Divergent sensory and immune gene evolution in sea turtles with contrasting demographic and life histories.

Sea turtles represent an ancient lineage of marine vertebrates that evolved from terrestrial ancestors over 100 Mya. The genomic basis of the unique physiological and ecological traits enabling these species to thrive in diverse marine habitats remains largely unknown. Additionally, many populations have drastically declined due to anthropogenic activities over the past two centuries, and their recovery is a high global conservation priority. We generated and analyzed high-quality reference genomes for the leatherback (Dermochelys coriacea) and green (Chelonia mydas) turtles, representing the two extant sea turtle families. These genomes are highly syntenic and homologous, but localized regions of noncollinearity were associated with higher copy numbers of immune, zinc-finger, and olfactory receptor (OR) genes in green turtles, with ORs related to waterborne odorants greatly expanded in green turtles. Our findings suggest that divergent evolution of these key gene families may underlie immunological and sensory adaptations assisting navigation, occupancy of neritic versus pelagic environments, and diet specialization. Reduced collinearity was especially prevalent in microchromosomes, with greater gene content, heterozygosity, and genetic distances between species, supporting their critical role in vertebrate evolutionary adaptation. Finally, diversity and demographic histories starkly contrasted between species, indicating that leatherback turtles have had a low yet stable effective population size, exhibit extremely low diversity compared with other reptiles, and harbor a higher genetic load compared with green turtles, reinforcing concern over their persistence under future climate scenarios. These genomes provide invaluable resources for advancing our understanding of evolution and conservation best practices in an imperiled vertebrate lineage.

Creating a data dictionary for pediatric autonomic disorders.

PURPOSE: Whether evaluating patients clinically, documenting care in the electronic health record, performing research, or communicating with administrative agencies, the use of a common set of terms and definitions is vital to ensure appropriate use of language. At a 2017 meeting of the Pediatric Section of the American Autonomic Society, it was determined that an autonomic data dictionary comprising aspects of evaluation and management of pediatric patients with autonomic disorders would be an important resource for multiple stakeholders. METHODS: Our group created the list of terms for the dictionary. Definitions were prioritized to be obtained from established sources with which to harmonize. Some definitions needed mild modification from original sources. The next tier of sources included published consensus statements, followed by Internet sources. In the absence of appropriate sources, we created a definition. RESULTS: A total of 589 terms were listed and defined in the dictionary. Terms were organized by Signs/Symptoms, Triggers, Co-morbid Disorders, Family History, Medications, Medical Devices, Physical Examination Findings, Testing, and Diagnoses. CONCLUSION: Creation of this data dictionary becomes the foundation of future clinical care and investigative research in pediatric autonomic disorders, and can be used as a building block for a subsequent adult autonomic data dictionary.

Sitting at the Bedside: Patient and Internal Medicine Trainee Perceptions.

BACKGROUND: Sitting at the bedside may strengthen physician-patient communication and improve patient experience. Yet despite the potential benefits of sitting, hospital physicians, including resident physicians, may not regularly sit down while speaking with patients. OBJECTIVE: To examine the frequency of sitting by internal medicine residents (including first post-graduate year [PGY-1] and supervising [PGY-2/3] residents) during inpatient encounters and to assess the association between patient-reported sitting at the bedside and patients' perceptions of other physician communication behaviors. We also assessed residents' attitudes towards sitting. DESIGN: In-person survey of patients and email survey of internal medicine residents between August 2019 and January 2020. PARTICIPANTS: Patients admitted to general medicine teaching services and internal medicine residents at The Johns Hopkins Hospital. MAIN MEASURES: Patient-reported frequency of sitting at the bedside, patients' perceptions of other communication behaviors (e.g., checking for understanding); residents' attitudes regarding sitting. KEY RESULTS: Of 334 eligible patients, 256 (76%) completed a survey. Among these 256 respondents, 198 (77%) and 166 (65%) reported recognizing the PGY-1 and PGY-2/3 on their care team, respectively, for a total of 364 completed surveys. On most surveys (203/364, 56%), patients responded that residents "never" sat. Frequent sitting at the bedside ("every single time" or "most of the time," together 48/364, 13%) was correlated with other positive behaviors, including spending enough time at the bedside, checking for understanding, and not seeming to be in a rush (p < 0.01 for all). Of 151 residents, 77 (51%) completed the resident survey; 28 of the 77 (36%) reported sitting frequently. The most commonly cited barrier to sitting was that chairs were not available (38 respondents, 49%). CONCLUSIONS: Patients perceived that residents sit infrequently. However, sitting was associated with other positive communication behaviors; this is compatible with the hypothesis that promoting sitting could improve overall patient perceptions of provider communication.

From Passive Gatekeeper to Quarterback: Evolving Perceptions of Primary Care Among Medical Students in Longitudinal Outpatient Clerkships.

BACKGROUND: Longitudinal clerkships provide students with meaningful clinical care roles that promote learning and professional development. It remains unclear how longitudinal primary care clerkships inform students' perceptions of primary care. OBJECTIVE: To explore perceptions of primary care among medical students enrolled in longitudinal primary care clerkships. DESIGN: Qualitative, semi-structured interviews with medical students over 4 years. PARTICIPANTS: Thirty-eight medical students participated at baseline; 35 participated in a 2-year follow-up interview; 24 participated at 4 years. Each student was enrolled in one of two longitudinal primary care clerkships: a team-based Education-Centered Medical Home (ECMH) or a one-on-one individual preceptorship (IP). APPROACH: De-identified interview transcripts were analyzed using a process of open and axial coding, followed by elaborative coding for longitudinal analysis. Codes were compiled into a set of themes and compared across time periods and between clerkships. KEY RESULTS: Students reported that primary care serves as a first point of contact, emphasizing longitudinal care with a wide scope of practice and approaching patient care with a biopsychosocial perspective. Student perceptions of primary care greatly expanded over the course of 4 years: for instance, initial perceptions of primary care physicians evolved from "passive gatekeeper" to a more nuanced "quarterback." Students in ECMH, whose clerkship provided more opportunity for patient continuity, further reflected on the relationships they themselves developed with patients. CONCLUSIONS: Regardless of their eventual specialty choice, longitudinal experiences may aid all students in fostering a sense of the broad scope and importance of primary care. However, without numerous opportunities to witness continuity of care, students may perceive primary care as having limited scope and importance. Longitudinal clerkships, emphasizing continuity with patients and preceptors, may foster in students a broad and nuanced perspective of the scope of primary care as a field.

Learning through Teaching: Peer Teaching and Mentoring Experiences among Third-Year Medical Students.

PHENOMENON: Classroom studies of peer-led teaching and mentoring report benefits for students both as teachers and learners. Such benefits include both improved content mastery and personal and professional development. While benefits of peer-led teaching in the clinical setting have been well characterized among other health professions, less is known within undergraduate medical education. In this study, we explored medical students' perceptions and experiences relevant to peer teaching and mentoring in outpatient clinical clerkships. APPROACH: Third-year medical students enrolled in two different longitudinal primary care clerkships, Education Centered Medical Home (ECMH) or Individual Preceptorship (IP), participated in semi-structured interviews in 2018. Students were asked to describe their peer teaching experiences during the clerkship and to reflect on their experiences serving as role models or mentors. We analyzed transcripts utilizing a two-cycle team-based inductive approach. FINDINGS: Thirty-three students completed interviews. We derived three main themes: (1) diversity of peer teaching and mentoring opportunities, (2) transitioning one's role from learner to teacher, and (3) personal and professional development. While participants from both clerkships participated in peer teaching and mentoring experiences, ECMH students described more opportunities to interact with students across all years of medical school training, noting that "getting that guidance and in turn being able to teach is a valuable experience." ECMH students further perceived the responsibility of creating a comfortable learning environment for others. Students from both clerkships reflected on 'learning through teaching,' that teaching served as a reaffirmation of the knowledge they gained, and that teaching experience contributed to their personal and professional growth. INSIGHTS: Students perceived their participation in peer teaching and mentoring experiences in the clinical setting as contributing positively to personal and professional development. Students from both clerkships reflected on their teaching and mentoring opportunities as a facilitator of growth in their own teaching skills; ECMH students further described a heightened sense of self-confidence and fulfillment. These findings highlight the importance of creating learning environments that foster peer teaching and mentoring, as such opportunities may lead to further growth as a learner and as a physician.

Inappropriate sinus tachycardia: a review.

Inappropriate sinus tachycardia (IST) has been defined as a resting heart rate of >100 beats per minute and an average 24-hour heart rate >90 bpm with distressing symptoms resulting from the persistent tachycardia. IST is prevalent in 1% of the middle-aged population, mostly females. Rarely can elderly patients also present with IST. Possible mechanisms of IST include intrinsic sinus node abnormality, beta-adrenergic receptor stimulating autoantibody, beta-adrenergic receptor supersensitivity, muscarinic receptor autoantibody, or hyposensitivity, impaired baroreflex control, depressed efferent parasympathetic/vagal function, nociceptive stimulation, central autonomic overactivity, aberrant neurohumoral modulation, etc. Symptoms associated with IST are palpitations, chest pain, fatigue, shortness of breath, presyncope, and syncope. Despite these distressing symptoms, IST has not been associated with tachycardia-associated cardiomyopathy or increased major cardiovascular events. Various treatment options for patients with IST are ivabradine, beta-adrenergic blockers, calcium channel blockers, psychiatric evaluation, and exercise training. Although, endocardial radiofrequency ablation targeting the sinus node has been used as a treatment modality for otherwise treatment-refractory IST, the results have been dismal. The other modalities used for refractory IST treatment are endocardial modification of the sinus node using radiofrequency energy, combined endo and epicardial ablation of the sinus node, thoracoscopic epicardial ablation of the sinus node, sinus node sparing thoracoscopic and endocardial hybrid ablation. The goal of this review is to provide the readership with the pathophysiological basis of IST and its management options.

Management strategies for vasovagal syncope.

Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).

Risks of adverse events in patients with orthostatic intolerance undergoing surgery with general anesthesia.

INTRODUCTION: Orthostatic intolerance (OI) is a group of disorders characterized by symptoms that occur upon standing and resolve with recumbence. Although well established but not widely recognized, these diagnoses may create uncertainty for clinicians dealing with a patient affected by OI and requiring a surgical procedure. OBJECTIVES: To determine the rate of intra- and postoperative major adverse events in patients with OI undergoing surgery with general anesthesia. METHODS: The study was a retrospective study of patients with orthostatic intolerance who underwent surgery requiring general anesthesia from 1 January 2000 to 31 December 2018. RESULTS: A total 171 patients with OI underwent 190 surgeries. In patients with POTS and orthostatic-induced VVS, there were no major significant adverse events. There was one episode of AVNRT in a patient with POTS and one episode of bradycardia secondary to vasovagal reflex in a patient with orthostatic-induced VVS. Moreover, there were 13 (6.8%) episodes of postoperative hypotension. However, the majority of these episodes were related to bleeding, volume depletion or sepsis. All cases of hypotension responded well to appropriate therapy. In patients with OH, the rate of postoperative major adverse cardiac events was 4.7%, and the 30-day mortality rate was 6.1%. This is not significantly different from the calculated risk for patients without OH. There were no myocardial infarctions or deaths at 30 days in patients with POTS or orthostatic-induced VVS. CONCLUSION: Patients with OI may not experience higher rates of perioperative complications compared with patients without OI syndromes.

Assessment of the Non-Technical Skills for Surgeons (NOTSS) framework in the USA.

BACKGROUND: Surgeons' non-technical skills are important for patient safety. The Non-Technical Skills for Surgeons assessment tool was developed in the UK and recently adapted to the US surgical context (NOTSS-US). The aim of this study was to evaluate the reliability and distribution of non-technical skill ratings given by attending (consultant) surgeons who underwent brief online training. METHODS: Attending surgeons across six specialties at a large US academic medical centre underwent a 10-min online training, then rated 60-s standardized videos of simulated operations. Intraclass correlation coefficient (ICC), and mean(s.d.) values for NOTSS-US ratings were determined for each non-technical skill category (score range 1-5, where 1 indicates poor, 3 average and 5 excellent) and for total NOTSS-US score (range 4-20; sum of 4 category scores). Outcomes were adjusted for rater characteristics including sex, specialty and clinical experience. RESULTS: A total of 8889 ratings were submitted by 81 surgeon raters on 30 simulated intraoperative videos. The mean(s.d.) total NOTSS-US score for all videos was 9·5(4·8) of 20. The within-video ICC for total NOTSS-US score was 0·64 (95 per cent c.i. 0·57 to 0·70). For individual non-technical skill categories, the ICC was highest for social skills (communication/teamwork: 0·63, 95 per cent c.i. 0·56 to 0·71; leadership: 0·64, 0·55 to 0·72) and lowest for cognitive skills (situation awareness: 0·54, 0·45 to 0·62; decision-making: 0·50, 0·41 to 0·59). Women gave higher total NOTSS-US scores than men (adjusted mean difference 0·93, 95 per cent c.i. 0·44 to 1·43; P = 0·001). CONCLUSION: After brief online training, the inter-rater reliability of the NOTSS-US assessment tool achieved moderate strength among trained surgeons rating simulated intraoperative videos.

ANTECEDENTES: Las habilidades no técnicas de los cirujanos (Non-Technical Skills for Surgeons, NOTSS) son importantes para la seguridad del paciente. La herramienta de evaluación de habilidades no técnicas para cirujanos se desarrolló en el Reino Unido y se adaptó recientemente al contexto quirúrgico de los Estados Unidos (NOTSS-US.). El objetivo de este estudio fue evaluar la fiabilidad y distribución de las calificaciones de habilidades no técnicas obtenidas por cirujanos adjuntos de cirugía (consultores) que recibieron una breve formación online. MÉTODOS: Cirujanos adjuntos de 6 especialidades en un gran centro universitario de Estados Unidos recibieron una formación online de 10 minutos de duración y seguidamente puntuaron vídeos estandarizados de operaciones simuladas de 60 minutos de duración. Se calcularon el coeficiente de correlación intraclase (intraclass correlation coefficient, ICC), la media y la desviación estándar (standard deviation, SD) para la puntuación de cada categoría de habilidad no técnica del NOTSS-US (rango 1-5, siendo 1 = pobre, 3 = promedio, 5 = excelente) y para la puntuación global de NOTSS-US (rango 4-20, suma de las puntuaciones de las cuatro categorías). Los resultados se ajustaron de acuerdo con las características del evaluador, incluyendo sexo, especialidad, experiencia clínica. RESULTADOS: En 30 videos intraoperatorios simulados, 81 cirujanos evaluadores proporcionaron 8.889 puntaciones. La puntuación media global de NOTSS-US para todos los vídeos fue de 9,5 sobre 20 (SD 4,8). El ICC de los vídeos para la puntuación global de NOTSS-US fue 0,64 (i.c. del 95% 0,57-0,70). Para las categorías individuales de habilidades no técnicas, el ICC más alto fue para las habilidades sociales (comunicación / trabajo en equipo: 0,63, (i.c. del 95% 0,56-0,71); liderazgo, 0,64 (i.c. del 95% 0,55-0,72)) y el más bajo para las habilidades cognitivas (conciencia de la situación 0,54 (i.c. del 95% 0,45-0,62); toma de decisiones 0,50 (i.c. del 95% 0,41-0,59)). Las evaluadoras femeninas presentaron puntuaciones globales de NOTSS-US más altas que los evaluadores masculinos (diferencia 0,93, i.c. del 95% 0,44-1,43; P = 0,001)). CONCLUSIÓN: Después de una breve formación online, la fiabilidad de la herramienta de evaluación NOTSS-US mostró una correlación moderada entre los cirujanos que puntuaron vídeos de simulaciones de intervenciones quirúrgicas.

Ivabradine in children with postural orthostatic tachycardia syndrome: a retrospective study.

BACKGROUND: Ivabradine is a unique medication that reduces the intrinsic heart rate by specifically blocking the inward funny current that controls the pacemaker activity of the sinus node. We conducted a retrospective cohort study to assess the efficacy of ivabradine in children suffering from postural orthostatic tachycardia syndrome. METHODS: A chart review was conducted of patients less than 18 years of age who were diagnosed with postural orthostatic tachycardia syndrome who had received ivabradine as treatment from January 2015 to February 2019 at our institution. Twenty-seven patients (25 females, 92.5%) were identified for the study. The outcomes which were assessed included a change in the severity and frequency of symptoms, heart rate, and blood pressure before and after starting ivabradine. RESULTS: There was an improvement in the symptoms of 18 (67%) out of 27 patients. The most notable symptom affected was syncope/presyncope with a reduction in 90%, followed by lightheadedness (85%) and fatigue (81%). The vital signs of the patients showed an overall significant lowering of the heart rate during sitting (89.7 ± 17.9 versus 73.2 ± 12.1; p-value <0.05) and standing (100.5 ± 18.1 versus 80.9 ± 10.1; p-value <0.05) without a significant change in the blood pressure. Two patients had visual disturbances (luminous phenomena). Severe bradycardia and excessive flushing were seen in two patients, respectively. Another one patient reported joint pain and fatigue. CONCLUSION: This study indicates that 67% of children treated with ivabradine report an improvement in symptoms.

Microclimate modelling of beach sand temperatures reveals high spatial and temporal variation at sea turtle rookeries.

The continual development of ecological models and availability of high-resolution gridded climate surfaces have stimulated studies that link climate variables to functional traits of organisms. A primary constraint of these studies is the ability to reliably predict the microclimate that an organism experiences using macroscale climate inputs. This is particularly important in regions where access to empirical information is limited. Here, we contrast correlative models based on both ambient and sea surface temperatures to mechanistic modelling approaches to predict beach sand temperatures at depths relevant to sea turtle nesting. We show that mechanistic models are congruent with correlative models at predicting sand temperatures. We used these predictions to explore thermal variation across 46 mainland and island beaches that span the geographical range of sea turtle nesting in Western Australia. Using high resolution gridded climate surfaces and site-specific soil reflectance, we predict almost 9 °C variation in average annual temperatures between beaches, and nearly 10 °C variation in average temperatures during turtle nesting seasons. Validation of models demonstrated that predictions were typically within 2 °C of observations and, although most sites had high correlations (r2 > 0.7), predictive capacity varied between sites. An advantage of the mechanistic model demonstrated here is that it can be used to explore the impacts of climate change on sea turtle nesting beach temperatures as, unlike correlative models, it can be forced with novel combinations of environmental variables.

Modulator of the PI3K/Akt oncogenic pathway affects mTOR complex 2 in human adenocarcinoma cells.

Chaetoglobosin K (ChK) is a natural product that has been shown to promote F-actin capping, inhibit growth, arrest cell cycle G2 phase, and induce apoptosis. ChK also has been shown to downregulate two important kinases involved in oncogenic pathways, Akt and JNK. This report investigates how ChK is involved in the receptor tyrosine kinase pathway (RTK/PI3K/mTORC2/Akt) to the centrally located protein kinase, Akt. Studies have reported that ChK does not inhibit PI3K comparable to wortmannin and does not affect PDK1 activation. PDK1 is responsible for phosphorylation on Akt T308, while mTORC2 phosphorylates Akt S473. Yet, Akt's two activation sites, T308 and S473, are known to be affected by ChK treatment. It was our hypothesis that ChK acts on the mTORC2 complex to inhibit the phosphorylation seen at Akt S473. This inhibition at mTORC2 should decrease phosphorylation at both these proteins, Akt and mTORC2 complex, compared to a known mTOR specific inhibitor, Torin1. Human lung adenocarcinoma H1299 and H2009 cells were treated with IGF-1 or calyculin A to increase phosphorylation at complex mTORC2 and Akt. Pretreatment with ChK was able to significantly decrease phosphorylation at Akt S473 similarly to Torin1 with either IGF-1 or calyculin A treatment. Moreover, the autophosphorylation site on complex mTORC2, S2481, was also significantly reduced with ChK pretreatment, similar to Torin1. This is the first report to illustrate that ChK has a significant effect at mTORC2 S2481 and Akt S473 comparable to Torin1, indicating that it may be a mTOR inhibitor.

Fear affects parental care, which predicts juvenile survival and exacerbates the total cost of fear on demography.

Fear itself (perceived predation risk) can affect wildlife demography, but the cumulative impact of fear on population dynamics is not well understood. Parental care is arguably what most distinguishes birds and mammals from other taxa, yet only one experiment on wildlife has tested fear effects on parental food provisioning and the repercussions this has for the survival of dependent offspring, and only during early-stage care. We tested the effect of fear on late-stage parental care of mobile dependent offspring, by locating radio-tagged Song Sparrow fledglings and broadcasting predator or non-predator playbacks in their vicinity, measuring their parent's behavior and their own, and tracking the offspring's survival to independence. Fear significantly reduced late-stage parental care, and parental fearfulness (as indexed by their reduction in provisioning when hearing predators) significantly predicted their offspring's condition and survival. Combining results from this experiment with that on early-stage care, we project that fear itself is powerful enough to reduce late-stage survival by 24%, and cumulatively reduce the number of young reaching independence by more than half, 53%. Experiments in invertebrate and aquatic systems demonstrate that fear is commonly as important as direct killing in affecting prey demography, and we suggest focusing more on fear effects and on offspring survival will reveal the same for wildlife.

Hospitalized Patients' Knowledge of Care: a Systematic Review.

BACKGROUND: Patients' comprehension of their medical conditions is fundamental to patient-centered care. Hospitalizations present opportunities to educate patients but also challenges to patient comprehension given the complexity and rapid pace of clinical care. We conducted a systematic review of the literature to characterize the current state of inpatients' knowledge of their hospitalization, assess the methods used to determine patient comprehension, and appraise the effects of interventions on improving knowledge. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library for articles published from January 1, 1995 through December 11, 2017. Eligible studies included patients under inpatient or observation status on internal medicine, family medicine, or neurology services. We extracted study characteristics (author, year, country, study design, sample size, patient characteristics, methods, intervention, primary endpoints, results) in a standardized fashion. The quality of observational studies was assessed using the NIH Quality Assessment Tool for Observation Cohort and Cross-Sectional Studies and the quality of interventional studies was assessed using adapted EPOC criteria from the Cochrane Collaboration. RESULTS: Twenty-eight studies met the criteria for inclusion, including 17 observational studies and 11 interventional studies. Patient knowledge of all aspects of their hospitalization was poor and patients often overestimated their knowledge. Older patients and those with lower education levels were more likely to have poorer knowledge. Intervention methods varied, but generally showed improvements in patient knowledge. Few interventional studies assessed the effect on health behaviors or outcomes and those that did were often underpowered. DISCUSSION: Clinicians should be aware that comprehension is often poor among hospitalized patients, especially in those with lower education and advanced age. Our results are limited by overall poor quality of interventional studies. Future research should use objective, standardized measures of patient comprehension and interventions should be multifaceted in approach, focusing on knowledge improvement while also addressing other factors influencing outcomes.

Role of implantable loop recorders in patients with postural orthostatic tachycardia syndrome.

INTRODUCTION: We previously reported on a subgroup of postural orthostatic tachycardia syndrome (POTS) patients who may also have features of neurocardiogenic syncope as well. In this subgroup of patients, we found syncope and presyncope were predominant clinical features. To understand the mechanism of syncope in this subgroup, we identified 39 patients who underwent loop recorder insertion. METHODS: We reviewed charts of 450 patients who had POTS and syncope seen at the University of Toledo Medical Center from 2003 to 2017. Thirty-nine patients had at least four episodes of syncope in the last 6 months and were included for this study. All of these patients had a prior evaluation with a Holter and an event monitor which were inconclusive. RESULTS: Thirty-nine patients, 33 (85%) women, aged 20-46 years, were included in this study. All patients demonstrated prolonged asystole (>6 seconds) or severe bradycardia (heart rate < 30 beats/min) during their syncope on implantable loop recorder (IRL). Fifteen patients demonstrated an asystole of >10 seconds and also had prolonged and convulsive syncope. All patients had abrupt syncope without any warning sign. All patients underwent dual-chamber pacemaker implantation using a closed loop stimulation algorithm. Syncope were completely eliminated in all patients following pacemaker implantation; however, they continued to have orthostatic tachycardia. CONCLUSION: POTS patients with unusually frequent syncope should be considered for ILR implantation if other monitoring modalities like 48-hour Holter monitor or event recorder are inconclusive. ILR may identify a subgroup of POTS patients who may benefit from pacemaker implantations.

Sequential Associations Between Caregiver Talk and Child Play in Autism Spectrum Disorder and Typical Development.

This study examined sequential associations between child play and caregiver talk in 98 caregiver-child dyads (Mmental age  = 14 months). Fifty dyads included a child with autism spectrum disorder (ASD). Analyses revealed sequential associations between child play and caregiver follow-in (FI) utterances (utterances related to the child's attentional focus) were stronger in the ASD as compared to the typically developing (TD) group. FI utterances were more likely to elicit functional play than caregiver-focused utterances, and more so in the ASD group. Across groups, FI directives were more likely to elicit functional play than FI comments. These findings have important implications for research involving caregiver-child play as an early intervention context for children with ASD.

Loggerhead sea turtle embryos (Caretta caretta) regulate expression of stress response and developmental genes when exposed to a biologically realistic heat stress.

Oviparous reptile embryos are expected to breach their critical thermal maxima if temperatures reach those predicted under current climate change models due to the lack of the maternal buffering processes and parental care. Heat-shock proteins (HSPs) are integral in the molecular response to thermal stress, and their expression is heritable, but the roles of other candidate families such as the heat-shock factors (HSFs) have not been determined in reptiles. Here, we subject embryonic sea turtles (Caretta caretta) to a biologically realistic thermal stress and employ de novo transcriptomic profiling of brain tissue to investigate the underlying molecular response. From a reference transcriptome of 302 293 transcripts, 179 were identified as differentially expressed between treatments. As anticipated, genes enriched in the heat-shock treatment were primarily associated with the Hsp families, or were genes whose products play similar protein editing and chaperone functions (e.g. bag3, MYOC and serpinh1). Unexpectedly, genes encoding the HSFs were not significantly upregulated under thermal stress, indicating their presence in unstressed cells in an inactive state. Genes that were downregulated under thermal stress were less well functionally defined but were associated with stress response, development and cellular organization, suggesting that developmental processes may be compromised at realistically high temperatures. These results confirm that genes from the Hsp families play vital roles in the thermal tolerance of developing reptile embryos and, in addition with a number of other genes, should be targets for evaluating the capacity of oviparous reptiles to respond adaptively to the effects of climate change.

Utility of High-Output His Pacing during Difficult AV Node Ablation. An Underutilized Strategy.

Atrioventricular (AV) node ablation is a commonly performed procedure for patients with chronic drug refractory atrial fibrillation (AF) with episodes of rapid ventricular response. We report on a 72-year-old man who had difficulty managing chronic drug refractory AFs with frequent hospitalizations for rapid ventricular rate. The patient was taken to the electrophysiology laboratory for AV node ablation. Extensive mapping and localization techniques of the compact AV node and ablation in the region were unsuccessful. Subsequently, high-output His bundle pacing using 20 mA at 2 ms of output energy was performed in an attempt to localize the His bundle in areas where high-output pacing resulted in a narrower QRS complex. Further ablations in the areas where pacing produced a narrower QRS complex resulted in complete heart block. This case highlights the importance of using this simple pacing maneuver to achieve complete heart block in patients in whom standard strategies to localize and ablate the compact AV node are unsuccessful.

Process evaluation of the Bristol girls dance project.

BACKGROUND: The Bristol Girls Dance Project was a cluster randomised controlled trial that aimed to increase objectively measured moderate-to-vigorous physical activity (MVPA) levels of Year 7 (age 11-12) girls through a dance-based after-school intervention. The intervention was delivered in nine schools and consisted of up to forty after-school dance sessions. This paper reports on the main findings from the detailed process evaluation that was conducted. METHODS: Quantitative and qualitative data were collected from intervention schools. Dose and fidelity were reported by dance instructors at every session. Intervention dose was defined as attending two thirds of sessions and was measured by attendance registers. Fidelity to the intervention manual was reported by dance instructors. On four randomly-selected occasions, participants reported their perceived level of exertion and enjoyment. Reasons for non-attendance were self-reported at the end of the intervention. Semi-structured interviews were conducted with all dance instructors who delivered the intervention (n = 10) and school contacts (n = 9) in intervention schools. A focus group was conducted with girls who participated in each intervention school (n = 9). RESULTS: The study did not affect girls' MVPA. An average of 31.7 girls participated in each school, with 9.1 per school receiving the intervention dose. Mean attendance and instructors' fidelity to the intervention manual decreased over time. The decline in attendance was largely attributed to extraneous factors common to after-school activities. Qualitative data suggest that the training and intervention manual were helpful to most instructors. Participant ratings of session enjoyment were high but perceived exertion was low, however, girls found parts of the intervention challenging. CONCLUSIONS: The intervention was enjoyed by participants. Attendance at the intervention sessions was low but typical of after-school activities. Participants reported that the intervention brought about numerous health and social benefits and improved their dance-based knowledge and skills. The intervention could be improved by reducing the number of girls allowed to participate in each school and providing longer and more in-depth training to those delivering the intervention. TRIAL REGISTRATION: ISRCTN52882523 Registered 25th April 2013.