BH4 supplementation reduces retinal cell death in ischaemic retinopathy.

Dysregulation of nitric oxide (NO) production can cause ischaemic retinal injury and result in blindness. How this dysregulation occurs is poorly understood but thought to be due to an impairment in NO synthase function (NOS) and nitro-oxidative stress. Here we investigated the possibility of correcting this defective NOS activity by supplementation with the cofactor tetrahydrobiopterin, BH4. Retinal ischaemia was examined using the oxygen-induced retinopathy model and BH4 deficient Hph-1 mice used to establish the relationship between NOS activity and BH4. Mice were treated with the stable BH4 precursor sepiapterin at the onset of hypoxia and their retinas assessed 48 h later. HPLC analysis confirmed elevated BH4 levels in all sepiapterin supplemented groups and increased NOS activity. Sepiapterin treatment caused a significant decrease in neuronal cell death in the inner nuclear layer that was most notable in WT animals and was associated with significantly diminished superoxide and local peroxynitrite formation. Interestingly, sepiapterin also increased inflammatory cytokine levels but not microglia cell number. BH4 supplementation by sepiapterin improved both redox state and neuronal survival during retinal ischaemia, in spite of a paradoxical increase in inflammatory cytokines. This implicates nitro-oxidative stress in retinal neurones as the cytotoxic element in ischaemia, rather than enhanced pro-inflammatory signalling.

Exploring Change in Children's and Art Therapists' Behavior during 'Images of Self', an Art Therapy Program for Children Diagnosed with Autism Spectrum Disorders: A Repeated Case Study Design.

(1) Background: 'Images of Self' (IOS) is a recently developed and evaluated art therapy program of 15 sessions to reduce difficulties in 'sense of self', 'emotion regulation', 'flexibility', and 'social behavior' of children diagnosed with Autism Spectrum Disorders (ASD). In this paper, it is explored whether change in the child's behaviors corresponds to the therapist's actions during IOS and 15 weeks later. (2) Method: In a repeated case study design, twelve children and seven therapists participated. Art therapists monitored their own and the children's behavior by applying two observation instruments: the OAT (Observation of a child with autism in Art Therapy) and EAT (Evaluation of Art Therapist's behavior when working with a child with autism). Child behaviors during art making were-individually and as a group-compared with therapist's actions at three moments during the program. (3) Results: Ten of twelve children showed a substantial or moderate positive behavior change considering all OAT subscales at the end of the program and 15 weeks after treatment. Improvement of 'social behavior' stood out. Halfway treatment art therapists most prominently showed support of 'emotion regulation', 'flexibility', and 'social behavior'. Clear one-on-one relationships between changes in children's behavior and actions of therapists could not be identified. (4) Conclusion: The study provides new insights in the AT treatment process by monitoring children's and therapists' behavior. The art making itself and the art therapy triangle (child, art making, therapist) offer opportunities to improve verbal and nonverbal communication skills of the child.

Use of complementary and alternative medicine by patients with hypermobile Ehlers-Danlos Syndrome: A qualitative study.

Background: Patients with hypermobile Ehlers-Danlos Syndrome (hEDS) often make use of complementary and alternative medical (CAM) techniques to manage their chronic pain and other symptoms. Nevertheless, how they use CAM, which techniques they favor, and how CAM use affects their allopathic care remain unclear. The purpose of this qualitative study was to understand patients' personal experiences with CAM and its role in their symptom management. Materials and methods: Thirty individuals living with hEDS completed a brief online survey related to their CAM use. Thereafter, in-depth interviews were conducted with 24 of the survey respondents, qualitatively investigating their experiences with CAM. Data were analyzed using thematic analysis. Results: Participants described massage therapy (N = 21), medical cannabis (N = 12), and mindfulness (N = 13) as some of the most useful CAM modalities for managing symptoms related to hEDS, but they expressed a general interest in pursuing any treatment that could potentially reduce their chronic pain. They suggested an overall trust in CAM modalities and practitioners and ascribed greater empathy to CAM practitioners than to conventional medical providers. However, they also described a critical skepticism of CAM (and conventional) therapies and recounted instances of injury from such treatments. Conclusion: Participants made extensive use of CAM therapies. They described both critical benefits as well as harms from the use of these non-conventional modalities. These results underscore the importance of clinicians maintaining communicative and compassionate relationships with their patients, and of an openness to the discussion and use of CAM treatments.

Rationale, design, demographics and baseline characteristics of the randomized, controlled, Phase 2b SAPPHIRE study of verinurad plus allopurinol in patients with chronic kidney disease and hyperuricaemia.

BACKGROUND: Verinurad is a human uric acid (UA) transporter (URAT1) inhibitor known to decrease serum UA (sUA) levels and that may reduce albuminuria. In a Phase 2a study (NCT03118739), treatment with verinurad + febuxostat lowered urine albumin-to-creatinine ratio (UACR) at 12 weeks by 39% (90% confidence interval 4-62%) among patients with Type 2 diabetes mellitus, hyperuricaemia and albuminuria. The Phase 2b, randomized, placebo-controlled Study of verinurAd and alloPurinol in Patients with cHronic kIdney disease and hyperuRicaEmia (SAPPHIRE; NCT03990363) will examine the effect of verinurad + allopurinol on albuminuria and estimated glomerular filtration rate (eGFR) slope among patients with chronic kidney disease (CKD) and hyperuricaemia. METHODS: Adults (≥18 years of age) with CKD, eGFR ≥25 mL/min/1.73 m2, UACR 30-5000 mg/g and sUA ≥6.0 mg/dL will be enrolled. Approximately 725 patients will be randomized 1:1:1:1:1 to 12, 7.5 or 3 mg verinurad + allopurinol, allopurinol or placebo. An 8-week dose-titration period will precede a 12-month treatment period; verinurad dose will be increased to 24 mg at Month 9 in a subset of patients in the 3 mg verinurad + allopurinol arm. The primary efficacy endpoint the is change from baseline in UACR at 6 months. Secondary efficacy endpoints include changes in UACR, eGFR and sUA from baseline at 6 and 12 months. CONCLUSIONS: This study will assess the combined clinical effect of verinurad + allopurinol on kidney function in patients with CKD, hyperuricaemia and albuminuria, and whether this combination confers renoprotection beyond standard-of-care.

MRI-based thalamic volumetry in multiple sclerosis using FSL-FIRST: Systematic assessment of common error modes.

BACKGROUND AND PURPOSE: FSL's FMRIB's Integrated Registration and Segmentation Tool (FSL-FIRST) is a widely used and well-validated tool. Automated thalamic segmentation is a common application and an important longitudinal measure for multiple sclerosis (MS). However, FSL-FIRST's algorithm is based on shape models derived from non-MS groups. As such, the present study sought to systematically assess common thalamic segmentation errors made by FSL-FIRST on MRIs from people with multiple sclerosis (PwMS). METHODS: FSL-FIRST was applied to generate thalamic segmentation masks for 890 MR images in PwMS. Images and masks were reviewed systematically to classify and quantify errors, as well as associated anatomical variations and MRI abnormalities. For cases with overt errors (n = 362), thalamic masks were corrected and quantitative volumetric differences were calculated. RESULTS: In the entire quantitative volumetric group, the mean volumetric error of FSL-FIRST was 2.74% (0.360 ml): among only corrected cases, the mean volumetric error was 6.79% (0.894 ml). The average percent volumetric error associated with seven error types, two anatomical variants, and motions artifacts are reported. Additional analyses showed that the presence of motion artifacts or anatomical variations significantly increased the probability of error (χ2  = 18.14, p < .01 and χ2  = 64.89, p < .001, respectively). Finally, thalamus volume error was negatively associated with degree of atrophy, such that smaller thalami were systematically overestimated (r = -.28, p < .001). CONCLUSIONS: In PwMS, FSL-FIRST thalamic segmentation miscalculates thalamic volumetry in a predictable fashion, and may be biased to overestimate highly atrophic thalami. As such, it is recommended that segmentations be reviewed and corrected manually when appropriate for specific studies.

Reversal of the Pathophysiological Responses to Gram-Negative Sepsis by Megadose Vitamin C.

OBJECTIVES: Oxidative stress appears to initiate organ failure in sepsis, justifying treatment with antioxidants such as vitamin C at megadoses. We have therefore investigated the safety and efficacy of megadose sodium ascorbate in sepsis. DESIGN: Interventional study. SETTING: Research Institute. SUBJECTS: Adult Merino ewes. INTERVENTIONS: Sheep were instrumented with pulmonary and renal artery flow-probes, and laser-Doppler and oxygen-sensing probes in the kidney. Conscious sheep received an infusion of live Escherichia coli for 31 hours. At 23.5 hours of sepsis, sheep received fluid resuscitation (30 mL/kg, Hartmann solution) and were randomized to IV sodium ascorbate (0.5 g/kg over 0.5 hr + 0.5 g/kg/hr for 6.5 hr; n = 5) or vehicle (n = 5). Norepinephrine was titrated to restore mean arterial pressure to baseline values (~80 mm Hg). MEASUREMENTS AND MAIN RESULTS: Sepsis-induced fever (41.4 ± 0.2°C; mean ± se), tachycardia (141 ± 2 beats/min), and a marked deterioration in clinical condition in all cases. Mean arterial pressure (86 ± 1 to 67 ± 2 mm Hg), arterial Po2 (102.1 ± 3.3 to 80.5 ± 3.4 mm Hg), and renal medullary tissue Po2 (41 ± 5 to 24 ± 2 mm Hg) decreased, and plasma creatinine doubled (71 ± 2 to 144 ± 15 µmol/L) (all p < 0.01). Direct observation indicated that in all animals, sodium ascorbate dramatically improved the clinical state, from malaise and lethargy to a responsive, alert state within 3 hours. Body temperature (39.3 ± 0.3°C), heart rate (99.7 ± 3 beats/min), and plasma creatinine (32.6 ± 5.8 µmol/L) all decreased. Arterial (96.5 ± 2.5 mm Hg) and renal medullary Po2 (48 ± 5 mm Hg) increased. The norepinephrine dose was decreased, to zero in four of five sheep, whereas mean arterial pressure increased (to 83 ± 2 mm Hg). We confirmed these physiologic findings in a coronavirus disease 2019 patient with shock by compassionate use of 60 g of sodium ascorbate over 7 hours. CONCLUSIONS: IV megadose sodium ascorbate reversed the pathophysiological and behavioral responses to Gram-negative sepsis without adverse side effects. Clinical studies are required to determine if such a dose has similar benefits in septic patients.

Mindful medical practice: An innovative core course to prepare medical students for clerkship.

BACKGROUND: Medical students show a decline in empathy and ethical reasoning during medical school that is most marked during clerkship. We believe that part of the problem is that students do not have the skills and ways of being and relating necessary to deal effectively with the overwhelming clinical experience of clerkship. APPROACH: At McGill University in Montreal, starting in January 2015, we have taught a course on mindful medical practice that combines a clinical focus on the combination of mindfulness and congruent relating that is aimed at giving students the skills and ways of being to function effectively in clerkship. The course is taught to all medical students in groups of 20, weekly for 7 weeks, in the 6 months immediately prior to clerkship, a time when students are very open to learning the skills they need to take effective care of patients. EVALUATION: The course has been well accepted by students as evidenced by their engagement, their evaluations, and their comments in the essays that they write at the end of the course. In a follow-up session at the simulation centre one year later students remember clearly and enact what they were taught in the course. REFLECTION: The next steps will be to conduct a formal evaluation of the effect of our teaching that will involve a combination of qualitative methods to clarify the nature of the impact on our students and a quantitative assessment of the difference the course makes to students' experience and performance in clerkship.

A general procedure to select calibration drugs for lab-specific validation and calibration of proarrhythmia risk prediction models: An illustrative example using the CiPA model.

INTRODUCTION: In response to the ongoing shift of the regulatory cardiac safety paradigm, a recent White Paper proposed general principles for developing and implementing proarrhythmia risk prediction models. These principles included development strategies to validate models, and implementation strategies to ensure a model developed by one lab can be used by other labs in a consistent manner in the presence of lab-to-lab experimental variability. While the development strategies were illustrated through the validation of the model under the Comprehensive In vitro Proarrhythmia Assay (CiPA), the implementation strategies have not been adopted yet. METHODS: The proposed implementation strategies were applied to the CiPA model by performing a sensitivity analysis to identify a subset of calibration drugs that were most critical in determining the classification thresholds for proarrhythmia risk prediction. RESULTS: The selected calibration drugs were able to recapitulate classification thresholds close to those calculated from the full list of CiPA drugs. Using an illustrative dataset it was shown that a new lab could use these calibration drugs to establish its own classification thresholds (lab-specific calibration), and verify that the model prediction accuracy in the new lab is comparable to that in the original lab where the model was developed (lab-specific validation). DISCUSSION: This work used the CiPA model as an example to illustrate how to adopt the proposed model implementation strategies to select calibration drugs and perform lab-specific calibration and lab-specific validation. Generic in nature, these strategies could be generally applied to different proarrhythmia risk prediction models using various experimental systems under the new paradigm.

Tuberculosis infection prevention and control: why we need a whole systems approach.

Infection prevention and control (IPC) measures to reduce transmission of drug-resistant and drug-sensitive tuberculosis (TB) in health facilities are well described but poorly implemented. The implementation of TB IPC has been assessed primarily through quantitative and structured approaches that treat administrative, environmental, and personal protective measures as discrete entities. We present an on-going project entitled Umoya omuhle ("good air"), conducted in two provinces of South Africa, that adopts an interdisciplinary, 'whole systems' approach to problem analysis and intervention development for reducing nosocomial transmission of Mycobacterium tuberculosis (Mtb) through improved IPC. We suggest that TB IPC represents a complex intervention that is delivered within a dynamic context shaped by policy guidelines, health facility space, infrastructure, organisation of care, and management culture. Methods drawn from epidemiology, anthropology, and health policy and systems research enable rich contextual analysis of how nosocomial Mtb transmission occurs, as well as opportunities to address the problem holistically. A 'whole systems' approach can identify leverage points within the health facility infrastructure and organisation of care that can inform the design of interventions to reduce the risk of nosocomial Mtb transmission.

pH-dependent effects of procaine on equine gamete activation†.

Procaine directly triggers pH-dependent cytokinesis in equine oocytes and induces hypermotility in stallion spermatozoa, an important event during capacitation. However, procaine-induced hyperactivated motility is abolished when sperm is washed to remove the procaine prior to sperm-oocyte co-incubation. To understand how procaine exerts its effects, the external Ca2+ and Na+ and weak base activity dependency of procaine-induced hyperactivation in stallion spermatozoa was assessed using computer-assisted sperm analysis. Percoll-washed stallion spermatozoa exposed to Ca2+-depleted (+2 mM EGTA) procaine-supplemented capacitating medium (CM) still demonstrated hyperactivated motility, whereas CM without NaCl or Na+ did not. Both procaine and NH4Cl, another weak base, were shown to trigger a cytoplasmic pH increase (BCECF-acetoxymethyl (AM)), which is primarily induced by a pH rise in acidic cell organelles (Lysosensor green dnd-189), accompanied by hypermotility in stallion sperm. As for procaine, 25 mM NH4Cl also induced oocyte cytokinesis. Interestingly, hyperactivated motility was reliably induced by 2.5-10 mM procaine, whereas a significant cytoplasmic cAMP increase and tail-associated protein tyrosine phosphorylation were only observed at 10 mM. Moreover, 25 mM NH4Cl did not support the latter capacitation characteristics. Additionally, cAMP levels were more than 10× higher in boar than stallion sperm incubated under similar capacitating conditions. Finally, stallion sperm preincubated with 10 mM procaine did not fertilize equine oocytes. In conclusion, 10 mM procaine causes a cytoplasmic and acidic sperm cell organelle pH rise that simultaneously induces hyperactivated motility, increased levels of cAMP and tail-associated protein tyrosine phosphorylation in stallion spermatozoa. However, procaine-induced hypermotility is independent of the cAMP/protein tyrosine phosphorylation pathway.

Mindfulness and associations with symptoms of insomnia, anxiety and depression in early adulthood: A twin and sibling study.

This study investigated associations between mindfulness and symptoms of insomnia, depression and anxiety. Mindfulness was disaggregated into five subscales: 'nonreactivity to inner experience', 'observing', 'acting with awareness', 'describing' and 'nonjudging of inner experience'. Twin models were used to examine genetic and environmental influences on mindfulness, symptoms of insomnia, depression and anxiety and on their associations. Data came from a longitudinal twin/sibling study (G1219) comprising 862 individuals (age range 22-32 years, 66% females). Less mindfulness was associated with greater symptoms of insomnia, depression and anxiety (r = .22-.48). Of the mindfulness subscales, 'nonjudging of inner experience' was most strongly associated with the other traits. Overall mindfulness was largely influenced by non-shared environmental factors (E = .72) although familial influences played a role for overall mindfulness, as well as for the 'acting with awareness' and 'describing' subscales. The genetic correlations between overall mindfulness and symptoms of insomnia, depression and anxiety ranged from .32 to .75 (but were non-significant), while the shared environmental correlations ranged from -.78 to .79 (also non-significant). The non-shared environmental influences between these three variables were moderately, significantly correlated (rE = .21-.55).

Low yield for routine laboratory checks in follow-up of coeliac disease.

AIM: To evaluate the yield of routine laboratory tests and Dual Energy X-ray Absorptiometry (DEXA) scans in coeliac disease. METHODS: A retrospective analysis of medical files of all followed-up patients with coeliac disease attending Rijnstate Hospital in 2016 was conducted with respect to blood tests of hemoglobin, vitamin B12, folate acid, iron status, calcium, vitamin D, glucose, thyroid function, DEXA-scans and related symptoms or signs of abnormalities. All patients had positive coeliac serology and/or biopsy-proven coeliac disease and attended regular visits after diagnosis. The chi-square test for trend was used for statistical analysis: a two-tailed probability of p < 0.05 was considered significant. RESULTS: We analyzed 250 patients with a median follow-up of 7.8 (1-22) years. At diagnosis, we found anemia in 24.4%, iron deficiency in 38%, folic acid deficiency in 22.6% and vitamin B12 deficiency in 15.9%. All deficiencies recovered within 1-2 years with or without supplements. Deficiencies or autoimmune diseases occurred in 50 patients (37 possibly coeliac-related) during follow-up. Twelve cases of coeliac-related deficiencies or autoimmune diseases occurred in patients with normal values at diagnosis of whom 10 were asymptomatic (incidence 10/1000 patient years). Osteoporosis and osteopenia were present in 23.3% and 35% at diagnosis. In most patients bone mineral density (BMD) improved or stabilized during follow up (p < 0.05), 8% deteriorated. CONCLUSIONS: The incidence of asymptomatic coeliac-related deficiencies or autoimmune diseases is low in patients with normal values at diagnosis. Therefore, routine laboratory screening is not necessary in this group: attending regular follow-up visits should be sufficient. DEXA scans are recommended.

Patients' perceived needs for allied health, and complementary and alternative medicines for low back pain: A systematic scoping review.

OBJECTIVES: Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP. METHODS: A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated. RESULTS: Forty-four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed-methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short-term duration of these therapies. CONCLUSIONS: Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient-centred guidelines and service models for LBP. Understanding patients' concerns regarding active-based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health-care system.

Use of a wine yeast deletion collection reveals genes that influence fermentation performance under low-nitrogen conditions.

A deficiency of nitrogenous nutrients in grape juice can cause stuck and sluggish alcoholic fermentation, which has long been a problem in winemaking. Nitrogen requirements vary between wine yeast strains, and the ability of yeast to assimilate nitrogen depends on the nature and concentration of nitrogen present in the medium. In this study, a wine yeast gene deletion collection (1844 deletants in the haploid AWRI1631 background) was screened to identify genes whose deletion resulted in a reduction in the time taken to utilise all sugars when grown in a chemically defined grape juice medium supplemented with limited nitrogen (75 mg L-1 as a free amino acid mixture). Through micro-scale and laboratory-scale fermentations, 15 deletants were identified that completed fermentation in a shorter time than the wildtype (c.a. 15%-59% time reduction). This group of genes was annotated to biological processes including protein modification, transport, metabolism and ubiquitination (UBC13, MMS2, UBP7, UBI4, BRO1, TPK2, EAR1, MRP17, MFA2 and MVB12), signalling (MFA2) and amino acid metabolism (AAT2). Deletion of MFA2, encoding mating factor-a, resulted in a 55% decrease in fermentation duration. Mfa2Δ was chosen for further investigation to understand how this gene deletion conferred fermentation efficiency in limited nitrogen conditions.

Patients' perceived needs of health care providers for low back pain management: a systematic scoping review.

BACKGROUND CONTEXT: Optimal management of low back pain (LBP) involves patients' active participation in care, facilitated by positive interactions with their health care provider(s) (HCP). An understanding of patients' perceived needs regarding their HCP is, therefore, necessary to achieve such outcomes. Therefore, the aim of the present study is to review the existing literature regarding patients' perceived needs of HCP managing LBP. METHODS: A systematic scoping review of publications in MEDLINE, EMBASE, CINAHL, and PsycINFO (1990-2016) was performed. Descriptive data regarding study design and methodology were extracted, and risk of bias was assessed. Aggregates of patients' perceived needs of HCP for LBP were categorized. RESULTS: Forty-three studies (30 qualitative, 12 quantitative, and 1 mixed methods) from 1,829 were relevant. Four areas of perceived need emerged: (1) there are several characteristics of HCP that patients desire, such as good communication and shared decision-making; (2) patients wanted HCP to provide information, including a cause of their LBP and legitimization of their symptoms; (3) patients' valued holistic, individualized care, and continuity of care; and (4) patients perceived long waiting times, difficulties with access to treatment, cost, and personal effort to be obstacles to care. CONCLUSIONS: Patients with LBP want patient-centered care, to be actively involved, and they have identified characteristics of HCP that foster a good provider-patient relationship. They noted areas of dissatisfaction with HCP and perceived obstacles to care. Given limited health care resources, HCP and policy makers need to implement novel methods of health care delivery that address these issues to facilitate improved patient satisfaction and achieve better patient and health system outcomes.

Long-term compliance and results of intravesical botulinum toxin A injections in male patients.

INTRODUCTION: Intravesical injections with botulinum toxin A (BoNT-A) is an established treatment for patients with overactive bladder (OAB) symptoms. However, most studies have evaluated the efficacy of this treatment in women and report short-term results. In this study, we evaluated the long-term compliance of BoNT-A in a heterogeneous group of male patients. MATERIALS AND METHODS: This is a retrospective, single-centre study. We evaluated all male patients who have been treated with BoNT-A from 2004 until 2010 in a large teaching hospital. Patients received 100-300 U of onabotulinum toxin-A in 20 intravescial injections. Some patients received dose adjustment with repeated injections. RESULTS: In total, 88 male patients were included. The mean follow-up was almost 6 years (69 months). Of all patients, 22 (25%) continued BoNT-A treatment at last follow-up (success). Of the patients who discontinued treatment, 35 had insufficient effect and 27 had tolerability issues (eg, urinary retention, self-catheterisation, voiding LUTS). Four patients abandoned treatment due to other reasons that were not related to BoNT-A. Of all patients, 24% had to use intermittent catheterisation (de novo) or indwelling catheters at some point during the follow-up. DISCUSSION: In this real-life, heterogeneous cohort of men, the long-term compliance with BoNT-A was 25%. Patients with neurogenic OAB symptoms appear to have the best results in our study with 36% of patients who were still on active treatment during last follow-up. Intravesical BoNT-A can be an effective treatment for men with OAB symptoms. In our study, only 25% of patients continued treatment during long-term follow-up. Larger, prospective trials are needed to confirm these results.

Deciding on child maltreatment: A literature review on methods that improve decision-making.

Assessment and decision-making in child maltreatment cases is difficult. Practitioners face many uncertainties and obstacles during their assessment and decision-making process. Research exhibits shortcomings in this decision-making process. The purpose of this literature review is to identify and discuss methods to overcome these shortcomings. We conducted a systematic review of the published literature on decision-making using PsychINFO and MEDLINE from 2000 through May 2014. We included reviews and quantitative research studies that investigated methods aimed at improving professional decision-making on child abuse and neglect in child welfare and child protection. Although many researchers have published articles on decision-making including ideas and theories to improve professional decision-making, empirical research on these improvements is scarce. Available studies have shown promising results. Structured decision-making has created a greater child-centred and holistic approach that takes the child's family and environment into account, which has made practitioners work more systematically and improved the analysis of complex situations. However, this approach has not improved inter-rater agreement on decisions made. Shared decision-making may improve the participation of parents and children and the quality of decisions by taking client treatment preferences into account in addition to scientific evidence and clinical experience. A number of interesting developments appear in recent research literature; however, child welfare and child protection must find additional inspiration from other areas, e.g., mental health services, because research on decision-making processes in child welfare and child protection is still rare.

Development of fluorescent substrates and assays for the key autophagy-related cysteine protease enzyme, ATG4B.

The cysteine protease ATG4B plays a role in key steps of the autophagy process and is of interest as a potential therapeutic target. At an early step, ATG4B cleaves proLC3 isoforms to form LC3-I for subsequent lipidation to form LC3-II and autophagosome membrane insertion. ATG4B also cleaves phosphatidylethanolamine (PE) from LC3-II to regenerate LC3-I, enabling its recycling for further membrane biogenesis. Here, we report several novel assays for monitoring the enzymatic activity of ATG4B. An assay based on mass spectrometric analysis and quantification of cleavage of the substrate protein LC3-B was developed and, while useful for mechanistic studies, was not suitable for high throughput screening (HTS). A doubly fluorescent fluorescence resonance energy transfer (FRET) ligand YFP-LC3B-EmGFP (FRET-LC3) was constructed and shown to be an excellent substrate for ATG4B with rates of cleavage similar to that for LC3B itself. A HTS assay to identify candidate inhibitors of ATG4B utilizing FRET-LC3 as a substrate was developed and validated with a satisfactory Z' factor and high signal-to-noise ratio suitable for screening small molecule libraries. Pilot screens of the 1,280-member library of pharmacologically active compounds (LOPAC(™)) and a 3,481-member library of known drugs (KD2) gave hit rates of 0.6% and 0.5% respectively, and subsequent titrations confirmed ATG4B inhibitory activity for three compounds, both in the FRET and mass spectrometry assays. The FRET- and mass spectrometry-based assays we have developed will allow for both HTS for inhibitors of ATG4B and mechanistic approaches to study inhibition of a major component of the autophagy pathway.