors.

BACE1 (Beta-site Amyloid Precursor Protein (APP) Cleaving Enzyme 1) is a promising therapeutic target for Alzheimer's Disease (AD). However, efficient expression, purification, and crystallization systems are not well described or detailed in the literature nor are approaches for treatment of enzyme kinetic data for potent inhibitors well described. We therefore developed a platform for expression and purification of BACE1, including protein refolding from E.coli inclusion bodies, in addition to optimizing a reproducible crystallization procedure of BACE1 bound with inhibitors. We also report a detailed approach to the proper analysis of enzyme kinetic data for compounds that exhibit either rapid-equilibrium or tight-binding mechanisms. Our methods allow for the purification of ∼15 mg of BACE1 enzyme from 1 L of culture which is higher than reported yields in the current literature. To evaluate the data analysis approach developed here, a well-known potent inhibitor and two of its derivatives were tested, analyzed, and compared. The inhibitory constants (Ki) obtained from the kinetic studies are in agreement with dissociation constants (Kd) that were also determined using isothermal titration calorimetry (ITC) experiments. The X-ray structures of these three compounds in complex with BACE1 were readily obtained and provide important insight into the structure and thermodynamics of the BACE1-inhibitor interactions.

Comparison of Two Fluid Replacement Protocols During a 20-km Trail Running Race in the Heat.

Lopez, RM, Casa, DJ, Jensen, K, Stearns, RL, DeMartini, JK, Pagnotta, KD, Roti, MW, Armstrong, LE, and Maresh, CM. Comparison of two fluid replacement protocols during a 20-km trail running race in the heat. J Strength Cond Res 30(9): 2609-2616, 2016-Proper hydration is imperative for athletes striving for peak performance and safety, however, the effectiveness of various fluid replacement strategies in the field setting is unknown. The purpose of this study was to investigate how two hydration protocols affect physiological responses and performance during a 20-km trail running race. A randomized, counter-balanced, crossover design was used in a field setting (mean ± SD: WBGT 28.3 ± 1.9° C). Well-trained male (n = 8) and female (n = 5) runners (39 ± 14 years; 175 ± 9 cm; 67.5 ± 11.1 kg; 13.4 ± 4.6% BF) completed two 20-km trail races (5 × 4-km loop) with different water hydration protocols: (a) ad libitum (AL) consumption and (b) individualized rehydration (IR). Data were analyzed using repeated measures ANOVA. Paired t-tests compared pre-race-post-race measures. Main outcome variables were race time, heart rate (HR), gastrointestinal temperature (TGI), fluid consumed, percent body mass loss (BML), and urine osmolality (Uosm). Race times between groups were similar. There was a significant condition × time interaction (p = 0.048) for HR, but TGI was similar between conditions. Subjects replaced 30 ± 14% of their water losses in AL and 64 ± 16% of their losses in IR (p < 0.001). Ad libitum trial experienced greater BML (-2.6 ± 0.5%) compared with IR (-1.3 ± 0.5%; p < 0.001). Pre-race to post-race Uosm differences existed between AL (-273 ± 146 mOsm) and IR (-145 ± 215 mOsm, p = 0.032). In IR, runners drank twice as much fluid than AL during the 20-km race, leading to > 2% BML in AL. Ad libitum drinking resulted in 1.3% greater BML over the 20-km race, which resulted in no thermoregulatory or performance differences from IR.

Current Quality of Videos on Colorectal Cancer Screening for General Public.

BACKGROUND: One-third of American adults encompassed by current colorectal cancer screening guidelines fail to obtain recommended screening evaluations. Educational videos are a valuable medium through which to educate and encourage recommended health behaviors in patients. METHODS: A cross-sectional study reviewing the quality of patient education videos addressing colorectal cancer screening. Video quality was assessed in 3 domains: accountability, content, and production. RESULTS: Forty-four videos met inclusion criteria. Out of 33 possible points, videos scored a median of 15.0 (interquartile range 12.9-16.6). Videos scored 1.0 (interquartile range .8-1.0) out of 4.0 for accountability, 6.0 (interquartile range 4.4-8.0) out of 20 for content, and 8.0 (interquartile range 7.4-8.0) out of 9.0 for production. Colonoscopy was the most frequently discussed method of screening (38, 86%). While 13 (34%) videos discussed the risk of colorectal cancer in the general population and 15 (32%) discussed the risk in those with a family history, few videos addressed those with other risk factors. Most (31, 70%) videos discussed the medical consequences of not receiving screening, but only 1 (2%) video discussed the social consequences. Similarly, medical benefits were discussed in 34 (77%) videos while other benefits were not discussed by any video. Only one-fifth of the videos address three or more barriers to screening. CONCLUSIONS: Videos on colorectal cancer screening have excellent production quality but need improvement in the domains of accountability and content. The videos included in this analysis did not adequately address the concerns of viewers nor the benefits of colorectal cancer screening.

Design, synthesis, biological and structural evaluation of functionalized resveratrol analogues as inhibitors of quinone reductase 2.

Resveratrol (3,5,4'-trihydroxylstilbene) has been proposed to elicit a variety of positive health effects including protection against cancer and cardiovascular disease. The highest affinity target of resveratrol identified so far is the oxidoreductase enzyme quinone reductase 2 (QR2), which is believed to function in metabolic reduction and detoxification processes; however, evidence exists linking QR2 to the metabolic activation of quinones, which can lead to cell toxicity. Therefore, inhibition of QR2 by resveratrol may protect cells against reactive intermediates and eventually cancer. With the aim of identifying novel inhibitors of QR2, we designed, synthesized, and tested two generations of resveratrol analogue libraries for inhibition of QR2. In addition, X-ray crystal structures of six of the resveratrol analogues in the active site of QR2 were determined. Several novel inhibitors of QR2 were successfully identified as well as a compound that inhibits QR2 with a novel binding orientation.

Consumer acceptance of the New Nordic Diet. An exploratory study.

With direct reference to New Nordic Cuisine and Nordic dietary recommendations, the OPUS Research Centre in Denmark is developing and testing a healthy, regional New Nordic Diet (NND) that promises to have outstanding gastronomic properties. The NND is disseminated to Danish consumers with a view to improving public health. To explore the acceptability of the NND to consumers, a qualitative study comprising focus groups, home-testing of NND prototype meals and personal interviews was conducted in urban and rural areas (N=38). Most participants, particularly women and residents in urban areas, are positive towards the ideas underlying the development of this new diet and enjoy the taste and appearance of NND meals. Barriers to acceptance include the untraditional formats of NND meals, the time needed to prepare them, the unfamiliarity of ingredients, perceived problems regarding product availability, reservations about the elitist character of this project and unwillingness to exclude non-Nordic dishes on an everyday basis. The study concludes that several social and cultural barriers must be overcome if the NND shall constitute a source of improved public health. The pursuit of this objective could more fruitfully take its point of departure in in-depth consideration of existing food practices among Danish consumers.

Pyridostigmine Bromide Pills and Pesticides Exposure as Risk Factors for Eye Disease in Gulf War Veterans.

To examine associations between the pyridostigmine bromide (PB) pill and/or pesticide exposure during the 1990-1991 Gulf War (GW) and eye findings years after deployment. A cross-sectional study of South Florida veterans who were deployed on active duty during the GW Era (GWE). Information on GW exposures and ocular surface symptoms were collected via standardized questionnaires and an ocular surface examination was performed. Participants underwent spectral domain-ocular coherence tomography (SD-OCT) imaging that included retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and macular maps. We examined for differences in eye findings between individuals exposed versus not exposed to PB pills or pesticides during service. A total of 40.7% (n = 44) of individuals reported exposure to PB pills and 41.7% (n = 45) to pesticides; additionally, 24 reported exposure to both in the GW arena. Demographics were comparable across groups. Individuals exposed to PB pills reported higher dry eye (DE) symptoms scores (the 5-Item Dry Eye Questionnaire, DEQ-5: 9.3 ± 5.3 vs. 7.3 ± 4.7, p = 0.04) and more intense ocular pain (average over the last week: 2.4 ± 2.6 vs. 1.5 ± 1.8, p = 0.03; Neuropathic Pain Symptom Inventory modified for the Eye (NPSI-E): 18.2 ± 20.0 vs. 10.8 ± 13.8, p = 0.03) compared to their non-exposed counterparts. DE signs were comparable between the groups. Individuals exposed to PB pills also had thicker OCT measurements, with the largest difference in the outer temporal segment of the macula (268.5 ± 22.2 µm vs. 260.6 ± 14.5 µm, p = 0.03) compared to non-exposed individuals. These differences remained significant when examined in multivariable models that included demographics and deployment history. Individuals exposed to pesticides had higher neuropathic ocular pain scores (NPSI-E: 17.1 ± 21.1 vs. 11.6 ± 12.9, p = 0.049), but this difference did not remain significant in a multivariable model. Individuals exposed to PB pills during the GWE reported more severe ocular surface symptoms and had thicker OCT measures years after deployment compared to their non-exposed counterparts.

Synthesis of novel МТ3 receptor ligands via an unusual Knoevenagel condensation.

New 5-acetamido-substituted melatonin derivatives were efficiently synthesized in excellent yields via Knoevenagel condensation. The relative binding affinity of new synthesized compounds to MT3 receptor was tested via enzymatic assays and the X-ray structures of the most potent compounds were determined in complex with MT3.

Critical Comparison of the Quality and Content of Integrated Vascular Surgery, Thoracic Surgery, and Interventional Radiology Residency Training Program Websites: Qualitative Study.

BACKGROUND: With the move to virtual interviewing, residency websites are an important recruitment resource, introducing applicants to programs across the country and allowing for comparison. Recruitment is highly competitive from a common potential pool between vascular surgery, thoracic surgery, and interventional radiology with the ratio of applicants to positions being highest in interventional radiology, followed by thoracic surgery and lastly vascular surgery, as reported by the National Resident Matching Program. OBJECTIVE: The aim of this study is to evaluate the accessibility and availability of online content for those integrated residency programs. METHODS: A list of accredited vascular surgery, thoracic surgery, and interventional radiology residencies was obtained from the Accreditation Council for Graduate Medical Education (ACGME) database. Program websites were evaluated by trained independent reviewers (n=2) for content items pertaining to program recruitment and education (scored absent or present). Statistical analysis was performed in R software. RESULTS: Of ACGME-accredited programs, 56 of 61 (92%) vascular surgery, 27 of 27 (100%) thoracic surgery, and 74 of 85 (87%) interventional radiology programs had functional websites (P=.12). Vascular surgery websites contained a median of 26 (IQR 20-32) content items, thoracic surgery websites contained a median of 27 (IQR 21-32) content items, and interventional radiology websites contained a median of 23 (IQR 18-27) content items. Two content items considered highly influential to applicant program decisions are procedural experience and faculty mentorship, which were reported at 32% (18/56) and 11% (6/56) for vascular surgery, 19% (5/27) and 11% (3/27) for thoracic surgery, and 50% (37/74) and 15% (11/74) for interventional radiology (P=.008 and P=.75), respectively. Key deficits were work hours, debt management, and curriculum for interventional radiology; resident profiles, sample contracts, and research interests in vascular surgery; and operative experiences and the program director's contact and message for thoracic surgery. Interventional radiology deficits were work hours, and thoracic surgery deficits were procedural experience. Both interventional radiology and thoracic surgery websites lacked information on evaluation criteria and faculty mentorship. CONCLUSIONS: This study has uncovered key differences in the availability of online content for residencies recruiting from the same pool of applicants. Thoracic surgery has the most information, followed by vascular surgery, with interventional radiology reporting the least content. In the era of virtual interviewing from the same potential pool of applicants, programs should review and revise their web presence with the aim to increase the availability of online content to attract valuable candidates.

Relationships between ocular surface sphingomyelinases, Meibum and Tear Sphingolipids, and clinical parameters of meibomian gland dysfunction.

PURPOSE: Sphingolipids (SPL) are a class of lipid molecules that play important functional and structural roles in our body and are a component of meibum. Sphingomyelinases (SMases) are key enzymes in sphingolipid metabolism that hydrolyze sphingomyelin (SM) and generate ceramide (Cer). The purpose of this study was to examine relationships between ocular surface SMases, SPL composition, and parameters of Meibomian gland dysfunction (MGD). METHODS: Individuals were grouped by meibum quality (n = 25 with poor-quality, MGD, and n = 25 with good-quality, control). Meibum and tears were analyzed with LC-MS to quantify SPL classes: Cer, Hexosyl-Ceramide (Hex-Cer), SM, Sphingosine (Sph), and sphingosine 1-phosphate (S1P). SMase activity in tears were quantified using a commercially available 'SMase assay'. Statistical analysis included multiple linear regression analyses to assess the impact of SMase activity on lipid composition, as well as ocular surface symptoms and signs of MGD. RESULTS: Demographic characteristics were similar between the two groups. nSMase and aSMase levels were lower in the poor vs good quality group. aSMase activity in tears negatively correlated with SM in meibum and tears and positively with Sph in meibum and S1P in tears. Lower SMase activity were associated with signs of MGD, most notably Meibomian gland dropout. CONCLUSION: This study suggests that individuals with MGD have reduced enzymatic activity of SMases in tears. Specifically, individuals with poor vs good meibum quality were noted to have alterations in SMase activity and SPL composition of meibum and tears which may reflect deviations from normal lipid metabolism in individuals with MGD.

Dry Eye Symptoms and Signs in US Veterans With Gulf War Illness.

PURPOSE: To examine dry eye (DE) symptoms and signs in individuals with vs without Gulf War illness (GWI). DESIGN: Prospective cross-sectional study. METHODS: We performed a prospective, cross-sectional study of South Florida veterans who were active duty during the Gulf War era (GWE; 1990-1991) and seen at an eye clinic between October 1, 2020, and March 13, 2021. Veterans were split into 2 groups: those who met Kansas criteria for GWI (cases, n = 30) and those who did not (controls, n = 41). DE symptoms were assessed via standardized questionnaires whereas DE signs were assessed using a series of ocular surface parameters. Differences between groups were assessed via Mann-Whitney U test. Linear regression analyses were used to examine which GWI symptoms most closely aligned with DE symptoms. RESULTS: Veterans with GWI had higher DE symptoms scores compared to controls (Ocular Surface Disease Index [OSDI] scores: mean 41.20±22.92 vs 27.99±24.03, P = .01). In addition, veterans with GWI had higher eye pain scores compared with controls (average eye pain over past week: 2.63±2.72 vs 1.22±1.50, P = .03), including on neuropathic ocular pain questionnaires (Neuropathic Pain Symptom Inventory modified for the Eye [NPSI-E]: 17.33±17.20 vs 9.63±12.64, P = .03). DE signs were mostly similar between the groups. GWI symptoms "nausea or upset stomach" (ß=14.58, SE = 3.02, P < .001) and "headache" (ß=7.90, SE = 2.91, P = .011) correlated with higher OSDI scores. CONCLUSION: Individuals with GWI have more severe DE symptoms and ocular pain scores but similar tear and ocular surface parameters compared to controls without GWI. This finding suggests that mechanisms beyond tear dysfunction drive eye symptoms in GWI.

Examining the influence of hydration status on physiological responses and running speed during trail running in the heat with controlled exercise intensity.

The purpose of this study was to determine the effects of dehydration at a controlled relative intensity on physiological responses and trail running speed. Using a randomized, controlled crossover design in a field setting, 14 male and female competitive, endurance runners aged 30 ± 10.4 years completed 2 (hydrated [HY] and dehydrated [DHY]) submaximal trail runs in a warm environment. For each trial, the subjects ran 3 laps (4 km per lap) on trails with 4-minute rests between laps. The DHY were fluid restricted 22 hours before the trial and during the run. The HY arrived euhydrated and were given water during rest breaks. The subjects ran at a moderate pace matched between trials by providing pacing feedback via heart rate (HR) throughout the second trial. Gastrointestinal temperature (T(GI)), HR, running time, and ratings of perceived exertion (RPE) were monitored. Percent body mass (BM) losses were significantly greater for DHY pretrial (-1.65 ± 1.34%) than for HY (-0.03 ± 1.28%; p < 0.001). Posttrial, DHY BM losses (-3.64 ± 1.33%) were higher than those for HY (-1.38 ± 1.43%; p < 0.001). A significant main effect of T(GI) (p = 0.009) was found with DHY having higher T(GI) postrun (DHY: 39.09 ± 0.45°C, HY: 38.71 ± 0.45°C; p = 0.030), 10 minutes post (DHY: 38.85 ± 0.48°C, HY: 38.46 ± 0.46°C; p = 0.009) and 30 minutes post (DHY: 38.18 ± 0.41°C, HY: 37.60 ± 0.25°C; p = 0.000). The DHY had slower run times after lap 2 (p = 0.019) and lap 3 (p = 0.025). The DHY subjects completed the 12-km run 99 seconds slower than the HY (p = 0.027) subjects did. The RPE in DHY was slightly higher than that in HY immediately postrun (p = 0.055). Controlling relative intensity in hypohydrated runners resulted in slower run times, greater perceived effort, and elevated T(GI), which is clinically meaningful for athletes using HR as a gauge for exercise effort and performance.

The protection of Salicornia rubra from ultraviolet radiation by betacyanins and phenolic compounds.

Salicornia rubra is a commonly occurring annual species of the salt playas of the Great Basin Desert of the western United States. In such habitats, plants experience high levels of ultraviolet radiation, which could potentially damage DNA. As a member of the Amaranthaceae (Caryophyllales), S. rubra shoots typically contain high concentrations of the red-violet pigments called betacyanins, which are ultraviolet-absorbing compounds. Nevertheless, some specimens of S. rubra are green even when growing with full exposure to the sun. We, therefore, tested several hypotheses regarding the causes of variation among S. rubra plants in betacyanin concentration and the role of betacyanins in the absorption of ultraviolet radiation. We measured ultraviolet radiation absorption and the concentrations of betacyanins and phenolic compounds of the cell sap expressed from red and green plants growing in full sun, as well as plants grown under various levels of shade. We found that while betacyanin concentrations were predictable from plant color (red plants contained more betacyanins than green plants), the ability to absorb ultraviolet radiation was determined primarily by the concentration of phenolic compounds, which was determined by the level of exposure to the sun. Therefore, the DNA of green plants growing in full sun appears to be at no greater risk than the DNA of red plants.

Critical analysis of the quality of internet resources for patients with varicose veins.

OBJECTIVE: Patients increasingly seek information on their medical conditions from the internet. The present study evaluated the quality and readability of readily available online patient resources for varicose veins. METHODS: An internet search for "varicose veins" was conducted using the meta-search engines Yippy and Dogpile and the general search engines Google, Yahoo, and Bing with a cleared-cache web browser in July 2019. Two trained raters scored the websites separately on the dimensions of accessibility, accountability, interactivity, structure, and content. Any discrepancies were discussed, and a consensus was reached. Readability was calculated using four readability metric systems. Rater consistency was evaluated using kappa, weighted kappa, and interrater correlation coefficient, as indicated. RESULTS: A total of 189 websites met the inclusion criteria. The total median quality score was 15.6 (interquartile range [IQR], 13.1-20.5; range, 7.4-31.3) of 38. The websites scored a median of 4 (IQR, 1-8) of 15 for accountability, 2 (IQR, 2-2) of 5 for interactivity, 4 (IQR, 2-4) of 4 for organization, and 6.4 (IQR, 3.9-7.9) of 14 for weighted content. Most websites (81.5%) were accessible. However, the overall readability was poor. The median Flesch-Kincaid reading ease score was 55.1 (IQR, 49.4-6.7), indicating that the text was fairly difficult to read. The median grade level was 10th grade using both the Flesch-Kincaid grade level and simple measure of the Gobbledygook index and 11th to 12th grade using the new Dale-Chall readability formula. Government websites were the most accountable, featured the best content, and were the most readable. The website traffic had a positive, nonlinear correlation with the total score and a negative, nonlinear correlation with the website rank (or position on the search result page). Website rank correlated negatively with the total score, although the correlation was weak. CONCLUSIONS: The quality of the online patient resources on varicose veins varies greatly, and the readability for most sites is poor. Government-sponsored websites had the highest quality and were the most readable. Physicians are advised to consider providing a list of appropriate websites to their patients to better inform them, avoid confusion, and ensure appropriate delivery of accurate and readable information.

Critical Evaluation of the Efficiency of Colorectal Fellowship Websites: Cross-sectional Study.

BACKGROUND: Websites are an important source of information for fellowship applicants, as they can influence ongoing interest and potential program selection. OBJECTIVE: This study aims to evaluate the current state of colorectal fellowship websites. METHODS: This cross-sectional study evaluates the quantity and quality of information available on websites of colorectal fellowship programs verified by the Accreditation Council for Graduate Medical Education in 2019. RESULTS: A total of 63 colorectal fellowships were included for evaluation. Websites were surveyed for content items that previous studies have found to be influential to program applicants. The 58 (91%) programs with a functional website were evaluated using an information index (calculated as a function of availability of content items concerning education, application, personnel, and benefits) and an interactive index (calculated as a function of accessibility and usability of the webpage). Programs had a median total score of 27.8 (IQR 21.5-34.5) of 79. The median score for the interactive index was 7.5 of 15 and for the information index was 20 of 64. The median scores for website application, education, personnel, and benefits or life considerations were 5, 5.5, 3.3, and 4 of 13, 24, 13, and 14, respectively. There was no difference in total score between programs in different geographical regions (P=.46). CONCLUSIONS: Currently, colorectal surgery fellowship program websites do not provide enough content for applicants to make informed decisions. All training programs, regardless of specialty, should evaluate and improve their digital footprint to ensure their websites are accessible and provide the information desired by applicants.

Digital Footprint of Academic Vascular Surgeons in the Southern United States on Physician Rating Websites: Cross-sectional Evaluation Study.

BACKGROUND: The internet has become a popular platform for patients to obtain information and to review the health care providers they interact with. However, little is known about the digital footprint of vascular surgeons and their interactions with patients on social media. OBJECTIVE: This study aims to understand the activity of academic vascular surgeons on physician rating websites. METHODS: Information on attending vascular surgeons affiliated with vascular residency or with fellowships in the Southern Association for Vascular Surgery (SAVS) was collected from public sources. A listing of websites containing physician ratings was obtained via literature reviews and Google search. Open access websites with either qualitative or quantitative evaluations of vascular surgeons were included. Closed access websites were excluded. Ranking scores from each website were converted to a standard 5-point scale for comparison. RESULTS: A total of 6238 quantitative and 967 qualitative reviews were written for 287 physicians (236 males, 82.2%) across 16 websites that met the inclusion criteria out of the 62 websites screened. The surgeons affiliated with the integrated vascular residency and vascular fellowship programs in SAVS had a median of 8 (IQR 7-10) profiles across 16 websites, with only 1 surgeon having no web presence in any of the websites. The median number of quantitative ratings for each physician was 17 (IQR 6-34, range 1-137) and the median number of narrative reviews was 3 (IQR 2-6, range 1-28). Vitals, WebMD, and Healthgrades were the only 3 websites where over a quarter of the physicians were rated, and those rated had more than 5 ratings on average. The median score for the quantitative reviews was 4.4 (IQR 4.0-4.9). Most narrative reviews (758/967, 78.4%) were positive, but 20.2% (195/967) were considered negative; only 1.4% (14/967) were considered equivocal. No statistical difference was found in the number of quantitative reviews or in the overall average score in the physician ratings between physicians with social media profiles and those without social media profiles (departmental social media profile: median 23 vs 15, respectively, P=.22; personal social media profile: median 19 vs 14, respectively, P=.08). CONCLUSIONS: The representation of vascular surgeons on physician rating websites is varied, with the majority of the vascular surgeons represented only in half of the physician rating websites The number of quantitative and qualitative reviews for academic vascular surgeons is low. No vascular surgeon responded to any of the reviews. The activity of vascular surgeons in this area of social media is low and reflects only a small digital footprint that patients can reach and review.

A streamlined proliferation assay using mixed lymphocytes for evaluation of human mesenchymal stem cell immunomodulation activity.

BACKGROUND: Mesenchymal stromal cells (MSCs) have been proposed for treatment of acute respiratory distress syndrome (ARDS), graft versus host disease (GVHD), wound healing and trauma. A consensus is building that immunomodulation by MSCs is important for therapeutic potential. MSCs suppress peripheral blood mononuclear cell (PBMC) proliferation in vitro, potentially reflecting an ability to suppress PBMC inflammatory responses in vivo. Current mixed lymphocyte reaction (MLR) assays commonly used to evaluate MSC potency generally rely on either direct co-culture or indirect culture using transwell systems for monitoring the proliferation of isolated PBMCs in the presence of mitotically inactive MSCs. Proliferation of PBMCs is monitored by several methods, including incorporation of radiolabeled nucleotides, BRDU labeling and ELISA assay or flow cytometry of carboxyfluorescein labeled PBMCs. Here we present a streamlined assay using MSCs in a direct co-culture system with unmodified MSCs using a luminescent ATP assay to evaluate both PBMC and MSC proliferation/survival. METHODS: PBMCs were isolated from fresh anti-coagulated whole blood by centrifugation over Ficoll-Paque in LeucoSep tubes. Isolated PBMCs from 8 to 10 donors were pooled and cryopreserved at 1 × 107/ml in 50% RPMI medium,10% DMSO, 40% human AB serum. MSCs derived from bone marrow, adipose tissue or umbilical cord (BM-MSC, Ad-MSC, UC-MSC, respectively) were serially diluted starting at 50-60,000 cells/well and cultured in 96 well plates for 4-48 h in their respective medium. On Day 0, MSCs were washed, resuspended in PBMC media (RPMI with 10% FBS, 2 mM Glutamine, 10 mM HEPES, pH 7.4) and incubated with or without 150,000 freshly thawed pooled PBMCs/well, in the presence or absence of phytohemagglutinin A (PHA, 0-5 µg/ml). Proliferation of both MSCs (adherent) and PBMCs (non-adherent) was assessed by quantitation of ATP levels using the bioluminescent reagent Cell Titer-Glo (Promega). Culture supernatant contained PBMC, while washed adherent cells were primarily MSCs. Both cell types were incubated for 30 min with an equal volume of Cell Titer-Glo reagent and then assayed in white plates on a luminescence plate reader. RESULTS: PBMC proliferation in response to PHA stimulation resulted in a robust increase in ATP by 72 h, with >6 fold increase over unstimulated PBMCs, which showed no increase. MSC proliferation was decreased <20% at the highest PHA concentrations. Co-culture with MSCs suppressed PBMC proliferation dependent upon MSC passage number, source, and prior growth conditions. Total time to complete the ATP assay was under an hour including incubations. With minimal manipulations in the assay, intra- and inter- assay variations averaged 11.1 and 15.7% respectively. CONCLUSIONS: Direct co-culture of live unmodified MSCs with freshly thawed pooled PBMCs gives a robust determination of immunosuppression by MSCs with unparalleled ease. Graded responses can be determined, allowing comparison of potency between MSC preparations as in comparisons between freshly thawed and cultured MSCs as well as interferon-γ licensed MSCs. With the 96 well plate assay, far fewer PBMCs are generally required than in a typical flow cytometry determination. This streamlined assay can be performed within 72 h, without irradiating cells and without specialized equipment.

Interactions of human mesenchymal stromal cells with peripheral blood mononuclear cells in a Mitogenic proliferation assay.

BACKGROUND: Immunomodulation by mesenchymal stromal cells (MSCs) is a potentially important therapeutic modality. MSCs suppress peripheral blood mononuclear cell (PBMC) proliferation in vitro, suggesting a mechanism for suppressing inflammatory responses in vivo. This study details the interactions of PBMCs and MSCs. METHODS: Pooled human PBMCs and MSCs were co-cultured at different MSC:PBMC ratios and harvested from 0 to 120 h, with and without phytohaemagglutin A (PHA) stimulation. Proliferation of adherent MSCs and non-adherent PBMCs was assessed by quantitation of ATP levels. PBMC surface marker expression was analyzed by flow cytometry. Indoleamine 2,3-dioxygenase (IDO) activity was determined by kynurenine assay and IDO mRNA by RT-PCR. Cytokine release was measured by ELISA. Immunofluorescent microscopy detected MSC, PBMC, monocyte (CD14+) and apoptotic events. RESULTS: PBMC proliferation in response to PHA gave a robust ATP signal by 72 h, which was suppressed by co-culture with densely plated MSCs. Very low level MSC seeding densities relative to PBMC number reproducibly stimulated PBMC proliferation. The CD4+/CD3+ population significantly decreased over time while the CD8+/CD3+ population significantly increased. No change in CD4+/CD8+ ratio is seen with high density MSC co-culture; very low density MSCs augment the changes seen in PHA stimulated PBMCs alone. IDO activity in MSCs co-cultured with PBMCs correlated with PBMC suppression. MSCs increased the secretion of IL-10 and IL-6 from stimulated co-cultures and decreased TNF-α secretion. In stimulated co-culture, low density MSCs decreased in number; fluorescence immunomicroscopy detected association of PBMC with MSC and phosphatidyl serine externalization in both cell populations. CONCLUSIONS: A bidirectional interaction between MSCs and PBMCs occurs during co-culture. High numbers of MSCs inhibit PHA-stimulated PBMC proliferation and the PBMC response to stimulation; low numbers of MSCs augment these responses. Low density MSCs are susceptible to attrition, apparently by PBMC-induced apoptosis. These results may have direct application when considering therapeutic dosing of patients; low MSC doses may have unintended detrimental consequences.